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: 2007
Reproductive Health and Research Unit (RHRU), as part of an outreach project in deprived inner city areas,
will implement four Other Prevention projects: Firstly, the provision of outreach prevention, clinical and
support services to commercial sex workers at an inner city primary health care clinic as well as prevention
information and condoms in the many brothels in Hillbrow, Johannesburg. Secondly, RHRU's sub-partner,
CARE, will offer home-based information, support and referral, and capacity building activities to improve
local faith-based organizations (FBOs), community-based organizations (CBOs) and non-governmental
organizations (NGOs). Prevention measures will be used as the entry point to household-based work.
Thirdly, RHRU will continue to provide a new program of prevention work for HIV-infected individuals, using
"motivational interviewing" techniques to reduce risky behavior. Lastly, RHRU will promote the uptake of
male circumcision through integration with existing services. Activities will include training, workshops and
other outreach covering condom usage and negotiation. Concurrent partner/partner reduction strategies
and HIV risk reduction will be integrated into all Other Prevention activities. The primary emphasis area for
these prevention activities is human development. The primary target populations for these interventions
are women, men, adolescents, people living with HIV, HIV-infected women including pregnant women,
commercial sex workers and their partners/clients, brothel owners, community-based and non-
governmental organizations (CBOs/NGOs). The sex worker component will be expanded in FY 2008 to an
additional neighborhood in Johannesburg. Prevention with Positives (PwP) will also be continued in all CT
and treatment programs.
RHRU, a unit of the University of the Witwatersrand in Johannesburg, currently provides technical support
to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South
Africa, which includes the national ARV roll-out. Under PEPFAR funding since FY 2004, RHRU has
provided regular on-site support, direct treatment, training and quality improvement to Department of Health
sites in three provinces. RHRU will continue these activities, and will continue both an inner city program
(Johannesburg) and a district-wide program (Durban), focusing on providing support to complete up and
down treatment referral networks. In addition, RHRU will continue the provision of counseling and testing
(CT), palliative care and prevention services. RHRU will seek to develop models of service delivery that can
be replicated and expanded, and produces findings from lessons learned and targeted evaluations to
disseminate and share with others. It should be noted that the success of antiretroviral treatment (ART)
scale-up depends on the comprehensive approach detailed in other program areas. In particular, the
strengthening of referral from other primary healthcare programs such as tuberculosis (TB), family planning,
antenatal/postnatal and STI services is critical. Prevention is an integral part of this system, and RHRU will
focus its condoms and other prevention program on high-risk groups such as commercial sex workers and
their clients, people infected with HIV, and also on building capacity of the CBOs and NGOs with which it
works. RHRU will also continue to develop strategies to address underserved communities affected by HIV,
such as couples (both concordant and discordant), high risk groups such as young people, and gender-
based interventions with women at risk, including pregnant women and commercial sex workers, and men.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: HIV Prevention for Women At Risk
RHRU will continue to target a large community of commercial sex workers with prevention and care
services, as well as treatment referral. The project is located in the deprived Johannesburg inner city, which
is densely populated, transitory and poor, with high HIV and unemployment rates. All women will be referred
for CT, and those with appropriate CD4 counts will be referred for ARV treatment. New treatment sites will
be identified in needy areas of the city, and the organization will work with local public sector clinics in the
area to sensitize staff to the special needs of this difficult-to-reach group and to provide outreach clinics in
local brothels, which are the hub of commercial sex workers in Hillbrow and Berea Johannesburg. RHRU
will also work with brothel owners, and clients and partners of commercial sex workers to increase their
awareness and affect a change in their norms and behaviors regarding HIV and AIDS. A specific focus will
be on changing gender norms through workshops and trainings, which will include such topics as
alternatives to risky behavior, women's rights, and reduction of gender-based violence. The project will
provide prevention outreach services including management of sexually transmitted infection (STI),
provision of condoms together with messages regarding correct and consistent use of condoms,
contraception and HIV prevention education including cross-generation and transactional sex, as well as
support for those who wish to leave sex work. The project will play a critical role in raising awareness of HIV
services and prevention through workshops and event days, and by distributing IEC materials. Furthermore,
this gender-related project will conduct HIV counseling and testing on high risk and difficult-to-access
groups, and will relate to the development of health networks and linkages by providing referral to HIV and
TB care and treatment services where necessary. To aid the expansion and sustainability of this program,
the local health authority will also contribute to this project. In addition, a manual has been developed to
provide a toolbox for other health authorities seeking to replicate this program, and technical consultation
will be provided. RHRU will share this with the Medical Research Council and others involved with high risk
ACTIVITY 2: Prevention with Positives
There is very little focus on prevention in South Africa among people already infected with HIV. Prevention
work to encourage safe-sex behaviors and limit infection and re-infection for those already positive is
currently being developed by some South African organizations. Innovative prevention methods, the
development of which will draw on models that have proven successful in other settings, will be introduced
in South Africa. Clinicians will be trained in this specific focus area, and the program will be monitored and
evaluated for efficacy. Programs that are proven successful will be expanded into other areas and used as
examples for other organizations. In addition, RHRU is currently adapting a flipchart on contraception for
HIV-infected clients for use by South African health care providers. This will be piloted in FY 2007-2008 and
will contribute to improved prevention for positive clients and will be integrated into care and treatment
ACTIVITY 3: Community-Based Prevention
RHRU will extend care and support services further into inner city areas, and incorporate prevention and
behavior change into their activities. With a combination of private sector and PEPFAR funding, RHRU runs
an information and support center in a high-risk area. A team of counselors and caregivers will be launched
from this center into the surrounding community. Team members will link with 30 households a week, with
the primary purpose of educating them on HIV prevention and understanding risk. Using prevention
messages as the entry to the household they will also assist them as needed with home-based care,
reaching orphans and vulnerable children, men and women, as well as contributing to the destigmatization
of HIV and AIDS.
ACTIVITY 4: Male Circumcision
No male circumcision training or service delivery will take place without the express consent of the National
Department of Health. In the absence of such approval and based on discussions with the PEPFAR South
Africa team, funds could fully or partially be reprogrammed. Should the approval for safe clinical male
circumcision activities be given, RHRU is proposing the following male activities:
Male circumcision has been identified as an important biological intervention that protects men from HIV
infection. It also creates opportunities to engage with men over a variety of reproductive health and risk-
taking issues. Men are grossly under-represented in terms of access to counseling and testing, as well as
HIV clinical services, including ART. Circumcision programs may allow expanded access to all forms of
care, including HIV testing. However, while the biological protection against HIV transmission has been
demonstrated beyond doubt, issues such as acceptability, operationalization, disinhibition and
programmatic integration, still remain. RHRU will explore the acceptability of integrating male circumcision
into existing services to broaden uptake. This will include piloting "opt out" circumcision for neonates, and
developing methods of raising awareness raising and counseling that address target groups including males
and young people. All activities will be conducted in accordance with the South African Government's new
In FY 2007- FY 2008, RHRU will continue to undertake M&E activities to inform and develop quality HIV
care. RHRU will be in a position to conduct targeted evaluations (TE) and Public Health Evaluations (PHE)
of some of its prevention related projects in FY 2008-09. For each PHE, a detailed proposal will be
developed and submitted to PEPFAR for review and funding approval.
RHRU will contribute to PEPFAR 2-7-10 goals by providing prevention services to a most-at-risk population
in a densely populated, poor, and highly transient inner city community.
The Reproductive Health and HIV Research Unit's (RHRU) Basic Care and Support activities for FY 2008
will be part of an integrated program and will specifically include: (1) palliative care arising from clinical (both
ARV and non-ARV) services rendered by RHRU staff through the activities described under the ARV
Services program area; (2) the provision of psychosocial support to commercial sex workers, (3) the
provision of support, home-based care and referral; and (4) the implementation of health provider training in
all aspects of palliative care. The major emphasis area for these activities is quality assurance and
supportive supervision, with additional focus on human resources, development of referral systems, and
training. Populations targeted for these interventions include PLHIV (children, youth and adults), HIV-
affected families, commercial sex workers, refugees, and public sector doctors, nurses, pharmacists,
traditional healers and other health care workers
Africa, which includes the national ARV rollout. Under PEPFAR funding since FY 2004, RHRU has provided
regular on-site support, direct treatment, training and quality improvement to DOH sites in 3 provinces. The
RHRU will continue these activities, which include inner city, district wide and rural programs focusing on
providing support to complete up and down treatment referral networks. In addition, RHRU will continue the
provision of counseling and testing (CT), palliative care, and prevention services. RHRU continues to
develop models of service delivery that can be replicated and expanded, and produces findings from
lessons learned and targeted evaluations to disseminate and share with others. It should be noted that the
success of ARV treatment scale-up depends on the comprehensive approach detailed in other program
areas. In particular, the strengthening of referral from other primary healthcare programs such as TB, family
planning, antenatal/postnatal and STI treatment is critical. Basic Health Care and Support is an integral part
of this system, and the RHRU will focus this part of its program on PLHIV, in impoverished areas such as
the Hillbrow neighborhood in Johannesburg, and at PHC clinics in Durban, and rural areas of the North
West Province by delivering high quality palliative care, psychosocial support, and intensive training of
doctors, nurses, and other health care professionals. Furthermore, RHRU will continue to develop strategies
to address underserved communities affected by HIV, such as couples, high risk groups such as
adolescents, and gender-based interventions with women at risk, including pregnant women, commercial
sex workers, and men.
ACTIVITY 1: Provision of Palliative Care
Through comprehensive support and quality improvement programs to the Johannesburg inner city,
eThekwini District in Durban, and through Mobile Clinical Support Teams operating in North West, KwaZulu-
Natal (KZN) and Gauteng provinces, RHRU will continue to provide the preventive care package and
opportunistic infection prevention and treatment, identification and treatment of syndromic STIs, provision of
regular CD4 counts, and pain and symptom management in conjunction with ARV treatment to adults and
children in partnership with the DOH. In addition, STI treatment will be provided to HIV-infected patients at a
network of local health authority sites in the inner city of Johannesburg. This includes the Women At Risk
Project that reaches commercial sex workers through a clinical and support outreach service that moves
between the inner city brothels, and a special service run from the clinic every weekday morning (see the
Other Prevention section for more details). Integrated reproductive health/HIV services will be provided to
HIV infected clients at a large family planning clinic in the Durban CBD and via the gender-related projects
described in the Other Prevention program area. Furthermore, health care and support will be provided to in
-patients at an HIV step-down and palliative care facility in KwaZulu-Natal. Lastly, as described in the Other
Prevention section, RHRU will provide home-based care in the deprived inner city suburb of Hillbrow
through its new program of community outreach.
ACTIVITY 2: Psychosocial Support
RHRU or its sub-partners will provide psychosocial support through counseling, wellness programs and
befriending. RHRU will assist with income generation, material support programs, and support group
facilitation. RHRU will be key in the strengthening of adherence initiatives through their work in HIV
treatment sites and within the community. RHRU will also assist the DOH in providing technical resources,
continuity and support to the up and down referral processes that must take place to enable ARV program
scale-up. Currently men are under-represented in seeking ARV treatment, and a family-based approach to
care ensures all family members are provided with treatment and prevention initiatives where appropriate.
Therefore, RHRU will also address gender issues by developing and providing specialized services such as
family clinic days 3 days per week, male clinic 5 days per week for CT and ART, and male only support
groups for families and men in order to improve access for these two key groups. In addition working with
antenatal and postnatal clinics, RHRU will provide psychosocial support and specialized adherence
counseling for HIV-infected pregnant women and new mothers, and will work with pediatric treatment sites
to provide specialized adolescent counseling and psycho social support. Through the Women At Risk
project, commercial sex workers are provided with support and information on appropriate topics at
outreach sites by community health workers, and referred into other psychosocial services as required,
including support groups, workshops on CSW-relevant issues (such as gender violence and gender norms
and behaviors), prevention with positives interventions, and income generation projects to provide peer
support and encourage the exiting of sex work. Refugee populations, often a neglected, overlooked group,
will also be targeted with services provided by RHRU. A special program for the care of refugees will be
expanded to include more systematic identification of refugees seeking assistance through public facilities.
These individuals will be counseled and provided full referral and follow up services to the NGO and private
sectors to receive care, treatment and support if they are ineligible to receive services through the public
ACTIVITY 3: Human Capacity Development
The objective of the training is to increase skills in the delivery of quality palliative care services including
Activity Narrative: elements of the preventive care package. RHRU will provide on-site and didactic training to DOH and NGO
doctors, nurses and counselors, and will specifically target ARV and non-ARV sites that need to be able to
care for, manage and appropriately refer HIV-infected clients. RHRU will also provide mentoring to DOH
staff via bedside teaching, case reviews, the sharing of quality improvement approaches, and support
during consultations. RHRU's Primary Health Care Project will provide tools, training and on-site guidance
to DOH staff in primary healthcare sites relating to quality improvement of primary healthcare services,
including palliative care. This project will also provide support to ARV treatment and is described in the ARV
Services section. In FY 2007-2008, RHRU will continue to undertake M&E activities to inform and develop
quality HIV care. RHRU will be in a position to conduct Public Health Evaluations (PHE) of some of its
palliative care related projects in FY 2008-2009. For each PHE, a detailed proposal will be developed and
submitted to PEPFAR for review and funding approval.
These activities contribute significantly to both the vision outlined in the USG Five-Year Strategy for South
Africa and to the 2-7-10 objectives by ensuring that HIV-infected individuals and their families are able to
access comprehensive care, and by expanding access to these services in both the public and private
The Reproductive Health Research Unit's (RHRU) TB-HIV activities include the ongoing provision of TB
clinical services and the expansion of referral networks and service integration in a deprived inner city area
of Johannesburg, South Africa. In addition, in KwaZulu-Natal (KZN), the RHRU is supporting
implementation of ARV services at two TB hospitals (Don McKenzie & Charles James, where over 80% of
TB patients are coinfected with HIV. Lastly, RHRU will pilot a program to provide a health screening
program to health care workers in the inner city of Johannesburg, to ensure a healthy workforce and early
referral and management of chronic disease. Emphasis areas include human capacity development and
local organization capacity building. Target populations include PLHIV, adults and children.
regular on-site support, direct treatment, training and quality improvement to DOH sites in 3 provinces. They
will continue these activities, which include inner city, district wide and rural programs focusing on providing
support to complete up and down treatment referral networks. In addition, RHRU will continue the provision
of counseling and testing (CT), palliative care, and prevention services. RHRU continues to develop models
of service delivery that can be replicated and expanded, and produces findings from lessons learned and
targeted evaluations to disseminate and share with others. It should be noted that the success of ARV
treatment scale-up depends on the comprehensive approach detailed in other program areas. In particular,
the strengthening of referral from other primary healthcare programs such as TB, family planning,
antenatal/postnatal and STI treatment is critical. Basic Health Care and Support is an integral part of this
system, and the RHRU will focus this part of its program on PLHIV, in impoverished areas such as the
Hillbrow neighborhood in Johannesburg, and at PHC clinics in Durban, and rural areas of the North West
province by delivering high quality palliative care, psychosocial support, and intensive training of doctors,
nurses, and other health care professionals. Furthermore, RHRU will continue to develop strategies to
address underserved communities affected by HIV, such as couples, high risk groups such as adolescents,
and gender-based interventions with women at risk, including pregnant women, sex workers, and men.
Although approximately 58% of TB patients in South Africa are HIV infected, published data have shown
that a low number of patients are referred from surrounding TB sites to ARV services. A large percentage of
these patients will qualify for immediate ARV treatment, and represent an untapped population requiring
immediate access to ARVs. RHRU has been working with health authorities to provide TB clinical services
and training, with the support of Emergency Plan-funding. RHRU has integrated TB into general palliative
care training, and trained thousands of health providers in these areas in previous years. In addition, RHRU
programs assist in treating HIV-infected people for TB. In FY 2008, RHRU will build on this program by
continuing to train health care providers, and continuing to emphasize TB and HIV integration as part of on-
site technical support to ARV treatment sites and primary health care clinics and their referral facilities.
RHRU will continue to work with the national and provincial departments of health and specifically with the
HAST (HIV, AIDS STI, and TB) managers to prioritize interventions designed to address weaknesses
(identified by the departments of health) in the DOTS and TB/HIV programs. RHRU will focus on improving
policy adherence and patient follow-up. Individuals will be hired for each site as tracers to track patients and
ensure that referrals are completed. RHRU is setting aside funding to develop (with other relevant partners
or agreement counterparts) standardized tools to ensure that policies and guidelines recommended by
NDOH are followed, including guidelines for infection control. RHRU will continue to integrate TB/HIV
interventions with existing agreement programs as they work seamlessly and side by side with government
employees at government facilities.
ACTIVITY 1: TB Treatment Support & Integration
Tuberculosis treatment represents an ideal opportunity for entry in to an ARV program. Patients being
treated for TB have to deal with the public health system entry, daily adherence, drug toxicity, and regular
follow-up evaluation, all of which are key components of the ARV program. Ensuring that health care
workers understand that referral from TB sites should be seamless, and encouraging patients to test for HIV
through the DOH program, will ensure a constant stream of well-prepared co-infected patients entering the
ACTIVITY 2: TB Referral & Staging
RHRU's teams will continue to work within the existing TB services in 3 provinces to expand CT, CD4
staging, initiation of opportunistic infection prophylaxis (cotrimoxazole) and preliminary ARV adherence
advice. RHRU will also facilitate direct referral of correctly staged patients into ARV treatment sites, and
ensure that other patients accessing ARVs in RHRU sites in the 2 provinces are referred for TB treatment
where necessary. Additionally, in the case of very immuno-compromised patients with TB who require
ARVs relatively quickly in terms of national guidelines, RHRU will train health care workers to recognize this
urgency and refer accordingly, while working with accepting ARV sites to similarly treat these cases with
RHRU will continue to develop and scale up TB/HIV training programs for TB service providers operating at
all levels of facilities in the provinces in which RHRU works. The primary focus will be on increasing access
to ARV services from TB services through continual training and engagement with TB managers. RHRU
anticipates that this approach will maintain a steady stream of patients into their ARV programs (see ARV
Services section for more information).
ACTIVITY 4: Health Maintenance Program for Health Care Workers
RHRU will continue to provide screening for TB, HIV and chronic diseases among health care workers in
Activity Narrative: City of Johannesburg health facilities, to ensure the preservation of human capacity and to determine the
risk of TB infection among this important group. In FY 2008, RHRU will continue to undertake M&E activities
to inform and develop quality TB/HIV care. RHRU will be in a position to conduct Public Health Evaluations
(PHE) of some of its TB-HIV related projects in FY 2008-2009. For each PHE, a detailed proposal will be
developed and submitted to PEPFAR for review and funding approval. This activity will contribute to both
the vision outlined in South Africa's 5 Year Strategy and to the 2-7-10 goals by identifying and directing
more people to ART, and by increasing access to care.
The Reproductive Health and HIV Research Unit's (RHRU) PEPFAR-funded program, subsequently
referred to as the "Follow-on to the RHRU Program" (FRP), was re-competed through an Annual Program
Statement (APS) in 2007, and awarded to the RHRU. PEPFAR funds will support the FRP to continue to
provide counseling and testing (CT) services, and to expand services tailored to target groups such as
couples, pregnant women, young people, children, and families, as part of an integrated prevention, care
and treatment program. FRP will also provide training and mentoring in voluntary counseling and testing to
Department of Health (DOH) staff, to ensure the implementation of provider-initiated testing and counseling
(PITC) in TB, STI, antenatal/postnatal and contraceptive services at all levels. Major emphasis in this
program area is on quality assurance and supportive supervision, with additional emphasis on the
development of network/linkages/referral systems, human resources, and training. These activities target
HIV-affected families (children, youth, and adults), sex workers, men, pregnant women, discordant couples,
and public health workers.
Africa, which includes the national antiretroviral (ARV) roll-out strategy. Under PEPFAR funding since FY
2004, RHRU has provided regular on-site support, direct treatment, training, and quality improvement to
DOH sites in three provinces (Gauteng, KwaZulu-Natal and North West). The FRP will continue these
activities, which include inner city, district wide and rural programs focusing on providing support to a
complete up and down treatment referral network. In addition, FRP will continue the provision of counseling
and testing (CT), palliative care, and prevention services. FRP will seek to develop models of service
delivery that can be replicated and expanded, and produces findings from lessons learned and targeted
evaluations to disseminate and share with others. It should be noted that the success of ARV treatment
strengthening of referral from other primary healthcare programs such as TB, family planning,
antenatal/postnatal and STI services is critical.
In FY 2007, FRP will continue to focus on further strengthening DOH adult and pediatric treatment, and on
continuing the development of a family-based approach to HIV care and treatment in the public sector.
Furthermore, FRP will continue to develop strategies to address underserved communities affected by HIV,
such as couples, high-risk groups such as adolescents, and gender-based interventions with women at risk,
including pregnant women and sex workers, and men. FRP places strong emphasis on quality assurance
for all interventions supporting CT and will draw on the tools that have a proven track record in terms of
improving quality of care, such as pocket reminders for counselors, wall charts with trigger messages for
clients and counselors, and routine performance assessments.
ACTIVITY 1: Counseling and Testing
PEPFAR funds will support FRP to continue to directly provide CT services at multiple sites, and to expand
services tailored to target groups such as couples, family planning clients, children, families, men, pregnant
women, and sex workers as part of an integrated prevention, care and treatment program. Discordant
couples will be targeted for prevention education, and concordant couples can benefit from referral to a
wellness program. Both groups will benefit from fertility and family planning advice. FRP will work closely
with the national DOH and will ensure that CT is integrated into other health programs at all levels. In
addition, FRP will focus on integrating provider-initiated testing and counseling (PITC) into TB, STI,
antenatal/postnatal and family planning services as recommended in the HIV & AIDS and STI Strategic
Plan for South Africa, 2007 - 2011.
ACTIVITY 1.1: Gender-based Voluntary Counseling and Testing
Approximately 70% of individuals currently accessing antiretroviral treatment (ART) are women. FRP will
continue to develop services that aim to address this gender inequality, and to increase the number of men
who obtain HIV care. This will be done through the development of male-friendly CT methods, such as
family-centered counseling and testing, and interventions to encourage health-seeking behaviors. This
program will contribute towards increasing gender equity in HIV and AIDS programs.
ACTIVITY 1.2: Family-Centered Testing
Children and families have special needs that will be addressed in the program. Previous work in antenatal
clinics and in pediatric treatment will have given FRP the opportunity to promote family testing to DOH staff
and community social workers, and to develop approaches to this activity. A youth-friendly CT model will
continue to be developed and implemented in the inner city of Johannesburg and Durban. Mobile CT units
will be utilized to increase access to CT for families at weekends and to other hard-to-reach groups. Age-
appropriate counseling and testing techniques will be developed, and opportunities to scale-up counseling
and testing of this group will be identified and interventions implemented accordingly.
ACTIVITY 2: Human Capacity Development
FRP will train counselors, doctors, nurses, and other healthcare workers to provide comprehensive and
appropriate CT services, in line with South African guidelines. This includes appropriate referral, and
updates on new practices and current debates in an evolving field. In addition, FRP staff will provide
mentoring to local NGOs, lay counselors, and DOH staff in the public sector facilities in which they work,
through weekly supportive supervision sessions with all counselors and regular meetings to discuss the
development and application of new practices.
In FY 2008, RHRU will continue to undertake monitoring and evaluation activities to inform and develop
quality HIV care. RHRU will be in a position to conduct targeted evaluations (TE) and Public Health
Evaluations (PHEs) of some of its counseling and testing projects in FY 2008 and FY 2009. For each PHE,
a detailed proposal will be developed and submitted to PEPFAR for review and funding approval.
These activities expand CT services to important high-risk populations, and serve as a critical entry point
into HIV care and treatment programs, thus contributing to the 2-7-10 goals by enabling access to treatment
and prevention for those who test.
The Reproductive Health and HIV Research Unit's (RHRU) will provide ARV rollout support services with
Department of Health (DOH) partners in over 30 facilities in 4 provinces. The emphasis areas are
renovation, human capacity development, and wrap-around programs. Services target people living with
HIV (PLHIV) and their families, including children, pregnant women, caregivers, doctors, nurses, traditional
healers, and other healthcare workers.
RHRU currently provides technical support to the South African Government (SAG) that includes the
national ARV rollout. With PEPFAR funding since FY 2004, RHRU has provided regular onsite support,
direct treatment, training and quality improvement to provincial departments of health (DOH) sites in
Gauteng, North West, Limpopo and KwaZulu-Natal (KZN). RHRU will continue these activities as well as an
inner city program in Johannesburg. Up and down treatment referral systems are being improved in all
provinces. In addition, RHRU will continue the provision of counseling and testing (CT), palliative care, and
prevention services. RHRU will develop service delivery models that can be replicated and expanded, and
produces lessons learned to share with others.
An effective, sustainable ARV treatment (ART) program is founded on strong partnerships with local public
sector treatment sites. The needs of each facility vary, and successful incorporation of ARV services at
facilities requires a thorough facility-based situational analyses. RHRU's aim is to deliver decentralized HIV
care or up and down referral between hospitals and related primary care clinics. ARV clients will be
identified, screened, prepared and initiated on ARV treatment with access to future care at up or down
referral sites. This system reduces congestion at primary treatment sites and improves patient access to
As of June 2007 RHRU-assisted sites were treating over 28,000 people with ART, and over 2,000 health
providers had been trained in ART. RHRU will continue assistance in existing sites and expand services to
several new sites. Pediatric support as well as ART for pregnant women will be expanded. In addition,
RHRU will continue an HIV Maternal Health Outreach Service, and provide planning, training and technical
assistance (TA) to two primary healthcare clinic (PHC) networks in Gauteng and KZN. This will enable
these clinics to receive down-referred patients, and initiate new patients in selected sites. Nurse-based
services will be promoted whenever feasible.
ACTIVITY 1: Treatment Support
Specialist HIV treatment teams will support urban and rural ARV sites for adults (including pregnant women)
and pediatrics. They will provide TA to new sites, and will develop and facilitate referral networks. Teams
include a doctor, nurse, management specialist and counselor and will rotate among a cluster of treatment
facilities providing onsite training and management support. In most cases, these teams will be anchored at
each site by a permanent quality improvement nurse and a patient tracker to reduce the number of patients
lost-to-follow-up and lost to initiation. The continuum of care will be emphasized including: prevention,
healthy lifestyle, responsible behavior, nutrition advice, opportunistic infection prevention/treatment,
palliative care, and ART. Materials previously developed to educate healthcare workers and HIV clients
about HIV care will be utilized. Outreach teams will provide ARV and referral clinics with TA on up and down
referral models. The teams will assist local clinic staff to improve practice, integrate and expand services
(including TB, see TB section), and maximize referral for CT, palliative care and ART. As part of this, clinic
renovations and provision of park homes, to maximize quality service delivery, may be necessary in
selected sites. RHRU will also explore the possibility of linking with the private health sector to access and
refer indigent populations into public sector care through low salaried family members on basic medical aid
plans. Furthermore, senior staff will provide TA to national and provincial government in the development of
policies and guidelines. ARV treatment and HIV care for perinatal women will provide outreach in maternal
services. Family-based and gender-specific services for underserved groups such as men and high-risk
women will also continue to be expanded.
Insufficient skills in HIV care and program management have been a barrier to scale-up of site support.
RHRU will develop an internal site-based training program to enhance staff skills. RHRU also offers a
structured program for young doctors interested in pursuing a career in HIV. All RHRU staff involved in the
PEPFAR program will become skilled HIV clinicians and program implementers, benefiting the program in
the short term, and improving the South African skill base in public health in the longer term.
RHRU will provide DOH staff in ARV sites with expert capacity and TA to develop models of effective
service delivery using existing infrastructure and resources. It will emphasize clinical training and promotion
of quality improvement techniques that can be applied by the DOH staff to develop local solutions to local
problems. The teams will provide onsite support to clinical management, referral, patient flow and data
Through the PHC and decentralized care projects, RHRU will assist PHC sites to integrate HIV care into
routine service delivery and will support sites with ARV accreditation if appropriate. Nurses will lead these
services, with doctor support when necessary (task shifting). RHRU will conduct formal training courses
including foundation courses in adult and pediatric ART for healthcare providers and traditional healers, and
HIV management for nurses and doctors.
ACTIVITY 3: Pediatrics
RHRU and its partners will expand pediatric and services for young people to additional provinces based on
a review of needs and requests from provincial authorities. The pediatric clinical support teams will rotate
through DOH sites, capacitating and strengthening clinical skills, and supporting the development of referral
networks. They will aid collaborations between healthcare facilities and local FBOs, NGOs and CBOs to
Activity Narrative: provide holistic care for children on ART. RHRU will play a pivotal role in initiating pediatric ARV services at
facilities where no pediatric services exist. Innovative methods of improving pediatric and adolescent
adherence to ART will be investigated.
The National Adolescent Friendly Clinic Initiative (NAFCI) supports the public sector to provide quality
services geared to youth, and are developing a referral system for HIV-infected adolescents to receive
ongoing care and provision of ART. RHRU will support services at NAFCI sites in proximity to HIV treatment
facilities in Soweto.
ACTIVITY 4: Referral Networks
RHRU will provide training, mentoring, management support and consultants across 4 provinces, to assist
DOH ART sites with referral processes. This includes increasing referral capacity at secondary sites to
channel and monitor stable patients at peripheral sites closer to patient's homes. This mechanism will
reduce congestion at primary sites, enable clinics to see more patients, reduce patient transportation costs
and increase adherence. RHRU will aid capacity development and training of local organizations, as well as
develop linkages, referral systems, human resources, information, education and communication (IEC),
needs assessments, policy and guidelines and strategic information.
ACTIVITY 5: Nutrition
RHRU will support several ART sites including TB hospitals in Johannesburg and Durban by employing
dieticians to provide TA, coordinate supplies of nutritional supplements from the district health office to
facilities for pediatric and TB/HIV-infected clients, provide nutrition information and counseling support and
develop IEC materials. RHRU will provide TA to national and provincial DOH about appropriate nutrition
interventions at different stages of disease in people infected with HIV and TB.
ACTIVITY 6: Monitoring and Evaluation
In FY 2008, RHRU will continue to undertake M&E activities to inform and develop quality HIV care.
These activities directly contribute to PEPFAR's goal of 2 million people on treatment. RHRU will support
the South Africa 5 year strategy by expanding access to HIV services, improving ARV service delivery, and
increasing the demand for and acceptance of ART.