Detailed Mechanism Funding and Narrative

Years of mechanism: 2010 2011 2012

Details for Mechanism ID: 7398
Country/Region: eSwatini
Year: 2010
Main Partner: University Research Corporation, LLC
Main Partner Program: NA
Organizational Type: Private Contractor
Funding Agency: USAID
Total Funding: $818,400

URC is an implementing partner for PEPFAR Swaziland in three separate but complementary areas, HVTB, HLAB and HVCT. The HLAB component undertakes broad based efforts to build laboratory capacity in support of health systems strengthening and decentralization. The HVCT component focuses on expanding provider-initiated HTC to increase the percentage of the population that knows their HIV status. The HVTB component (HCI) supports Partnership Framework efforts to improve the management of TB/HIV co-infection and to facilitate the roll out of a comprehensive HIV-related care package. This component is described more fully below.

The Health Care Improvement (HCI) project will help Swaziland expand coverage of TB, TB/HIV and MDR-TB services; make services meet the needs of underserved populations; improve efficiency and reduce the costs; and improve health worker capacity, motivation, and retention. HCI is working with the National TB Program (NTP) and the Swaziland National AIDS Programme (SNAP) to apply lessons from HIV/AIDS and TB quality improvement (QI) activities in developing integrated service delivery models for health facilities and providers.

URC assisted the NTP to update TB treatment guidelines, supported clinical training in TB-HIV co-infections, and developed programmatic and clinical MDR-TB guidelines.

The overall HCI goal is to reduce the number of TB and HIV deaths by increasing TB detection and treatment, as well as addressing MDR-TB and TB/HIV co-infections. The objectives are to:

increase TB enrollment and treatment by decentralizing services to PHC clinics and expanding links between communities and those facilities;

increase the quality of services through integration of TB and HIV services at national, regional, facility and community levels;

increase the quality of adult and pediatric HIV treatment and ARV services for TB patients by introducing ART into TB clinics;

strengthen programmatic and clinical MDR-TB case management;

strengthen the capacity of NTP and SNAP to lead and manage scale-up of adequate HIV/TB care and treatment services, and;

institutionalize modern QI approaches as an integral part of health care.

The objectives of the HCI project are aligned with the Partnership Framework 2009-2013 to ensure increased:

national capacity to lead and manage roll-out of HIV and TB care and treatment;

TB treatment enrollment and success, and the number receiving ART services;

numbers of HIV-infected people receiving a comprehensive care package, and;

numbers of adults who know their HIV status.

The HCI project will work across Swaziland to support 22 diagnostic units and 79 clinics. HCI will work with the following populations: people at risk for TB and HIV, people living with HIV, pediatric TB and HIV patients, members of the military and armed services, inmates and prison service members in 4 main prisons, and employees of large-scale corporate organizations.

URC uses QI approaches to strengthen health systems. QI is based on four principles: 1) understanding and focusing on client needs, 2) understanding how processes of care function within the system, 3) using data to measure results, and 4) engaging teams of health providers in improvement. The emphasis on systems is central to QI and cost efficiency over time, since poorly designed systems generate inefficiency and waste, and poor health care quality and outcomes.

HCI has a full-time monitoring and evaluation (M&E) officer to support TB/HIV M&E activities. The M&E officer works with national systems to collect, analyze and disseminate data from facilities to partners. The M&E and TB/HIV officers provide direct technical assistance to assure quality data reporting.

HCI will encourage cost-effectiveness by introducing tools and building partner capacities to streamline services and policies in the TB/HIV programs. HCI will explore appropriate public/private partnerships to reduce the burden on public health facilities and will assist in minor repairs and infrastructure improvements to enhance service delivery. HCI will work with other URC programs in Swaziland to pool resources for supervision, procurement and logistics support to health facilities.

Funding for Care: Adult Care and Support (HBHC): $35,000

Increase the number of HIV infected adults receiving adult HIV/AIDS care and support

Provide TA and support for provision of cotrimoxazole preventive therapy for TB/HIV co-infected adults: HCI will work with SNAP, NTP and ICAP to finalize the CCP and conduct trainings for health care workers (HCWs) from TB diagnostic units on HIV management and cotrimoxazole prophylaxis, and HCWs from HIV care settings on diagnosis and management of TB. HCI will assist with provisioning of cotrimoxazole in all TB diagnostic sites.

Provide TA and support for TB screening for Intensified Case Finding at HIV care settings: HCI developed and validated a TB screening tool which has been adopted by the National TB/HIV Coordinating Committee. HCI will work with SNAP and NTP in implementation of TB screening using the validated TB screening tool in HIV care settings, OPD, ANC and MCH clinics. HCI will also provide TA and support in development and printing of job aides for ICF, IPT and TB screening tool.

Provide training and on-site mentoring for implementation of the 3Is: HCI will conduct training and refresher courses to HCWs from HIV care settings and TB clinics on the 3Is and working with SNAP and NTP will conduct supervision and mentoring on implementation of the 3Is.

Provide TA support for provision of Isoniazid preventive therapy for HIV infected adults: HCI will work with SNAP and NTP to scale up provision and implementation of Isoniazid Preventive Therapy for treatment of latent TB infection among HIV-positive people to prevent development of active TB in HIV care settings. HCI will assist in provisioning of Isoniazid in HIV care settings.

HVTX

OBJECTIVE: Increase quality Adult HIV and AIDS Treatment/ARV Services for TB patients by introducing ART in TB clinics.

The Stop TB Department at the WHO has emphasized the urgent need to make ART available to HIV infected patients with TB worldwide. In Swaziland it is estimated that about 80% of all TB patients are infected with HIV. Hence, HIV testing is a critical first step to the integration of antiretroviral therapy into TB services. It is estimated that about 8,000 of the 10,000 TB patients diagnosed in Swaziland in 2007 were HIV positive. Integration of ART in the medical care of TB-HIV co-infected patients in Swaziland would result in an additional 4,000 TB patients being initiated on ART resulting in about 400 deaths being averted each year.

Recruit and deploy staff to provide TA and clinical management for HIV and AIDS treatment in TB clinics: The HCI project will support the MOH initiatives for implementation of ART provision in TB clinical care settings in order to save lives through a patient-centered approach to management of TB/HIV co-infections. HCI will provide direct technical assistance in monitoring the proportion of TB-HIV co-infected patients receiving combined TB and HIV treatment and outcomes after a course TB treatment. HCI will systematically support CD4 testing for all TB patients testing HIV-positive and those who eligible for ART and initiated on ART within TB clinical settings. In order to scale up provision of ART in TB clinics, HCI will recruit Medical Officers to provide clinical and programmatic and clinical support.

Provide training & on-site implementation support for scale up of ART provision in TB clinics: In the previous year, HCI supported initiation of ART in 5 facilities. In FY10, HCI will scale up the provision of ART in TB clinics from 5 to 10 sites and continue working with the NTP, SNAP and NRL to strengthen the performance of CD4 count tests for all co-infected TB patients in order to facilitate early identification of TB patients eligible for ART.

Provide TA and implementation support for community-based support program for TB and ART medication adherence: HCI will work with the NTP, SNAP, CBOs and FBOs to provide treatment support for co-infected TB patients on both TB and ARV treatment through training and ongoing support supervision, as well contract community support groups to conduct education, patient tracking and follow-up. Approaches for combined support for TB and ARV treatment piloted in Dvokolwako HC also will be scaled up.

Provide training in Integrated Management of Adult and Adolescent Infections: HCI will assist the TB clinics to prepare and implement ART initiation and follow-up in TB care settings for eligible TB/HIV co-infected persons, and work with SNAP to conduct trainings for nurses on IMAI, adherence and support, and ARV recording and reporting.

Provide (infrastructure) resources for TB and ART activities in TB clinical settings: In FY 09, HCI procured prefabricated consultation space for three health facilities to address space shortage, which was one of the main constraints in the provision of integrated TB/HIV services. In FY 10, more TB clinics will be supported with infrastructure modifications and furniture

Funding for Treatment: Adult Treatment (HTXS): $30,000

OBJECTIVE: Increase quality Adult HIV and AIDS Treatment/ARV Services for TB patients by introducing ART in TB clinics.

The Stop TB Department at the WHO has emphasized the urgent need to make ART available to HIV infected patients with TB worldwide. In Swaziland it is estimated that about 80% of all TB patients are infected with HIV. Hence, HIV testing is a critical first step to the integration of antiretroviral therapy into TB services. It is estimated that about 8,000 of the 10,000 TB patients diagnosed in Swaziland in 2007 were HIV positive. Integration of ART in the medical care of TB-HIV co-infected patients in Swaziland would result in an additional 4,000 TB patients being initiated on ART resulting in about 400 deaths being averted each year.

Recruit and deploy staff to provide TA and clinical management for HIV and AIDS treatment in TB clinics: The HCI project will support the MOH initiatives for implementation of ART provision in TB clinical care settings in order to save lives through a patient-centered approach to management of TB/HIV co-infections. HCI will provide direct technical assistance in monitoring the proportion of TB-HIV co-infected patients receiving combined TB and HIV treatment and outcomes after a course TB treatment. HCI will systematically support CD4 testing for all TB patients testing HIV-positive and those who eligible for ART and initiated on ART within TB clinical settings. In order to scale up provision of ART in TB clinics, HCI will recruit Medical Officers to provide clinical and programmatic and clinical support.

Provide training & on-site implementation support for scale up of ART provision in TB clinics: In the previous year, HCI supported initiation of ART in 5 facilities. In FY10, HCI will scale up the provision of ART in TB clinics from 5 to 10 sites and continue working with the NTP, SNAP and NRL to strengthen the performance of CD4 count tests for all co-infected TB patients in order to facilitate early identification of TB patients eligible for ART.

Provide TA and implementation support for community-based support program for TB and ART medication adherence: HCI will work with the NTP, SNAP, CBOs and FBOs to provide treatment support for co-infected TB patients on both TB and ARV treatment through training and ongoing support supervision, as well contract community support groups to conduct education, patient tracking and follow-up. Approaches for combined support for TB and ARV treatment piloted in Dvokolwako HC also will be scaled up.

Provide training in Integrated Management of Adult and Adolescent Infections: HCI will assist the TB clinics to prepare and implement ART initiation and follow-up in TB care settings for eligible TB/HIV co-infected persons, and work with SNAP to conduct trainings for nurses on IMAI, adherence and support, and ARV recording and reporting.

Provide (infrastructure) resources for TB and ART activities in TB clinical settings: In FY 09, HCI procured prefabricated consultation space for three health facilities to address space shortage, which was one of the main constraints in the provision of integrated TB/HIV services. In FY 10, more TB clinics will be supported with infrastructure modifications and furniture.

Funding for Care: Pediatric Care and Support (PDCS): $15,000

Increase the number of HIV-infected children receiving Pediatric HIV/AIDS care and support

Provide TA and support for provision of cotrimoxazole preventive therapy for TB/HIV co-infected children: HCI will work with SNAP, NTP, ICAP and the Baylor Center of Excellence to finalize the pediatric package of comprehensive care. HCI also will conduct trainings on pediatric HIV management and cotrimozaxole prophylaxis for HCWs from TB diagnostic units, and on diagnosis of TB in children for HCWs from HIV care settings. HCI will assist provision of cotrimoxazole in TB diagnostic sites.

Supervision, improved quality of care and promoting integration with routine pediatric care: HCI staff will provide support supervision using a checklist that specifically includes a pediatric section to ensure prioritization of pediatric care at clinics. HCI developed and validated a pediatric TB screening tool that was adopted by the National TB/HIV Coordinating Committee. HCI will work with NTP, SNAP and the Baylor pediatric clinic to scale up implementation of TB-screening and pediatric care in HIV care settings, OPD, ANC and MCH clinics. HCI will also advocate for availability of PPD to increase the diagnostic capacity of pediatric TB. HCI also will provide TA and support in the development and printing of job aides for ICF, IPT and TB screening tool.

Provide TA support for provision of Isoniazid preventive therapy for HIV infected children

HCI will work with SNAP, NTP, EGPAF and the Baylor pediatric clinic to scale up provision and implementation of isoniazid preventive therapy for latent TB infections among HIV-positive persons in order to prevent development of active TB in HIV care settings. HCI will assist provisioning of Isoniazid HIV care settings.

Funding for Treatment: Pediatric Treatment (PDTX): $20,000

Increase quality Pediatric HIV and AIDS Treatment/ARV Services for TB patients by introducing ART in TB clinics

Recruit and deploy staff to provide TA and clinical management of HIV and AIDS treatment in TB clinics: The MOH plans to treat all HIV-positive pediatric TB patients eligible for ART in TB clinical settings to minimize TB transmission, and provide comprehensive TB/HIV services under one roof. In order to scale up provision of pediatric ART in TB clinics, HCI will recruit a Medical Officer to provide clinical and programmatic support on pediatric ART/TB treatment.

Provide training and on-site implementation support for scale up of ART provision to pediatric cases in TB clinics: The HCI medical officer will provide on-site TA for ARV initiation of pediatric cases attending TB clinics in the four regions. In the previous year, HCI supported initiation of ART in five facilities. In FY10, HCI will scale up ART in ten TB clinics. HCI will provide training for clinicians and others on pediatric HIV treatment, especially among co-infected patients, including clinical monitoring of patients on treatment.

Provide support to strengthen laboratory support and diagnostics for pediatric clients: HCI will work with the NTP, SNAP, stakeholders and NRL to strengthen HIV testing for children, including DBS and performance of CD4 tests for all co-infected pediatric TB patients to facilitate early identification of ART-eligible TB patients.

Support the development of community-based support program for TB and ART medication adherence: HCI will work with the NTP, SNAP, CBOs and FBOs to provide treatment support for co-infected TB patients on both TB and ARV treatment through training and ongoing support supervision, as well contract community support groups to conduct community education and patient tracking and follow-up. Pilot approaches for combined support for TB and ARV treatment piloted in Dvokolwako HC will be scaled up.

Provide TA for finalization of Pediatric ART guidelines: HCI will work with SNAP, NTP and the Baylor Center of Excellence to finalize the pediatric ART guidelines.

Funding for Care: TB/HIV (HVTB): $718,400

HCI will assist the NTP to finalize the national TB community Directly Observed Treatment, Short-course (DOTS) strategy, and the development of job aides for the TB defaulter tracing guidelines; reach out to traditional health practitioners in order to increase their knowledge about TB, prompt referrals of TB suspects and encourage their engagement in promoting treatment adherence to anti-TB treatment, and; advocate for increased political commitment for TB, community awareness and involvement in treatment support.

HCI will work with the CDC laboratory project to provide TA for quality-assured TB bacteriology by strengthening laboratory services. HCI will continue to work with the MOH and other laboratory partners in strengthening staff capacity in smear microscopy, new technologies (e.g., sputum concentration and fluorescence microscopy), culture and first-line drug-susceptibility testing. Support will also be provided to strengthen supervision of staff at peripheral levels by the National Referral Laboratory (NRL), implementation of quality management systems for laboratory services, and linkage with the South African Medical Research Council for culture and second-lines DST services.

HCI will provide TA and resources for monitoring and evaluation (M&E) activities to improve reporting and recording systems. For example, HCI will continue to assist the NTP in monitoring national and international TB, TB/HIV and MDR-TB indicators on a quarterly basis, and facilitate trainings on the updated versions of the TB electronic Register (eTR). HCI will organize quarterly meetings with facility staff to review performance and support use of standard evaluation system journals for documenting QI interventions. HCI also will assist in MDR-TB patient mapping and resistance patterns, and will work with NTP and MSH to develop an electronic database (eTB manager) for programmatic and clinical management of MDR-TB.

HCI will provide TA and resources to decrease the burden of TB among HIV patients and will support the scale-up of TB case-finding to all HIV care and treatment settings, starting with ART units. Health care workers will be trained on the 3I's (Intensified case finding, Isoniazid preventive therapy, and Infection control in congregated settings).

HCI will work with stakeholders to implement Infection Control and Prevention (ICP) for TB practices, assist facilities to conduct infection control assessments, and assist the NTP and SNAP to scale-up isoniazid preventive therapy for people living with HIV.

Cross Cutting Budget Categories and Known Amounts Total: $75,000
Construction/Renovation $30,000
Human Resources for Health $45,000
Key Issues Identified in Mechanism
Increasing gender equity in HIV/AIDS activities and services
Child Survival Activities
Military Populations
Tuberculosis
Workplace Programs