Operational Plan Report



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South Africa
Operational Plan Report
FY 2013
Note: Italicized sections of narrative text indicate that the content was not submitted in the Lite COP year, but was derived from the previous Full COP year. This includes data in Technical Area Narratives, and Mechanism Overview and Budget Code narratives from continued mechanisms.

Operating Unit Overview

OU Executive Summary

Country Context:


South Africa has four concurrent health burdens that heavily impact the health sector – HIV/AIDS and TB, poverty related illnesses (perinatal, neonatal, childhood, and maternal diseases), non-communicable diseases, and violence and injury. South Africa continues to grapple with massive health inequities, a legacy of apartheid. There are marked differences in rates of disease and mortality between races (National Planning Commission Report, 2011). [Redacted] Child mortality initially increased from the MDG baseline in 1990 of 60 deaths under the age of 5 years per 1,000 live births, peaked at 82 deaths/1,000 births in 2003, and finally decreased to 57 deaths/1,000 births in 2010. The maternal mortality ratio is an estimated 310 maternal deaths per 100,000 live births (2008) . HIV and its related diseases contribute significantly to maternal mortality (50%) and mortality under five years of age (35%).
South Africa has a population of nearly 52 million and the largest HIV epidemic in the world, with approximately 5.7 million people living with HIV (PLHIV). Similar to other generalized, hyper-endemic HIV epidemics, the South African epidemic is largely driven by heterosexual transmission. HIV prevalence among the adult population (15-49 years) is estimated to be 16.6%, with an estimated HIV incidence of 1.4% in 2011, though prevalence and incidence vary significantly across geographic areas with 54% of PLHIV living in Gauteng and KwaZulu Natal Provinces. Antenatal HIV prevalence has stabilized around 30% over the past four years with women and girls bearing approximately 60% of the overall HIV disease burden.
There are a number of underlying behavioral, socio-cultural, economic, and structural factors that influence risk for HIV transmission. Risk factors include mobility and migration, race, economic and educational status, alcohol and drug use, early sexual debut, sexual violence, and low levels of consistent condom use, especially in longer-term relationships and in pregnancy/post-partum. Of particular relevance, gender dynamics and unequal power relations between men and women play a significant role in heterosexual HIV transmission. A 2011 report by the Desmond Tutu HIV Foundation, estimates one third of young girls in South Africa indicate have a forced first sexual experience, and nearly 75% have had at least one non-consensual sexual encounter. In addition, there are low and/or late marriage rates across all populations and unstable long-term relationships that can lead to multiple concurrent partnerships and potentially foster HIV transmission through complex, linked sexual networks, especially where there is high population mobility.
Key population groups also carry a significant burden of HIV infections in South Africa. Migration and mobility are important risk factors that dramatically increase vulnerability to HIV. A study conducted by the International Organization for Migration (IOM) on migrant farm workers found that 39.5% were HIV positive. Significant transmission also occurs among sex workers, their clients, and men who have sex with men. The South African Centre for Epidemiological Modeling and Analysis (SACEMA) estimated 19.8% of all new HIV infections are related to sex work. Eight studies of South African MSM conducted between 2005 and 2010 revealed HIV prevalence ranged from 10.4 to 43.6%.
In conjunction with the HIV/AIDS epidemic, South Africa ranks third in the world in TB burden, with an incidence of 993 new infections per 100,000 population in 2011 (WHO estimate). While the TB cure rate increased to 73% in 2010 from 54% in 2000, this is still well below the global target of over 85%. The TB epidemic is compounded by high levels of multidrug-resistant tuberculosis (MDR-TB) with an estimated 5,000 confirmed MDR-TB cases among new pulmonary TB cases in 2011. High rates of co-infection (approximately 65% of TB patients are co-infected with HIV) lead to further expansion of the epidemics and complicate treatment and care of patients.
Status of the National Response:
On December 1, 2011, the South African National AIDS Council (SANAC) launched the National Strategic Plan for HIV, STIs, and TB (2012 – 2016) (NSP). The NSP reflects strong SAG leadership, civil society engagement, and commitment to a robust multisectoral HIV response and outlines four strategic objectives that form the basis of the national response:
1. Address social and structural barriers to HIV, STI, and TB prevention, care, and impact;

2. Prevent new HIV, STI, and TB infections;

3. Sustain health and wellness; and

4. Increase the protection of human rights and improve access to justice.


In line with these objectives, the NSP sets five broad goals that also guide PEPFAR investment decisions:
• Reduce new HIV infections by at least 50%, using combination prevention approaches;

• Initiate at least 80% of eligible patients on antiretroviral treatment (ART), with 70% alive and on treatment five years after initiation;

• Reduce the number of new TB infections, as well as the number of TB deaths by 50%;

• Ensure an enabling and accessible legal framework that protects and promotes human rights in order to support implementation of the NSP; and



• Reduce the self-reported stigma and discrimination related to HIV and TB by 50% by 2016.
The SAG currently funds approximately three quarters of the national HIV/AIDS response with PEPFAR providing approximately 20% and other donors providing between 5 - 10% of annual funding. SAG has increased spending for HIV through the conditional grant from just under ZAR 5 billion (US$576 million) in 2008 to around ZAR 11 billion (US$1.25 billion) in 2012, with planned further growth in spending already included in SAG budget projections for the coming years.
In August 2012, the Partnership Framework Implementation Plan (PFIP) was signed by the U.S. Ambassador and SAG Minister of Health. The PFIP outlines a joint agreement to shift the financial and implementation responsibility for clinical care and treatment services to the South African health system over the next five years. The SAG views the provision of health services as an inherent responsibility of the government. PEPFAR will continue to support the SAG expansion of treatment services through capacity building that increases access, efficiency and quality in patient outcomes, while the SAG works to absorb current PEPFAR-support for clinical services. Both governments will work together to communicate these shifts, emphasize the continual scale-up of the national HIV and TB response, maintain high quality continuum of care, and ensure that all patients continue to receive care and treatment services without interruption.
Health Systems Context:
South Africa has established 4,000 Primary Health Care (PHC) clinics and community health centers (CHC) as the foundation of the public health system to improve coverage and make it possible for 95% of the population to access health care within a 5 mile radius of their homes. However, larger facilities absorbed the enormous increase in demand during the initial scale-up of treatment services. PEPFAR is supporting the referral of patients to smaller clinics as the ART program continues to expand. The SAG approach to strengthen the District Health System and re-engineer Primary Health Care level is implemented through three steams: 1) providing integrated community based services through ward-based PHC outreach teams; 2) strengthening clinical governance through district specialist teams; and 3) launching a school-based health services program.
In addition to PHC re-engineering, the SAG launched the Aid Effectiveness Framework in 2011 to improve development partner coordination in health. PEPFAR coordinates closely with the European Union, United Kingdom, Germany, Sweden, UN agencies, Clinton Health Access Initiative, Global Fund, Gates Foundation, Elma Foundation, Johnson & Johnson, MAC AIDS Fund, Anglo American, Atlantic Philanthropies, and others through participation in the AIDS and Health Development Partners’ Forum to discuss specific programs that may complement PEPFAR’s work.
Progress & Future Direction:
Following finalization of the PFIP, a bilateral Management Committee was constituted as well as four bilateral work streams which include participation from the USG, SAG and other key stakeholders. The Management Committee has met several times to deepen joint USG-SAG planning, and the bilateral work streams conducted reviews of the PEPFAR portfolio which were used to inform COP 2013 planning.
Programmatic success includes the launch of the Accelerated PMTCT Plan that has resulted in universal access to PMTCT services across the country and a decrease to 2.7% in early transmission; a rapid increase in access to antiretroviral treatment (ART) with more than 1.7 million people on treatment in 2012; improvement in the TB cure rate to 73%; and declining HIV incidence from 2.4% in 2001 to 1.5% in 2009 (UNAIDS, 2011). The SAG will continue to expand HIV care and treatment and as of April 2013 will roll out revised treatment guidelines to make ART available to all pregnant women for PMTCT and gradually expand the use of fixed dose combination triple ARV therapy for patients in need of treatment.
The 2013 COP has been reviewed and endorsed by the bilateral Management Committee which oversees PFIP execution. PEPFAR’s investments for COP 2013 will focus on the following priorities: 1) continued support for scale up of clinical services including pediatric and adult care and treatment as well as PMTCT while developing a concrete and actionable plan for sustainable clinical services that transition to SAG financing and implementation over the next five years; 2) continued support for HIV prevention services focusing on combination prevention including HIV testing and counseling, scale up of male circumcision, positive health, dignity and prevention (prevention with positives) and condom promotion; 3) continued support for the positive development of orphans and vulnerable children (OVC) infected or affected by HIV/AIDS; and 4) a broad range of systems strengthening activities including support for HIV/AIDS-related surveillance, laboratory systems strengthening, human resource capacity building, health information systems, and other key strategic investments. The significant funding shifts in this year’s operational plan include a 15% reduction in adult treatment and a 50% reduction in ARV procurement accompanied by a 37% increase in pediatric care and treatment and a 25% increase in TB/HIV programming. HIV testing and counseling received a 25% increase in funding along with a 21% decrease in abstinence-focused prevention programming. The 53% reduction in male circumcision investment is due to one-time funding of $40 million received in FY 2012 – base funding for VMMC is level with FY 2012.
With respect to the program priorities outlined in the COP 2013 funding level memorandum, PEPFAR SA is developing a draft five-year operational outline that includes a sustainability plan for clinical services. In accordance with the PFIP, the PEPFAR SA team will work through the Management Committee and bilateral work streams to develop joint USG and SAG consensus for sustainability. This outline will identify the key areas of transition for clinical services over the next five years as well as the challenges anticipated, plans for agreements ending in the next 24 months and a work plan outlining the consultation process at the national, provincial, district and partner levels. Key priorities for achieving sustainable health outcomes include: 1) ensuring no interruptions in patient services as a result of transitions; 2) planning in close partnership with provincial and district leadership to transition PEPFAR-supported patients to the public sector; and 3) mapping PEPFAR-supported human resources in public sector health facilities and planning for the deliberate absorption of these posts into the government payroll and supervision systems. The operational outline will also include PEPFAR SA’s preliminary strategic five year vision for sustainability of U.S. supported investments in HIV prevention, OVC and systems strengthening.

HIV/AIDS PREVENTION:


The primary objective of PEPFAR’s overall prevention portfolio is to expand coverage of combination prevention interventions addressing the key drivers of HIV infection, reducing vulnerability to HIV and TB infection, and strengthening systems and capacity to implement programs in concentrated areas. PEPFAR SA will focus on priority geographic areas and key populations through targeted intervention packages that maximize value for money. PEPFAR SA staff work to ensure a coordinated and integrated HIV prevention approach among the Departments of Health, Basic Education, Higher Education, Correctional Services, Social Development, and Women, Children, and Disabilities. Activities addressing populations at high risk of HIV infection include technical cooperation with SAG for policy development, targeted social and behavior change communication (SBCC), community mobilization programs and biomedical interventions. The SBCC and community programs use data and community involvement, to provide culturally appropriate messages through mass and social media that are linked to community outreach programs. SBCC activities promote the use of a range of HIV health services, including VMMC, PMTCT, HCT, Post Exposure Prophylaxis (PEP), treatment, and other impact mitigation interventions. Community-based interventions actively engage local and traditional leaders, employers, religious groups, schools, PLHIV, and other affected populations. In informal settlements and other hard-to-reach communities, specific door-to-door campaigns are used to reach adults at high risk of HIV infection. PEPFAR programs also target adults in the workplace, including working with unions, mining, and farming enterprises.
In 2013, PEPFAR SA will finalize a prevention strategic framework that supports the NSP goal of reducing new HIV infections by at least 50 percent by 2016. PEPFAR SA will support HIV testing and counseling which is critical both for increasing ART coverage and scaling up voluntary medical male circumcision (VMMC). PEPFAR SA will promote the use and availability of condoms and foster other healthy sexual behaviors through SBCC. PEPFAR SA will intensify support in high prevalence areas, areas with limited access to MMC services, urban informal settlements with high migrant and mobile populations, poor rural areas with high population density, farms on border areas, and villages along major transportation routes. PEPFAR SA will provide technical assistance in selected provinces, districts and sub-districts to ensure coverage of prevention interventions,, integration of gender strategies, monitoring and evaluation, and use of information and research data to inform and improve program planning and implementation. USG will also support the SAG’s efforts to integrate sexual HIV prevention and family planning services and implementation of emerging prevention interventions.
A) HIV Counseling and Testing (HCT): PEPFAR SA contributes to the national goal to increase the number of people screened and tested for HIV and TB and to ensure that referrals are made to appropriate interventions and services. In addition, PEPFAR SA supports the scale up of Provider Initiated Care and Treatment (PICT) and related training for SAG health facility management teams at district and sub-district levels. For the next two years, the PEPFAR SA program will target 5,500,000 people with HCT each year through a combination of technical assistance for PICT and direct delivery of HCT services through mobile HCT, couples testing, and home-based HCT. Interventions will also strengthen the quality of rapid HIV testing via implementation of a quality management system at all HIV rapid testing sites as well as linkages from HCT to prevention, care, and treatment services including PICT in hospitals. A mixed-model approach to HCT enables the program to target hard-to-reach populations that may not be accessing health facilities including MARPs, farm workers, migrant and mobile populations, and sero-discordant couples.
B) Voluntary Medical Male Circumcision (VMMC): All PEPFAR SA partners working in VMMC service delivery establish and maintain quality, efficient and high volume operations that offer VMMC as part of a comprehensive package of HIV prevention and sexual and reproductive health services. The PEPFAR SA team will continue to support rapid scale up of neonatal and adult circumcision to meet the SAG goal of circumcising 600,000 men in 2013/14 and 1,000,000 men in 2014/15 with 4.3 million total circumcised by 2015/16. PEPFAR SA will assist the SAG with VMMC planning, coordination and implementation including monitoring and evaluation, quality assurance systems such as adverse event surveillance, standardized registers and patient forms, operations research, advocacy, communication, and social mobilization. Partners engaged in service delivery prioritize linkages to and from VMMC for clients needing ART, HIV care, or TB and STI treatment. PEPFAR SA also provides VMMC training to service providers through requests from Provincial Departments of Health and will work with the Regional Training Centers (RTCs) in support of the VMMC scale-up. PEPFAR SA’s VMMC partners conduct outreach and education campaigns through mass media, local radio and working with traditional leaders and communities. PEPFAR’s VMMC partners use Models to Optimize Volume and Efficiency (MOVE) endorsed by the World Health Organization which emphasizes the forceps-guided surgical method in service delivery and training. PEPFAR SA supports full-time static and mobile VMMC teams in SAG facilities, and a PEPFAR monthly VMMC reporting system has been established for data exchange with National and Provincial Departments of Health. While the SAG has allocated significant resources for VMMC, PEPFAR investments will contribute to increased coverage levels and achievement of population-level impact on HIV incidence.
C) Positive Health Dignity and Prevention (PHDP): Prevention services for HIV-positive persons include both behavioral and biomedical activities aimed at reducing morbidity and mortality and the risk of transmission to HIV-negative partner(s) and infants. HIV prevention messages and services are delivered as part of the routine care offered to HIV-positive persons in additional to other clinical settings such as TB, PMTCT, and STIs. PEPFAR SA supports PHDP training of health care staff, implementation of community-based activities, and development of a national PHDP Framework to strengthen HIV prevention activities in all service settings.
D) Condoms: Consistent condom use is predicated on a reliable, widely available, robustly promoted, and accessible supply of condoms. The SAG and PEPFAR SA continue to prioritize promotion and increasing the availability of male and female condoms where and when people need them. PEPFAR will focus on demand creation and distribution programs for female condoms and lubricant. Programs will also support the SAG to strengthen condom logistics and to address bottlenecks in acquisition and distribution.
E) Most-at-risk populations (MARPs): PEPFAR SA is strengthening efforts to target MARPs with the goal of reducing the number of new HIV infections in South Africa among sex workers (SW), migrant populations, MSM, and their sex partners. Prevention, treatment, and care services for MSM and SW are largely implemented in urban centers, along major transportation corridors and at identified hot-spot locations. In 2013, services will include treatment and prevention packages for sex workers through public-private partnerships. Programs targeting MSM include specific support for TB/HIV integration employing combination prevention approaches. Activities focus on preventing new infections, achieving early diagnosis and rapidly enrolling men into treatment, integrating HIV and TB care within an efficient chronic care delivery system, and improving patient adherence and defaulter tracing through community outreach teams. PEPFAR SA is also strengthening its work with migrant populations (estimated at 2.2 million people in 2010). Activities supporting migrants and farm workers are concentrated along major national transportation routes, commercial farms, cross-border centers in Limpopo, Mpumalanga, and KwaZulu-Natal provinces, and in districts sharing borders with Mozambique, Swaziland and Zimbabwe. In addition, PEPFAR SA will continue to support activities that specifically target miners, truckers, inmates, and farmers to provide prevention services, including HCT.
F) Youth: PEPFAR has refocused youth activities to be more strategic by targeting at-risk youth and strengthening systems within SAG to implement evidence-based HIV prevention programs for at-risk youth between 10 – 19 yrs. PEPFAR assists the SAG with the coordination and implementation of the integrated school health program to include sexuality education and HIV prevention in school curricula as well as evidence-based programs to reduce sexual risk behavior among in- and out-of-school youth. The programs are age-appropriate and include developing mandatory, scripted lesson plans that target grades 7 – 9. Improved coordination between basic education, health, and social development departments is needed to more effectively implement sexuality education programs. PEPFAR SA will provide technical assistance to the Department of Basic Education’s to develop appropriate policies and a strategic framework for HIV prevention in schools and strengthen implementation, monitoring, and evaluation of the integrated HIV and AIDS strategy at the local level. Further support will focus on strengthening teacher training programs with local universities to institutionalize sexual reproductive health in teacher training curricula and promote cost-effective interventions for school-based HIV prevention programs that can be scaled-up nationally.
G) Gender: PEPFAR SA will continue to address drivers of gender-based violence (GBV) which increases vulnerability to HIV infection. The vulnerability of women and girls to sexual violence contributes to the higher HIV burden (60%) among women. This vulnerability must be addressed if the goal of an AIDS-free generation is to be realized. PEPFAR SA’s gender activities have been strengthened through integration of gender elements across all technical areas. In alignment with the PEPFAR Gender Strategy, a Gender Advisor was appointed in January 2013 through USAID to co-ordinate gender activities and develop an overall strategy for gender activities in collaboration with the SAG. PEPFAR will continue to support SAG's rollout plan for Thuthuzela Care Centres, the SAG's national public awareness campaigns which are culturally and community nuanced, and the engagement of NGOs providing community prevention messages targeted to men and boys. PEPFAR SA is also scaling up support for the economic development of women through micro-finance lending and GBV prevention activities.
New Procurements in Prevention: New procurements include: 1) a program focused on strengthening the coordination capacity of SANAC; 2) support for prevention services in correctional facilities; 3) youth-focused programs including Families Matters and other interventions; 4) the combination prevention and HCT communities initiative; 5) VMMC targeting males aged 15 – 49; 6) a program in support of DBE for strengthening systems; 7) a gender program focused on women and girls; and 8) a program to continue prevention research, surveillance and evaluation activities.
CLINICAL SERVICES:
PEPFAR SA’s primary objective is to support scale up of the national HIV treatment and care program, including pediatrics, TB/HIV, PMTCT and care components, through partnerships covering all districts (52) and all public facilities offering HIV services. While beginning to transition aspects of the care and treatment portfolio to the SAG, PEPFAR SA will bridge key gaps in direct service delivery and capacity building to ensure that this transition does not result in disruptions in patient care. PEPFAR SA will also support critical areas in which the SAG has requested support including: pediatric treatment services in community-level clinics; services for advanced clinical management of AIDS and TB/HIV; HIV and TB services in prison settings; services for vulnerable and at-risk populations such as commercial sex workers (CSW) and men who have sex with men (MSM); as well as services for other underserved groups such as youth, immigrants and people living in informal settlements.
The PEPFAR SA care and treatment portfolio is divided into two categories. Comprehensive district-based partnerships represent over 70% of the PEPFAR SA care and treatment funding and support all 52 districts. These partnerships are designed to improve HIV-related patient outcomes by strengthening health and patient management systems at facility, sub-district and district levels while building capacity in coordination, management and planning to strengthen HIV services. Focal care and treatment partnerships (30% of funding) support advanced clinical care services or target specific clinics and populations. Populations targeted include prisoners, military personnel, migrants, residents of informal settlements, adolescents, commercial sex workers and men who have sex with men (MSM). In addition, focal support is provided at the national and provincial levels for capacity building in monitoring and evaluation, TB/HIV, PMTCT, pediatric HIV, and nutrition, care and support.
A) Adult Treatment: Adult treatment activities will focus on following: 1) support for the roll-out of NIMART through multi-disciplinary mentoring teams focused on strengthening clinical services in facilities and clinical program management in districts; 2) building effective quality improvement programs for service delivery; 3) supporting effective linkages to adherence, retention and community support; 4) addressing gap needs in advanced HIV case management 5) support for roll-out of HIV and TB services in correctional facilities; 6) increased access to treatment for key populations (immigrants, informal settlements, remote populations, etc); 7) cryptococcal screening pilot for HIV-infected patients with CD4 counts < 100 cells/ul; 8) cervical cancer screening; and 9) strengthening supply chain management in the public sector.
B) Pediatric Treatment: Pediatric treatment in public facilities has significantly lagged behind adult HIV care and treatment scale-up, resulting in limited access to pediatric HIV services at the primary health care (PHC) level across much of the nation. PEPFAR district partners support the strengthening of pediatric HIV services through both service delivery and capacity building with a focus on nurse training (pediatric NIMART and IMCI), mentorship through roving teams and support of data quality. PEPFAR also funds focal technical partners to provide youth-friendly HIV care and treatment services, pediatric and adolescent psychosocial support, and quality improvement for pediatrics. Other programming includes: 1) referral centers and learning hubs for clinicians and nurses in pediatric and adolescent HIV; 2) mainstreaming youth friendly services at provincial and district levels; 3) developing guidelines for pediatric-specific NACS and infant and young child feeding (IYCF); and 4) developing guidelines and SOPs for pediatric/adolescent psycho-social support.
C) Adult Care & Support: Adult care and support activities include strengthening district and service delivery systems through district partners and providing targeted TA through specialized provincial and national partners. PEPFAR support of community health systems are supported within the context of PHC re-engineering through CHW training, mentoring and supervision, and strengthening referrals and linkages between communities and facilities. PEPFAR’s major initiative under NDOH to roll out the I-ACT program in all provinces and districts is a key support activity. Other areas of program focus include: 1) integrating NACS as a routine and integral part of HIV care and support; 2) support for pre-ART programs and tracing early defaulters; 3) screening, diagnosis and treatment of TB, STIs, opportunistic infections and other HIV-related conditions; 4) support for implementation of cotrimoxazole and isoniazid prophylaxis (IPT); 5) support for PHDP guidance development, training materials and implementation; and 6) program evaluations related to PHC re-engineering, I-ACT, linkages, retention and LTFU.
D) Pediatric Care & Support: In pediatric care and support, PEPFAR will continue to strengthen strategies for early infant diagnosis, intensified case finding of HIV-infected children and adolescents, and capacitating healthcare workers and facilities to better serve this population. Support for the development of child-specific NACS will also be a key focus, along with updating and rolling out new IYCF guidelines and supporting broader capacity support around breastfeeding.
E) Prevention of Mother-to-Child Transmission: In FY 2013 the PEPFAR SA program will address gaps related to linkages and retention of women on PMTCT to full ART. PMTCT will be supported across all districts and facilities through an integrated mentoring and capacity building approach. Training, mentoring and technical assistance to provincial, district, sub-district, and facility management teams will support the roll-out of South Africa’s new PMTCT guidelines (universal ART for PMTCT) along with quality improvement programs focused on ANC and PMTCT. Programming will also include: 1) developing a stronger QI framework and approaches at provincial and national levels; 2) using community-based interventions to support sensitization, mobilization and literacy in the context of PMTCT; 3) increasing focus on follow-up of mother-baby pairs post-delivery (after 6 weeks) and infant feeding to ensure durable PMTCT outcomes; and 4) continuing support to the national PMTCT Impact and Effectiveness Evaluation program.
F) TB/HIV: PEPFAR supports NDOH priority districts based on high TB case load, poor treatment outcomes, high TB/HIV co-infection rates, MDR/XDR-TB prevalence, smear coverage and smear conversion rates. TB/HIV funding is integrated into the district partnerships to ensure that program capacity building and outcomes are supported across South Africa. PEPFAR partners train health workers on improved reporting for better data quality and accelerated implementation of the “Five I’s”: ICF, IPT, IC, integration of TB/HIV services, and early initiation of ART. PEPFAR is also supporting MDR-TB decentralization through task-shifting and funding the pilot and roll out of nurse-initiated management of MDR-TB.
ORPHANS & VULNERABLE CHILDREN:
Nearly one third of South Africa’s population is under 15 years of age. and approximately 22% of the country’s 18.6 million children are affected by HIV/AIDS with more than 2 million children orphaned by AIDS. The 2010 General Household Survey suggests that the overall number of orphans could be as high as 3.7 million while the UNICEF 2010 South Africa Annual Report indicates that 3.9 million children have lost one or both parents. The impact of HIV and AIDS on children and their families is complex and multi-faceted. The National Action Plan for OVC and Other Children Made Vulnerable by HIV and AIDS” (NAP) reflects strong SAG leadership and commitment to a robust multi-sectoral national HIV response. The plan recognizes OVC as a key population for whom specific interventions will be implemented as a primary prevention strategy for HIV and to mitigate impact and break the cycle of ongoing vulnerability. The Department of Social Development (DSD) has been tasked with leading HIV prevention in the areas of social and individual behavior change, including changes in gender norms that are necessary for the prevention of new HIV infections, especially among OVC and youth.
Over the next five years, PEPFAR SA will continue to support the DSD to: 1) strengthen the coordination of OVC programs at all levels (national, provincial and district) and build monitoring and evaluation capacity at all levels; 2) build implementation and management capacity of local structures that protect, care and support OVC; 3) support local programs to initiate and maintain the linkages and referrals to programs that keep parents alive, delay orphanhood and prevent HIV infection in the 0-18 age group; 4) support family and community-based responses to protect OVC with a specific focus on the 0-5 year group, child survivors of abuse and GBV and children living with sick or elderly caregivers; 5) create a supportive multi-sector environment for OVC by building the evidence and knowledge base and promoting integration and strengthened coordination with other sectors such as Health and Education; and 6) strengthen the social service professional workforce serving children.
The majority of PEPFAR OVC implementing partners reached the end of their five-year agreements in 2012, and PEPFAR will fund eight new implementing partners that refocus the OVC portfolio. These new awards will: (1) provide comprehensive evidence-based programs that strengthen families, households, and communities to meet the holistic needs of OVC affected by HIV and AIDS; (2) be innovative and focus on sustainable community-based responses that support OVC and specifically adolescent OVC to meet their own needs through meaningful youth participation and strong HIV prevention education; (3) support the transition to adulthood for OVC; and (4) build the capacity for communities to create a supportive environment where children can grow up safe and develop into productive members of society.
The PEPFAR OVC portfolio will focus on improving linkages and referrals for the provision of sexual and reproductive health and prevention services for vulnerable adolescents. OVC programs will continue to address known HIV risk factors that are particularly prevalent in OVC populations, such as poverty and psychosocial distress. In addition to delivering HIV education and services, these programs will prioritize livelihood opportunities and psychosocial well-being — key factors in sexual decision making and also indicators of overall well-being. System strengthening is the center piece of the OVC portfolio and the new DSD Government Capacity Building and Support award will provide technical assistance and capacity development within DSD to strengthen its capacity to address the social and structural barriers that increase OVC vulnerability to HIV and AIDS. Key areas of focus include coordinating planning and implementation of gender and age sensitive OVC services through a multisectoral response at national, provincial and community levels; building management information systems and an integrated national OVC reporting system; improving DSD’s use of data for strategic decision making; assuring quality improvements in service delivery; and integrating social and individual behavior change and community HIV prevention.
One of the new OVC awards is for the National Association of Child Care Workers (NACCW) to provide accredited training for the Child and Youth Care Worker (CYCW) qualification to a total of 10,000 workers and volunteers working in this sector. This formalized training will provide a sustainable solution for strengthening communities’ ability to care for their children and increase the professional social welfare workforce serving children. The award is co-funded by each provincial DSD that has been allocated funding to train new CYCW and to set up Isibindi programs to provide services to OVC. In addition, PEPFAR SA is in the final stages of negotiating a direct Host Country Agreement with the DSD to support the request for Technical Advisors to assist in managing the roll out of training of additional CYCWs for 400 new sites over the next five years.
Tulane University is the implementation research partner for the OVC portfolio and is conducting a longitudinal study to evaluate four different OVC program models in KwaZulu-Natal. Tulane University is also undertaking a prospective 20-month study of adolescents in Eastern Cape, South Africa to assess the cost benefit and impact of two interventions that target HIV risk factors among vulnerable adolescents. In addition, evidence-based research that measures the outcomes of OVC interventions is required for all new OVC partners and continues to be a foundation of the SA OVC program.
SYSTEMS STRENGTHENING, STRATEGIC INFORMATION & LABORATORY:
A) HEALTH SYSTEMS STRENGTHENING (HHS):
Through consultative engagement with the SAG, the HSS portfolio has been developed to address key gaps including supply chain management, human resources for health, governance, training, policy development, and health finance. In supply chain management, activities include support for improved quantification and forecasting, support for pharmaceutical depot management and distribution, and assistance with tendering processes to improve access to HIV-related pharmaceuticals. PEPFAR also supports the implementation of a SAG managed Human Resource Information System that tracks human resources training with the intention of improving staff retention through capacity development. PEPFAR supports multiple activities to improve evidence-based budgeting at national, provincial and district levels. Activities include developing cost models for national policy, costing provincial strategic plans, and building the financial management capacity of provincial and district health managers. During the past year, PEPFAR conducted an analysis of USG and SAG budget cycles to identify key opportunities for joint planning. Future engagement is planned to facilitate PEPFAR engagement with the SAG’s Medium-Term Expenditure Framework and mid-year SAG budget adjustment. PEPFAR is also using the results of the Expenditure Analysis to contribute to HIV resource allocation models to identify potential program and geographic areas that are not receiving sufficient resources. The HSS portfolio also supports operational research (OR) to evaluate best practices for scale up including the cost effectiveness of task shifting and active TB/HIV case finding; acceptability, uptake and cost of alternative scenarios for HIV treatment initiation; and the potential budgetary impact of changes to HIV treatment policy.
PEPFAR HSS program priorities include the following:
Strengthen Human Resource (HR) Capacity: PEPFAR SA supports efforts in three categories: 1) transition of USG-supported posts to host country mechanisms; 2) training; and 3) support to the NDOH HR information system. To date, transition of posts from PEPFAR grantees to SAG has primarily occurred for clinical positions. During the upcoming fiscal year, PEPFAR SA and SAG will plan for sustainable support of Community Health Workers (CHWs) that aligns with national strategy. In addition, PEPFAR will work with NDOH to develop a supervision framework for health care workers based on the existing Supervision Manual for Clinical Health Care Workers. The framework will contain supervisory competencies and create an accountability system for measuring the effectiveness of supervisors.
Strengthen Governance and Leadership Capacity: PEPFAR will support development of a Leadership and Management Academy with NDOH. Future PEPFAR-supported leadership and management training will be done in collaboration with this academy. In addition, a new procurement in COP 2013 will focus on strengthening the coordination capacity of the South Africa National AIDS Committee (SANAC) and supporting the Global Fund Country Coordinating Mechanism (CCM).
Strengthen the Supply Chain for HIV/AIDS-Related Commodities: PEPFAR will support supply chain strengthening to reduce the occurrence of drug shortages at the local level. Priorities for COP 2013 include pooled procurement for ARVs, procurement of MMC kits, procurement of Diflucan, procurement of ARVs for the PopART study in Western Cape and development of supply chain transition plans for each partner actively working in commodity procurement. PEPFAR SA intends to fully transition ARV procurement to the SAG over the next 1-2 years for all routine services.
Strengthen Financial Management Systems: PEPFAR will pursue three health financing priorities: a) partner with the SAG to identify alternative funding sources to address the resource gaps of the NSP; b) strengthen public financial management capacity at local levels; and c) coordinate budget processes between PEPFAR and SAG to ensure joint planning and sustainable support for programs. PEPFAR SA also supports Global Fund Principal Recipients to improve financial management systems and utilization of funds.
B) STRATEGIC INFORMATION:
The Strategic Information (SI) portfolio builds capacity of PEPFAR partners and SAG counterparts to monitor and evaluate national and project-specific HIV/AIDS programs, improve the quality of data, and improve utilization and dissemination of data. The SI portfolio includes development and maintenance of the Partnership Information Management System which serves as the electronic data reporting system for all PEPFAR SA grantees.
The SI program will continue to support the NDOH to improve SAG reporting systems. PEPFAR supports the improvement of DHIS, roll out of the three tier ART reporting system, and development of core national surveillance systems including incidence monitoring. PEPFAR also supports national population size estimation and surveillance of key populations. Surveillance activities also include monitoring of HIV drug resistance, HIV and TB incidence, MTCT surveillance, Pre-ART tracking, opportunistic infections, gender-based and child violence, pharmacovigilance, as well as STI, infant and maternal mortality.
PEPFAR will fund multiple new awards with FY2013 resources to continue implementation of the SI portfolio.
Redacted
C) LABORATORY:
PEPFAR SA will work with SAG to establish a laboratory unit within the NDOH to improve governance, strengthen delivery and access to laboratory services, and improve overall laboratory operations and infrastructure. PEPFAR will continue to support rollout of the new laboratory information system (Trakcare) to improve timely access to test results. . PEFPAR will also conduct pilot evaluations and support rollout of innovative technologies (e.g. GeneXpert, Web Enabled Lab Result) to enhance early detection of TB as well as improve access to laboratory results in rural facilities.
PEPFAR will collaborate with the NDOH to introduce new technology, monitor and evaluate programs, and develop laboratory infrastructure around clinics. HIV-associated opportunistic infections (OI) are not routinely reported to the NDOH, except for tuberculosis. Thus, PEPFAR support for national laboratory-based surveillance for OIs provides critical information regarding trends in the burden of HIV-associated OIs such as cryptococcal meningitis, pneumocystis jiroveci pneumonia (PCP), pneumococcal disease and disease caused by non-typhoidal Salmonella enterica. The laboratory program provides training programs that aim to a) improve the competency of laboratory technologists; b) train and increase the number of epidemiologists that are competent in laboratory diagnostics; and c) improve laboratory quality leading to accreditation.


Population and HIV Statistics

Population and HIV Statistics




Additional Sources

Value

Year

Source

Value

Year

Source

Adults 15+ living with HIV

5,100,000

2011

AIDS Info, UNAIDS, 2013










Adults 15-49 HIV Prevalence Rate

17

2011

AIDS Info, UNAIDS, 2013










Children 0-14 living with HIV

460,000

2011

AIDS Info, UNAIDS, 2013










Deaths due to HIV/AIDS

270,000

2011

AIDS Info, UNAIDS, 2013










Estimated new HIV infections among adults

350,000

2011

AIDS Info, UNAIDS, 2013










Estimated new HIV infections among adults and children

380,000

2011

AIDS Info, UNAIDS, 2013










Estimated number of pregnant women in the last 12 months

1,059,000

2010

UNICEF State of the World's Children 2012. Used "Annual number of births as a proxy for number of pregnant women.










Estimated number of pregnant women living with HIV needing ART for PMTCT

240,000

2011

WHO










Number of people living with HIV/AIDS

5,600,000

2011

AIDS Info, UNAIDS, 2013










Orphans 0-17 due to HIV/AIDS

2,100,000

2011

AIDS Info, UNAIDS, 2013










The estimated number of adults and children with advanced HIV infection (in need of ART)

2,568,974

2011

WHO










Women 15+ living with HIV

2,900,000

2011

AIDS Info, UNAIDS, 2013













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