SOUTH AFRICA

Partnering to save lives: ICAP SUPPORT FOR THE rapid scale-up of hiv prevention, care, and treatment Contents

ADDRESSING THE GLOBAL HIV EPIDEMIC . . 1

ICAP IN ...... 5

MOVING FORWARD IN SOUTH AFRICA . . . . 20

REFERENCES 21

ADDRESSING THE GLOBAL HIV EPIDEMIC

lobally, 34 million people are living with HIV,1 tions in 22 of the most severely affected countries dropped and 7,000 are newly infected each day.2 As of by more than 26 percent.4 2011, HIV has infected more than 60 million Funding for this report was provided to ICAP at the Mailman School of Public Acknowledgements gpeople and caused at least 30 million deaths. Health, Columbia University as part of the Multicountry Columbia Antiretroviral A major reason for this dramatic turnaround has been the ICAP would like to extend its sincere gratitude to the National Program (MCAP) and is supported by Cooperative Agreement #U62PS223540 initiation of the United States President’s Emergency Plan from the US Centers for Disease Control and Prevention (CDC). The contents Department of Health (NDOH) for their support and for fostering an In the face of such overwhelming figures, it is easy to lose of this report are solely the responsibility of the authors and do not necessarily enduring partnership. We express our appreciation and heartfelt for AIDS Relief (PEPFAR), which was launched in 2003. represent the official views of the CDC. thanks to the Presidents Emergency Plan for AIDS Relief (PEPFAR) sight of the remarkable strides that have been made in the for the funding support and the United States Centers for Disease response to HIV over the past decade. Millions of people liv- Now, after its eighth anniversary, it has proved notable in More information on ICAP and its activities in South Africa can be obtained Control and Prevention - South Africa for facilitating the funding its size, scale, and impact on increasing access to HIV pre- by calling +27.11.656.3650, e-mailing [email protected], or writing to arrangements and for providing programmatic support. ing with HIV have built better futures for themselves, their vention, care and treatment and has proven one of the most ICAP, The Braides, Building B/C-First Floor; 115 Bowling Avenue; Gallo Manor, ICAP would also like to express its thanks to the Departments of families, and their communities as a result of innovative, 2052, Republic of South Africa. Information on ICAP’s global activities can be Health in Eastern Cape, , Northern Cape and KwaZulu-Natal effective HIV prevention, care, and treatment programs. successful large-scale global public health undertakings addressed to ICAP, Columbia University, 722 West 168th Street, New York, provinces, the management teams and staff of hospitals and health NY 10032 USA or by email to: [email protected]. centers for their dedication in coordinating HIV program activities and ever. By September 2011, the US government had directly delivering services in all ICAP-supported districts and facilities. supported ART for 50% of the global response—more www.columbia-icap.org/ A Global Response We wish to thank the associations of people living with HIV, the clients than 3.9 million men, women, and children worldwide, © February 2012 by ICAP. All rights reserved. enrolled in care and treatment, the many NGOs working on health- At the end of 2010, roughly 6.65 million people in low- and more than 13 million of those in HIV care and sup- related activities in general and HIV-related activities in particular, and middle-income countries were receiving antiretroviral and the private sector for their collaborative activities with ICAP and port services.5 for their active involvement in HIV prevention, care and treatment treatment (ART),3 almost a 22-fold increase since 2001 and programs. We would also like to thank peer educators, who worked closely with ICAP to expand family focused HIV services and bring an achievement that many considered impossible 10 years Understanding how this turnaround was achieved can help about sustainable behavior change in HIV care in the community. earlier. Over the same period, the rate of new HIV infec- inform health and development efforts around the world. We gratefully acknowledge ICAP staff in New York and South Africa, whose dedication and collective work have made our support in South Africa a great success. ICAP in south africa f 1 Key Partner In 2002, in response to the United Nations Secretary Gen- HIV in South Africa HIV Prevalence (%), Ages 15–19, 2008 eral’s Call to Action, the Mailman School of Public Health 18.6–25.8 South Africa is home to an estimated 5.6 million people at Columbia University helped to establish the MTCT-Plus living with HIV, more than any other country in the world. 15.3–18.5 Initiative to address the HIV treatment and care needs of AIDS is the leading cause of maternal mortality and impoverished communities around the world. This initia- 9.1–15.2 accounts for 35% of deaths in children under five. National tive, funded first by a coalition of private foundations and HIV prevalence among those aged 15–49 is estimated at 5.4–9.0 subsequently expanded with funding from the United 17.8%, but rates vary widely across provinces, from 16.9% States Agency for International Development (USAID), Today a global leader in HIV service delivery, human 5.3 in Western Cape to 39.5% in KwaZulu-Natal. Women are supported provision of comprehensive and specialized care, capacity development, and systems strengthening, ICAP Limpopo disproportionately affected by HIV, particularly in younger including ART, to HIV-infected women, their partners, has supported work at more than 2,000 facilities across age groups; among South Africans aged 20–24, prevalence and their children identified in prevention of mother-to- 21 countries. More than one million people have accessed 6 was 21.2% among women but only 5.1% among men. PRETORIA child transmission (PMTCT) programs. Mailman’s experi- HIV services through ICAP-supported programs, and ap- A high TB burden and an active migrant labor system pose North Gauteng ence implementing the MTCT-Plus Initiative helped to proximately one patient in 10 receiving PEPFAR-funded Mpumalanga additional challenges to South Africa’s HIV prevention, West inform the model and approaches later adopted by ICAP. ART in sub-Saharan Africa is obtaining it at an ICAP- 7 care, and treatment efforts. Kwazulu-Natal supported health facility. Free Columbia University’s role in implementing PEPFAR Northern State The apartheid system, which endured un- Cape began in 2003, when it received funding from the Global ICAP is grounded in the belief that HIV services should be til 1994, created stark inequalities along both AIDS Program of the Centers for Disease Control and Pre- universally accessible and that people in resource-poor areas geographic and racial lines, and its effects are still vention (CDC) under the University Technical Assistance can adhere to life-saving treatment regimens. ICAP works visible in the form of vast disparities in health care Eastern Projects (UTAP) to support the development of important with ministries of health, local organizations, and people Cape infrastructure and access from one province to another. components of national HIV programs, including treat- living with HIV to develop sustainable, locally appropri- Many primary health clinics in the country’s poorest Western as well as the ment protocols and training. In 2004, ICAP was founded ate HIV prevention, care, and treatment programs that are Cape provinces—including Eastern Cape and KwaZulu- planned change in and was awarded a new cooperative agreement from CDC integrated with national AIDS control programs. ICAP’s Natal—are understaffed and in dire need of additional eligibility to those with CD4 under the PEPFAR framework to provide comprehensive comprehensive model consists of: space and upgrades. In Eastern Cape Province, where ICAP count of fewer than 350 cells/mm3, program chal- HIV care and treatment in five countries: Kenya, Mozam- ■■ A family-focused approach to HIV prevention, care, and has worked since 2004, more than 4 million people (nearly lenges continue. Human resource shortages, late entry into bique, Rwanda, South Africa, and Tanzania, with program- treatment services 70% of the population) live in poverty,8 and the estimated health services by many people with HIV, requiring more ming in Côte d’Ivoire, Ethiopia, and Nigeria subsequently HIV prevalence is 28.1%. The province’s burden of tuber- intensive care, and a rapidly increasing patient load will test added. This initiative, the Multicountry Columbia Antiret- ■■ Support for multidisciplinary teams of health care providers culosis—which includes strains that are multidrug-resistant the continuing expansion of ART and demand substantial roviral Program (MCAP), has rapidly expanded programs ■■ A continuum of clinical and supportive services to meet and extremely drug-resistant—is the second-highest in the future investment by the government of South Africa and for HIV care and ART by promoting early diagnosis of patient and family needs at every stage of HIV disease country.9 Access to health services is inhibited by long dis- other stakeholders. HIV infection, maintaining the health of those living ■ tances to health facilities and a high rate of departure from with HIV, and preventing further transmission of HIV ■ Programs to promote retention and adherence to HIV In this report, ICAP’s key achievements, with a particular the public sector among doctors. within the community. MCAP programming, in addition care and treatment focus on MCAP programming, is described using program to being focused on rapidly scaling up care and treatment ■■ Empowerment of patients and their families The scale-up of care and treatment services in South Africa data as well as through the stories of the individuals, families, in partnership with host-country governments, also has under PEPFAR has vastly increased the number of people and communities behind the numbers. It will be demon- ■■ Linkages to community resources emphasized the full continuum of HIV-related services, on ART. At the end of 2007, it was estimated that only strated how ICAP, working in partnership with the Depart- continued capacity building and health systems strengthen- ■■ High-quality services, with carefully set standards of care 27% of people with CD4 counts less than 200 cells/mm3 ment of Health, nongovernmental organizations, and people ing, and transition of operations to host governments and and methodologies for program evaluation, operations were accessing ART.10 By the end of 2009, this figure had living with HIV, has helped to achieve these and other gains local nongovernmental organizations. research, and program improvement increased to 56%.11 Given the number of new infections in the areas of access, quality, and capacity in South Africa.

2 f ICAP in south africa ICAP in south africa f 3 ICAP IN SOUTH AFRICA

CAP began supporting HIV and TB prevention, care, and Itreatment activities in South Africa in February 2004. From the beginning, ICAP adopted a network model characterized by Rapid Scale-Up close collaboration with provincial and district Department of With PEPFAR funding, ICAP expanded beyond the initial Health authorities in all phases of project implementation. ICAP MTCT-Plus facilities in Johannesburg and Cape Town, to was an innovator in making care and treatment services available Eastern Cape Province, one of the country’s most underserved at primary health centers, at a time when these services were of- and most resource-constrained regions. Despite notable ad- fered predominantly at large district or teaching hospitals. vances in the scale-up of HIV services in other provinces, con- As care and treatment services began to take root at facilities ditions in the Eastern Cape remained extremely challenging in throughout South Africa, ICAP support expanded to include 2004. Health infrastructure consisted of little more than basic a full range of family-focused HIV services, spanning commu- clinics and facilities, some of them inaccessible by road; formal nities, hospitals, and primary health centers in Eastern Cape HIV care training for health professionals was lacking; and Province. TB infection control as well as services for integrated people living with HIV were not receiving appropriate care, TB/HIV care, prevention of mother-to-child transmission of much less the ART they urgently required. It was difficult to HIV, and psychosocial support (including peer education and recruit staff to manage and administer HIV care and treatment home-based care and support groups) became priorities along- programs in so rural and poor an area. Nonetheless, ICAP had side basic HIV care and treatment services. a clear, compelling mandate: to support the Department of Health in the rapid scale-up of HIV care and treatment while In 2008 and 2009, ICAP extended its program activities to building health care worker capacity. KwaZulu-Natal, Free State, and Northern Cape Provinces. In each province, ICAP intensified its collaboration with province- ICAP collaborated with the Centers for Disease Control and and district-level Department of Health authorities to support Prevention (CDC) and the Eastern Cape Department of rollout of high-quality HIV care and treatment programs. ICAP Health to plan a joint response to pressing local needs. ICAP adopted a district approach emphasizing sustainable, systems- established an office within Walter Sisulu University in Mtha- based initiatives to increase the quality of services—skills tha, the provincial capital, and began support to three hospi- building and performance improvement activities, continuing tals and their associated primary health care clinics in nearby education, development of standard operating procedures, and districts, with the introduction and expansion of quality HIV implementation of the standards of care curriculum. care and treatment services.

Over the space of eight years, ICAP has supported the Depart- ICAP next rapidly expanded its technical support to health ment of Health in extending ART to more than 69,017 men, facilities throughout the Eastern Cape in partnership with local women, and children living with HIV in South Africa. During institutions. To promote quality improvement, ICAP worked the same period, also as a result of ICAP’s collaboration with with the Eastern Cape Department of Health to develop user- the Department of Health, more than 108,858 people living friendly tools for patient management, support, and moni- with HIV benefited from ICAP-provided care and support toring consistent with domestic and international standards. services, and nearly 70,000 women have received HIV testing Several of these tools were formally adopted by South African and results through PMTCT, including 20,000 HIV-positive national or provincial governments; others, such as the patient pregnant women who have received services and antiretroviral referrals directory, were used across multiple ICAP-supported drugs to prevent the transmission of HIV to their infants. municipalities.

ICAP in south africa f 5 Facilities Providing Hiv Care and Treatment with Icap Support 2004–2010

Systems Strengthening in South Africa. To lighten the load on overburdened health 100 sites While facilitating the rapid scale-up of quality HIV services, systems, ICAP recruited highly skilled staff and seconded them ICAP emphasized human capacity development, particularly to the Department of Health, providing needed additions to for nurses and other nonphysician personnel categories such the workforce and increasing providers’ skill levels. 80 as pharmacy assistants and counselors. Starting in 2006, ICAP The years 2008 and 2009 ushered in a series of strategic and collaborated with the Department of Health and local aca- programmatic changes for ICAP in South Africa. ICAP’s geo- demic institutions to empower nurses as advanced practitioners 60 graphic expansion resulted in a massive increase in the number in HIV management through personalized, hands-on mentor- of patients supported by ICAP and a greater role for ICAP ship and learning. This innovative approach became a model at national level.12 To its assistance to hospitals and primary for other organizations supporting HIV care and treatment 40 health clinics, ICAP added a district support package consist- ing of training and mentorship of Department of Health man- An Urgent Need agers and staff; tools to further develop programs, rapidly assess facility needs, and prepare facilities for accreditation as HIV 20 ICAP’s global director, Wafaa El-Sadr, recalls the centers; and secondment of technical experts to health depart- sense of desperation that greeted her during a facility ments to alleviate severe human resource shortages. Work- visit to Native Unit #8 Clinic in Eastern Cape in Oc- ing alongside provincial and district Department of Health tober 2004. The clinic was struggling to obtain the 2004 2010 accreditation required by the Government of South staff to address jointly identified needs, ICAP helped achieve Africa to start providing care and treatment services for systemwide improvements in care and treatment services. For HIV, and medical staff were increasingly frustrated with example, in response to a critical shortage of ART prescribers, ICAP provided technical, managerial, and financial support for ICAP-Supported Facilities the process. The nurse on duty produced a notebook she had been updating assiduously with the name of a 24-month pharmacist-assistant apprenticeship course, which in South Africa each patient in immediate need of ART. helped stabilize delivery of care and treatment at overburdened As of September 30, 2011, ICAP supported 122 facilities in facilities in Free State and Eastern Cape provinces. South Africa. “Her sense of urgency was palpable,” El-Sadr re- members. “Each name in that book represented a By September of 2011, ICAP was assisting with HIV care and human life that could be saved only through access treatment at over 100 facilities in four provinces and had en- Limpopo to treatment.” At the conclusion of the visit, El-Sadr rolled nearly 70,000 patients in ART. ICAP-supported medical officers, professional nurses, quality assurance coordinators, PRETORIA asked ICAP’s staff in South Africa to do everything Gauteng monitoring and evaluation assistants, and health promotion North West in their power to expedite the facility’s accreditation, Mpumalanga assistants have all helped expand the scope, quality, and size of Kwazulu-Natal resolving that the purpose of her next visit would be to check in on the status of active ART patients. provincial care and treatment programs. Northern Free Cape State District and provincial Department of Health staff The ICAP Approach Eastern in Eastern Cape expressed gratitude for ICAP’s assis- Cape tance in navigating the facilitie and laboratory accredi- In collaboration with its partners, ICAP in South Africa Western Cape tation processes, singling out this assistance as one of achieved rapid scale-up of care and treatment services by build- the organization’s most important contributions. ing on proven approaches that emphasize individual access to care and treatment, the system capacity to provide it, and the KWAZULU-NATAL–27 NORTHERN CAPE–18 During El-Sadr’s next visit to Eastern Cape, care and quality of the services provided. These approaches include a EASTERN CAPE–40 GAUTENG–1 treatment services at NU8 Clinic were in full swing, comprehensive model of care; innovative, systems-focused hu- and the names of patients had been transferred from a man capacity building; and active engagement of people living FREE STATE–36 nurse’s makeshift notebook into official patient records. with HIV and their communities. Map Sources: ICAP URS http://mericap.columbia.edu as of 30 Sep 2011; MEASURE DHS (Demographic and Health Surveys); ESRI; Center for International Earth Science Information Network (CIESIN), Columbia University; and Centro Internacional de Agricultura Tropical (CIAT). 2005. Gridded Population of the World Version 3 (GPWv3): National Boundaries. Palisades, NY: Socioeconomic Data and Applications Center (SEDAC), Columbia University. Available at: http://sedac.ciesin.columbia.edu/gpw/ 6 f ICAP in south africa ICAP in south africa f 7 Cumulative Number of Hiv-Infected “As a country, we were having a very big problem Individuals Enrolled in ICAP-Supported with PMTCT data collection and quality. HIV Care and Treatment ICAP . . . was our biggest partner in this area and worked hard with us to develop the PMTCT register. We saw a change for the better in the 120 thousand people quality of PMTCT because of ICAP’s technical A Comprehensive Model of Care contribution.” The ICAP model of care, one key to improving access to HIV 90 — Precious Robinson, PMTCT Manager, National Department of Health services in South Africa, is part of ICAP’s broader Clinical Systems Mentorship (CSM) approach to strengthening health systems. The model of care defines the minimum package of services essential to high-quality HIV care, including a focus 60 on the family as the core for provision of care, engagement with a multidisciplinary team of providers, an emphasis on Prevention of Mother-to-Child adherence and prevention, and strong linkages between clinical Transmission 30 and community services. When services are integrated and Despite the fact that women of childbearing age constitute delivered in accordance with this model of care, people living the segment of South Africa’s population who are most at with HIV and their families can access a full range of neces- risk for HIV acquisition, the nation’s PMTCT efforts started sary services in a single visit to the health center, reducing the slowly: health care workers and facilities were overburdened, burden of time associated with seeking care. 2005 2011 the understanding of mother-to-child transmission was limited ICAP peer educator who provided support to patients in among health care staff and the general public; and PMTCT ICAP operationalized its model of care by applying measurable St. Patrick’s Hospital in the Eastern Cape Province services were concentrated at referral health care facilities standards of care for HIV services. These provide a framework Total Number in HIV Care Total Number on ART (despite most births occurring at primary health clinics). for assessing the quality of care and for systematically identify- Working through multidisciplinary teams and Department of ing and remediating barriers to care; and, thereafter, for imple- NOTE: Seven clinics transitioned away from ICAP support as part of transition Health authorities in four provinces, ICAP built on the model menting innovative approaches to HIV care and treatment, to plan in June 2011. established under the MTCT-Plus program to improve access PMTCT, and to treatment for TB/HIV coinfection developed to PMTCT services via a variety of interventions at provincial in response to the challenges identified by multidisciplinary and national levels, including: teams on the ground. ■■ Implementing a “one-stop shop” approach, allowing ■■ Renovating and upgrading facilities to eliminate over- Cumulative PMTCT Results pregnant women and their families to secure all needed HIV Care and Treatment crowding, and to improve basic amenities ICAP has provided wide-ranging support for HIV prevention, services during a single visit to their health care site ■ care, and treatment in each of the four-supported provinces. At ■ Reengineering patient flows to reduce wait times and Facilities supported 101 ■■ Advocating for a quick-start policy that would allow each facility, ICAP has worked with a multidisciplinary team facilitate patients’ access to multiple services during a Pregnant women counseled, tested, and pregnant women to initiate treatment within two weeks of health care providers and support staff to implement a mod- single visit receiving results 68,994 of screening for treatment eligibility el of care consistent with national and international standards, ■■ Designing and delivering a nurse mentorship training HIV-infected pregnant women receiving including clinical and immunologic staging (CD4 testing) and ■■ Designing and introducing an assessment tool, the program to equip nurses to initiate and manage ART antiretroviral prophylaxis to prevent mother- 19,547 provision of cotrimoxazole prophylaxis as well as counseling, to-child transmission of HIV Pregnancy Wheel, that helped health care workers laboratory screening, ART, and psychosocial support. ICAP’s ■■ Developing the adult clinical record monitoring tool, assess the pregnancy stage and the new mother’s HIV-exposed infants receiving antiretroviral support for care and treatment included: known as the ACR, adopted throughout Eastern Cape prophylaxis in maternity 20,420 eligibility for services ■■ Holding regular planning and data review meetings ■■ Providing patient support groups so that people with All numbers as of September 30, 2011 ■■ Providing technical leadership for PMTCT by develop- with multidisciplinary teams to identify and address HIV infection could be be open about HIV, leading to a ing national norms, guidelines, and tools, including a barriers to care reduction of the stigma associated with HIV standardized PMTCT register

8 f ICAP in south africa ICAP in south africa f 9 The Chatty Primary Healthcare Clinic devised an innovative “cough priority box” for charts of patients suspected to have TB; this simple measure reduced the wait time of patients from over two hours to 15 minutes.

TB/HIV Tuberculosis is a major public health problem in South Africa, which ranks fifth on the global list of high-burdenT B coun- tries. Given the high susceptibility of HIV-infected individuals to TB as well as the need to protect health care workers from TB infection, TB was a high priority for ICAP from day one. Following the World Health Organization’s “3 I’s” for TB/ TB Infection Control at Health HIV—that is, intensified case finding, isoniazid preventive Facilities therapy, and TB infection control—ICAP employed a combi- nation of bottom-up and top-down approaches to combat TB ICAP and the Eastern Cape Department of Health, work- in South Africa, including: ing with a group of facilities, developed materials aimed at educating and motivating health care workers to adopt TB ■■ Supporting early diagnosis of TB among people infection control practices in order to protect their own health living with HIV via TB screening tools for patients and minimize transmission of TB within their health facilities. in HIV care Health care worker training and job aids emphasized the im- portance of being alert for coughing patients and prioritizing ■■ Training health care workers in integrated TB/HIV care them—ensuring that they are seen quickly so as to minimize ■ their potential to infect others. ■ Helping TB clinics implement HIV testing Cumulative TB/HIV Results ■■ Working with facilities to establish TB infection control ICAP supported facilities to establish infection control com- committees and develop customized infection control plans Facilities supported 100 mittees and develop customized infection control plans that included such strategies as good ventilation in waiting areas, ■ ■ Educating patients enrolled in HIV care and treatment Cumulative number of new patients screened outdoor sputum collection, and managing patient flow to pre- for active TB at enrollment into HIV care 39,993 about cough etiquette and other protective measures vent the spread of infection. The Chatty Primary Healthcare Clinic devised an innovative “cough priority box” for charts of ■■ Introducing isoniazid preventive therapy for HIV Cumulative number of new patients with unknown HIV status who were tested for HIV patients suspected to have TB; this simple measure reduced to patients that do not have active TB 20,817 while in care at theTB clinic just 15 minutes, from 146, the wait time of patients suspected ■■ Supporting community-based intensified case manage- Cumulative number of new patients to have TB. With waiting-room posters promoting “cough ment and treatment of multidrug-resistant TB in Tugela etiquette,” ICAP also educated patients in HIV care about the diagnosed with HIV while in care at the TB 8,919 Ferry through subpartner Yale University clinic who were subsequently enrolled in HIV importance of TB infection control. care and treatment

All numbers as of September 30, 2011 10 f ICAP in south africa ICAP in south africa f 11 Innovation in Human Capacity Development In order to help the Department of Health fill gaps in human Engagement of People Living resources for health—for doctors, pharmacists, and data man- ■■ Ensuring continuous mentorship for nurses at nearly with HIV, Involvement of Local agers—ICAP implemented an innovative, multiprong strategy 100 public health facilities Communities for human resource development. Its main elements included: ■■ Conducting training in nurse-initiated management of Increasing utilization of services for HIV care and treatment ■■ Secondment of staff to provincial health departments ART (NIMART) for staff at primary health clinics on Peer educators advised people living with HIV must address HIV-related stigma, as well as other barriers. The to fill gaps and build knowledge in areas of need, such comprehensive HIV care and procurement and antiret- on disclosing their status to others; worked use of outreach peer educators (who are HIV-infected them- as monitoring and evaluation, pharmacy, commodities roviral-drug stock management with serodiscordant couples and family selves), and support groups is essential to improving not only management, and laboratory adherence but also overall quality of life for people living with ■■ Providing technical, managerial, and financial support members to promote HIV testing, care, and HIV. Early on, ICAP recognized the critical role of peer educa- ■■ Implementing—in partnership with local academic for a 24-month pharmacist-assistant apprenticeship treatment; counseled and educated people tors in conducting outreach and reducing stigma, especially in institutions—ICAP’s nurse mentorship training program course, resulting in the training and placement of 62 rural areas, where awareness of accurate HIV information was to empower nurses as primary caregivers for patients pharmacist assistants at public health facilities in Free living with HIV and family members on weak and and misconceptions about HIV were widespread. To enrolled in HIV care State and Eastern Cape Provinces coping strategies and positive living; and—as better respond to the clinical and nonclinical needs of people task-shifting initiatives engaged nurses as living with HIV, ICAP implemented adherence and psycho- primary caregivers—helped to reinforce the social support activities in partnership with multidisciplinary Community-Based Detection and Treatment of image of nurses as capable professionals. teams and communities, including: Multidrug-Resistant TB in Tugela Ferry months, the program dispatches a nurse to the home ■■ Ensuring adherence counseling for HIV care and treat- In 2005, at the Church of Scotland Hospital (COSH) of a patient with multidrug-resistant or extensively ment patients at every clinic visit in Tugela Ferry, a poor, rural area of KwaZulu-Natal, drug-resistant TB to administer injectable medica- researchers identified multiple cases of a deadly and tions. Patients stay with their families and communities ■■ Installing Wellness Centers next to high-volume HIV nearly untreatable form of TB occurring among people rather than in prolonged isolation in hospital wards; clinics to provide HIV education, pre-test and post- living with HIV. The diagnosed cases of this infec- costs are lower; and very few patients leave treatment. test counseling, support groups, and other assistance to tion—resistant to almost all anti-TB drugs available in The program’s success, replicated throughout South people living with HIV South Africa—constituted the largest recorded cluster Africa, has been incorporated into national guidelines ■ of HIV-related cases of extensively drug-resistant TB, for treatment of drug-resistant TB. ■ Establishing peer education programs to help those alarming medical and public health officials worldwide. newly diagnosed with HIV adhere to their care and In 2010, Yale University, the Department of Health, treatment regimens At the time, the system of care for drug-resistant TB in and Philanjalo extended the community-based ap- KwaZulu-Natal consisted of a single specialty hospital proach to intensifiedT B case finding. Community ■■ Launching psychosocial support groups for individuals in Durban that was incapable of managing a province- TB screening allows for earlier identification of drug- of different ages and backgrounds (including adolescents wide multidrug-resistant TB epidemic. Dr Gerald resistant TB cases while facilitating linkages to care and and pregnant and postpartum women) Friedland of Yale University recalls, “Mortality was treatment for HIV. Of the more than 3,000 individuals These services help fill the gap between what the formal health extremely high among people arriving at the hospital screened for TB in the community to date, 10–12% system provides and the broader needs of HIV patients. with multidrug-resistant TB. Diagnosis took months. have tested HIV positive. These individuals have been Many died before being diagnosed.” referred to care and treatment at local health facilities. ICAP’s peer educators were critical to implementing the program. Peer educators advised people living with HIV on COSH, the University of KwaZulu-Natal, a local non- The success of this communityT B treatment and in- disclosing their status to others; worked with serodiscordant governmental organization called Philanjalo, and ICAP tensified case finding demonstrates the value of extend- couples and family members to promote HIV testing, care, subpartner Yale University collaborated with the De- ing critical clinical services beyond the health facility. and treatment; counseled and educated people living with HIV partment of Health to pioneer an innovative program Dr Friedland notes, “You have to go to where people and family members on coping strategies and positive living; in UMzinyathi District, TF Cares, for treating cases of are and not wait for them to come to you, particularly multidrug-resistant TB in the community. Daily for six in poor, rural communities.”

12 f ICAP in south africa ICAP in south africa f 13 A New Beginning for Godfrey and—as task-shifting initiatives engaged nurses as primary caregivers—helped to reinforce the image of nurses as capable yond the call of duty, leveraging their relationships with other Phehello Godfrey Ramabodu comes from a poor professionals. ICAP psychosocial support officer Thulani Vazi staff to link ART patients to critical services such as the ante- family in , Free State. A “people person” by noted, “The peer education program has shifted the focus away natal clinic, pediatric care, and outpatient clinics. Recognizing nature, Godfrey always sought a career that would from the medical to the individual. People now see that HIV is in ICAP’s activities both a response to urgent patient needs allow him to help others. In 1998, after completing something you live with. Peer education has allowed people to and an opportunity to build their own clinical skills, nursing his secondary schooling in Senekal, he went to study see the individual above all else.” supervisors and clinic managers would regularly encourage a at the University of Limpopo but was soon forced to high level of energy and focus from the entire team in support drop out by financial pressures. ICAP-sponsored support groups provided people living with of ICAP activities. Health care workers’ engagement during HIV with psychosocial care that was tailored to their age and In 2008, while working a temporary job to make multidisciplinary team meetings facilitated many significant life situation. PMTCT support groups, targeting pregnant ends meet, one of Godfrey’s friends told him about incremental improvements to facility procedures. women in their third trimester or postpartum women, focused a pharmacist-assistant apprenticeship course being on timely HIV testing and good care for their infants. Adoles- offered by the Department of Health with support Communities cent support groups stressed life skills, adherence, disclosure, from ICAP. The course was designed to address the ICAP actively engaged communities by setting up wellness and transition to adult care. Still other support groups helped pharmacist shortage in South Africa, which was im- programs and centers that served as community hubs, where psychologically prepare children infected through mother- peding access to HIV care and treatment. Seeing the residents could participate in groups and meet on topics to-child transmission for the loss of one or both parents and course as a potential stepping stone towards a career relating to HIV care and treatment. During local government- helped these youngsters build social safety nets (see “Planning in human services, Godfrey applied and was selected sponsored health fairs, ICAP provided staff and peer educators to Remember,” next page). The combined effect of ICAP’s as one of 20 new trainees in Free State. to advise those in attendance on the availability of HIV testing social support activities was to reduce the stigma associated A park home was installed to house the HIV clinic and wellness center at Holy services. ICAP routinely met with community leaders and When the course began in July 2009, Godfrey with HIV, to allow people to see that it was possible to lead a Cross Hospital in the Eastern Cape Province in 2005. The hospital did not elders to discuss pressing health care issues and ways to im- have an HIV clinic before this structure was erected. distinguished himself as one of the most commit- fulfilling life when HIV-infected, and to access ART and HIV prove community health. In some of the most rural settings in ted trainees. He learned about antiretroviral drugs services without shame. Eastern Cape, ICAP supported the Department of Health with and pharmaceutical management at Mohau District staffing of and procurement for mobile HIV clinics to bring Hospital, and there benefited from the experience Partnership and Consultation health care services and HIV testing to communities with poor and guidance of his tutors—professional pharma- ICAP succeeded in supporting the rapid scale-up of care and access to health clinics. Over time ICAP supported significant cists who, in his words, “helped me settle down and treatment services in South Africa by working in close partner- made sure I understood how a pharmacy works and ship with stakeholders at every level of the health system. Local Governments improvements to health infrastructure— what would be expected from me.” conversion of an old maternity ward into a People Living with HIV ICAP’s has consistently worked in partnership with govern- Two years after finishing the course, Godfrey is modern pharmacy; conversion of outbuildings ment at national, provincial, and district levels. Many ICAP now employed as a post-basic pharmacist assistant ICAP helped bring about important changes at facility and staff, while observing that this approach takes more time than to house ART services; addition of windows at Mohau (Hoopstad). He feels that his life was community levels by empowering people living with HIV— the alternative, have found that it pays off in the end by ensur- to waiting rooms to improve ventilation and transformed by the experience. Not only is he able specifically, by training them to provide health care, work as ing that activities were implemented and managed with a view peer educators, and lead support groups. Not only did this reduce TB transmission; installation of air to provide for his family in a way that he previously to long-term viability and respect for national structures and could not, but he is also making a difference in inclusive approach allow health facilities to serve more people, institutions. As a result, ICAP’s assistance and technical advice conditioning units; and furnishing waiting the lives of his patients. In reflecting on what the it also made HIV care more effective and more meaningful to are seen as objective, professional, and strategic, and taken seri- rooms with comfortable, sheltered seating and course meant to him and his 19 fellow students, all who received it. ously. Repeatedly, Department of Health representatives noted monitors continuously showing educational Godfrey expressed gratitude for the opportunity to that ICAP didn’t have its own agenda but instead would col- “put into practice what he have learned to improve Health Care Workers laborate with them to identify gaps and develop a joint plan. videos to promote family wellness. lives in our communities.” Because ICAP engaged them as agents of change at every stage Department of Health staff also expressed appreciation for of the program, health care workers often went above and be- ICAP’s flexibility and active participation in problem solving.

14 f ICAP in south africa ICAP in south africa f 15 Planning to Remember: Memory Boxes and Family Trees ICAP professional counselor Cynthia Nthangeni has provided psychosocial support services to people living with HIV, orphans and vulnerable children, and their families in Free State Province since 2009. She noted orphaned children and adolescents who were unable to access government services because

Peer Educators during their intensive three-week training at they lacked proper documentation (e.g., birth St. Patrick’s Hospital in the Eastern Cape Province in 2006 certificates and their parents’ identification cards). Other orphaned children bounced from institution Strengthening Local Systems to institution for want of a record of any extended familial connections. Cynthia was determined to In South Africa, ICAP’s approach to strengthening local health prevent other children and adolescents from living systems involved collaboration with the Department of Health through similar experiences. on local health departments’ most pressing system-related needs as well as preparing for the transition of many of its With health department community counselors, activities to local nongovernmental organizations. Cynthia and ICAP brought together adolescent support group members to create “Memory Boxes,” ICAP-supported renovations and repairs to health facili- shoe boxes brightly decorated with wrapping paper ties made a dramatic difference for patients and providers in and ribbon that could be used to store photocopies Eastern Cape, Free State, KwaZulu-Natal and Northern Cape of vital records and other identifying information, Provinces. In response to health department requests, ICAP in order to ensure access to education and support provided support for other systems. In Free State, for example, services for the children if their parents died. Each the provincial laboratory was struggling to balance its accounts Memory Box is kept safe at the health facility where and reconcile them with the records kept by the national the child is enrolled in care and treatment. Support laboratory. ICAP seconded a state accountant to the lab to group leaders visit local hospitals to track down manage this process. In less than a year, the accounts had been records for children who have none; the documents reconciled and the Free State Department of Health was saving are then added to the child’s Memory Box. money after the identification of several duplicative or errone- ous charges. To facilitate future placement of orphans with extended family, Cynthia introduced the Family ICAP’s active participation in annual Department of Health Tree, a graphical depiction of a child’s family net- strategic planning exercises at the provincial, district, and work created by tracing an outline of each child on Cumulative Heath Care Workers Trained subdistrict levels has helped ensure that its transition activities kraft paper and filling in the outline with names, are aligned with local priorities. With ICAP’s support, the Uni- contact information, and other facts about the Health care workers trained in HIV care 10,254 versity of Fort Hare has assumed management responsibility child’s relatives. for the advanced clinical HIV management certificate course Health care workers trained in ART 8,878 for nurses and now supports comprehensive HIV treatment Memory Boxes and Family Trees have the additional Health care workers trained in PMTCT 3,236 programs at Department of Health facilities in East London. benefit of preparing children psychologically for the possible death of one or both parents, reminding Similarly, ICAP contracted and worked with the Foundation Health care workers trained in TB/HIV 856 for Professional Development to meet the human resources for them of their connections to other loved ones. integration health needs in KwaZulu-Natal and Eastern Cape Provinces. Health care workers trained in counseling and testing 570

All numbers as of September 30, 2011 16 f ICAP in south africa Transition Within South Africa and globally, PEPFAR has emphasized program sustainability and local capacity development. ICAP in South Africa has met this mandate by gradually transferring its management responsibilities to local institutions. IHPS was formally registered in October 2010 with ICAP sup- In 2010, ICAP helped establish a new locally registered non- port. Building on its core values and experience, ICAP assisted governmental organization—the Institute for Health Programs IHPS with the early stages of organizational development, and Systems (IHPS)—to assume responsibility for elements of from forming a board to developing funding proposals. ICAP its portfolio. IHPS is now operating independently and moving has mentored IHPS in project management and program forward with a variety of human capacity development activities development and has guided the organization as it provided and addressing broader health care issues in South Africa. technical support and assistance to the Department of Health.

Strengthening the Capacity of the Free State Department of Health and the Free State Department of Health developed memorandums of understanding to guide the second- When ICAP initiated support to Free State in 2008, ments and to ensure that they were sustainable and it immediately met with the provincial Depart- achieved their intended purpose. ment of Health to discuss the most pressing needs in Lejweleputsa and Fezile Dabi districts and determine Together the province and ICAP developed and needed support. The agency was having trouble dis- implemented standards of care and other quality tributing medicine and meeting the audit and record- improvement measures; ICAP provided mentoring of keeping requirements of the national department of professional nurses in compliance with NIMART and health. The capacity building strategy that emerged performed infrastructure improvements at three clinics. from these discussions involved support for a series of targeted, temporary staff secondments that the Depart- Several factors contributed to success of ICAP’s capac- ment of Health would absorb within two years. ity building collaboration in Free State. The depart- ment welcomed the partnership and in 2007 became Particularly careful planning by ICAP and the Free the first provincial health department in South Africa State Department of Health was required to arrange to establish a partnership directorate. The two partners for the secondment of staff—a state accountant for the discussed priorities and gaps early in the project, as well provincial laboratory (which was experiencing seri- as the scope and substance of ICAP support. ICAP staff ous challenges with the monitoring and reconciliation participated actively in Department of Health plan- of its accounts); district-level quality improvement ning meetings in the context of South Africa’s national officers; and staff nurses at NIMART facilities as well strategic plan for HIV/AIDS, and developed an under- as the training and placement 20 pharmacist assistants standing of local strategies and how ICAP could assist. at ART posts; the recruitment and placement of 10 When strategies changed or a new need was identified, pharmacist assistants to staff the medical depot. ICAP ICAP consistently demonstrated willingness to adapt.

18 f ICAP in south africa References

1. Joint United Nations Programme on HIV/AIDS (UNAIDS). AIDS at 30. Nations at the Crossroads. Geneva, Switzerland: UNAIDS; 2011. Available at: http://www.unaids.org/en/ resources/presscentre/pressreleaseandstatementarchive/2011/june/20110603praids30/. 2. United Nations General Assembly. Political Declaration on HIV/AIDS: Intensifying Our Efforts to Eliminate HIV/AIDS. Resolution Adopted by the General Assembly on 10 June 2011. A/RES/65/277. Geneva, Switzerland: UNAIDS; 2011. Available at: http://www.unaids. org/en/media/unaids/contentassets/documents/document/2011/06/20110610_UN_A- MOVING FORWARD in SOUTH AFRICA RES-65-277_en.pdf. 3. Joint United Nations Programme on HIV/AIDS (UNAIDS). Global HIV/AIDS Response. s ICAP transitions program management responsibilities during group training. At the same time, mentoring em- Epidemic Update and Health Sector Progress Towards Universal Access. Progress Report 2011. Geneva, Switzerland: UNAIDS; 2011. Available at: http://www.unaids.org/en/media/ A to IHPS and other local partners, its focus is on consoli- powers individuals to become actively involved in their unaids/contentassets/documents/unaidspublication/2011/20111130_UA_Report_en.pdf. dating the gains its work has accomplished in South Africa, own performance and professional development. 4. UNAIDS. World AIDS Day Report 2011. Geneva, Switzerland: UNAIDS; 2010:7. and identifying specific technical areas that ICAP can continue Available at: http://www.unaids.org/en/media/unaids/contentassets/documents/ ■■ Peer education and support group services improve care unaidspublication/2011/JC2216_WorldAIDSday_report_2011_en.pdf. to contribute to in the increasingly robust response to HIV in and treatment outcomes in two ways: first by educating 5. United States President’s Emergency Plan for AIDS Relief. Washington, DC: US South Africa. ICAP has established itself as a respected source Agency of the Global AIDS Coordinator, Bureau of Public Affairs, US State Department. people living with HIV about what they can do to maxi- Using science to save lives: latest PEPFAR results. Available at: http://www.pepfar.gov/ of HIV technical expertise and has earned a reputation for results/index.htm. mize their clinical and psychosocial outcomes, and second collaboration and innovation. Several lessons learned during 6. UNAIDS. UNAIDS Report on the Global AIDS Epidemic 2010. Geneva, Switzerland: by reducing the stigma associated with HIV, which in UNAIDS; 2010. Available at: http://www.unaids.org/globalreport/Global_report.htm. implementation of MCAP, ICAP’s largest program in South turn increases uptake of counseling and testing services. 7. The World Bank . Washington, DC: The World Bank. South Africa: Country Brief; Africa, will inform future work by ICAP and IHPS: September 2010. Available at: http://go.worldbank.org/GSBYF92330. ■■ Supporting longer-term training initiatives (such as the 8. Eastern Cape Department of Social Development. Socio-Economic and Demographic ■■ In order to break down barriers to access, programs must Profile. 2010. Available at: http://www.socdev.ecprov.gov.za/documentscentre/Eastern%20 two-year pharmacist-assistant apprenticeship course) re- Cape%20Demographics/Eastern%20Cape.pdf. focus both on strengthening health services and on creat- quires considerable investment but also leads to longer- 9. Peters AC. WHO Three I’s Meeting: Infection Control [PowerPoint presentation]. ing supportive, community-based systems. Pretoria, South Africa: CDC South Africa; 2010. Available at: http://www.stoptb.org/wg/ lasting, systemwide improvements that benefit future tb_hiv/assets/documents/MeetingDocs4/A_Peters_Implementing_IC_in_South_Africa.pdf ■■ Forging improvements in service quality that are sustain- care and treatment patients. 10. World Health Organization (WHO) and UNAIDS. Towards Universal Access: Scaling Up able requires structured, collaborative mechanisms for Priority HIV/AIDS Interventions in the Health Sector. Geneva, Switzerland: UNAIDS; 2008. ■■ Collaboration with local health departments during all Available at: http://www.who.int/hiv/pub/towards_universal_access_report_2008.pdf. analyzing and responding to challenges, in which all phases of planning and program implementation re- 11. WHO and UNAIDS. Towards Universal Access: Scaling Up Priority HIV/AIDS team members have a voice. Interventions In The Health Sector. Geneva, Switzerland: UNAIDS; 2010. Available at: quires substantial time, but contributes to making those http://whqlibdoc.who.int/publications/2010/9789241500395_eng.pdf. ■■ Mentoring health care workers is an effective way to programs more strategic, more sophisticated, and more 12. Consequently, ICAP chose to convert its East London office into a regional office, start a central office in Johannesburg, and establish additional regional offices in Port Elizabeth, reinforce knowledge and skills that have been acquired sustainable over the long term. Port Edward, Kimberley, and .

20 f ICAP in south africa Report design by Erin Dowling Design