The programme package for the community component included HIV Testing Services, Track and Trace of Early Missed Appointments and Unconfirmed Lost to Follow Up and Adherence Clubs. The APACE KI program began 1 October 2018 in the Cape Metro and it included the Clinical and Community Components. This report covers only the community component. Recruitment, training and inductions of staff for the programme commenced in Q1 (Jan –March 2019). Full programme implementation commenced from 1 April 2019 to the end of the year. Data presented in this report covers Q2 (April –June 2019), Q3 (July –September 2019) and Q4 (October –December 2019).
The report covers activities and achievements of the following programs:
During the reporting period KI supported 26 Siyenza sites and 4 non-Siyenza sites in the Cape Metro. The focus of the program was on case finding activities, which included Index Case Testing (ICT), targeted testing to reach men and youth via community hotpots, TVET colleges and workplaces with supervised HIV Self Screening offered at pilot sites. In Q2, KI contracted Africa Centre as a Sub Recipient to assist with case finding. The data presented is inclusive of the Africa Centre data for Q2.
In the reporting period a total of 74 752 clients were tested, with 3,151 testing positive giving a yield of 4.2%. Targeted outreaches to reach men and youth contributed significantly to the total HIV positives. Facility ICT done in community and community ICT done in adherence clubs did not happen as planned due to challenges and hence affected case finding performance. TVETS and Work Place testing produced low yields.
Throughout the reporting period, the KI team actively supported efforts to link all clients to treatment. In Q2, KI provided transport for HIV positive service users for ART initiation at the nearest facility. KI Community Testers and Linkers undertook follow-ups with all clients referred to facilities for treatment initiation to ensure successful linkage and provided support where needed.
Through the APACE program KI supported the facilitation of adherence clubs (AC) in 15 PHC sites in the Cape Metro. KI assessed three outcomes: retention in care, retention in club care and viral suppression. In 2019, a total of 1,136 Adherence Clubs were being supported by KI with a total of 27802 service users remaining in clubs by the end of December 2019. The overall decanting percentage was 41%. The decanting percentage was however still lower than the 50% of the decanting WCDOH target. By end of December 2019 the viral load analysis showed a VL suppression rate of 99% for clients that had their VL test done and recorded in the Club Register (31,6%) at 12 months after adherence club enrolment. Critically, 90% of patients retained in clinic care at 12 months were still receiving their care in adherence clubs, suggesting a high level of satisfaction with the service delivery model.
Northern and Eastern districts in Western Cape.
Kheth’Impilo continued to implement the integrated home and community based care programme with WC DOH as its funder during the reporting period. During 2017, the WC DOH introduced the concept of Community Orientated Primary Care (COPC) to their staff and strategic partners. This COPC concept, which informed the services provided by the KI programme during this period, is both a philosophy and methodology that assists the Health Department in strengthening the more preventative and promotive aspects of its services within community-based settings.
The WC DOH contracted Kheth’Impilo to implement a programme rendering health services to address the assessed health needs in Kraaifontein, Scottsdene, Macassar, Mfuleni and Eersterivier according to the following objectives:
• Self-management &/or psychosocial rehabilitation interventions;
• Nutrition interventions;
• Rehabilitative care;
• Palliative care;
• Wellness &/or counselling interventions that complement both facility &/or community-based services.
The home- & community-based services are implemented in the allocated and defined geographic area together with the main referral Primary Health Care facility. In March 2019, WC DOH informed KI that it allocated the Mfuleni site as part of the KI implementation area.
Home- and Community-Based (HCB) services are provided to patients in their own home or an alternate living environment offering individual assessment and interventions supporting admission avoidance, faster recovery from illness, timely discharge from hospital and achievement and maintenance of optimal functioning. Wellness, health promotion and prevention of ill health consists of an array of interventions that support the actions people take to maintain health and wellbeing, prevent illness and accidents, care for minor health problems/ailments and long term conditions. HCB services include screening and referral (where applicable); assessment; care planning; interventions/treatments; and monitoring & review.
Kheth’Impilo worked to include components of the COPC concept in the HCB implementation of the programme. The aim of the COPC concept is to re-orientate health services from not only reacting when people become ill enough to present themselves for care, but to proactively look at a whole community and addressing the most important challenges together with community members and organisations. This approach means promoting health and carrying out more preventative interventions at household and community level, as well as in health facilities.
Previously the WC DOH programme was severely underfunded and staff salaries were underfunded. This discrepancy, including many others, was brought to the attention of the department and this year the department included improved benefits for staff members such as uniforms.
Achievements: across all the areas of implementation, KI managed to achieve the allocated set targets for the programme.
The WCDOH programme included the provision of counselling services in both facility and community settings. Staff members were allocated to the various nodes identified by WCDOH. WC DOH also informed all NPOs that this category of staff was only to be employed through 31 March 2020 for operational reasons.
Sarah Baartman and Chris Hani districts in Eastern Cape
KfW, a German donor, through the Foundation for Professional Development (FPD) supported the Community Based HIV (CB-HTS) Testing program that KI implemented in the two Eastern Cape districts of Sarah Baartman and Chris Hani.
For this programme, KI as a consortium member of the KfW programme covered the mentioned two EC implementation districts of the programme. Other consortium partners covered Mpumalanga and two further EC districts of Nelson Mandela and ORT. The focus of the KfW programme was to identify people living with HIV within community settings and to link them to treatment in alignment with UNAIDS 90-90-90 strategy which the South African government fully adopted as a measure of progress in its HIV response. For the KI component of the programme a total number of 103 identified facilities were supported within the KI allocated districts - namely, 41 facilities in Sarah Baartman and 62 facilities in Chris Hani. These facilities were the entry points for all programme services that were provided in the targeted communities that included being a source of HIV index clients, resource for testing kits and to support the linkage to care for identified HIV positives.
The programme utilized multiple modalities and strategies to ensure the achievement of set goals. Some of the modalities included index case trailing (ICT), workplace testing, twilight, mobile testing and home based-HTS. Home based testing was at the centre of all HTS services that were offered by the programme due to its nature of being easier to enter a community and being less complex to navigate. Through the index client trailing modality, the programme positivity yield ranged between a minimum of 4% to a high of 38%. The programme approach also varied between the districts due to their geographical differences that fundamentally influenced community programming. An example of this included work place testing being prioritised in the Sarah Baartman district as the district was at the centre of commercial citrus farming in the Eastern Cape Province.
Achievements: In summary, the programme managed to test 218,519 clients, representing 82% of the final grant target of 267,270 through 30 June 2019. This programme achievement is in line with what other organisations are achieving implementing similar programmes and as reported by EC DOH at the last KfW programme review meeting in June 2019.
Investing for Impact against Tuberculosis and HIV (Phase III)
The Global Fund (GF) programme implementing the Investing for Impact against Tuberculosis and HIV (Phase III) programme with KI as Principal Recipient (PR) ended on 31 March 2019. The programme was implemented the programme as one of the eight PRs for GF with specific focus on adherence support, service provision to young women and girls (YWG) and the provision of specific support to department of basic education (DoBE). The programme was implemented in nine (9) districts across three (3) provinces (KwaZulu Natal, Eastern Cape and Western Cape) and with specific support to the national department of basic education. KI implemented the following activities under this program:
• Provision of a comprehensive package of health, education and support services for young women and adolescent girls, in and out of school, age 10-24, aimed at implementing life skills education, behaviour change and empowerment for young women and girls, through the peer-education youth club model (in and out of school);
• Targeting parents of young women and girls, and adolescents who bear the responsibility of parenting to equip them with the necessary skills;
• Strengthening the ability of schools to identify and support vulnerable children and mobilise resources in the school and community;
• Providing adherence intervention model for people living with HIV through community/local level interventions based on a patient-centered, customizable (differentiated) adherence support and adherence club approach.
The target group/beneficiaries of the Global Fund Program include: young women and girls; adolescents and youth, (in and out of school); community based organisations; other vulnerable populations; and ART patients.
Delivery of this component of the programme was through a community/local level intervention based on a patient-centered, customizable adherence support. This involved psychosocial support and enhanced adherence-counselling systems that address the causes of adherence risk and non-adherence on an individual-level and multi-session time-limited intervention for people recently diagnosed with HIV.
At the end of the adherence programme KI was supporting over 200 DOH facilities reaching a total of 339,959 (97%) ART patients with adherence support and 88.9% with suppressed viral loads.
Adherence Programme: The KI treatment care and support (Adherence) component was aligned to SA National Strategic Plan for HIV, TB and STIs 2017–2022, which aimed to accelerate progress towards meeting the fast-track targets by: (1) reducing new HIV infections; improving treatment, care and support; reaching key and vulnerable populations; and (2) addressing the social and structural drivers of HIV, tuberculosis and sexually transmitted infections.
Lessons learned from implementing the Adherence programme component included the following:
• Patients see the option to pick up more months of medication at more convenient locations as a key strength of interventions. KI believes that this will improve adherence. Further, it is important to ensure that issues of staffing and medication delivery logistics be resolved prior to implementation.
• Patients enrolled in adherence clubs of the DMD reported high satisfaction with these services in terms of convenience and saving time. These patients were able to frequent the clinic less often and there was a perception of improved quality of care amongst adherence club members.
• Information sessions on viral load testing and strengthening of beneficiaries knowledge of the results was appreciated by most club members. Requests received were for off-site laboratory blood test and clinical consultations. Patients were not appreciative of blood drawn and test results being lost causing tests to be repeated unnecessarily.
Prior to AGL introduction in a clinic, it is important to address some of the perceived clinic-level barriers to adherence, ensuring site readiness and sufficient resources so that providers feel engaged and empowered to implement the interventions and address the issues of clinical staff attitudes towards patients and the recruitment of eligible patients for DMD medication scripting resolved.
The KI’s home-based ECHS program targets HIV affected caregivers and children between 0-5 years of age who are unable to access centre-based ECD services. Key components of the KI home-based ECHS model include caregiver training, facilitation of age-specific playgroups, setting-up caregiver Circles of Support (CoS), mentoring and debriefing of Home Visitors and mobilizing community support. The project supports the development of children <5 years through improved parenting and child development skills within HIV affected households, while also addressing psycho-social and economic barriers that adversely affect early childhood development.
The objectives of the programme include the following:
1. To increase the number of children between the ages 0 - 5 years who receive physical, cognitive and emotional stimulation in their household during early childhood;
2. To strengthen parents / guardian and caregiver capacity to provide a positive relationship and a developmental environment that promotes early childhood development;
3. To build the capacity of organizations to enable them to provide good quality ECHS supervision and support services.
The programme covered the following geographic areas within the two districts:
EThekwini Ntuzuma G, Newtown A, Mshayazafe, Amaoti Namibia, Besta, Ezimangweni, Dube Village, Bhambai, Ohlange, & Stop 8, Kwa – Mashu Section A,B,C and D, section P, J,K,M, Mancinza, Siyanda and Ntlungwana
Msunduzi Copseville, Honeyville, Swapo,Ezink etheni, France, Eastwood, Sobantu, Mbali, Snathingi, Pata, Thamboville, Thembalihle, Cinderella and Mpolweni
KI has contributed to linkage to care and treatment cascade of 95-95-95 by reaching 99.9% of first ‘95 as total of 3,976 OVC who knew their HIV status. Second ‘95 had been reached by 100% of the OVC that tested positive and who were linked to care and initiated on ART. KI further also successfully aligned the ECHS programme to UNICEF 95-95-95 objectives ensuring that all programme beneficiaries knew their status. All beneficiaries that tested positive (1,384) under the programme were also linked to care and of which 1,346 OVCs had suppressed viral loads. This represents a 97.3% suppression rate using all the viral load results reported under 1000 copies/ml.
Pregnant mothers living with HIV/AIDS were enrolled into the programme and KI reports that all children were delivered without HIV. This result was achieved through ongoing educational support and follow up by KI case finders at the facilities and at home.
Programme Achievements: KI successfully managed to reach 7,486 which totals 125% of the set target for OVC serviced (OVC_SERV) at the end of this implementation period. Coordination between KI M&E and programme departments allowed for successful achievement of results. Beneficiaries as per the OVC sub-populations (HIV positive children, HIV-exposed infants, biological children of female sex workers, children living with HIV-positive caregivers and children exposed to GBV) were all served with programme services.
KI also strengthened support groups for children living with HIV/AIDS within facilities. This was a change from the previous home-based focus of service provision linked to the establishment of play groups in a home setting. However, the programme still noted a decline in children with high viral loads as the management of HIV/AIDS through psycho-social support that impacted the families receiving programme support.
KI maintained a good working relationship with all DSPs and further strengthened successful working relations with DOH facilities and other stakeholders by actively participating in and attending war room and nerve centre meetings. The employment of a linkage officer who is an enrolled nurse as part of the KI programme improved communication between DOH nursing staff and the KI programme.
The KI ECHS programme was set a target of reaching at least 20% of CLHIV. KI was able to reach total of 1,384 (20%) HIV positive children. KI achieved this target by retaining and supporting HIV positive children carried forward from the previous year. KI also targeted positive children in clinics with high TROA (total remaining on ART) numbers within the respective districts of EThekwini and Msunduzi.
A total of 47% of the total beneficiaries reached were caregivers who were offered education support at the facilities with emphasis on the themes of Basic HIV/AIDS education and facts. KI rendered educational support as well as awareness on the concepts of viral load, adherence as well as gender based violence.
KwaZulu-Natal (KZN) province of South Africa has one of the highest HIV prevalence rates amongst women attending public sector antenatal clinics of all the nine provinces of South Africa at 41.1%. The ILembe district within the province ranks the fourth highest rates (43,1%) of all the districts if SA. The district has higher levels of teenage pregnancy relative to the provincial and national rates.
As part of the Health and Community Systems strengthening support provided to the Government of South Africa, particularly with respect to HIV, TB and non-communicable diseases, Kheth’Impilo implemented a school-based service-linked Sexual Reproductive Health and Rights (SRHR) program to underserved adolescents in a rural, high HIV prevalence sub-district, Ndwedwe, four years ago.
KI established a support group for pregnant or parent learners to keep girls in school, reduce HIV risk and to improve the maternal and child health outcomes. For the period, 90% enrolled in antenatal care. All pregnant learners enrolled in antenatal care were HIV tested. The overall teenage pregnancy rate was reduced from 14% in 2014 to 1.4% in December 2019. A total of 77 learners were on ongoing ARV care and support and 70 % were virologically suppressed. With respect to the SRHR modules, 85% of learners were reached, and a total of 8,931 individual & group school-based counselling for HIV, STI & SRHR sessions were provided by the roving teams. The cumulative uptake for contraceptive services was 54%. KI has continuously engaged with the National Departments of Health and Education with regard to the implementation of the SRHR Integrated School Health Policy, in the context of policy, strategy, and implementation at the district levels. KI delivered training to educators and offered SRHR training during the school holidays to 87 grade 9 learners within the district in collaboration with the Department of Education. A total of 536 learners were successfully assisted with acquiring identity documents.
The program model is premised on the National Integrated School Health Policy (ISHP) of South Africa (SA), which involves key sectoral partners such as the Depts. of Social Development, Health, Education, Community-Based Organizations (CBO) and the private sector to deliver integrated SRHR services. The goal of this project is to reduce the HIV/STI infections, unintended pregnancies and to improve SRHR service uptake including HIV treatment care and support for high-school learners. The project integrates these services by leveraging-off the school as a platform to deliver comprehensive HIV prevention, treatment, care & support services. A team comprising of social workers, social auxiliary workers (SAWs), nurses and primary health care staff deliver these services and is supported by a roving technical team. The key program outputs covers the period January 2019 to December 2019. A total of 7,500 recipients (target n=6500) were reached. A total of 10,644 visits were made to the school-based and clinic-based services, with 13% of these being first-time visits. The cumulative proportion of learners seeking SRHR services for the first time was 92%. The cumulative uptake of HIV Testing Services was 63% in December 2019.
KI trained and delivered with the Ndwedwe Municipality a SRHR jamboree reaching over 600 learners in December 2019. As part of the community strengthening strategy, 13 high-school graduates, who were previously recipients of our program through KI’s mentorship, were enrolled into a post-matric programme to train as Youth Health Workers and Social Auxiliary Workers. This is the cadre of staff who can deliver the SRHR program. This training initiative was funded by the National Skills development framework of SA. All 13 learners graduated from the program, 7 of these secured further funding to pursue higher-level university degrees in finance and social work. The remaining were supported by KI to enter the labour market as health and social welfare cadre.