Kheth’Impilo started implementing the USD85,000,000 (estimated R.1 billion) 5-year APACE programme with effect from 01 October 2019 in both the Western and Eastern Cape provinces. For this programme, KI prioritized targeted, validated, efficient and comprehensive HIV and TB prevention, case finding, treatment initiation, retention and adherence, with interventions differentiated for population and location. An appropriate mix of staff cadre and local public and private partners delivered on two critical outcomes, namely: 1) achieving epidemic control in supported facilities in across the districts and 2) strengthening health and community systems at district, provincial and national levels. The program had 4 Components which was detailed as follows:
Preventing new HIV infections and reducing HIV morbidity and mortality through an improved
and sustained HIV and TB Continuum of Care.
The three (3) result areas included the following:
Result 1: Increase the proportion of PLHIV who
know their status;
Result 2: Increase the proportion PLHIV who are
Result 3: Increase PLHIV who are virally
Strengthening Provincial Health Systems. This support was only provided to Western Cape Province.
Strengthening District Health System (DHS) to support of the HIV/TB Continuum of Care. This component will be implemented in both BCM and CoCT through Health Systems Strengthening (HSS) focusing on:
• MER systems
• Pharmaceutical systems
• Human resource systems
Strengthening National Health Systems.
The support to be provided will focus on:
• National Adherence Guideline
• School-Based HIV/SRHR services
Additionally, this programme included clinical and community components and staff were recruited to ensure programme outcomes are achieved. After five (5) months (end March 2019) of implementing the programme, USAID informed KI that the Western Cape clinical component of the programme be transferred in full to ANOVA. Through negotiations with both USAID and ANOVA it was agreed that KI could continue with implementing the community component of the APACE programme in Western Cape.
Kheth’Impilo (KI) pharmaceutical services aspire to improve Health systems through three focus areas. These focus areas include improvement of good pharmacy practice and supply chain management, the development and implementation of differentiated models of care, promotion of pharmacovigilance and training through existing models as well as ongoing innovations.
As part of improvement of pharmacy and patient care, KI employed roving pharmacists and post basic pharmacist assistants (PBPAs) take responsibility to support primary healthcare facilities in the quality provision of essential medication and good pharmacy practice (GPP) according to the national core standards and essential medicine lists.
In 2014, the KI Pharmacy Department implemented a quarterly assessment tool, which focus on; Supply Chain Management (SCM) and Good Pharmacy Practice (GPP) compliance; the availability of essential medication; security of medicine storage
areas; cold chain management; quality of pharmacy and patient related documentation and facility decongestion strategies.
Roving pharmacists focus their mentoring and support efforts at clinic level on gaps identifies
during the quarterly audits.
From the time KI implemented the quarterly
quality assessment tool, to project completion,
the assessment results from four districts, indicates that quality of specific focus areas improved from 58% to 80%.
Sub-Saharan Africa (SSA) has 25% of the world’s HIV disease burden but only 1.3% of the world’s health workers. This shortage of human resources for health is a critical limitation to the provision of antiretroviral treatment (ART) to those in need of it in SSA, the region having the highest burden of HIV globally. The lack of qualified human resources is a major challenge to meeting the United Nations three 90's targets for testing, treatment coverage and viral suppression.
Pharmaceutical services also experience staff shortages and workload pressure, particularly as the ART programme has expanded rapidly during the last two decades. Additionally, hospitals, community health clinics and some primary healthcare clinics have pharmacists; though, the rest of the clinics, medicine is managed and dispensed by nurses or post-basic pharmacist assistants (PBPAs). The African region has the lowest density of pharmaceutical staff worldwide. Pharmaceutical care is an important component of the ART programme. To address this critical shortage, Kheth’Impilo embarked on a pharmacist Assistant Learnership programme with start-up funding from the Elton John AIDS Foundation (EJAF) in 2011.
In conjunction with the work done to improve medicine management and quality of medicine storage at facility level, KI supports the decanting of clients into a variety of differentiated models of care (DMOC) to improve access to medication and patient experience. Since 2010, KI supported the development and implementation of adherence clubs in the Eastern Cape, KZN and the Western Cape. KI supported the implementation of the CCMDD program and Fast Lanes in KZN and the Eastern Cape. In the DRC and Burundi KI – as part of the EQUIP consortium – KI supported the development and implementation of medicine points of distribution (PODIs) and in Zimbabwe Community ART (CARGs) groups.
In the first 7 years of the KI Pharmacist assistant Learnership, 513 young South Africans, mostly from marginalised communities, earned a Post Basic Pharmacist assistant qualification. With this qualification, the majority of these learners are working in the public health sector as pharmacist assistants. Based on the entry-level salary for a pharmacist assistant with a two-year qualification, these learners earn more than R79 million rand every year. Earnings they use to support whole families. The total cost of the Learnership during the seven years was approximately R71 million. The KI EJAF pharmacist assistant learners showed a 95% completion rate.
During the period that EJAF, later with great contributions from the USAID, HWSETA and SASSIX, funded the KI pharmacist assistant learnership, 1006 learners received a national accredited qualification (Basic and/or Post basic). 491 qualified as basic pharmacist assistants and 515 as Post Basic Pharmacist Assistants (PBPAs). A further 20
learners are in training at time of publication.
Because these learners work in public health
facilities from day one of their vocational training, they form part of a multidisciplinary team that supported more than 657 864 patients per month
of whom more than 133 643 were on ART at any
The project was implemented by Kheth’Impilo with technical and implementation support provided by partners Pulse Health Solutions (Pulse), Amity Health Consortium (Amity) and Jembi Health Care. The project aimed to strengthen capacity for the implementation of Advanced Clinical Care (ACC) services and referral systems covering three provinces, namely, Free State (FS), Gauteng (GP) and Mpumalanga (MP). Across these provinces, 9 districts were served – five (5) in Free State, two (2) in Gauteng and two (2) in Mpumalanga. The programme ensured the delivery of quality care to patients at high risk of morbidity and mortality due to advanced or complicated HIV and TB.
The project had four objectives which were the same across all three provinces with some variations in the implementation as a result of Provincial preferences, needs and capacity.
1. Establish and/or strengthen three Regional Centres for Advanced Clinical management of HIV/TB in adults and paediatrics– including failure on 2nd and 3rd line.
2. Establish and or strengthen up- and down-referral systems from PHCs and district hospitals to these referral centres.
3. Build and support the capacity of DoH
facility staff at district and PHC level to manage patients –through training, mentoring and coaching.
4. Transition ACC activities to DOH.
Programme success included:
• The number of district hospitals providing ACC services went from 0 – 21 during the lifespan of the program.
• Supported the establishment of referral pathways and processes to 224 health facilities (PHC and CHC).
• Under these ACC sites, services were extended to 224 PHCs through referral pathways and teleconsulting services.
• Improved Rate of Switching from 1st to 2nd Line through facilitated improved management of 6,624 individuals who had 2 consecutive unsuppressed viral loads. 5,328 of these switched to second line regimen over a period of 4 years with the others provided with enhanced adherence support.
The KI technical approach had four-prongs to facilitate the expansion of the ACC programme
1. Collaborate, build upon and leverage the experience and expertise of clinical staff in the Provincial Departments of Health (PDoH) the PEPFAR-funded District Support Partners (DSPs) already working in HIV & TB programmes.
2. Capacity building of DOH and DSP clinicians (nurses and pharmacists) through training and onsite targeted expert coaching & mentoring.
3. Clinical care quality improvement for patients through clinical ward rounds to review complicated cases, the provision of TA in the management of identified complications as well as targeted clinical chart audits.
The programme utilized existing DOH health information systems (Tier.Net, EDR Web) and National Health Laboratory Services (NHLS) data including ACC programmatic information to identify and assist DOH and DSPs to manage complicated cases.
• Expanded access and clinical monitoring of HIVDR and Third Line Therapy.
• Decentralization of MDR-TB Management.
• Closing the Loop on Management Patients with CNS Cryptococcal disease.
• Trained 196 doctors; 703 professional nurses, 186 pharmacists and 28 others (clinical associates, OM) from DOH.
• Provided mentorship and coaching to 1870 HIV clinicians on various HIV/TB related complications by KI Quality Nurse Mentors (QNM) and ACC doctors.
• Setup 24 Centres of Excellence and Regional Competent Sites and 387 Primary Care Facilities.
The EQUIP programme commenced activities in Zimbabwe starting October 2016. This was a four year funding grant from USAID. The Permanent secretary in the Ministry of Health and Child Care gave authority for EQUIP to start operating in country in November 2016. The Director of the HIV/AIDS/TB unit at the Ministry of Health and Child Care (MOHCC) introduced EQUIP to implementing partners. At the start of the programme MOUs for CARGs implementation were signed with the Rural District Councils of Mberengwa, Beitbridge and Bulilima.
EQUIP implemented the activities outlined in the approved work plan. EQUIP Zimbabwe’s work was a combination of Technical Assistance (TA), demonstration projects and direct service delivery (DSD). Technical assistance was in the form of data analysis of a package of interventions by USAID funded implementing partners. Organization for Public Health Interventions and Development (OPHID) was the facility partner, while Population Services International (PSI) and FHI360 were the community-based partners. Direct Service delivery (DSD) was done through implementation of Community Antiretroviral Refill Groups (CARGs) in 3 districts. The demonstration projects implemented were the Chitungwiza viral load scale up, multi month scripting and dispensing (MMD) evaluation. DSD implemented was CARGs in the community in 3 high HIV burden districts of Beitbridge, Bulilima and Mberengwa.
4. Implementing differentiated models of ART delivery in rural and urban health facilities through CARGs within Zimbabwe.
5. Determination of the costs of implementing the different models of MMSD in the different settings;
6. Introduction of HIV self-testing (HIVST) to increase HIV diagnosis for partners and household contacts of CARG members, who would not have been tested and linked to care and treatment, after testing positive for HIV infection.
EQUIP work encompassed several performance areas:
1. Implementation of the Accelerated Remediation Plan (ARP) to support the roll out of Treat All, through the expansion of high yield testing models for universal access to testing and the accelerated scale-up of ART coverage in 32 high burden USAID-supported facilities. Implementation of ARP has been in accordance with the Government of Zimbabwe’s “Test and Treat” strategy under the Zimbabwe National HIV and AIDS Strategic Plan III 2017 - 2020.
2. Supported the implementation of multi-month scripting and dispensing (MMSD) in 30 selected facilities and models of community ART delivery at facilities in Zimbabwe in non-MMD/CARG study sites. This includes a DSD subcomponent for the delivery of ART through CARGS in 3 districts (Bulilima, Mberengwa and Beitbridge);
3. Expansion of site level viral load monitoring to ensure the achievement of the 3rd 90 in Chitungwiza City.
The Health Systems Strengthening Programme provided technical assistance, modified facility and community direct service delivery (DSD,) and capacity building of Health Care Workers (HCWs). These services were provided at 61 facilities in the Metro of the Western Cape Province and 50 facilities in 3 districts of Kwa Zulu Natal Province, 18 in Amajuba, 17 in ILembe districts, and 15 in UMsunduzi sub-district of UMgungundlovu district.
Goal: To improve HIV and TB related Patient Outcomes by Strengthening Health and Patient Management Systems to achieve the 90-90-90 targets.
(i) To support the implementation of strategies which contribute to achieving the 90-90-90 targets.
(ii) To support the implementation of the PMTCT program that prevents new pediatric HIV infections towards achieving zero transmission.
(iii) To support the reduction of new TB infections as well as deaths by 50% .
(iv) To increase retention in care of those on treatment with a target of 70% retention in care after 5 years on treatment using community support links
KI supported the implementation of Population Effects of Antiretroviral Therapy on HIV Transmission (PopART) trial in eight (8) facilities in the City of Cape Town. The primary outcome of the trial intended to measure the HIV incidence in the communities where the full range of interventions were implemented while monitoring the NDoH 90:90:90 targets for HIV and TB. The facilities were randomised into three (3) arms (A, B and C) to 1 of 3 package of services.
This project was implemented from January 2014 to June 2018. individuals were provided with HTS totalled 202 791 across eight (8) PopART facilities. The positivity rate was 16% (32 704 tested positive) and 20 699 individuals were initiated on ART: 8,320 in Arm A , 6,541 in Arm B , 5,838 in Arm C facilities.
With the ‘Focus for Impact’ 90-90-90 strategy and a reduction in the number of PEPFAR supported districts from 52 to 27 in 2017, KI transitioned out of Amajuba and ILembe districts and focussed programme support to 132 facilities (14 facilities in UMsunduzi SD and 118 in the Metro of the Western Cape through the end of the programme in September 2018.
Over the 6 year period, KI provided HTS to 7 102 762 individuals; identified 625 355 HIV positive clients and initiated 432 285 on ART. Patients eligible for viral load test totalled 375 525 with 91% having documented viral load suppression across supported facilities.
The DREAMS project was implemented from June 2016 to September 2018 in 116 schools (54 Primary and 62 Secondary) in Umlazi South, Kwa-Makhutha & Mbumbulu, in eThekwini district of Kwa Zulu Natal Province. 34 948 (18 983 girls 10 to 14 year old and 15 965 15 to 19 year old) learners completed the 11 educational themes and graduated from the program a project target achievement of 165% for girls 10 to 14 year old and 129% for girl 15 to 19 year old.