A diverse group of non-governmental organizations (NGOs), funded by the United States President's Emergency Plan for AIDS Relief (PEPFAR), presented their first year’s progress at a satellite conference of the 2nd South African AIDS Conference in Durban. Funded projects focused on providing aid to orphans and vulnerable children, `faith-based` HIV prevention services, voluntary counselling and testing services, collaborations with traditional healers, operational research into the long-term success of PMTCT programmes, nurse-driven antiretroviral therapy, and antiretroviral treatment delivery in an antenatal clinic.
According to Dr Gray Handley, medical attache for the United States embassy in South Africa, PEPFAR is 'partnered' with 76 primary partners and 153 sub-partners throughout South Africa's nine provinces. The partners include faith-based, community-based and non-governmental organizations, government, academic institutions, as well as public/private partnerships. Several addressed the audience at the satellite conference.
Nurturing Orphans and AIDS for Humanity (NOAH)
Niven Postma of NOAH began by thanking PEPFAR for helping her organisation dramatically scale up its community-based model of care for orphans and vulnerable children. "We're moving into the second year of the grant now with 44% of our "ark" being PEPFAR funded."
"The weight of what we are saying: one million children actually gets lost. How do you come up with a model to reach so many children and reach them in an effective way in their communities? And the problem is just going to get worse over the next five to ten years." She also noted that they don't use the strictest definition of orphan, because AIDS has made many children in the community more vulnerable.
So how do you reach these children in their communities? "We can't direct community development so we look for communities that are already doing things and offer them support." For the community-driven approach to work, communities need to have three features (or pillars):
- A committee of community leaders: "if you go to the influential people in the community, you can make things happen," said Postma.
- A group of volunteers.
- Some sort of resource centre (NOAH often uses local schools).
She noted that the latest estimates suggest that only "10% of orphans are living in child-headed households. That means that 90% of them are being taken care of by someone else or by the extended family. How do you account for 900,000 children being taken care of by the family? Those families need as much support as possible."
NOAH is partnering with schools throughout South Africa to provide daycare/aftercare, homework supervision and to provide children with food aid. All of this, she says, helps to alleviate the strain of extended family caregiving "so that when they go back to the family that is providing care for the orphan, it’s really just a case of brushing their teeth and putting them to bed."
NOAH has set up 22 resource centres (although Postma said more are required to reach to younger children), they have screened 18,600 children, registered 12,000 children and are currently providing services to 2,972 children on a daily basis.
"How do you build some kind of future for these children: we need to help them find something to live for,” Niven Postmas asked. She noted that successful people have three things in common: they have something to do, someone to love, and something to look forward to. To give that to these kids, she said, they would have to follow US President Woodrow Wilson's example when he said: "Not only do I use all my brains, but I use all the brains that I can beg, borrow or steal."
Hope Worldwide
Hope Worldwide (HW) is a faith-based organisation that has been working for years on community mobilisation and HIV prevention (including condom distribution) in Kenya, Ivory Coast, Nigeria, and at 50 local sites in South Africa.
"Despite the distribution of condoms the epidemic continues to progress rapidly," Roger Dickenson of HW told the audience. So with PEPFAR-funding, HW is focusing on behavioural interventions based upon the ABC approach within the communities. One project focuses on "men as partners," in an effort to reduce risk-taking behaviours and gender-based violence.
HW also has a high-risk area programme that focuses on community outreach in the townships or informal settlements. For example, HW is trying to intervene "in the informal settlements where we would find a high number of single women, who were not necessarily involved in commercial sex but who would engage in transactional sex for money for rent or food." This programme also performs outreach in clinics, and has a door-to-door campaign where they talk to people on a one-on-one basis.
In schools and churches, HW is partnering with the Departments of Health, Education and Social Development on an "Abstinence, Be faithful-based programme targeting Youths" (ABY) for individuals aged ten to 24. ABY, said Dickenson, aims "to promote abstinence as an equal option to condoms, not as a panacea or a holy grail."
Nevertheless, some in attendance criticized the ABC/ABY approach to prevention. One audience member said ABC had failed to produce results in South Africa. “The church has been trying to preach sexual abstinence and fidelity for millenia” and yet infidelity and babies born out of wedlock remain common. The majority of South Africans and people from Botswana consider themselves Christians, yet these are the nations with the highest HIV prevalence. Another member noted that being faithful does not protect a woman from an unfaithful partner.
New Start VCT Services
Miriam Mhazo, programme director of the Society of Family Health (SPH), described the New Start (not-for-profit) Voluntary HIV Counselling and Testing (VCT) service, which she says uses social marketing to create demand. PEPFAR funding has helped New Start set up a network of high quality VCT sites (currently there are three in the city centres of Durban, Johannesburg and Cape Town) as well as a new mobile VCT clinic service to complement the Department of Health’s testing efforts.
The tests cost 25 Rand (~$4) at the stationary clinics (though the service is offered even if the client cannot afford to pay), 120 Rand (~$20) when the mobile clinic goes to a business, but is free whenever the mobile clinic is stationed outside of a community. Since being established late last year, the clinics have seen 3326 clients, of which 98% chose to get tested and 21% have been HIV-positive. Uptake has increased substantially since TV ads for the service began running in April this year.
In the future, they hope to franchise their standardised testing procedures to non-governmental organisations, and perhaps to offer CD4 cell count monitoring and sexually transmitted infections (STI) screening and treatment.
Biomedical and Traditional Healing Collaboration on HIV/AIDS
One of the most unusual PEPFAR projects is at the Nelson R. Mandela School of Medicine, University of KwaZulu-Natal. This project is fostering collaboration on HIV/AIDS between western and traditional medical practitioners (this project will be covered in a separate AIDSMAP article).
Good Start Study - an operational effectiveness study of PMTCT in South Africa
Dr Mark Colvin presented a first glimpse of the first large study to evaluate the actual effectiveness of South Africa’s national programme to prevent the mother-to-child transmission of HIV (PMTCT).
The study found that transmission and survival varied greatly depending upon whether the PMTCT sites were in resource-poor or relatively resource-rich parts of the country. This research was presented in greater detail later at the South African AIDS conference and will be reviewed in a separate article on PMTCT and infant feeding studies.
The Vulindlela CAT Project
South Africa is a large country, and many of its people with HIV live in remote rural areas that cannot always easily access the government’s accredited antiretroviral treatment clinics. According to Dr. Terence Moodley of the Centre for the AIDS Program of Research in South Africa’s (CAPRISA’s) AIDS Treatment (CAT) programme, there is an inherent difficulty in obtaining medical staff in remote areas.
Vulindlela is one example of these poor communities in the rural midlands of KwaZulu Natal, about 140 km west of Durban, where the HIV prevalence is 41%.
However, Vulindlela does have access to comprehensive primary healthcare services largely administered by nurses. Consequently, with PEPFAR assistance, CAT launched a project in Vulindlela to see whether a small primary health group with four nurses and one doctor; access to one pharmacist; counsellors and an administration, could successfully roll out ART in this community.
Nurses are responsible for pre-screening, counselling and testing, follow-up, investigations and referrals. The doctor screened patients to see whether they were ready and qualified for ART, and wrote the prescriptions.
So far, the project has screened 950 HIV-infected patients.Of these individuals, 239 were eligible, and 212 have initiated ART (a once daily regimen of efavirenz/3TC/ddI).
Of those initiated on HAART, the median baseline CD4 cell count was 97 cells/mm3 (27.2% had CD4 count below 50 cells/mm3; 24.2% of participants had a history of TB and 9% are currently on treatment for TB). The average age was 33.8 years old (range 15 - 55). A total of 84.8% were unemployed, 65.6% lived in mud huts, and about a quarter of the group had no access to electricity or running water.A total of 73.3% of the participants were financially reliant on a family member, who was in turn reliant on state social grants (50.5%).
This model has worked to deliver treatment in this rural setting, and while the majority are benefiting, among some of the most ill individuals, there has been a paradoxical deterioration following ART due to TB-related immune response inflammatory syndrome (IRIS). They have also observed a number of adverse events related to efavirenz (Sustiva).
Rolling out ART in an antenatal clinic
Another challenge of the rollout in South Africa is getting pregnant women who need ART for their own health into “rollout” sites before childbirth. Sometimes it just isn’t possible. As a result, one of the most successful PEPFAR funded projects (in collaboration with Reproductive Health Research Unit (RHRU) of the University of Witwatersrand) is a pilot ART clinic in the obstetrics department of an antenatal clinic. So far, this project has placed 184 women onto treatment. This study and other efforts to improve treatment options for pregnant women with HIV will be covered in an upcoming article on www.aidsmap.com.