South Africa Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

SOUTH AFRICA

Project Title: South Africa Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

Budget Summary:

	Field Programs Funding by Account						Central Programs
	Notified November 2007			Notified February 2008			Notified as of February 2008	Allocations to Date
Implementing Agency	GAP	GHCS - State	Subtotal: Field Programs Funding	GAP	GHCS - State	Subtotal: Field Programs Funding	Subtotal: GHCS Central Programs	Grand Total:  Field & Central Funding
DOD	-	-	-	-	1,250,000	1,250,000	-	1,250,000
DOL	-	-	-	-	-	-	-	-
HHS	-	7,524,000	7,524,000	4,818,000	218,007,638	222,825,638	22,016,823	252,366,461
Peace Corps	-	-	-	-	863,000	863,000	-	863,000
State	-	-	-	-	1,800,000	1,800,000	-	1,800,000
USAID	-	-	-	-	321,327,362	321,327,362	6,862,862	328,190,224
TOTAL	-	7,524,000	7,524,000	4,818,000	543,248,000	548,066,000	28,879,685	584,469,685

HIV and AIDS Epidemic in South Africa:
Adults (aged 15-49) HIV Prevalence Rate: 18.8% (UNAIDS, 2006)
Estimated number of People Living with HIV: 5,500,000 (UNAIDS 2006)
Estimated number of Orphans due to AIDS: 1,200,000 (UNAIDS, 2006)

Country Results and Projections to Achieve 2-7-10 Goals:

Botswana	Total # Individuals Receiving Care and Support	Total # Individuals Receiving ART
End of FY 2004*	599,900	12,200
End of FY 2005**	548,200	93,000
End of FY 2006***	763,200	210,300
End of FY 2007****	1,349,500	329,000
End of FY 2008*****	1,799,960	380,000
End of FY 2009*****	2,272,700	500,000

^* "Engendering Bold Leadership: The President’s Emergency Plan for AIDS Relief.” First Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, March 2005.
^** “Action Today, a Foundation for Tomorrow: The President’s Emergency Plan for AIDS Relief.” Second Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, February 2006.
^*** "The Power of Partnerships: The President’s Emergency Plan for AIDS Relief.” Third Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February 2007.
^**** "The Power of Partnerships: The President's Emergency Plan for AIDS Relief." 2008 Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, January 2008.
^***** Projections from FY 2008 Country Operational Plan

Program Description/Country Context:

Over the past 12 years, South Africa has transformed itself into an egalitarian democracy, aggressively addressing social and economic challenges and the racial inequalities of its apartheid past. Despite a relatively high per capita GDP ($3,480), 40% of South Africans live in poverty. Since achieving democracy, the country’s adult HIV prevalence has risen from less than 3% to an estimated 16% for the 15-49 age group. With 5.5 million citizens infected with HIV, South Africa has one of the highest numbers of infected adults and children in the world. South Africa’s HIV epidemic is generalized and maturing, characterized by: (1) high levels of prevalence and asymptomatic HIV infections; (2) an infection rate that may be beginning to plateau, but is still extremely high; (3) high infection rates among sexually active young people, other vulnerable and high-risk populations (mobile populations, people in prostitution and their clients, and uniformed services), and newborns; (4) vulnerability of women and girls; and (5) important regional variations, with antenatal seroprevalence rates ranging from 15.7% to 39.1% in the nine provinces.

Though 75% of people living with HIV are asymptomatic, South Africa is witnessing increased levels of immunodeficiency and HIV-associated morbidity, frequently manifested by tuberculosis (TB), pneumonia, and wasting. The cure rate for TB is low (56.3% in 2006), and treatment default rates remain high (9.9%), which heightens concerns regarding the development of both multi-drug-resistant TB (MDR-TB), and the more recently seen extensively drug-resistant TB (XDR-TB). 58% of TB patients in SA are co-infected with HIV. AIDS-associated mortality rates are high (336,000 AIDS deaths in 2005), with large increases in HIV mortality among young adults and children. As mortality increases, so too will the number of children who have lost one or both parents, currently estimated to be 3.4 million (an estimated 1.2 million due to AIDS).

In fiscal year 2008, PEPFAR funding will be focused on the following programmatic areas to achieve the 2-7-10 targets:

Prevention: $98,250,585 ($88,488,340 Field; $9,762,245 Central) (18.5% of prevention, care and treatment budget)

Prevention activities in South Africa include prevention of mother-to-child transmission (PMTCT), abstinence and faithfulness programs, blood and injection safety, and condoms and other prevention initiatives. In FY 2008, the PEPFAR PMTCT program will continue to support the national PMTCT program by addressing some of the inherent programmatic gaps in service delivery. These include ongoing support and supervision for health care providers and community health care workers; the promotion of provider-initiated counseling and testing; providing follow-up for mother-baby pairs post delivery; quality improvement; ensuring integration of PMTCT into maternal, child and women’s health services; community outreach and referral into wellness and treatment programs for HIV-infected mothers and exposed infants; and scale-up of early infant diagnosis services. In FY 2008, PEPFAR will work with partners to ensure finalization of policy and guideline development, updating health care workers, and providing site specific support to ensure readiness and implementation of the new PMTCT policy to provide all HIV-infected pregnant women with dual therapy.

USG agencies will support primary prevention activities, with special emphasis on abstinence and being faithful. Through both community-based and large-scale NGO/faith-based organization (FBO) programs, PEPFAR will support young people to delay sexual debut and practice abstinence, faithfulness, responsible decision-making and the avoidance of multiple concurrent partnerships. At the same time, the USG will initiate new prevention activities targeting key adult populations. The lynchpin of these efforts will be a high visibility, multilevel, multi-media campaign to increase understanding of the risks associated with multiple and concurrent partners.

With FY 2008 funding, the USG will significantly expand coverage to populations of persons engaged in high risk behaviors (PEHRBs), with an emphasis on persons in prostitution and men who have sex with men. The USG will significantly increase support to NGO consortia in three major cities that provide linked drug treatment and comprehensive prevention and other HIV services for drug-using PEHRBs and will broaden this activity to include non-drug using PEHRBs. The USG will continue to support ongoing prevention efforts in correctional facilities, with sex workers and clients in inner city Johannesburg and selected mining communities. The USG will also continue to assist the South African National Defense Force (SANDF) in providing comprehensive coverage of the armed forces, with special attention to the role of alcohol in sexual risk-taking.

The USG will also expand programming for alcohol abuse; intensify prevention for migrant and mobile populations; target the 11 “high transmission” districts, with a focus on adult male behaviors and the vulnerability of young women; and continue to scale up and improve post-exposure prophylaxis services for rape survivors in partnership with the US President’s Women’s Justice and Empowerment Initiative. PEPFAR is in ongoing consultations with the Government of South Africa (GSA) and UNAIDS on male circumcision (MC). FY 2008 funds are budgeted for an MC technical advisor at the National Department of Health (NDOH), development of policies and guidelines, provision of safe clinical male circumcision, and creating and disseminating prevention messages in the context of MC. Training and service delivery activities will not be launched unless the GSA provides official approval.

Principal Partners: South African Government partners include the National Department of Health (NDOH), Department of Provincial and Local Governments (DPLG), Department of Correctional Services (DCS), Department of Education (DOE), SANDF, South African National Blood Service (SANBS), the National Institute for Communicable Diseases (NICD) and the National Health Laboratory Service (NHLS). International partners include the American Association of Blood Banks, Africare, Absolute Return for Kids, BroadReach, CARE International, Salvation Army World Services, Columbia University, Population Council, JHPIEGO, Humana People to People, EngenderHealth, Training Institute for Primary Health Care, Genesis Trust, Johns Hopkins University, Hope Worldwide, John Snow, Inc., Academy for Educational Development, Family Health International, PATH, Partnership for Supply Chain Management, Research Triangle Institute, Pathfinder International, Medical Care Development International, Health Policy Initiative, University Research Corporation, Harvard School of Public Health, Fresh Ministries, and the Elizabeth Glaser Pediatric AIDS Foundation. Local South African partners include the Medical Research Council, University of Pretoria, Africa Centre for Health and Population Studies, Aurum Health Institute, Health Systems Trust, Human Sciences Research Council, Mothers 2 Mothers, Soul City, Kagiso, Wits Health Consortium, University of Western Cape, South African Clothing & Textile Workers' Union, CompreCare, GRIP Intervention Program, Ingwavuma Orphan Care, Living Hope Community Center, Muslim AIDS Project, the Nelson Mandela School of Medicine, Leonie Selvan Communications, LifeLine, Muslim AIDS Program, Mpilonhle, Ingwavuma Orphan Care, GoLD, Scripture Union, Living Hope, Salesian Mission, TB Care Association, University of KwaZulu-Natal, Scripture Union, St. Mary’s Hospital, Stellenbosch University-Desmond Tutu TB Center, Perinatal HIV Research Unit, Reproductive Health Research Unit, Youth for Christ-South Africa, and Ubuntu Education Fund.

Care: $168,815,459 ($166,991,110 Field; $1,824,349 Central) (31.7% of prevention, care and treatment budget)

Care activities in South Africa include basic palliative care and support, TB/HIV, support for orphans and vulnerable children (OVC), and counseling and testing (CT). With 5.5 million HIV-infected individuals, the clinical and palliative care needs of patients suffering from AIDS place a severe strain on health services. Accordingly, PEPFAR supports programs to increase the availability and quality of palliative care services, including the provision of training, technical and financial assistance. Services are provided through the public sector health facilities, hospice and palliative care organizations, NGOs, FBOs, community-based, and home-based care programs.

South Africa has one of the highest estimated TB infection rates in the world: 58% of all TB patients are also HIV-infected. In FY 2008, activities will aim to provide additional technical and financial resources for provincial and district health management teams to increase the effectiveness of referral networks between TB and HIV services and to improve the mechanisms of TB and HIV program collaboration. The USG will continue to support the development of a National TB Reference Lab to improve diagnosis of TB among People Living with HIV/AIDS (PLWHA). Additional laboratory activities will focus on quality assurance, expansion of TB culture and drug susceptibility testing, and supporting improvements in information systems and testing technology. Public-private partnerships will continue to expand access to TB/HIV services among people living with HIV (PLWHA). Efforts to better understand the interaction between TB, HIV and drug resistance extent of these threats and to control them will be accelerated through 2008.

Care and support of OVC is a key component in efforts to mitigate the impact of the epidemic in South Africa, where an estimated 1.2 million children have lost one or both parents to AIDS. USG will provide financial and technical assistance to OVC programs focusing on mobilizing community and FBOs to improve the number and quality of services provided for OVC. These programs encompass the entire care and support continuum, including psychosocial and nutritional support, maximizing OVC access to GSA benefits, and strengthening OVC support through referrals for health care, support groups, and training.

Expanding the availability, access, and quality of CT services is a critical component of the USG HIV/AIDS program in South Africa. As the majority of CT services are provided in public facilities, PEPFAR will continue to support NDOH efforts to expand CT sites and services. All USG CT activities are intentionally linked to clinical care and support and treatment activities in order to ensure that individuals who test HIV positive have access to needed services. Many USG programs have mobile CT programs targeting high-risk populations, underserved communities, and men.

Principal Partners: South African Government partners include the NDOH, DPLG, DCS, Department of Social Development (DSD), SANDF, NICD and NHLS. International partners include Africare, CARE International, Catholic Relief Services, Salvation Army World Services, Boston University, Humana People to People, Medical Care Development International, Population Council, EngenderHealth, Johns Hopkins University, JHPIEGO, National Association of State and Territorial AIDS Directors, Hope Worldwide, Management Sciences for Health, John Snow, Inc., Family Health International, Columbia University, Harvard University, Pathfinder International, Population Services International, and the Elizabeth Glaser Pediatric AIDS Foundation. Local South African partners include: the Medical Research Council, Hospice Palliative Care Association of South Africa, Africa Center for Health and Population Studies, GRIP Intervention Program, Perinatal HIV Research Unit, National Association of Childcare Workers Reproductive Health Research Unit, Medical Research Council, South African National Council of Child and Family Welfare, Foundation for Professional Development, BroadReach Healthcare, Aurum Health Institute, Ingwavuma Orphan Care, CompreCare, Starfish, Nurturing Orphans for AIDS and Humanity, South African Catholic Bishops Conference, South African Clothing & Textile Workers' Union, LifeLine, Mpilonhle, McCord Hospital. St. Mary’s Hospital, Right To Care , Project Support Association of Southern Africa, HIVCare, Training Institute for Primary Health Care, Living Hope Community Center, the Nelson Mandela School of Medicine, Xstrata Coal SA & Re-Action!, World Vision South Africa, and Stellenbosch University-Desmond Tutu TB Center.

Treatment: $265,211,303 ($247,918,212 Field; $17,293,091 Central) (49.8% of prevention, care and treatment budget)

In 2003, the GSA took the historic step of developing a comprehensive plan to implement a nationwide antiretroviral treatment (ART) program. In May 2007, the NDOH released the new HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011 (NSP). This plan has provided an ideal opportunity for the USG to contribute to the GSA’s target of universal access to ARV services by 2009. The USG program will strengthen comprehensive care for HIV-infected people, including scaling up existing effective programs; initiating new treatment programs; providing direct treatment services; increasing the capacity of the National and provincial Departments of Health to develop, manage, and evaluate AIDS treatment programs, and increasing demand for, acceptance of, and compliance with ART regimens through treatment literacy campaigns and community mobilization.

Principal Partners: South African government partners include the NDOH, DCS, SANDF, NICD and NHLS. International partners include Africare, Boston University, Catholic Relief Services, Population Council, Family Health International, Absolute Return for Kids, JHPIEGO, John Snow, Inc., Partnership for Supply Chain Management, Johns Hopkins University, Pathfinder International, Columbia University, Elizabeth Glaser Pediatric AIDS Foundation, Management Sciences for Health, International Training and Education Center on HIV, and University Research Corporation. Local South African partners include Foundation for Professional Development, Africa Center for Health and Population Studies, Health Science Academy, McCord Hospital, St. Mary’s Hospital, South African Clothing and Textile Workers Union, Soul City, Perinatal HIV Research Unit, Reproductive Health Research Unit, BroadReach Healthcare, Right to Care, Medical Research Council, Xstrata Coal SA & Re- Action!, Aurum Health Institute, Toga Laboratories, HIVCare, TB Care Association, and the University of KwaZulu-Natal.

Other Costs: $52,192,338

The USG will support the NDOH in designing and implementing an integrated monitoring and evaluation (M&E) system. To facilitate the management of the PEPFAR monitoring and reporting process, the USG has implemented a single consolidated data warehouse that serves as the focal point for all PEPFAR data collected by partners. By collaborating with and assisting the GSA to strengthen the implementing partners’ strategic information systems, the USG also will support specific public health evaluations (in order to improve prevention, care, and treatment programs), identify potential new interventions, and document best practices. The USG also will support the DSD in strengthening its M&E system to identify and track OVC.

Principal Partners: South African Government partners include the NDOH, DCS, DSD, SANDF, and the NICD. International partners include Population Council, JHPIEGO, American International Health Alliance, Health Policy Initiative, Harvard University, , and the National Alliance of State and Territorial AIDS Directors. Local South African partners include Human Sciences Research Council, Foundation for Professional Development, Khulisa Management Services, Medical Research Council, University of Pretoria, University of KwaZulu-Natal, Perinatal HIV Research Unit and Reproductive Health Research Unit.

Management and Staffing costs will support both the program and the technical assistance required to implement and manage PEPFAR activities. Department of State, USAID, HHS/CDC, Peace Corps and Department of Defense personnel, travel, management, and logistics support in-country are included in these costs.

Other Donors, Global Fund Activities, Coordination Mechanism:

The USG is the largest bilateral donor to South Africa’s health sector. It is one of nearly 20 bilateral and multilateral donors providing technical and financial assistance in support of South Africa’s NSP. In addition to the Global Fund, other major donors include the European Union, the United Kingdom, Belgium, the Netherlands, Australia, France, Sweden, and Germany. The Global Fund has entered into agreements for two grants from South Africa for AIDS and TB programs. The primary HIV/AIDS coordinating body is the South African National AIDS Council (SANAC). The USG meets regularly with key officials of individual Ministries (Health, Social Development, Treasury, Defense, Education, and Correctional Services), to ensure that USG assistance complements and supports the South African Government’s plans for prevention, care, and treatment. The USG and implementing partners also meet with South African Government officials at the provincial level to ensure synergy with provincial priorities and activities.

Program Contact: Health Attache Mary Fanning, PEPFAR Coordinator Marsha Singer

Time Frame: Fiscal Year 2008 – Fiscal Year 2009

Approved Funding by Program Area: South Africa