Periodic Review ccm request template
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- 1.3 Summary of CCM Request for Renewal
- 1.3.2 Proposed Changes in Programmatic, Budgetary and Implementation Arrangements
- 1.3.3 CCM Request for Renewal
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The contact details of the GF CCM members are also available on the sanac website: www.sanac.org.za. The initial renewal proposal was approved by the NSP Financing Committee, which is chaired by the Minister of Health and reports to the general SANAC Plenary, on Tuesday 19 March 2013. The proposal was also approved for submission by the full CCM and all members signed approval- see General Annex 1 a for list of signatures of all Global Fund (GF) CCM Members. At the last GF CCM meeting on 25 March 2013, all members present were asked to raise their hands to show support for the proposal, to which all members raised their hands. At this meeting on the 25 March 2013, Brian Kanyemba (civil society sector rep) moved for the adoption of the proposal and Kallie Synman (Head of Secretariat: North West Provincial Council on AIDS) seconded the motion. The changes to the renewal proposal were approved by the GF CCM Meeting on the 28th May 2013. At the GF CCM Meeting on 28 May 2013, all members approved the proposal with a show of hands and Marlene Poolman (Head of Secretariat of the Western Cape Provincial Council on AIDS) moved for the adoption of the proposal and Khunjulwa Makatesi (Head of Secretariat of the Northern Cape Provincial Council on AIDS) seconded the motion. The list of signatures of the GF CCM members is attached as General Annex 1b.
The overarching objective of this Renewal Request is to follow the evidence of recent local studies, which recommend an increased focus on prevention while maintaining and expanding delivery of antiretroviral treatment and care. This approach is in line with the objectives of the Government of South Africa (GSA), as articulated in the National Strategic Plan on HIV, STIs and TB, 2012-2016 (NSP), namely: (1) to utilize combination prevention activities to reach key populations; (2) to ensure those eligible for antiretroviral therapy (ART) have timely access to needed medications; and (3) to strengthen the technical and human infrastructure that supports stable, long-term treatment. We are also expanding the local evidence base through a focus on three areas of innovation: (1) ART adherence support (2) behaviour change communication targeting young women and girls and (3) a convenient chronic disease drug delivery system for patients stable on ART . To bring all current Global Fund grants in line with the NSP, particularly its prioritization of certain key populations, the following strategic goals have been prioritised for the next implementation phase:
An added overarching benefit to these activities is that this proposal will focus on key populations that have been neglected and gender based violence that is a key structural driver of the epidemic; hence will gather useful information for future programming and scale up of best practices. Treatment, Care and Support South Africa has prioritised early initiation of adults and children as a central element of the strategy to arrest the HIV epidemic. This focus on ensuring early access to antiretroviral therapy as quickly as possible helps keep parents alive and reduces the burden of orphans and vulnerable children, keeps HIV positive people at work, prevents the loss of skilled labour to the economy, reduces the transmission rate and reduces the infection rate at the community level as shown by the Africa Centre study published in February 2013. Currently SA has the largest ART programme in the world, with 1.9 million people remaining in care on ART as at 31 December 2012. Consequently we have seen a drop in AIDS related mortality, a decline in mother to child HIV transmission and an increase in life expectancy (albeit not to previous levels). However the number of HIV positive people continues to grow and there are still more than 2 million people who need ART before the National Strategic Plan for HIV and AIDS, TB and STI target of 4.2 million people on ART as at 31 March 2017, can be reached. This number will increase further when South Africa implements the revised WHO ART guidelines for pregnant women in April 2013. This proposal enables the expansion of the ART programme and contributes to the provision of antiretroviral drugs for patients expected to enrol on ART during the course of this implementation period, increasing from 254 153 to 342 229 people initiated and maintained on ART. The number of patients on ART being provided for through this proposal includes patients who are on treatment to prevent mother to child transmission and adults and children. In addition to the cost of the antiretroviral drugs, this proposal also contributes to the cost of staff and laboratory tests in the Western Cape antiretroviral treatment programme. The National Department of Health’s Central Procurement Unit (NDOH-CPU) and Domestic Distribution Centre supported by this programme will also significantly reduce the risk of stock-outs at the health facility level. The cost of reaching the NSP target of ensuring access to ART for 80% of eligible PLHIV by 31 March 2017 is substantial and SA has a significant financial gap for the provision of antiretroviral therapy. This is despite considerable investment by the South African government with funding for HIV AIDS increasing over 7 times from $250 million in 2006/7 to almost $1.8 billion budgeted for in 2015/16. It is estimated that the need for antiretroviral therapy in 2016 will cost $1.9 billion; while the South African Treasury’s medium term estimates allocate approximately $1.1 billion. In support of the focus on the efficient procurement and distribution of antiretroviral therapy, this proposal also focuses on complementary services to: (a) minimise the risk of drug resistance and optimise clinical drug therapy for improved long term costs and (b) strengthen Phase 1 Service Delivery Areas designed to improve monitoring and evaluation (M&E) of the ART programme, clinical drug management and adherence support. Convenient Chronic Disease drug delivery system for patients stable on ART: To improve access to and availability of ART, the NDOH proposes to implement a ART drug delivery system that ensures timely, convenient and uninterrupted provision of ARV drugs to selected patients who are stable on ART, in order to enhance adherence. The system will be implemented through South African Pharmacy Council (SAPC)- registered and approved service providers. The NDOH will issue an Expression of Interest (EOI) request that will provide comprehensive information on the different drug delivery pharmacy models to be offered, in which patients can potentially access their medicines through the following access points: 1) Direct delivery to Patients’ Homes, 2) Post offices, 3) Community centres and faith based organisations, 4) Private community pharmacies, and 5) Other established chain stores (PEP, Checkers, etc.). It is understoond that each option may have a different operating model and resource requirements, with different cost implications. The current proposal is based on consultation with a service provider who is successfully offering distribution of pre-packed chronic medicines to primary health care (PHC) facilities in the Western Cape Province. This is an innovation that is being considered as part of the National Health Insurance Primary Health Care Re-engineering programme to deal with patients on ART as well as other chronic diseases, hence making it sustainable in the future but also contributing to the knowledge base to inform future costing and implementation. ART and Monitoring: Due to the successful tender processes in 2010 and 2012, South Africa has reduced ARV costs and initiated a move to single dose fixed combination ARV, which were previously unaffordable. The continued scale up of the NDOH’s central procurement unit (CPU) (established by the R10 grant) will further strengthen ARV supply chain management to reduce waste, minimise stock-outs and control costs. The Tier.Net reporting system has enabled closer monitoring of ART uptake and outcomes, providing vital information to improve future planning and implementation of services. Once fully rolled out the Tier.net system will speed up and routinize data flow, driving efficiency and transparency to further bring down ART costs. Under this renewal request the Central Procurement Unit has prioritized improvement of understanding of monitoring and evaluation procedures and technical requirements within the unit and among Principal Recipients and Sub-Recipients to improve reporting and troubleshooting. The Tier.Net information platform (currently only fully impelmented in the Western Cape Province) will modernise the ART M&E system for the national programme and will provide cohort data allowing for the monitoring of retention in care and average survival on treatment, that is essential for optimising the monitoring and measuring the outcomes and impact of this GF supported programme. HIV Care & Support: Promoting adherence to ART is important to optimise outcomes and limit future costs for the ARV programme as well as optimising the impact of treatment as prevention. The NSP aims to have 80% of people who require ART to be on ART by March 2017 but also that 70% of patients started on ART are still alive and on ART after 5 years. Paterson et al in 2000 showed that for every 10% decrease in adherence there is a 16% increase in HIV related mortality and in 2012 Van Cutsem et al estimated that retention in care in South Africa is 60% at 4 years. So as the South African Government scales up access to ART with more effective regimens that fully suppress viral replication, adherence becomes the single most important factor that can lead to resistance. Problems with adherence are due to structural, economic and social obstacles, with many patients having difficulty accessing information, resources and personal support to maintain steady and optimal treatment. Under this proposal, substantial investment has been made in supporting the implementation of two innovative models of adherence support for adults and children on ART that will be provided through a combination of facility and community based services. The one model assists health facilities in setting up support groups to monitor adherence and provide pre-packed medication off-site and the other model uses patient advocates who track patients and families from health facilities to their homes and back again. This will be supplemented by home-based care and facility based palliative care services in some of the districts. Careful monitoring and follow up also gives insight into the causes of loss-to-follow-up, which, in turn, informs future planning of services. These two models will be evaluated to inform future government interventions as adherence is rapidly becoming the single most important intervention across all HIV programmes and this application kick starts a national effort to invest in adherence support; not only for ART but for all HIV and TB related interventions and ultimately also provides essential information to guide adherence programming for all other chronic diseases. Drug Resistance Testing & Monitoring: Optimal clinical drug management is important to minimize the future costs of life-long antiretroviral treatment and the cost of hospitalisation for complications of ART. While drug resistance is often driven by non-adherence to strict medication regimes, the rollout of a countrywide ART programme also has an effect on the resistance profile of ARVs being used, and this has to be monitored and evaluated. So while focus on improving adherence through the provision of single dose ART and the provision of individualised adherence support for people on ART is important, this is not enough to inform long term planning of ART. This proposal will support both the drug resistance testing and monitoring to inform future antiretroviral drug treatment guidelines as well as capacitate the National Department of Health’s National Institute of Communicable Diseases unit to be able to scale up such drug resistance testing and monitoring across the country. Pharmacovigilance: This proposal will ensure the scale up of a countrywide pharmacovigilance service to monitor adverse drug reactions (ADR) at all health facilities nationally and then strengthen the capacity of the National Department of Health to collate and use this information for decision making, both in the implementation of programmes and the updating of antiretroviral treatment guidelines. Together drug resistance testing and monitoring and pharmacovigilance serve to inform evidence based care and treatment guidelines for optimal care at minimal cost as well as informing post-marketing drug surveillance by the Medicines Control Council and future regulatory activities. OVC Support: Because of the unique and broad array of challenges faced by OVC and the widespread need, this renewal request looks to refine and focus the geographical coverage of OVC outreach services, with a comprehensive support package in identified high risk districts. This is to ensure a greater impact of this investment given the fact that only a small portion of the total need will be covered. Support services will be rendered by a cadre of care workers who are familiar with the individual situations of OVC (including housing, family and community supports and overall health needs). These care workers can reach OVCs through schools, communities and care givers to provide the appropriate blend of prevention and treatment/adherence support and can connect OVC with an array of vital services. By integrating critical basic services (i.e., shelter, nutrition and basic healthcare) with HIV prevention, treatment and care services, OVC will see tangible improvements in quality of life (both for themselves and their care givers). Moreover, engaging with community-based organizations and caregivers not only strengthens the broader support structures but also reduces stigma. As this proposal contributes direct service delivery to a small portion of the total need in the country, albeit in a way that maximises impact, it will also contribute susbtantially to assisting the Department of Social Development to scale up its National Action Plan 2012-2016 and specifically the plan developed for Children affected by HIV and AIDS in order to build sustainability of all direct service delivery interventions. It will support the Department of Social Development’s (DSD’s) aim of training 10 000 Community Youth Care Workers (CYCWs), improving the information available for decision-making about resource allocation and achieving sustainable, uniform high-standard OVC programmes in the country. This will be achieved through (a) the training of 696 care givers across the country as fully fledged Community Youth Care Workers, (b) the provision of data capturers in each district to ensure data collection of services provided by NGOs and their outcomes (c) the provision of mentoring and knowledge sharing services for establised CYCWs, (d) the provision of care for the caregiver services for CYCWs to ensure staff retention and optimal quality of services provided, (e) the expansion of key special programmes that form part of the DSD’s gold standard Isibindi model for OVC- special protection for child victims of sexual assault, services for disabled children and the establishment of safe parks, and (f) the expansion of the full Isibindi model to new communities in the Eastern Cape that have been identified as critical by the DSD. Together ART and the described support services will bring us closer to universal access and reduced or delayed HIV-related morbidity and mortality, with the added advantage of treatment-as-prevention, potentially reducing the treatment burden down the line. Prevention South Africa has made significant strides over the past decade to bring millions of HIV positive people onto treatment, dramatically reducing mortality rates and increasing life expectancy. New infections among children have dropped rapidly, particularly over the past three years, due to the accelerated scaled-up national Prevention of Mother to Child Transmission (PMTCT) programmes. Infection rates appear to have stabilized, and the incidence of new HIV infections has dropped by 40% among adults (15-49 years). Voluntary medical male circumcision (VMMC) rates are on the rise as more facilities open and drive up demand. However, even with these improvements, there were nearly 350,000 new HIV infections in 2010, with key populations targeted by this proposal representing a disproportionate percentage of these cases. To improve the effectiveness and sustainability of HIV prevention efforts, the NSP calls for combination prevention efforts that specifically target more than a dozen higher risk groups with a package of prevention services. The Know Your Epidemic, Know Your Response (KYEKYR) study of 2011 identified the highest impact populations for combination prevention in SA – SWs, MSM, prisoners, those of low socio-economic status and youth – which are the primary targets of this proposal’s Service Delivery Areas (SDAs). The activities focused on these neglected key populations proposed for this proposal will allow identification of best practices which can then be scaled up as well as assist with prevention modelling to inform future planning and budget allocations. Sex Workers: Nearly 20% of new HIV cases in South Africa (SA) involve SWs or their clients. Sex work is still a crime, which undoubtedly increases stigma and makes it less likely that SWs will access health and medical services. SWs are much more likely to be victims of GBV, and social stigma and legal obstacles make it less likely that they will seek care or justice in the aftermath of an incident. SW-focused programming has proven to be effective, but more work needs to be done to refine the package of services offered to this group. Hence this proposal will focus on reaching 22% of the sex worker population with a package of combination prevention services and ensure that all of those reached receive an HIV test so that they know their HIV status. SA has recently done a sex worker enumeration study so that we have estimations of the sex worker populations size for the first time, and we will build on this with this proposal as we gather more information about optimal programming for sex workers through the scale up and also through an Incidence study. MSM & LGBTI: It is estimated that 9.2% of all new HIV infections are related to MSM (including gay, transgendered and bisexual men) but there is presently very little programming in these areas. Even though SA’s legal framework decriminalized homosexual sex, MSM and LGBTI are still severely impacted by discrimination and stigma, and it is difficult, if not impossible, to find MSM/LGBTI friendly health and wellness services across the country. Outreach and prevention efforts in a handful of cities have proven effective at limiting transmission, but the reach of programming is very limited. This proposal aims to increase the number of MSM/LGBTI friendly health facilities available (including at institutions of higher learning) and to maximise the uptake of these services and the continuous improvement of these services in response to feedback and information gathered from MSM and LGBTI communities. Although no baseline information is available it is planned to increase the level of HIV testing amongst MSM and LGBTI through improving the access to relevant sensitive health services. We also plan to gather more information about this specific key population during the implementation of this grant through Knowledge, attitudes and practice surveys and Incidence studies as well, to inform future programming needs. Prisoners: The extent of the need for HIV and TB services in prisons is unknown but has been identified as an area of need. The number of TB infections per 100,000 population (rate of TB infection) is known to be very high in SA prisons, and the Jali Commission of Inquiry (2006) found high levels of male rape in SA prisons. It also found that there was an extreme likelihood that prisoners who are exposed to violent unprotected sex will be infected with HIV – highlighting the link between sexual violence and HIV. Same sex/ MSM practices in prison also include consensual and coercive sex. This proposal aims to increase the access to HCT and TB screening as part of a comprehensive package of appropriate combination prevention services in 11 big prisons (and their feeder prisons) in the country, where service provision has already been strengthened in Phase 1. Persons of Low-Socio Economic Status: People with the lowest socio-economic status are associated with a higher risk of HIV infection and hence forms one of the key populations described in the NSP. This group overlaps other key populations identified in the NSP: people working in the informal sector, women with less disposable income, people living in informal settlements, migrant workers, youth in- and out- of -school and women aged 15 to 24 years. Due to the wide geographical spread of this key population and its varied subsets, this proposal aims to start to address some of the subsets including rural and farming communities who will be provided with a package of targeted combination prevention services, focusing on ensuring greater coverage of most vulnerable districts across the country, based on the geographical presence and competencies of PRs. Gender Based Violence (GBV) Victims: SA is grappling with high levels of violence against women, with sexual assault and intimate partner violence seen as key structural drivers of the HIV epidemic and addressed as such in the NSP. Hence better-targeted efforts are required to reach the often socially marginalised victims. While valuable, simply providing supportive counselling for victims of GBV, including assistance in applying for protective orders or reporting sexual assault to the police, does not adequately address the full array of the needs of GBV victims. This proposal aims to provide a more holistic package of services that includes emergency medical care, post-exposure prophylaxis (PEP), HIV Counselling and Testing (HCT), psychosocial counselling, statement taking and court preparation, in an integrated and victim-friendly manner, to victims of GBV who go to domestic violence courts and the Thuthuzela Care Centres (set up for rape victims). This proposal also includes a comprehensive package of services to child victims of sexual assault in previously under-served rurual areas. There will also be a new focus on changing the attitudes and behaviours that drive gender based violence and inhibit access to care and support services through a focus on (a) training police officers who play an important role in ensuring that all victims of sexual assault get access to the justice system and are referred to the necessary medical and psychosocial support services and (b) Empowerment programmes for young women and men to address vulnerability and attitudes and behaviour. So this proposal aims to improve the package of services that are offered to victims of gender based violence, the response of the police to ensure victims have their cases registered and are referred timeously and appropriately and ultimately improve the conviction rate of cases, ensuring the legal consequences for perpetrators of gender based violence function and contribute to primary prevention of GBV. Uncircumcised Men: Voluntary Medical Male Circumcision (VMMC) is an evidence-based and cost effective intervention prioritised by the Government of South Africa (GSA) as a pillar of prevention efforts. The National Strategic Plan (NSP) target for VMMC is 1.6 million by the end of 2016 but this is currently under review due to the UNAIDS recommendation that SA should be targeting 5 million people for VMMC. However, given the fact that SA was not able to reach their target of 500,000 VMMC in 2012, much work needs to be done in this area. The GF R10 grant-funded high volume VMMC facilities were initially slow to launch, but now that several facilities are online the focus has to be on increasing the numbers reached while maintaining high quality standards, as this encourages word of mouth recommendations. In addition to targeting uncircumcised men, women must also be informed of the indirect benefits, and this is done through the social mobilisation and combination prevention programmes. This programme also has the added benefit in that all men are offered HIV testing as part of the package and there is substantial uptake of this service with the main reason for non-uptake being that their HIV status is already known ; hence contributing to the overarching aim of increasing the number of people who know their HIV status and increasing the levels of knowledge about HIV. Youth (Young Women and Men): The NSP 2012-2016 indentifies young women between the ages of 15 and 24 years as one of the key populations that is at higher risk for HIV infection and should therefore be targeted for specific prevention, care, treatment and support interventions based on risk and need. In general, South African young women between the ages of 15 and 24 years are four times more likely to have HIV than males of the same age. This risk is especially high among pregnant women between 15 and 24 years, and survivors of physical and/or intimate partner violence. On average, young females become HIV positive about five years earlier than males1. SA researchers also found that women accounted for 90 per cent of all new HIV infections in the 15–24 age group. This proposal seeks to both address the issues of young women and girls directly through an innovative national Behaviour Change Commmunication programme targeting young women and girls but also through focused interventions for: faith based peer educators and life skills workers amongst youth in- and out-of school, a youth ambassador programme focusing on out of school youth, youth in schools (Department of Basic Education) and in higher learning institutions (Department of Higher Education- Higher Education HIV/AIDS Programme). The latter two present an opportunity to reach higher numbers of youth as they are concentrated in learning facilities and the youth can be exposed to multiple interventions over time, ultimately maximising their learning and employment opportunities and minimising their risk of HIV. All these interventions will provide us with much needed information to inform scale up of best practices for this neglected key population.
Prevention activities that target these key populations will have greater impact if delivered as a comprehensive package –“combination prevention” – via channels and materials specifically designed for the group or subgroup. As each key population or focus area has specific sexual and reproductive health needs and faces particular social and structural challenges (including, in some cases, stigma and discrimination) in accessing HIV and TB care and treatment, this combination prevention package will be tailored to meet the needs of the key population being addressed. At a minimum each package will provide:
This package of combination prevention services for each of the above groups will be improved upon as necessary throughout the implementation period as more information is collected and knowledge gaps are addressed. Individuals reached through combination prevention will be referred to appropriate health services but will not subsequently be tracked to ensure that they actually access these services. There is a recognition that South Africa must improve systems to track this essential element of the patient care continuum (drive awareness of services ensure access to services satisfactorily deliver services follow up). However, the process has not yet been fully described in government policy and is presently still being piloted with support from the US government. This forms part of the work being done presently in the piloting of the National Health Insurance (NHI) in one district in each province. Enabling Environment The Global Fund has been a forerunner in promoting community systems strengthening (CSS) as an essential element of a comprehensive, effective and efficient sustainable HIV and TB strategy. The UNAIDS Investment Framework has demonstrated that social and programmatic enablers are critical success factors for all HIV programmes. This proposal looks to bolster Community Systems Strengthening (CSS) and programme management and oversight to better deliver on the prevention and treatment aims. Community Systems Strengthening (CSS): In this proposal we seek to build the capacity of nongovernmental organizations (NGOs) and community based organizations (CBOs) to deliver quality services to people in local communities according to their specific need and in an appropriate language. There will also be substantial information gathering and sharing through different engagement platforms to optimise the content of present and future programmes and identify efficiencies and share in Programme delivery. To complement this effort, government-employed health care workers, police and justice service providers will receive sensitization training re: key populations to reduce stigmatizing attitudes and improve interactions with clients in these key populations. Communities at large will also be sensitized to issues around human rights, stigma and discrimination as deemed appropriate. Programme Management & Monitoring; Effective programme planning, management and monitoring is central to optimising every step of the implementation of services. This proposal includes monitoring and evaluation of programmatic and financial performance and quality of programmes, identification and minimisation of risk, the tracking of outputs and outcome of the interventions and our overall progress in meeting our goals as measured by impact indicators. This will also include specific HIV incidence studies among MSM, SWs and prisoners to work towards developing a good baseline for the eventual evaluation of the impact of these programmes. Specific activities include building the capacity of the PRs and their management units to fully manage the effective and efficient implementation of their grants as well as the training and mentoring of their sub recipients to align with the uniform standards set. This links well to the improved oversight provided by the GF CCM described in Section 2, as this closes the feedback and learning loops so essential to on-going improvement of all programmes covered by this proposal. The expected value of these activities is demonstrated in the following impact and outcomes indicators in the Table below, the more detailed output indicators and coverage data covered in the Overview Section that starts on page 65 and the detailed description of the activities and their reach that is covered in Annex 1 of each Principal Recipient (NDOH, WCDOH, NACOSA, NRASD, RTC) :
If yes, please indicate the nature of the change. Table 3: changes in the Implementation Arrangements
Below is a table that compares the Phase 1 activities, broken down by PR and Budget, against the Phase 2 SDAs, PR involvement and anticipated budget. In reviewing the table, please note the following:
Table 4: Comparison Phase 1 (SDA, PR and Budget) with Phase 2 (SDA, PR and budget)
These changes reflect the work done by the GF CCM to respond to the new Global Fund strategy of investment for maximum impact, the need to focus 100% on key populations, the revised National Strategic Plan for HIV, TB and STIs, the response to the latest local evidence available in regard to where our focus should be, the contribution of many stakeholders and the unique competencies and geographical presence of the PRs. Please describe and provide rationale and justification for each proposed change. Reallocation of funds between PRs: The main reallocation of funds in this proposal involves the NDOH and the WCDOH. In the case of the NDOH, all funds that were being onward granted to civil society have been closed down and not continued in this grant. This is because onward granting to too many Civil Society SRs by the NDOH was identified by the OIG as a high risk activity as well as the decision to refocus the NDOH allocations to its core functions of ART. This focus on ART is in keeping with the significant expansion of the ART programme in SA over the last three years but also because of the growing need to put more people on treatment. In the case of the WCDOH, funds previously ascribed to WCDOH for antiretroviral treatment and peer education programmes in schools, are now reallocated to prevention-related activities for key populations carried out in higher HIV prevalence provinces by other PRs. WCDOH has been quite effective in managing its existing GF grant, but equity compels a reallocation. The Western Cape’s disease burden is lowest in the country but its per capita expenditure is greatest. At the same time, 60% of new HIV infections are concentrated in three provinces (KwaZulu- Natal (KZN), Gauteng (GA) and Eastern Cape (EC)). Funding allocations were based on decisions relating to: the activities of the previous proposal to build on successes that fit the new strategy; the size of the need and the funding gap for that programme; the latest evidence for areas of investment for maximal impact, the NSP 2012-2016 and the ability of existing PRs to deliver. Overall, there is significant shift towards focussed prevention in key populations whilst maintaining a meaningful contribution to the expanding ART programme. For the first time, there are significant contributions to programmes for sex workers, MSM, prisoners, rape survivors. uncircumcised men and youth (young women and men), signalling the long-awaited launch of natioanl programmes in South Africa for these key populations. Reallocation of funds between priorities: Funds have been allocated to ensure a balance between the provision of ART (which has a high cost) and prevention activities for key populations. The budget is now broken down as follows: Prevention interventions account for 22% of the budget; ART programme costs account for 49% of the budget (and antiretroviral drugs specifically account for 34 %). Community Systems Strengthening and programme management related activities (Supportive Environment) account for 10% of the budget. The rest of the budget covers: HIV care and support (9%), Support to OVC (7%), Drug resistance testing and monitoring (1%) and Pharmacovigilance (2%). Given the many SDAs of the previous proposals it has been difficult to accurately compare budget allocations in the same way as we are now able to do. This is an improvement brought about by the new GF proposal structure. If you are adding new PR(s) to the grant/program, please provide name(s). A new Principal Recipient will be added to implement the Behaviour Change Communication programme, but this is yet to be determined. If you are discontinuing any PR(s) in the grant/program, please provide name(s). N/A
If yes, please describe and provide rationale and justification for the proposed change. The performance framework is tied to the new NSP 2012-2016, so it has a slightly different format but still links to similar goals and impact indicators, with certain improvements as a consequence of the focus on new key populations. Do the proposed changes entail material reprogramming compared to the original proposal(s)? Yes If yes, please indicate and explain whether the changes affect the entire Programme or a specific PR. The changes apply to all PRs to a certain degree and include the following:
People living with disabilities, as there is an increased focus on major key populations as identified by the NSP and the KYEKYR report; and TB case finding in TB crisis districts as we move to combination prevention which includes a broader package of services. Elements that remain the same are:
The Table below shows the budget that the CCM is requesting as part of this renewal. The detail of the various elements of this table is to be found within the proposal (Principal Recipient Sections 5 .2.1 and 6.2.1 and 6.2.2) as well as in the Financial Renewal Table in General Annex 2a and the Budget Narrative in General Annex 2b. In addition, attached as General Annex 2c find an Investing for impact - Sustainability plan. Table 5: CCM Requested Budget for Renewal
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