*THE PRESIDENT'S EMERGENCY PLAN FOR AIDS RELIEF*

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*STRATEGIC INFORMATION MANUAL FOR IMPLEMENTING PARTNERS IN SOUTH AFRICA*

*July 2007*

*Version IV*

**Table of Contents**

[Acronyms and Abbreviations 3](#acronyms-and-abbreviations)

[Introduction 4](#introduction)

[Overview of M&E for HIV/AIDS Programmes
5](#overview-of-me-for-hivaids-programmes)

[Indicator Development 13](#indicator-development)

[An Introduction to the Management of Data Quality
17](#an-introduction-to-the-management-of-data-quality)

[Reporting on Programme Results for the President's Emergency Plan for
AIDS Relief
24](#reporting-on-programme-results-for-the-presidents-emergency-plan-for-aids-relief)

[Indicators for Monitoring the President's Emergency Plan for AIDS
Relief
27](#indicators-for-monitoring-the-presidents-emergency-plan-for-aids-relief)

[Abstinence and Be Faithful 30](#abstinence-and-be-faithful)

[Condoms and Other Prevention 34](#condoms-and-other-prevention)

[Medical Transmission/ Blood Safety and Injection Safety
37](#medical-transmission-blood-safety-and-injection-safety)

[Prevention of Mother-To-Child Transmission
40](#prevention-of-mother-to-child-transmission)

[Counseling and Testing 47](#counseling-and-testing)

[Orphans and Vulnerable Children 51](#orphans-and-vulnerable-children)

[Palliative Care: Basic Health Care and Support and TB/HIV
59](#palliative-care-basic-health-care-and-support-and-tbhiv)

[Antiretroviral Treatment Services
71](#antiretroviral-treatment-services)

[Laboratory Infrastructure 90](#laboratory-infrastructure)

[Policy Analysis and System Strengthening
92](#policy-analysis-and-system-strengthening)

[Strategic Information 98](#strategic-information)

[Appendix A: Glossary of Key M&E Terms
100](#__RefHeading___Toc204575415)

[Appendix B: Illustrative Examples of HIV-Related Palliative Care
Services for Adults and Children
111](#appendix-b-illustrative-examples-of-hiv-related-palliative-care-services-for-adults-and-children)

[Appendix C: Sample M&E Frameworks
114](#appendix-c-sample-me-frameworks)

[Appendix D: Indicator Protocol Reference Sheet
118](#appendix-d-indicator-protocol-reference-sheet)

[Appendix E: Data Quality Tools 120](#appendix-e-data-quality-tools)

[Appendix F: Results of FY 05 Data Quality Audit: Recommendations for
Partners and USG
127](#appendix-f-results-of-fy-05-data-quality-audit-recommendations-for-partners-and-usg)

[Appendix G: Additional M&E Resources
130](#appendix-g-additional-me-resources)

# Acronyms and Abbreviations

AB abstinence and be faithful

ABC abstain, be faithful, and, as appropriate, correct and consistent
use of condoms

AIDS acquired immunodeficiency syndrome

ANC antenatal clinic

ART antiretroviral treatment

ARV antiretroviral (drug)

BCC behavior change communication

BSS behavioral surveillance survey

CBO community-based organization

CDC Centres for Disease Control and Prevention (United States)

COP Country Operational Plan

CSW commercial sex worker

CT counseling and testing

DHS Demographic and Health Survey

DOD Department of Defense (United States)

DQA Data Quality Audit

DQP Data Quality Plan

FBO faith-based organization

FY fiscal year

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria; *Monitoring
and Evaluation Toolkit:*

*HIV/AIDS, Tuberculosis, and Malaria* (see references)

HHS Department of Health and Human Services (United States)

HIV human immunodeficiency virus

HMIS health management information system

IDU injecting drug user

IEC information, education, and communication

M&E monitoring and evaluation

MIS management information system(s)

MSM men who have sex with men

NGO non-governmental organization

OGAC Office of the Global AIDS Coordinator (United States)

OI opportunistic infection

OVC orphans and vulnerable children

PEPFAR President's Emergency Plan for AIDS Relief (PEPFAR)

PCR polymerase chain reaction

PLWHA people living with HIV/AIDS

PMTCT prevention of mother-to-child transmission

RARG WHO Injection Practices, Rapid Assessment and Response Guide

SAG South African Government

SI Strategic Information

STI sexually transmitted infection

TB tuberculosis

UNAIDS Joint United Nations Programme on HIV and AIDS

USAID United States Agency for International Development

USG United States Government

WHO World Health Organization

# Introduction

The purpose of this manual is to provide overall Strategic
Information/Monitoring and Evaluation (SI/M&E) guidance for all United
States Government (USG) partners implementing the President's Emergency
Plan for AIDS Relief (PEPFAR). SI/M&E is a key component of PEPFAR in
order to appropriately plan and monitor programmes and to ensure that
money is spent both effectively and efficiently. Placing a greater
emphasis on SI/M&E will improve programmes and aid our partners in
absorbing the increased levels of funding.

Monitoring and evaluation of PEPFAR is conducted at the global,
national, and project levels. It is important to understand the larger
context of national and global goals and M&E guidelines in order to gain
a better understanding of the rationale for specific PEPFAR data and
reporting requirements. However, M&E should not be viewed only as a set
of requirements but rather as a vital tool for all programme partners to
use to initiate positive and effective change within their own projects.
The USG SI/M&E team intends to support an increased emphasis on M&E as
part of effective programme implementation.

The aim is to provide a manual that is useful for both new partners who
are less familiar with the USG M&E systems and for partners with
extensive USG experience who will need this information to guide them
through the recent changes. The USG SI/M&E team also conducts regular
workshops for partners focusing on M&E at the programme level. In
addition, the USG SI/M&E team is available to answer questions and
provide further M&E guidance and concrete support to foster partnership
forums as we move forward.

The development of this manual is an iterative process as many of the
key M&E tools are still under development or are undergoing continued
refinement. The manual begins with an overview of key M&E concepts, and
then continues with guidance on indicator development, an introduction
to data quality, and guidance for reporting on PEPFAR indicators (July
2005 version; detailed definitions are available in the glossary), and
several resources as appendices including indicator reference sheets and
a glossary of M&E terms.

We welcome your comments and input on the manual as we work towards
creating a document that will best suit our partners' needs.

# Overview of M&E for HIV/AIDS Programmes

As the body of knowledge surrounding HIV grows, so does the interest in
monitoring and evaluating the success of programmes designed to reduce
the spread of infection and the impact it has on the lives of families
and communities. This interest comes from national governments,
programme directors, and international donors who support their efforts.
The need for better M&E systems has also spawned a growing number of
data collection instruments and indicators. M&E systems track what is
being done and whether the programme is making a difference. M&E systems
allow programme managers to calculate how to allocate resources to
achieve the best overall result. However, the HIV epidemic is relatively
new, consequently, new interventions are constantly proposed, and each
must be shown to be effective to justify becoming part of a South
African or international response. This section gives an overview of the
different functions of M&E and the main features of a sound M&E system.

HIV is politically charged in most countries. Influential religious,
political or popular lobbies may oppose intervention, and senior
decision makers may be reluctant to tackle the issue in consequence,
preferring to focus on maternal mortality, child nutrition or other more
"politically neutral" programmes. It is in this context that M&E is
perhaps most useful to all programmes. Only careful measurement and
recording of the success of existing initiatives will persuade reluctant
policy makers to expand programme efforts.

***M&E Basics***

Monitoring and evaluation helps programme implementers make informed
decisions about programme operations; make the most effective and
efficient use of resources; determine the extent to which the
programme/project is on track; and to make any needed corrections
accordingly. Finally, M&E helps programmes evaluate the extent to which
the programme or project is having or has had the desired impact.

M&E is indispensable because these tools inform planners, managers, and
implementers whether -- or to what extent -- the programme or project is
operating effectively and according to expectations. By keeping track of
specific areas of programme performance, operational problems can be
identified while they can still be corrected and thus ongoing
performance can be improved. Meanwhile, managers can also keep track of
the extent to which activities are having their desired effects. Results
demonstrated through good monitoring and evaluation techniques also
enable decision makers to correct strategies or even overcome
unanticipated difficulties. In sum, M&E improves the programme's
ultimate impact through better information and increased understanding
even while activities are in progress.

The diagram below illustrates that programme strengthening is the most
important M&E goal. Reporting/accountability and sharing information
with partners are also important, but should be accomplished without
sacrificing programme strengthening.

The significance and value of M&E is realized only through the **use of
M&E data**. It is not important in and of itself to collect numbers,
even the best numbers, nor is it abstractly important to construct the
perfect indicators. If data is not reviewed and interpreted and then fed
back into decision making, the ultimate purpose of M&E \-- programme
improvement \-- cannot be met. To be effective, it must be M&E that is
actively used in problem-solving within the ongoing programme, and in
further steps of the decision making process.

***The Different Functions of Surveillance, Monitoring and Evaluation***

While surveillance, monitoring and evaluation all have different
functions, there is a great deal of overlap among the three activities.
This section clarifies the different functions of surveillance,
monitoring and evaluation.

Surveillance, monitoring and evaluation all play a role in providing
information to help determine the links between programme efforts and
resources, and to determine the programme\'s goals. In the case of
national AIDS programmes, the ultimate goals will be to reduce the
spread of HIV, to improve care for those infected, and to minimize the
social and economic impact on affected families and communities. For a
programme to achieve its goals, **inputs** such as money and staff time
must result in **outputs** such as stocks and delivery systems for drugs
and other essential commodities, new or improved services, trained staff
and information materials. If these outputs are well designed and reach
the populations for which they were intended, the programme is likely to
have positive short-term **outcomes** or effects such as a higher age at
first sex among young people. These positive short-term outcomes
necessarily lead to changes in the longer-term **impact** of programmes,
measured in fewer new cases of sexually transmitted infections (STIs) or
HIV, or less HIV-associated deaths.

Surveillance and monitoring and evaluation activities are all needed to
track whether programme inputs are producing the desired outputs,
whether those outputs are having an effect and, ultimately, whether the
effect is having the impact that the programme aims to achieve. But each
fulfills a different function, as described below.

**Surveillance** is the routine tracking of disease (disease
surveillance) or, less commonly, risk behavior (behavioral surveillance)
using the same system over time. Surveillance helps describe an epidemic
and its spread, and can contribute to predicting future trends. In the
case of HIV, surveillance systems typically track impact in terms of
HIV, and sometimes STI prevalence, and effects in terms of sexual risk
behavior. It is typically performed at both district and national
levels.

**Monitoring** is the routine tracking of priority information about a
project or programme and its intended effects. This is likely to include
monitoring of inputs and outputs through record-keeping and regular
reporting systems as well as health facility observation and client
surveys. Data are compiled and forwarded to the national level to be
aggregated. Such monitoring is called *programme, process* or *output
monitoring*.

The linked interpretation of data from multiple indicators is a key
component of useful monitoring systems. Often, one indicator alone will
be unconvincing. The advocacy value of an indicator is greatly
strengthened if it is presented together with other data.

In tracking the status of HIV infection, the behaviors that spread the
disease, and the strength of different areas of response, monitoring
indicators function like the "vital signs" of the HIV epidemic at a
district, regional or national level. They help programme managers
determine which areas are in need of greater effort, and flag questions
that might contribute to an improved response but that can only be
answered by more refined research methods than those used in routine
surveillance and monitoring.

**Evaluation** is a collection of activities designed to determine the
value or worth of a specific programme, intervention or project. That
means being able to link a particular output or outcome directly to a
particular intervention. Three levels or phases of evaluation are
distinguished. The first phase involves the assessment of the
programme's content, scope or coverage, together with the quality and
integrity of implementation. It is known as process evaluation. If
findings from this phase are adequate, then and only then, evaluation
activities are designed to determine the
programme/intervention/project's immediate or short-term effects or
outcomes. This phase is typically called *outcome evaluation*.

What is the difference between outcome monitoring and outcome
evaluation? Essentially, *outcome* *monitoring* tracks changes in
outcomes following the implementation of a programme or project, but is
not able to attribute those changes directly to the intervention. In
*outcome evaluation*, however, the intervention is designed specifically
with the intention of being able to attribute the changes to the
intervention itself. Without the appropriate evaluation design, the
monitoring of outcome indicators alone cannot produce causal evidence
about the effectiveness of a specific programme. At the very least, the
evaluation design has to be able plausibly to link observed outcomes to
a well-defined programme, and should be able, too, to demonstrate that
changes are not the result of non-programme factors.

If there is adequate evidence that the programme/intervention/project
has achieved or is achieving (if the project is ongoing) its immediate
or short-term objectives, then, and only then, one goes on to determine
the longer-term impact. This assessment of the longer-term effects of a
programme is called *impact evaluation*. In the case of HIV, an *outcome
evaluation* may aim to demonstrate that a specific project has actually
reduced risk behavior, while an *impact evaluation* would aim to
demonstrate that the change in behavior attributable to the project had
an impact in terms of reduced transmission of HIV. Impact evaluations
take a long time, are expensive, and are methodologically very complex.
This is due to multiple influences that accumulate over time, and that
make it difficult to pinpoint what led to any observed changes. Trying
to pinpoint the exact cause of behavior change or of reduced HIV
incidence often involves a rigorous study design that enables the
researcher to distinguish between the effect of the intervention itself
and the effect of other factors that may have influenced an outcome.
Such study designs usually include a control group that has not been
exposed to a particular intervention. With a fatal disease such as HIV,
establishing controlled studies is often ethically problematic. In
addition, most national AIDS programmes attempt to attack the epidemic
on a number of different fronts simultaneously so it is difficult to
determine which intervention played what part in reducing the risk of
infection or improving the quality of life of an infected person.
Depending on the size of the intervention, it is not always appropriate
for projects/programmes to do this level of evaluation due to the
factors mentioned above.

***Using a Conceptual Framework to Better Understand, Monitor and
Evaluate a Programme***

Conceptual frameworks are diagrams that identify and illustrate the
relationships among all relevant systemic, organizational, individual,
or other salient factors that may influence programme/project operation
and the successful achievement of programme or project goals. The
framework provides a perspective for understanding programme objectives
within a complete context of relevant factors in an operating
environment. It also clarifies analytical assumptions and their
implications for programme possibilities or limitations on success, as
well as measuring and analyzing that degree of success.

The following framework presents all the different elements that can
influence the success of an HIV/AIDS programme including individual,
family and political/community level factors and programmatic
interventions, and they all influence proximate and biological
determinants and ultimately health outcomes.

***A Monitoring and Evaluation System***

A coherent M&E system contributes to more efficient use of data and
resources by ensuring, for example, that indicators and sampling
methodologies are comparable over time and by reducing duplication of
effort. Where resources are scarce, this is an important asset. Data
generated by a comprehensive M&E system ought to serve the needs of many
constituents, including programme managers, researchers and donors,
eliminating the need for each to repeat baseline surveys or evaluation
studies when they might easily use existing data. Good coordination
should lead to better use of resources.

From the point of view of the national programme, a coherent M&E system
helps ensure that donor funded M&E efforts best contribute to national
needs, rather than simply serving the reporting needs of agencies or
legislatures overseas. A further advantage of coordination in monitoring
and evaluation is that it encourages communication between different
groups involved in the national response to HIV. Shared planning,
execution, analysis, or dissemination of data can reduce overlap in
programming and increase cooperation between different groups, many of
whom may work more efficiently together than in isolation.

From the point of view of an NGO, a coherent M&E system helps ensure
that inputs contribute to desired results. This requires that high
quality information is collected and used in a consistent way.

Successful M&E systems share common elements. A list of some of these
elements is given in Table 1.

**Table 1**: Checklist of Features of a Good M&E System

+-----------------+----------------------------------------------------+
| **M&E UNIT**    | -   An established M&E unit                        |
+-----------------+----------------------------------------------------+
|                 | -   A budget for M&E that is about 10 percent of   |
|                 |     the programme budget                           |
+-----------------+----------------------------------------------------+
|                 | -   A formalized (M&E) link with research          |
|                 |     institutions                                   |
+-----------------+----------------------------------------------------+
|                 | -   A formalized (M&E) link with NGOs, government  |
|                 |     bodies and donors                              |
+-----------------+----------------------------------------------------+
|                 | -   Epidemiological expertise in the M&E unit or   |
|                 |     affiliated to the unit                         |
+-----------------+----------------------------------------------------+
|                 | -   Social science expertise in the M&E unit or    |
|                 |     affiliated to the unit                         |
|                 |                                                    |
|                 | -   Data processing and statistical expertise in   |
|                 |     the M&E unit or affiliated to the unit         |
|                 |                                                    |
|                 | -   Data dissemination expertise in the M&E unit   |
|                 |     or affiliated to the unit                      |
+-----------------+----------------------------------------------------+
| **CLEAR GOALS** | -   Well-defined programme goals and targets       |
+-----------------+----------------------------------------------------+
|                 | -   Regular reviews/evaluations of the progress of |
|                 |     the implementation of the programme plans      |
+-----------------+----------------------------------------------------+
|                 | -   Guidelines and guidance to districts and       |
|                 |     regions or provinces for M&E                   |
+-----------------+----------------------------------------------------+
|                 | -   Guidelines for linking M&E to other sectors    |
+-----------------+----------------------------------------------------+
|                 | -   Coordination of an organizations own M&E with  |
|                 |     national and donor M&E needs                   |
+-----------------+----------------------------------------------------+
| **INDICATORS**  | -   A set of priority indicators and additional    |
|                 |     indicators at different levels of M&E          |
+-----------------+----------------------------------------------------+
|                 | -   Indicators that are comparable over time       |
+-----------------+----------------------------------------------------+
|                 | -   A number of key indicators that are comparable |
|                 |     with other countries/programmes                |
+-----------------+----------------------------------------------------+
| **DATA          | -   An overall data collection and analysis plan   |
| COLLECTION &    |                                                    |
| ANALYSIS**      |                                                    |
+-----------------+----------------------------------------------------+
|                 | -   A plan to collect data and analyze indicators  |
|                 |     at different levels of M&E                     |
+-----------------+----------------------------------------------------+
|                 | -   Second generation surveillance, where          |
|                 |     behavioral data are linked to HIV/STI          |
|                 |     surveillance data                              |
+-----------------+----------------------------------------------------+
| **DATA          | -   An overall data dissemination plan             |
| DISSEMINATION** |                                                    |
+-----------------+----------------------------------------------------+
|                 | -   A well-disseminated informative semi-annual    |
|                 |     and annual report of the M&E unit              |
+-----------------+----------------------------------------------------+
|                 | -   Annual meetings to disseminate and discuss M&E |
|                 |     and research findings among staff,             |
|                 |     stakeholders, donors, policy makers and        |
|                 |     planners                                       |
+-----------------+----------------------------------------------------+
|                 | -   A clearinghouse for generation and             |
|                 |     dissemination of data                          |
+-----------------+----------------------------------------------------+
|                 | -   A centralised database or library of all       |
|                 |     HIV/AIDS/STI related data collection and       |
|                 |     ongoing research                               |
+-----------------+----------------------------------------------------+
|                 | -   Coordination of national and donor M&E needs   |
|                 |     for dissemination                              |
+-----------------+----------------------------------------------------+

***The Monitoring and Evaluation Unit***

**Human capacity** is a major constraint to M&E in many programmes.
While M&E units or committees do exist in many programmes, they are
generally understaffed. Capacity building is vital if M&E systems are to
be strengthened. Ideally an M&E unit should have access to an
epidemiologist, a statistician, a social scientist and a data manager.

**Clearly stated programme goals.** It is not possible to monitor --
much less to evaluate -- progress towards goals unless the programme
goals are clear. An important step in developing an M&E plan is to
understand interventions and systems in place and how they are currently
monitored and evaluated.

***A Data Collection and Analysis Plan***

Once a decision has been made about what to measure, a coherent plan
must be made. This plan predicts all necessary indicators and takes into
account all major data collection efforts, leading to the most efficient
use of resources in data collection. The data collection plan should
stipulate systems by which data from other sources will be collected,
reported and analysed by the M&E system. A data collection plan will
detail the frequency of data collection and who is responsible for what,
how much it will cost and who will pay.

A centralised database or library of all HIV/AIDS/STI related data
collection contributes immensely to the efficiency of M&E efforts. The
database should list ongoing data collection efforts as well as those
already completed, to avoid the duplication of studies before their
results are published.

***A Data Use Plan***

There is no point in collecting data that cannot or will not be used.
The ultimate use of the data should guide the design of a coherent M&E
system, especially the selection of the most appropriate indicators. A
clear plan for data use and dissemination will include outlining the end
users for each indicator, and how the data will be presented to them. It
may include a plan for developing a shared database of information, and
for sharing data among programme elements, programme managers, board of
directors, headquarters, donor agencies and others. A framework for
regular dissemination of information to the public may also be included.
In general, the data generated by M&E systems are used in three major
ways: advocating for action; planning, revising and improving
programmes; and attributing change in the epidemic to interventions
undertaken.

### 

***Planning, Revising and Improving Programmes***

Both monitoring systems and evaluation studies generate information that
should be used to improve existing programmes and to plan more
successful interventions in the future. Monitoring information can be
fed into programming immediately to correct for weaknesses and improve
performance. This mechanism can indicate whether an intervention is on
track or on budget, or whether it is producing the desired number of
trained nurses or the targeted increase in condom sales outlets.
Evaluation results can be used to inform future programme design,
prompting a decision to replicate an intervention in other areas, or to
scrap it altogether because it is expensive and not achieving the
intended results.

# Indicator Development

The programme goals will dictate the areas in which progress might be
expected, and therefore the areas in which it might be measured. But how
can "progress" in these areas be measured? This is where the choice of
indicators comes in. Which indicators should be selected? A number of
guiding principles can help us choose the most appropriate set of
indicators for M&E of AIDS programmes. First, we need to use a
conceptual framework for M&E to select indicators and to interpret
results. Second, we should consider specific qualities of the
indicators, such as the link with programme goals, indicator\'s ability
to measure change, the cost and feasibility of data collection and
analysis, comparability with past indicators, and comparability between
countries, or population groups.

***Why Use Indicators?***

Tracking changes in indicators over time will help programme managers
and decision makers tell how successful the programme is in meeting its
goals. Indicators are just that -- they give an indication of the
magnitude or direction of changes over time.

However, most indicators are not designed to explain *why* a situation
has changed or has failed to change -- they are designed simply to
measure the change. Only smaller qualitative studies can answer the
"why?" question, although answering the "why?" and inquiring about "how"
change occurs are essential first steps in deciding what to do about a
problem. While small explanatory studies do not necessarily form part of
a regular tracking system for HIV and the behaviors that spread it, they
are essential links between M&E systems and policy formulation. It is
worth stressing that small explanatory studies do not yield standard
indicators that are comparable across countries: by definition they are
trying to explain something that is situation specific.

Operations research, in which the effects of a specific intervention are
assessed, also has a contribution to make. Once small scale research
studies have demonstrated that an intervention can produce the desired
result under ideal research conditions, operations research puts the
intervention through its paces under real world conditions, carefully
monitoring inputs and outputs and evaluating the outcome.

### 

***Selection of Indicators***

Good indicators for M&E of HIV/AIDS programmes need to be relevant to
programmes, feasible to collect, easy to interpret and able to track
changes over time. The choice of indicators will depend upon the aims of
the programme.

As a first step, M&E specialists should monitor the inputs and outputs
of the programme. Unless these change, any change in outcome cannot be
ascribed to programme effort. Input and output indicators are often
relatively easy and cheap to collect; where they register change, they
indicate the need for monitoring and evaluation at the outcome or impact
level.

Indicators should be chosen to measure change in key areas of programme
effort. Since most HIV/AIDS programmes tailor their responses to the
state of the epidemic in their country, it follows that the appropriate
indicators will also differ according to the epidemic state.

***Needs for Data Collection***

Ideally, indicators should be measurable with existing data. Most
frequently, however, special data collection efforts are needed to
construct reliable indicators. In general, the costs and difficulty of
data collection increases as indicators shift from input through output
and effect to impact. It should be possible to collate data for input
and output indicators centrally from regular health reporting systems,
whereas data for many outcome and impact indicators must be collected
through surveys (or surveillance) of health facilities, or in
population-based surveys. The cost and incremental benefit of more
regular, or more extensive data collection must also be borne in mind.
It may worthwhile to increase the sample size for sentinel surveillance
so that data can be disaggregated by age, yielding important
information. The trade-off may, however, be to reduce the number of
sentinel sites, or to reduce the frequency of surveillance.

***Types of Indicators***

-   [Number]{.underline}: This is a straight count. How many. This is
    most commonly used as an output level indicator. Examples: the
    number of condoms distributed in a month or the number of women who
    received ARV prophylaxis in a specified time period.

-   [Ratio]{.underline}: A ratio compares two or more cohorts. X vs. Y.
    Examples: Education levels of boys vs. girls, or the HIV incidence
    in the 12-15 age category vs. the 16-21 age category.

-   [Percentage]{.underline}: A percentage compares two numbers. The
    numerator is looking at a subset of the total and comparing a
    change. X compared to Y or X/Y. A percent is one step of analysis
    beyond collecting straight numbers; therefore it is usually used at
    the outcome or impact level. Examples: The percentage of clients who
    returned for post-test counseling out of the total number that
    tested. The percentage of people who were able to pass a competency
    test compared to the total number who attended the training.

-   [Average]{.underline}: This is obtained by adding the sum of the
    data set and dividing by the number of data in the set. An average
    is trying to pull out what is the most common number found in the
    data set. An average is usually used as a measure of outcome or
    impact. Examples: The average CD4 counts of all ARV patients at a
    site within a month or the average condom distribution by a
    programme over a year.

-   [Rate]{.underline}: This indicator involves three pieces of data.
    Because it is a secondary analysis, a rate is most commonly used at
    the outcome or impact level, especially if one element is time.
    Outcome and impact level indicators are long-term or over time.
    Examples: The number of new infections among an uninfected
    population over a one year time period (incidence rate).

-   [Index]{.underline}: An index is a composite of indicators, which
    can be assigned values, totaled and then compared. This allows items
    which are not necessarily similar to be compared and is used to
    measure outcomes or impact level results. Examples: The UNDP
    Development Index. This index assigns ranks to countries\'
    education, health, economic and other social systems. The individual
    ranks are added together to get one sum. The sum is then compared
    from one country to another, and may indicate, for instance, how
    Cuba ranks in comparison to the United States. Another example is
    the orphans and vulnerable children (OVC) index. As a child enters a
    programme, s/he is assigned a rank from 1 to 5 in four categories:
    nutritional status, education, psychosocial and health. Then, after
    six months of enrollment in the programme, the numbers of each
    category are re-assessed and added together again. One can now
    compare the sum after six months to the initial sum to judge
    progress on the scale from 0 to 20 (maximum score).

***The Use of Indicators at Different Levels***

This manual identifies a set of indicators and measurement methods to be
used at the project level. These indicators are intended to measure a
broad range of issues regarding the HIV epidemic and the country's
response to that epidemic. They provide a way to track changes over time
in specific prevention and care areas. They also allow comparison of the
overall implementation and effectiveness of the USG response in
different countries.

However, because the indicators cover so many programme areas and
because substantial resources can go into collecting indicators, the
number of indicators in any particular area must remain limited. This
means that the set presented here will not comprehensively address all
the specific monitoring and evaluation needs of individual projects to
prevent and mitigate the impacts of HIV/AIDS. In this section we will
briefly discuss the roles which these indicators play in M&E at three
levels: international, national, and project.

### 

**[International Level]{.underline}**

At the international level, the collection of these indicators in
different countries will help international agencies and donors to:

-   Track the trends in the epidemic and the response on a global scale.

-   Identify regional trends or patterns in the epidemic and the
    response.

-   Highlight persistent global and regional problems in responding to
    the epidemic.

-   Advocate for expanded resources to address the pandemic.

-   Allocate financial and technical resources so as to have the
    greatest impact on the global pandemic.

It is therefore important that these indicators are defined and measured
in the same way, across countries and regions, so that they are
understandable when viewing and comparing at the global level. This
manual provides detailed recommendations as to how to measure each of
the indicators. Although contextual information is needed to form a full
picture behind any particular indicator, taken roughly they can be
compared directly from country to country.

### 

**[National Level]{.underline}**

At the national level the indicators presented in this manual can be
used to track trends, identify problem areas, advocate for and allocate
resources. At the national level the indicators will also inevitably
contribute to evaluation of the effectiveness of the country's overall
response, that is the sum total of all activities going on in-country
which relate to the HIV/AIDS epidemic. In deciding on a national set of
indicators, it is important that countries realize they are not limited
to the set of indicators proposed by international agencies such as
UNAIDS. The choice of indicators should be driven instead by the
objectives, goals, and activities that constitute the national response
to HIV and by the local epidemiology and epistemology of HIV and risk
behaviors, keeping in mind that it costs time and money to collect and
analyze data for each indicator. When necessary, however, projects
should add indicators to make certain the data collected is linked to
improving programmes.

### 

**[Project Level]{.underline}**

The indicators presented in this manual will not cover the full range of
project monitoring and evaluation needs. Good project monitoring and
evaluation requires a mix of input, process, output, outcome and impact
indicators that are directly tied to the project activities, goals and
objectives. These should then feed directly back into the project to
improve the implementation of activities and maximize the project's
impacts.

While much of the impetus for standardizing indicators has come from
international bodies wishing to make cross-country comparisons, the
value of standardized indicators within a country cannot be
overemphasized. The M&E specialist should always bear in mind the
national standard for indicators in that field when designing monitoring
and evaluating activities for a specific project. The project may have
unique information needs that conform to a rigorous evaluation design.
However one is often able to choose indicators with standard reference
periods that allow the collected data to be fed easily into the national
M&E system.

Using comparable measures can provide the national programme with
valuable measures of the same indicator in different populations,
permitting triangulation of findings and allowing regional or local
inconsistencies and differences to be noted and addressed. This can help
to direct resources to regions or sub-populations with greater needs,
identify areas for intensification or reduction of effort at the
national level, and aid in improving the overall effectiveness of the
national response.

# An Introduction to the Management of Data Quality

All projects and programmes that involve the collection, collation,
manipulation and reporting of data must ensure that such data meets
minimum criteria for data quality. These criteria are far more than a
statistical exercise and involve the design, implementation and
management of a Data Quality Management System (DQMS) documented in the
Data Quality Plan (DQP). This means that persons managing the data must
know and understand data quality criteria, be able to design a plan to
manage data quality and be able to internally audit the quality of the
data. In essence, the end user or recipient of data has a right to
information that is valid, reliable and accurate. The data quality
manager has the obligation to ensure that this is the case in practice.
In this set of introductory notes, the reader is introduced to the:

-   Minimum data quality criteria;

-   Construction of a Data Quality Plan; and

-   Data Quality Audit Process

    As these notes are only a very brief introduction, they cannot
    contain comprehensive information about data quality. Nor do they
    guarantee that having read them, an implementing partner will be
    able to produce data of the highest quality. Readers are encouraged
    to interact with their data quality auditors and reporting partners
    in order to improve their data quality practices. A list of
    references for further information is supplied at the end.

***The Criteria for Data Quality***

There are five basic criteria for the establishment of data quality.
These criteria originate from various statistical methods and techniques
but have evolved to be equally applicable to both quantitative and
qualitative data. In essence all data whether at source or post
manipulation must demonstrate acceptable levels of:

-   Validity;

-   Reliability;

-   Timeliness;

-   Precision; and

-   Integrity.

**[Measure of Validity]{.underline}**

Validity, in terms of data quality, is the assurance that we have
actually measured what we intended to measure at the outset. Thus the
data is reflective of the true differences among the respondents from
the population group that was evaluated. The greatest data quality risk
to validity exists in the design and construction of the indicators and
their associated definitions at programme level. Often an inappropriate
definition is applied to an indicator, therefore attribution cannot be
demonstrated. At project implementation level risks to validity occur
when an implementing partner *fails* to:

-   Contextualize the definition of the indicator to their own project.
    For example, what does training mean in your organization;

-   Recognize the data that must be included and/or excluded from a data
    set. In terms of the PEPFAR indicators, OVC *excludes* all
    individuals over 18 years of age;

-   Recognize whether data is directly valid or a proxy measure (see
    Definitions in Appendix)

-   Establish the inherent biases that exist in terms of the operational
    definitions -- is there an underlying assumption that a behavior
    change intervention actually leads to the intended change? This
    needs to be proven, not an assumption.

**[Measure of Reliability]{.underline}**

In the broadest sense reliability is associated with the concepts of
accuracy, precision and consistency. For the purposes of data quality,
reliability is the ability of the implementing partner to be able to
consistently collect data of the same quality over time. Reliability is
a pre-requisite for validity. The greatest quality risks to achieving
reliability occur when an implementing partner *fails to identify* those
elements in the:

-   Collection methodology that cannot be consistently applied. For
    example, a survey could be done of participants when they finish a
    training, with the intention of a follow-up survey being completed
    in six months. If the project is working with a mobile population,
    survey methodology will not be able to be repeated with the same
    group as it would be difficult to locate them again;

-   Collection instruments or tools that allow for variation with time,
    place or persona. Any collection tool or instrument must have well
    documented instructions and definitions;

-   Sampling frameworks which are affected by time, place or persona;

-   Selection and appointment of new data management personnel which
    allow for the introduction of personal interpretations and data
    management methods;

-   Arithmetic methodologies that may include rounding up or down, as
    well as any other form of inconsistency or data 'torture'.

**[Measure of Timeliness]{.underline}**

The whole point of having quality data is to ensure that decisions
regarding programmes and projects can be made in a timely manner. If
significant time lags exist between the collection, collation and
eventual reporting of data then the relevance of the data to the
decision making process is lost. This is not to say that all data must
be reported at the time it is collected and collated. Sometimes data is
collected retrospectively and only reported years after its initial
derivation. The quality test for timeliness is whether the data being
collected, collated and reported still carries the desired relevance at
the time of reporting. Timeliness as a measure of quality is negatively
affected when an implementing partner *fails* to:

-   Establish collection dates related to the relevance of the actions
    that will be taken following the reporting of the data; and

-   Establish the ratio for acceptable time lags between data
    collection, collation and reporting. It may take a facility one
    month to compile service statistics. This must be built into
    reporting expectations that data is always one month behind actual
    service delivery.

**[Measure of Precision]{.underline}**

Although accuracy and precision are statistically addressed with
reliability, they are of such importance to the management of data
quality to be measured and monitored separately. Like reliability,
therefore, precision is a pre-requisite for validity. Due to the
contractual nature and funding implications associated with the data
reported for many programmes and projects, it is essential that there be
some form of guarantee that the data is as free from bias (accuracy) and
error (precision) as possible. The typical data management issues that,
when *not addressed* result in data quality failure in terms of the
measure of precision include identifying whether:

-   There are any source errors or bias;

-   The instruments used for collection, collation, manipulation and
    storage produce error or bias. For example, an Excel spreadsheet has
    been corrupted and the formula no longer is accurate;

-   The sampling results in bias based on time, place or persona or in
    under or over reporting errors. Sampling should be random. A project
    could not take HIV test results from individuals who showed up to a
    mobile clinic on a Wednesday and extrapolate prevalence rate for
    that area, for example. The fact that it is a Wednesday is a time
    bias because many people work on a Wednesday. Also, the individuals
    that showed up at the mobile clinic were self-selecting and may have
    come to get tested because they knew they were at risk;

-   The transcription methods allow for the introduction of under or
    over entry errors and the nature of their origin e.g. the data
    capturer entered 71 instead of 17;

-   Calculations and other forms of data manipulation can be affected by
    bias and if so what form of over or under report they create. A
    project manager may assume that 20 percent of all patients are HIV
    positive, if actual results are unavailable. This may bias the data
    set. Ensure assumptions are backed up by data.; and

-   Ensure that the margin of error is evaluated and calculate for any
    data set.

    Often, depending on the type of data being managed, it is not
    possible to establish with a high degree of precision the actual
    degree of error. In these cases it is essential that the data
    quality manager is able to give an indication of the risk magnitude
    (high or low) and direction of the error (under report or over
    report). The risk magnitude is based on whether or not the expected
    error will be greater than the desired target the programme or
    project is aiming to achieve. In the case of low risk magnitudes
    that data can still be used for reporting purposes. The direction of
    the error must be established as being either a potential under
    report or a potential over report. It is no good establishing after
    the fact, during a DQA, what the margins of error are, as this is
    somewhat like placing an airplane on a commercial flight, full of
    passengers, before having tested the wing tolerances for maximum
    load. In essence, precision is not something that just happens, it
    is something that is carefully planned, measured and monitored and
    often acts as an early warning signal for deteriorating data
    quality.

**[Measure of Integrity]{.underline}**

Although we would always like to believe the best of everyone the
reality is that even data management systems are open to manipulation
with a subsequent lack of data integrity. Sometimes the loss of data
integrity, or truthfulness of the data, occurs from human error or
actual human interference. On other occasions, loss of data integrity
occurs when technology fails us. From a data quality perspective it is
essential to know what risks exist to the integrity of the data, where
in the data management process these risks exist, and to ensure that we
have contingency plans to manage such risks. Classic integrity risks
exist when we *fail* to:

-   Establish whether the costs associated with collection lead to
    temptation to fudge data. For example, if an interviewer for a
    survey is paid for each survey that is filled out -- that may lead
    to an interviewer to fill out additional surveys falsely;

-   Establish whether there is any reason for respondents to give false
    data for personal or political reasons;

-   Establish whether the data collectors are influenced to provide
    false data or manipulate the data collected;

-   Establish whether the data cleaning, handling and storage systems
    are tamper-proof, regardless of whether the systems are electronic
    or hard copy based. A programme may want to limit the number of
    people who have access to the data set; and

-   Include internal and external audit as a means of verifying and
    validating the DQMS.

***Determining the Cost of Indicator Collection***

A recommended method to use for this is a partial cost accounting basis
that determines the directly attributable costs. The purpose of the
exercise would be to establish a cost-benefit ratio which the
organization receiving the funding could then use to determine whether
or not there is benefit to be gained in improving the quality of data or
not.

[Method:]{.underline}

1.  Determine the direct costs for staff involved (level of effort cost)
    in the data management system on a unit cost basis, regardless of
    whether they source, collect, collate, analyze or report the data.
    The unit cost is a function of the staff member's total cost to
    organization per month divided by their normal number of hours
    worked per month. This gives their unit cost per hour. The direct
    costs are calculated by determining the amount of time they spend,
    or should spend, on data management activities for a specific
    indicator. It is thus essential that accurate time sheets be kept in
    this regard.

2.  Other direct costs per indicator are calculated by firstly
    understanding the nature of the data management system and
    establishing which elements in the system have a directly
    attributable cost. For example, a particular indicator may have
    printed tools for data collection. The unit cost for printing these
    tools would be established by knowing the number of copies made and
    the cost per copy plus the cost of the paper.

3.  By calculating the total direct costs for an indicator an
    organization can determine whether an increased direct cost would be
    warranted to improve data quality. For example, if precision errors
    were running at 20% and it would take a 35% increase in level of
    effort costs to improve the error to 10% (i.e. an improvement of
    only 10%), it would be considered as an unwarranted cost and thus
    the data would be reported as is with a note related to the error,
    so that the Funder can adjust if need be. Ideally the increased
    costs in improving data quality should be less than the improvement
    being achieved.

To prevent over-complicating the calculation of the costs of an
indicator, the indirect costs related to overhead and non-attributable
activities are left out. Although this is not ideal in a cost accounting
system, for the purposes of the cost-benefit exercise it would not be
inappropriate, as the direct costs would be sufficient for proving or
disproving warranted expense.

***The Data Quality Plan***

In order to ensure data quality and to avoid unnecessary and costly data
repairs a Data Quality Plan (DQP) is developed in support of the
Monitoring and Evaluation Plan (MEP) and in line with the Indicator
Information Sheets (IIS). The DQP forms the basis for ensuring that the
five critical elements of data quality, namely: validity, reliability,
timeliness, precision and integrity, are considered during the planning
for monitoring and evaluation and activity rollout. The DQP is an
essential record of how the project managed its data quality issues, and
is an excellent source of information for the Auditor during a Data
Quality Audit (DQA).

The DQP includes explanations of how data quality will be achieved as
well as the sources of information or evidence that are used to validate
and verify data quality. A good DQP should also include a data quality
risk analysis. An example of a generic template used for a DQP is given
in Appendix D.

***Establishing Risks to Data Quality***

Sometimes it is not possible for data to meet all five data quality
characteristics to the same degree. It is for this reason that the
various aspects of data management should be evaluated for relative risk
against an established and consistent risk matrix. The use of the matrix
enables the data quality manager to establish those data management
areas that require greater attention, contingency plans and more regular
review. All data has an associated quality risk and sometimes the cost
of managing the risk outweighs the additional benefit to be gained from
improving the data quality. The use of a risk matrix enables the
implementing partner to establish those elements within the data
management system, which pose the greatest data quality risk so that the
appropriate controls can be put in place to minimize the impact of a
risk.

Table 1: Data Quality Risk Matrix

  --------------- --------------- -------------- --------------- --------------
  **Overall       **Probability                                  
  Effect on Data  of Error                                       
  Quality**       Occurring**                                    

                  *(4) -          *(3) --        *(2) -          *(1) --
                  Constantly*     Frequently*    Occasionally*   Unlikely*

  *(4) -          **16**          **12**         **8**           **4**
  Catastrophic*                                                  

  *(3) --         **12**          **9**          **6**           **3**
  Critical*                                                      

  *(2) -          **8**           6              **4**           **2**
  Marginal*                                                      

  *(1) -          **4**           **3**          **2**           **1**
  Negligible*                                                    
  --------------- --------------- -------------- --------------- --------------

Table 2: Data Quality Risk Analysis Table

  --------- ------------ -------------------------------------------------
  **Risk    **Risk       **Remedial Action**
  Score**   Type**       

  **9 -     **High       Establish contingency plan to reduce risk, verify
  16**      Risk**       and validate *prior to each reporting episode*,
                         maintain strict audit trail.

  **4 - 8** **Medium     Establish contingency plan to reduce risk, verify
            Risk**       and validate *prior to annual return*, maintain
                         strict audit trail.

  **1 - 3** **Low Risk** No immediate action required; risk could be
                         managed through normal internal audit processes.
  --------- ------------ -------------------------------------------------

***Data Quality Auditing***

Data Quality Auditing (DQA) is an established tool within the M&E field.
Unfortunately it is often applied in the absence of DQPs thus yielding
poor audit results. It is an excellent tool for implementers to
establish and verify the quality of both their data management practices
as well as the data itself. DQAs usually involve the following elements:

-   A self-evaluation for keeping an internal audit record, or for
    submission to the external auditor for evaluation (Self-evaluation
    given in Appendix D);

-   An on-site review of data management practices and a sampling based
    audit of actual data;

-   Construction of compliance plans for those elements which do not
    meet data quality standards (both internal and external audits); and

-   An audit report to the organization (internal audit) or the
    reporting authority (external audit).

The USG South Africa HIV/AIDS task force conducts regular DQAs of PEPFAR
partners to both build capacity among partners to improve data
management systems and to validate the data that are reported. The
recommendations for partners and USG from the FY 05 DQAs are provided in
Appendix E.

***References for Data Quality***

The DQA should be based on USAID Automated Directive Systems (ADS) data
quality standards, specifically:

-   ADS Chapter 203 Requirements for Data Quality Assessment:

\[http://www.usaid.gov/policy/ads/200/203.pdf\]

-   ADS Chapter 578 Information Quality Guidelines

\[http://www.usaid.gov/policy/ads/500/578.pdf\]

The following documents also establish a point of reference for carrying
out the DQA:

-   TIPS: Guidelines for Indicator and Data Quality

\[http://pdf.dec.org/pdf_docs/PNACA927.pdf\]

-   U.S General Accounting Office, The Results Act: An Evaluators Guide
    to Assessing Agency Performance Plans

\[http://www.gao.gov/special.pubs/gg10120.pdf\]

-   U.S General Accounting Office, Performance Plans: Selected
    Approaches for Verification and Validation of Agency Performance
    Information

\[http://www.gao.gov/archive/1999/gg99139.pdf\]

-   U.S General Accounting Office, Standards for Internal Control in the
    Federal Government

\[http://www.gao.gov/special.pubs/ai00021p.pdf\]

-   Price Waterhouse Coopers (PWC): The Performance Management Toolkit
    \-- A Guide to Developing and Implementing Performance Plans (non
    proprietary). This toolkit will be provided by USAID.

# Reporting on Programme Results for the President's Emergency Plan for AIDS Relief

PEPFAR partners that receive funding for direct ARV treatment services
are required to report on programme results each quarter by ARV service
outlet. For partners working in all other programme areas, only
semi-annual and annual reports are required. The reporting schedule is
as follows:

-   **Quarter 1 Treatment Report** (covering October 1-December 31) to
    be submitted end of January

-   **Quarter 2 Treatment Report** (covering January 1-March 31) and
    **Semi-annual Report** (covering October 1 -- March 31) to be
    submitted end of April

-   **Quarter 3 Treatment Report** (covering April 1 -- June 30) to be
    submitted end of July

-   **Quarter 4 Treatment Report** (covering July 1 -- September 30) and
    **Annual Report** (covering October 1 -- September 30) to be
    submitted end of October

In addition, each USG agency may have additional reporting requirements.
Partners should contact their USG activity manager to find out about any
other requirements.

Each year, around August, partners are required to submit a Country
Operational Plan (COP) that describes current and planned activities
including targets for required indicators. The targets that are set in
the COP are for the subsequent fiscal year and are used to monitor
partner performance in the semi-annual and annual reports. The reports
mentioned above include: 1) programme indicator results, including
narrative sections to explain training activities, progress on targets
outlined in the COP, and an explanation of direct and indirect support;
2) narrative sections explaining challenges and accomplishments; and 3)
success stories.

[]{.mark}

When reporting on PEPFAR indicators, double counting should be avoided,
particularly within one service/programme area and reporting period. For
example, if an individual receives psychological care and treatment for
opportunistic infections as part of a package of palliative care
services during the same reporting period, this person should only be
counted once as an individual being supported with palliative care
within the reporting period. In other words, this indicator intends to
capture the *number of individuals* receiving palliative care services,
rather than the *number of visits* regardless if the visits are for the
same or difference services that would be categorized as palliative
care. However, for individuals served by multiple programme areas, it is
acceptable to count individuals once for each programme area (e.g., OVC,
ART, and palliative care). Persons receiving services in one reporting
cycle can be counted again in the next cycle if they are still receiving
services. Thus, the report shows the total number of persons currently
being served within each reporting period (6 or 12 months or 3 months
for treatment reports). The same applies to counting numbers of
individuals trained. A person trained in a particular area or for a
particular program more than once in one reporting period is only
counted as one person trained. However, if this person is trained in a
different programme area then s/he can be counted once for each
programme area in which s/he is trained. For example, if a person is
trained in providing psychosocial support for HIV-infected persons and
also in the provision of opportunistic infections, s/he should only be
counted once under the indicator "Number of persons trained in
HIV-related palliative care." However, if a person was trained in the
provision of ART and the provision of prophylaxis for opportunist
infections, s/he can be counted under both indicators "Number of persons
trained in the provision of ART" and "Number of persons trained in the
provision of HIV-related palliative care." Lastly, if two or more PEPFAR
partners are working in the same facility and/or reaching the same
people, it is [important]{.underline} to inform the USG agency in the
narrative section of the report in order to minimize the double counting
in the overall South Africa PEPFAR programme progress report. Each
partner still reports their reach and progress toward their targets,
however, when aggregated to a total USG sum, the USG SI team must adjust
for duplicate counting.

[]{.mark}

Partners must report on all indicators that are relevant to
PEPFAR-funded programme activities during the reporting period
regardless of whether targets were set at the beginning of the period.
For example, a treatment programme may do counseling and testing in
order to enroll patients on ARVs. The number of people counseled and
tested should be reported even though a target may not have been set in
the COP. If an indicator is relevant but data are not available,
partners should indicate that in the report.

The indicators presented here are the minimum programme-level reporting
requirements under PEPFAR. However, they represent only a subset of the
information needed by programmes to effectively monitor, manage and
improve their programmes locally. A good example of additional
information that would be recommended is geographical coverage of
service sites. Age of clients served is another useful variable that is
not required in the aggregate counts (with the exception of ART), but is
recommended for programme management and planning purposes. If partners
would like to report on additional indicators that they are using to
manage their program and measure program success, they can report those
data in the narrative text sections of the quarterly, semi-annual, and
annual reports.

PEPFAR partners are required to report via the Data Warehouse that is a
password-protected web-based reporting system
([www.sharing.org.za](http://www.sharing.org.za/)). To obtain further
information about the Data Warehouse, please contact a USG Strategic
Information Advisor.

***Direct and Indirect Results***

All PEPFAR indicators aim to reflect direct programme support. However,
as directed by the Office of the Global AIDS Coordinator (OGAC), there
are seven indicators that are collected for both "direct" and "indirect"
support:

**PMTCT:**

-   Number of pregnant women who received HIV counseling and testing for
    PMTCT and received their test results

-   Number of pregnant women receiving a complete course of
    antiretroviral prophylaxis in a PMTCT setting.

**Care:**

-   Total number of individuals provided with general HIV-related
    palliative care (including TB/HIV)

```{=html}
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```
-   Number of HIV-infected clients attending HIV care/treatment services
    that are receiving treatment for TB disease (a subset of all served
    with palliative care)

-   Number of OVC served by an OVC programme.

    **Counseling and Testing:**

```{=html}
<!-- -->
```
-   Number of individuals who received counseling and testing, and
    received results.

    **Treatment:**

```{=html}
<!-- -->
```
-   Number of individuals receiving antiretroviral therapy at the end of
    the reporting period.

An intervention is considered to be a type of "direct" support if it can
be associated with counts of uniquely identified individuals receiving
care or support (or prevention messages) at a specific service delivery
point that is receiving assistance from the partner. Results that are
direct are documented and auditable.

"Indirect" support is an *estimate* of individuals receiving care,
treatment or other services as a result of the USG's contribution to
local, provincial or national activities such as policy development,
logistics, protocol/guideline development and dissemination, and
laboratory support.

There are three guiding principles to apply when distinguishing between
"direct" and "indirect" support:

-   **Frequency of assistance:** To justify a partner counting patients
    (or number of people served) directly, the implementing partner must
    be at the service delivery site at least twice monthly and the
    partner intervention must lead to improved availability or quality
    of service.

-   **Results test:** In order to count an intervention as direct, the
    implementing partner must be able to justify that either: 1) the
    intervention or service would not have happened without the
    involvement of the organization or 2) the organization's provision
    of resources, staff or mentoring enabled the service/activity to
    take place or enhance the availability or quality of the service.

-   **Auditability:** When deciding whether a partner's data should be
    counted as direct, the USG considers whether the numbers would
    withstand an external audit review. A critical determination is
    whether the partner has access to official records kept by the
    service delivery site. If the partner has access to the official
    patient records to support their reported results, then the figures
    can be included in the count of direct support.

***Data Quality***

PEPFAR partners are expected to report on valid and reliable data to the
extent that is possible and feasible. A reasonable margin of error not
greater than 10% is acceptable in cases whereby the cost of data
collection and reporting exceeds the value of the data itself. Any
issues around data quality must be reported to the USG agency. In
addition, if estimates were used to report on the number of individuals
reached, where exact counts could not be determined, the method of
calculation must be reported and approved by the USG agency. Lastly, if
there is more than one PEPFAR partner reporting on the same individuals
reached, please indicate that in all progress reports and to the USG
agency to reduce double-counting when figures are aggregated at the USG
level.

***South African Government Reporting***

All USG partners receiving funding through PEPFAR, working in either
private or public service delivery sites, are also encouraged to report
data to local, provincial and national government counterparts. This
data is valuable information for planning purposes and to capture
program coverage and service uptake. Please contact the local or
provincial government to obtain required indicators specific to a
location.

# 

# 

# 

# 

# Indicators for Monitoring the President's Emergency Plan for AIDS Relief

+-----------------------------------------------------------------------+
| **PREVENTION**                                                        |
+-----------------------------------------------------------------------+
| **Abstinence and Being Faithful**                                     |
+-----------------------------------------------------------------------+
| 1.  Number of individuals reached through community outreach that     |
|     promotes HIV prevention through abstinence and/or being faithful  |
|     (disaggregated by gender)                                         |
+-----------------------------------------------------------------------+
| > 1.1A Number of individuals reached through community outreach that  |
| > promotes HIV prevention through abstinence (disaggregated by        |
| > gender) (subset of 1.1)                                             |
+-----------------------------------------------------------------------+
| 2.  Number of individuals trained to promote HIV prevention           |
|     programmes through abstinence and/or being faithful               |
+-----------------------------------------------------------------------+
| 3.  Number of hours of technical assistance provided for abstinence   |
|     and/or being faithful programmes to: 1) National Government; 2)   |
|     Local or Provincial Government; and 3) Other NGOs                 |
+-----------------------------------------------------------------------+
| **Condoms and Other Prevention**                                      |
+-----------------------------------------------------------------------+
| > 2.1 Number of targeted condom service outlets                       |
+-----------------------------------------------------------------------+
| 2.  Number of individuals reached through community outreach that     |
|     promotes HIV prevention through other behavior change beyond      |
|     abstinence and/or being faithful (disaggregated by gender)        |
+-----------------------------------------------------------------------+
| 3.  Number of individuals trained to promote HIV prevention through   |
|     other behavior change beyond abstinence and/or being faithful     |
+-----------------------------------------------------------------------+
| 4.  Number of hours of technical assistance provided for condoms      |
|     other prevention programmes to: 1) National Government; 2) Local  |
|     or Provincial Government; and 3) Other NGOs                       |
+-----------------------------------------------------------------------+
| **Medical Transmission/Blood Safety and Injection Safety**            |
+-----------------------------------------------------------------------+
| 1.  Number of service outlets carrying out blood safety activities    |
+-----------------------------------------------------------------------+
| 2.  Number of individuals trained in blood safety                     |
+-----------------------------------------------------------------------+
| 3.  Number of individuals trained in medical injection safety         |
+-----------------------------------------------------------------------+
| > 3.4 Number of facilities with good waste management and procurement |
| > systems to support injection safety                                 |
+-----------------------------------------------------------------------+
| > 3.5 Number of public health facilities (clinics and hospitals)      |
| > receiving IEC printed material on injection safety and infection    |
| > control                                                             |
+-----------------------------------------------------------------------+
| **Prevention of Mother-to-Child Transmission**                        |
+-----------------------------------------------------------------------+
| > 4.1 Number of service outlets providing the minimum package of      |
| > PMTCT services according to South African or international          |
| > standards                                                           |
+-----------------------------------------------------------------------+
| > 4.2 Number of pregnant women that attended first antenatal care     |
| > visit                                                               |
+-----------------------------------------------------------------------+
| > 4.3 Number of pregnant women who received HIV counseling and        |
| > testing for PMTCT and received their test results                   |
+-----------------------------------------------------------------------+
| > 4.4 Number of pregnant women provided with a complete course of ARV |
| > prophylaxis                                                         |
+-----------------------------------------------------------------------+
| > 4.5 Number of infants receiving an ARV prophylaxis                  |
+-----------------------------------------------------------------------+
| > 4.6 Number of infants tested by PCR at 6-14 weeks                   |
+-----------------------------------------------------------------------+
| > 4.7 Number of infants tested at 12 months                           |
+-----------------------------------------------------------------------+
| > 4.8 Number of HIV-infected pregnant women referred to: 1) a         |
| > wellness programme and 2) a treatment programme                     |
+-----------------------------------------------------------------------+
| > 4.9 Number of pregnant women who received HIV counseling and        |
| > testing for PMTCT and received their test results (indirect)        |
+-----------------------------------------------------------------------+
| > 4.10 Number of pregnant women provided with a complete course of    |
| > ARV prophylaxis in a PMTCT setting (indirect)                       |
+-----------------------------------------------------------------------+
| > 4.11 Number of health workers trained in the provision of PMTCT     |
| > services according to South African or international standards      |
+-----------------------------------------------------------------------+
| > 4.12 Number of hours of technical assistance provided for PMTCT     |
| > programmes to: 1) National Government; 2) Local or Provincial       |
| > Government; and 3) Other NGOs                                       |
+-----------------------------------------------------------------------+
| **COUNSELING AND TESTING**                                            |
+-----------------------------------------------------------------------+
| > 5.1 Number of service outlets providing counseling and testing      |
| > according to South African or                                       |
| >                                                                     |
| > international standards                                             |
+-----------------------------------------------------------------------+
| > 5.2 Number of individuals who received pre-test counseling          |
| > (disaggregated by gender)                                           |
+-----------------------------------------------------------------------+
| > 5.3 Number of individuals who received counseling and testing and   |
| > received their test results (disaggregated by gender)               |
+-----------------------------------------------------------------------+
| > 5.4 Number of individuals who received counseling and testing and   |
| > received their test results (indirect)                              |
+-----------------------------------------------------------------------+
| > 5.5 Number of HIV-infected individuals who were referred to: 1)     |
| > wellness programme; 2) treatment programme; 3) STI services; and 4) |
| > TB services                                                         |
+-----------------------------------------------------------------------+
| > 5.6 Number of individuals trained in counseling and testing         |
| > according to South African or international standards               |
+-----------------------------------------------------------------------+
| > 5.7 Number of hours of technical assistance provided on counseling  |
| > and testing to: 1) National Government; 2) Local or Provincial      |
| > Government; and 3) Other NGOs                                       |
+-----------------------------------------------------------------------+
| **CARE**                                                              |
+-----------------------------------------------------------------------+
| **Orphans and Vulnerable Children**                                   |
+-----------------------------------------------------------------------+
| > 6.1 Number of OVC served by an OVC programme (disaggregated by      |
| > gender)                                                             |
+-----------------------------------------------------------------------+
| 6.1A Number of OVC receiving increased access to health care (subset  |
| of 6.1)                                                               |
+-----------------------------------------------------------------------+
| > 6.1B Number of OVC receiving antiretroviral treatment (subset of    |
| > 6.1)                                                                |
+-----------------------------------------------------------------------+
| > 6.1C Number of OVC receiving support to increase access to          |
| > education (subset of 6.1)                                           |
+-----------------------------------------------------------------------+
| > 6.1D Number of OVC receiving access to economic support (subset of  |
| > 6.1)                                                                |
+-----------------------------------------------------------------------+
| > 6.1E Number of OVC receiving food or nutritional support (subset of |
| > 6.1)                                                                |
+-----------------------------------------------------------------------+
| > 6.1F Number of OVC receiving legal assistance (subset of 6.1)       |
+-----------------------------------------------------------------------+
| > 6.1G Number of OVC provided with or referred to psychosocial        |
| > support (subset of 6.1)                                             |
+-----------------------------------------------------------------------+
| > 6.1H Number of OVC provided with protection from abuse (subset of   |
| > 6.1)                                                                |
+-----------------------------------------------------------------------+
| > 6.1I Number of OVC benefiting from community mobilisation to        |
| > respond to OVC needs (subset of 6.1)                                |
+-----------------------------------------------------------------------+
| > 6.2 Number of OVC served by OVC programmes (indirect)               |
+-----------------------------------------------------------------------+
| > 6.3 Number of family members of OVC provided with HIV-related       |
| > palliative care                                                     |
+-----------------------------------------------------------------------+
| > 6.4 Number of providers/caretakers trained in caring for OVC        |
+-----------------------------------------------------------------------+
| **Palliative Care: Basic Health Care and Support and TB/HIV care**    |
+-----------------------------------------------------------------------+
| > 7.1 Number of service outlets providing HIV-related palliative care |
| > (including TB)                                                      |
+-----------------------------------------------------------------------+
| > 7.1.A Number of service outlets providing treatment for TB to       |
| > HIV-infected individuals in a palliative care setting (subset of    |
| > palliative care outlets)                                            |
+-----------------------------------------------------------------------+
| > 7.2 Number of individuals provided with HIV-related palliative care |
| > (including TB) (disaggregated by gender)                            |
+-----------------------------------------------------------------------+
| > 7.2.A Number of HIV-infected individuals that received treatment    |
| > for TB disease (disaggregated by gender) (subset of 7.2)            |
+-----------------------------------------------------------------------+
| > 7.2.B Number of individuals that received post exposure prophylaxis |
| > (subset of 7.2)                                                     |
+-----------------------------------------------------------------------+
| 7.2C Number of HIV-infected individuals that received cotrimoxazole   |
| prophylaxis (subset of 7.2)                                           |
+-----------------------------------------------------------------------+
| 7.3 Number of TB patients counseled and HIV tested and received test  |
| results (disaggregated by gender)                                     |
+-----------------------------------------------------------------------+
| > 7.4 Number of family members of HIV-infected individuals provided   |
| > with HIV-related palliative care                                    |
+-----------------------------------------------------------------------+
| > 7.4 Number of TB cases                                              |
+-----------------------------------------------------------------------+
| > 7.5 Number of Pulmonary TB                                          |
+-----------------------------------------------------------------------+
| > 7.6 Number of new smear positives                                   |
+-----------------------------------------------------------------------+
| > 7.7 Number of successfully treated TB                               |
+-----------------------------------------------------------------------+
| > 7.8 Number of HIV-infected individuals in a palliative care program |
| > that were referred for ART                                          |
+-----------------------------------------------------------------------+
| > 7\. 9 Number of individuals provided with HIV-related palliative    |
| > care(including TB) (indirect)                                       |
+-----------------------------------------------------------------------+
| > 7.9A Number of HIV-infected individuals who received treatment for  |
| > TB disease (subset of 7.9)(indirect)                                |
+-----------------------------------------------------------------------+
| 7.10 Number of individuals trained to provide HIV-related palliative  |
| care (including TB/HIV)                                               |
+-----------------------------------------------------------------------+
| > 7.10A Number of individuals trained to provide treatment for TB to  |
| > HIV-infected individuals (subset of 7.10)                           |
+-----------------------------------------------------------------------+
| > 7.11 Number of hours technical assistance provided in HIV-related   |
| > health care and support                                             |
+-----------------------------------------------------------------------+
| > 7.12 Number of hours technical assistance provided for              |
| > strengthening TB/HIV services                                       |
+-----------------------------------------------------------------------+
| **TREATMENT**                                                         |
+-----------------------------------------------------------------------+
| **Direct ART Services**                                               |
+-----------------------------------------------------------------------+
| > 8.1A Number of service outlets providing HIV counseling and testing |
+-----------------------------------------------------------------------+
| > 8.1B Number of service outlets providing HIV-related palliative     |
| > care (including TB)                                                 |
+-----------------------------------------------------------------------+
| > 8.1C Number of service outlets providing treatment for TB (subset   |
| > of palliative care outlets)                                         |
+-----------------------------------------------------------------------+
| > 8.1D Number of service outlets providing antiretroviral treatment   |
+-----------------------------------------------------------------------+
| > 8.2 Number of individuals counseled and HIV tested and received     |
| > test results (disaggregated by gender)                              |
+-----------------------------------------------------------------------+
| 8.2 A Number of TB patients counseled and tested and received test    |
| results (subset of above)                                             |
+-----------------------------------------------------------------------+
| > 8.3 Number of HIV-infected individuals who received pre-treatment   |
| > training                                                            |
+-----------------------------------------------------------------------+
| > 8.4 Number of HIV-infected individuals who received ARV adherence   |
| > counselling                                                         |
+-----------------------------------------------------------------------+
| > 8.5 Cumulative number enrolled in HIV care by the beginning of      |
| > quarter (disaggregated by age, gender and pregnancy status)         |
+-----------------------------------------------------------------------+
| > 8.6 New enrollees in HIV care during the quarter (disaggregated by  |
| > age, gender)                                                        |
+-----------------------------------------------------------------------+
| > 8.7 Cumulative number enrolled in HIV care by the end of the        |
| > quarter (disaggregated by age, gender)                              |
+-----------------------------------------------------------------------+
| > 8.8 Number who received HIV care during the reporting period        |
| > (disaggregated by age, gender)                                      |
+-----------------------------------------------------------------------+
| > 8.9 Number in HIV care during the quarter & eligible for art, but   |
| > not started ART by the end of the quarter                           |
+-----------------------------------------------------------------------+
| > 8.10 Number in HIV care that are receiving treatment for TB disease |
| > (disaggregated by gender)                                           |
+-----------------------------------------------------------------------+
| > 8.11 Number of HIV-infected individuals receiving cotrimoxazole     |
| > prophylaxis                                                         |
+-----------------------------------------------------------------------+
| > 8.12 Cumulative number started on ART by the beginning of the       |
| > quarter (disaggregated by age, gender and pregnancy status)         |
+-----------------------------------------------------------------------+
| > 8.13 Number new on ART during the quarter (disaggregated by age,    |
| > gender and pregnancy status)                                        |
+-----------------------------------------------------------------------+
| > 8.14 Number on ART who transferred in during the quarter            |
| > (disaggregated by age, gender and pregnancy status)                 |
+-----------------------------------------------------------------------+
| > 8.15 Number started on ART programme during the quarter (includes   |
| > new and transfers) (disaggregated by age, gender and pregnancy      |
| > status)                                                             |
+-----------------------------------------------------------------------+
| > 8.16 Cumulative number started on ART by the end of the quarter     |
| > (disaggregated by age, gender and pregnancy status)                 |
+-----------------------------------------------------------------------+
| > 8.17 Number on ART at the end of the quarter (current)              |
| > (disaggregated by age, gender and pregnancy status)                 |
+-----------------------------------------------------------------------+
| 8.18 Number of health workers trained to deliver ART services         |
+-----------------------------------------------------------------------+
| > 8.19 Number of health workers trained to deliver HIV palliative     |
| > care (non-ART)                                                      |
+-----------------------------------------------------------------------+
| > 8.19A Number trained to provide TB treatment to HIV-infected        |
| > individuals (subset                                                 |
| >                                                                     |
| > of above)                                                           |
+-----------------------------------------------------------------------+
| > 8.20 Number of individuals in cohort (6 and 12 month cohorts)       |
+-----------------------------------------------------------------------+
| > 8.21 Number in cohort who have CD4+ counts (6 and 12 month cohorts) |
+-----------------------------------------------------------------------+
| > 8.22 Number in cohort who received ARVs for entire time period (6   |
| > and 12 month cohorts)                                               |
+-----------------------------------------------------------------------+
| > 8.23 Median CD4+ count for cohort (6 and 12 month cohorts)          |
+-----------------------------------------------------------------------+
| > 8.24 Number of patients on each regimen at the end of the quarter   |
| > (by age)                                                            |
+-----------------------------------------------------------------------+
| > 8.25 Number of persons who started on ART at the facility in the    |
| > PEPFAR programme who were not on ART at the end of the quarter      |
+-----------------------------------------------------------------------+
| **Activities in Support of ART Services**                             |
+-----------------------------------------------------------------------+
| > 8.26 Number of HIV-infected individuals provided with ARV treatment |
| > at the end of the reporting period (indirect)                       |
+-----------------------------------------------------------------------+
| > 8.27 Number of health workers trained to deliver ART services       |
+-----------------------------------------------------------------------+
| > 8.28 Number of hours of technical assistance provided for ART       |
| > services                                                            |
+-----------------------------------------------------------------------+
| Laboratory, Policy/System Strengthening and Strategic Information     |
+-----------------------------------------------------------------------+
| **Laboratory Infrastructure**                                         |
+-----------------------------------------------------------------------+
| > 9.1 Number of laboratories with capacity to perform 1) HIV tests    |
| > and 2) CD4 tests and/or lymphocyte tests                            |
+-----------------------------------------------------------------------+
| > 9.2 Number of tests performed at USG supported laboratories 1) HIV  |
| > testing; 2) TB diagnostics; 3) syphilis testing; and 4) HIV disease |
| > monitoring                                                          |
+-----------------------------------------------------------------------+
| > 9.3 Number of individuals trained in the provision of laboratory    |
| > related activities                                                  |
+-----------------------------------------------------------------------+
| **Policy analysis and system strengthening**                          |
+-----------------------------------------------------------------------+
| > 10.1 Number of local organizations provided with technical          |
| > assistance for HIV-related policy development                       |
+-----------------------------------------------------------------------+
| > 10.2 Number of local organizations provided with technical          |
| > assistance for HIV-related institutional capacity building          |
+-----------------------------------------------------------------------+
| > 10.3 Number of individuals trained in HIV-related policy            |
| > development                                                         |
+-----------------------------------------------------------------------+
| > 10.4 Number of individuals trained in HIV-related institutional     |
| > capacity building                                                   |
+-----------------------------------------------------------------------+
| > 10.5 Number of individuals trained in HIV-related stigma and        |
| > discrimination reduction                                            |
+-----------------------------------------------------------------------+
| > 10.6 Number of individuals trained in HIV-related community         |
| > mobilization for prevention, care and/or treatment                  |
+-----------------------------------------------------------------------+
| **Strategic Information**                                             |
+-----------------------------------------------------------------------+
| > 11.1 Number of local organizations provided with technical          |
| > assistance for strategic information                                |
+-----------------------------------------------------------------------+
| > 11.2 Number of individuals trained in strategic information         |
+-----------------------------------------------------------------------+
| > 11.3 Number of hours of technical assistance provided for strategic |
| > information                                                         |
+-----------------------------------------------------------------------+

## Abstinence and Be Faithful

**[Programme Overview]{.underline}**

One of the PEPFAR goals is the prevention of 7 million HIV infections by
2010. Abstinence and faithfulness programmes are a key intervention in
reaching this goal.

Abstinence and faithfulness programmes are activities or programmes that
promote abstinence combined with the importance of faithfulness in
reducing the transmission of HIV among individuals in long-term sexual
partnerships. These programmes include the following elements:
elimination of casual sex and multiple sexual partnerships; development
of skills for sustaining marital fidelity; adoption of social and
community norms supportive of marital fidelity and partner reduction
using strategies that respect and respond to local customs and norms;
and adoption of social and community norms that denounce forced sexual
activity in marriage or long-term partnerships.

Activities or programmes that *only* promote the importance of
abstinence in reducing the prevention of HIV transmission among
unmarried individuals include the following elements: decision of
unmarried individuals to delay sexual activity until marriage;
development of skills in unmarried individuals for practicing
abstinence; and adoption of social and community norms that support
delaying sex until marriage and that denounce forced sexual activity
among unmarried individuals.

Community outreach programmes are those that have as their primary
behavioral objective the dissemination of abstinence and/or being
faithful messages. Community outreach programmes could include community
mobilization, peer education, classroom, small group and/or one-on-one
information, education, and communication (IEC) and behavior change
communication (BCC) messages/programmes to promote abstinence and/or
being faithful. If programme content primarily addresses being faithful
messages, such as one aimed at married men, it would count here.

Activities or programmes that promote abstinence must include at least
one of the following components:

-   Importance of abstinence in reducing the risk of HIV transmission
    among unmarried individuals;

-   Decision of unmarried individuals to delay sexual activity until
    marriage;

-   Development of skills in unmarried individuals for practicing
    abstinence; and

-   Adoption of social and community norms that support delaying sex
    until marriage and that denounce forced sexual activity among
    unmarried individuals.

Activities or programmes that promote being faithful must include at
least one of the following components:

-   Importance of being faithful in reducing the transmission of HIV
    among individuals in long-term sexual partnerships;

-   Elimination of casual sex and multiple sexual partnerships;

-   Development of skills for sustaining marital fidelity;

-   Adoption of social and community norms supportive of marital
    fidelity and partner reduction using strategies that respect and
    respond to local customs and norms; and

-   Adoption of social and community norms that denounce forced sexual
    activity in marriage or long-term partnerships.

-   Gender messaging supporting behavior change to reduce violence,
    coercion and multiple partners\
    \
    Please see OGAC \"ABC guidance\" for further detail.

**[Indicators]{.underline}**

**[1.1 The number of individuals reached through community outreach that
promotes HIV prevention through abstinence and/or being faithful
(disaggregated by gender)]{.mark}**

*Definition:* The number of individuals reached through community
outreach that promotes abstinence and/or being faithful. Community
outreach is defined as any effort to effect behavior change that might
include peer education, classroom, small group and/or one-on-one IEC or
BCC. Community outreach does not include any messages disseminated by
radio or media, but should be face-to-face. This data should be reported
as a total, and then separately by number of males reached and number of
females reached..

*Rationale/what it measures:* Community outreach is an important
programmatic strategy for reaching the target population at the
community level. This indicator measures the number of individuals who
attended community outreach activities focused on abstinence and/or
being faithful and must be reported separately for males and females. In
any prevention campaign, the more individuals who receive the message,
the higher number who may make the behavioral changes involved.

*Inclusions/exclusions:* If the programme has a condomize message that
is an equal or greater part of the behavior change campaign, it should
be included under Condoms and Other Prevention rather than AB (see
indicator 2.2)

*Strengths and weaknesses*: This indicator measures any changes in the
number of people reached, indicating overall reach of the message.
However, this indicator does not provide any indication of the quality
of the community outreach nor does it indicate the coverage of a given
community outreach programme. If an estimate of the target population
were known, then it would be possible to calculate the percentage of the
target population reached through community outreach (coverage). The
number of people reached also does not indicate whether behavior in
these individuals actually changed.

**[1.1.A The number of individuals reached through community outreach
that promotes HIV prevention through abstinence (subset of 1.1)
(disaggregated by gender)]{.mark}**

*Definition:* The number of individuals reached through community
outreach that promotes abstinence (subset of the number of individuals
reached with abstinence and/or being faithful messages). Community
outreach is defined as any effort to effect change that might include
peer education, classroom, small group and/or one-on-one IEC or BCC.
Community outreach does not include any messages disseminated by radio
or media, but should be face-to-face. This data should be reported as a
total, and then by number of males reached and number of females reached
separately.

*Rationale/what it measures:* Community outreach is an important
programmatic strategy for reaching the target population at the
community level. This indicator measures the number of individuals who
attended community outreach activities focused on abstinence and must be
reported separately for males and females. In any prevention campaign,
the more individuals who receive the message, the higher number who may
make the behavioral changes involved.

*Inclusions/exclusions:* This is a subset of indictors 1.1. If the
programme includes a being faithful message then it should be included
under indicator 1.1 only.

*Strengths and weaknesses*: Countries will be able to monitor their
success in these efforts by setting goals that include tangible
increases in the number of people reached, indicating further overall
reach of the message. However, this indicator does not provide any
indication of the quality of the community outreach nor does it indicate
the coverage of a given community outreach programme. If an estimate of
the target population were known, then it would be possible to calculate
the percentage of the target population reached through community
outreach (coverage). The number of people reached also does not indicate
whether behavior in these individuals actually changed.

[]{.mark}

[]{.mark}

**[1.2 Number of individuals trained to promote HIV prevention
programmes through abstinence and/or being faithful]{.mark}**

*Definition:* The number of individuals trained in implementing
programmes that promote abstinence and/or being faithful. Training
refers to training or retraining of individuals and must follow a
curriculum with stated objectives and/or expected competencies. An
individual should only be counted once they have completed the training.
Individuals that are mid-way through a training course should be counted
in the next reporting period. Individuals attending more than one
training in a particular program area during a reporting period should
only be counted once.

*Rationale/what it measures:* This indicator is a measure of peer or
health educators who have been trained in the delivery of prevention
messages to the target audience. It measures the number of individuals
who are able to deliver HIV prevention messages with a primary focus on
abstinence and/or being faithful.

In many countries, the national AIDS coordination body and/or
professional organizations have defined training standards. This applies
in particular to countries that have introduced certification systems
for HIV/AIDS training. The training must equip trainees with a minimum
set of competencies needed to take an active role in supporting HIV/AIDS
programmes in line with national recommendations and/or guidelines.
Usually the presence of such competencies is assessed based on
successful completion of training and practical experience during the
reporting period.

*Inclusions/exclusions:* If the training programme promotes behavior
change through a condomize message that is an equal or greater part of
the behavior change campaign, it should be included under Condoms and
Other Prevention rather than AB (see indicator 2.2). Indicator 1.2 and
2.2 are mutually exclusive and the same individual cannot be counted
under both indicators.

*Strengths and weaknesses*: This indicator is useful in that it tracks
the number of peer and/or health educators trained to provide community
outreach services to prevent HIV infection. The indicator attempts to
document increasing capacity to deliver prevention interventions,
however, no conclusion should be drawn regarding the quality of training
nor does it measure the outcomes of the training in terms of
competencies of the individuals trained or their job performance.

**[1.3 Number of hours of technical assistance provided for abstinence
and/or being faithful programmes to: 1) National Government; 2) Local or
Provincial Government; and 3) Other NGOs]{.mark}**

*Definition:* The number of person hours of technical assistance
provided by the PEPFAR-supported partners to improve the implementation
of abstinence and/or being faithful programmes. Programmes can be
implemented by national government entities, local or provincial
government entities, or NGOs. Technical assistance (TA) is defined as
the identification of need, and delivery of, practical programmatic
support for design, implementation and evaluation of programmes in the
specified area. TA should include regular technical communications and
information dissemination sustained over a period of time. TA can be
provided through a combination of strategic approaches and dissemination
strategies including individualized and on-site peer and expert
consultation, site visits, ongoing consultative relationships, national
and/or regional meetings, consultative meetings and conferences,
conference calls and web-casts, development and implementation of
training curricula with the goal of improving programme quality such as
curriculum development for training of community outreach workers or
developing messages for IEC material.

*Rationale/what it measures:* This indicator measures the amount of
technical assistance provided by USG funded technical experts in the
area of abstinence and/or being faithful programmes to governmental and
non-governmental partners. It reflects capacity building efforts to
improve programmes and develop policies in this area.

*Inclusions/exclusions:* If the programme has a condomize message that
is an equal or greater part of the behavior change campaign, it should
be included under Condoms and Other Prevention (see indicator 2.4)

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator attempts to capture an input into a
process, but does not indicate the quality of the technical assistance
provided or if the intended output was achieved.

## Condoms and Other Prevention

**[Programme Overview]{.underline}**

Condoms and Other Prevention *beyond* abstinence and/or being faithful
includes the targeting of behaviors that increase risk for HIV
transmission such as engaging in casual sexual encounters, engaging in
sex in exchange for money or favors, having sex with an HIV positive
partner or one whose status is unknown, using drugs or abusing alcohol
in the context of sexual interactions, and using intravenous drugs.
Women, even if faithful themselves, can still be at risk of becoming
infected by their spouse, regular male partner, or someone using force
against them. Other high risk persons or groups include men who have sex
with men (MSM) and workers who are employed away from home. This
programme area could include targeted social marketing and/or the
promotion of condoms to high risk groups.

Please see OGAC "ABC guidance #1" for further detail.

**[Indicators]{.underline}**

[]{.mark}

**[2.1 Number of targeted condom service outlets]{.mark}**

*Definition:* The number of condom service outlets that are supported at
the service delivery level, i.e. where condoms are distributed to the
public, as opposed to distribution to facilities. Condom service outlets
are fixed distribution points or mobile units with fixed schedules
providing condoms for free or for sale. Targeted refers to a target, or
high risk, population. In a generalized epidemic, this could be
considered the entire population.

*Rationale/what it measures:* This indicator provides a tangible measure
of the potential reach and coverage of condom distribution to a given
community as an important part of a comprehensive prevention message.
Partners should count the number of distribution points at which condoms
are available to their target population.

*Inclusions/exclusions:* Include only those service outlets that provide
condoms at service outlets supported at least in part with USG
resources. Do not include any outlets that only distribute to other
health facilities.

*Strengths and weaknesses*: While the indicator gives a single summary
figure of all outlets, the partner can collect the data so it can also
be disaggregated by outlet type. This will provide invaluable
information for programme managers, and for those seeking to improve the
marketing of condoms. Outlets such as bars, places where young people
congregate and other high transmission sites such as border areas may
need to be identified through key informants. When there are serious
disruptions to condom supply at the central level, the repercussions may
be felt simultaneously at a large majority of venues. If the indicator
is measured at this time, it will appear as though the peripheral
distribution system is inadequate whereas in fact the fault lies at the
central level. This indicator also does only capture USG supported
sites, whereas in South Africa, most condom distribution happens through
sole support of the government.

**[2.2 Number of individuals reached through community outreach that
promotes HIV prevention through other behavior change beyond abstinence
and/or being faithful (disaggregated by gender)]{.mark}**

*Definition:* The number of individuals reached through community
outreach that promotes HIV prevention beyond abstinence and/or being
faithful. If the programme has a comprehensive ABC message whereby the
condomize message is an equal part of the behavior change campaign,
those individuals should be included in this indicator (the indicators
for Condoms and Other Prevention and AB are mutually exclusive). The
Condoms and Other Prevention programme area also includes individuals
reached by HIV prevention programmes that focus on HIV prevention with
discordant couples, programmes that target commercial sex workers (CSW),
and the social marketing and/or promoting of condoms. This data should
be reported as a total, and then by number of males reached and number
of females reached separately.

Community outreach is defined as any effort to effect change that might
include peer education, classroom, small group and/or one-on-one IEC or
BCC. Community outreach does not include any messages disseminated by
radio or media, but should be face-to-face.

*Rationale/what it measures:* Community outreach is an important
programmatic strategy for reaching the target population at the
community level. This indicator measures the number of individuals who
attended community outreach activities focused on prevention beyond
abstinence and/or being faithful and must be reported separately for
males and females. In any prevention campaign, the more individuals who
receive the message, the higher number who may make the behavioral
changes involved.

*Inclusions/exclusions:* If the programme is primarily focused on
abstinence/be faithful messages and less than half of the focus is on
other prevention strategies, then it should be only included under
abstinence and be faithful section.

*Strengths and weaknesses*: Countries will be able to monitor their
success in these efforts by setting goals that include tangible
increases in the number of people reached, indicating further overall
reach of the message. However, this indicator does not provide any
indication of the quality of the community outreach nor does it indicate
the coverage of a given community outreach programme. If an estimate of
the target population were known, then it would be possible to calculate
the percentage of the target population reached through community
outreach (coverage). The number of people reached also does not indicate
whether behavior in these individuals actually changed.

[2.3 Number of individuals trained to promote HIV prevention through
other behavior change beyond abstinence and/or being faithful]{.mark}

*Definition:* The number of individuals trained to implement programmes
that promote HIV prevention through messages beyond abstinence and/or
being faithful. Condoms and Other Prevention programmes include those
that focus on HIV prevention with discordant couples, programmes that
target CSWs, and the social marketing and/or promoting of condoms.

Training refers to training or retraining of individuals and must follow
a curriculum with stated objectives and/or expected competencies. An
individual should only be counted once they have completed the training.
Individuals that are mid-way through a training course should be counted
in the next reporting period. Individuals attending more than one
training in a particular program area during the reporting period should
only be counted once.

*Rationale/what it measures:* This indicator is a measure of peer or
health educators who have been trained in the delivery of prevention
messages to the target audience. It measures the number of newly trained
or retrained individuals who are able to deliver HIV prevention messages
beyond abstinence and/or being faithful. The assumption is more trained
people will result in further distribution of the message.

In many countries, the national AIDS coordination body and/or
professional organizations have defined training standards. This applies
in particular to countries that have introduced certification systems
for HIV/AIDS training. The training must equip trainees with a minimum
set of competencies needed to take an active role in supporting HIV/AIDS
programmes in line with national recommendations and/or guidelines.
Usually the presence of such competencies is assessed based on
successful completion of training and practical experience during the
reporting period.

*Inclusions/exclusions:* If the programme is primarily focused on
abstinence/be faithful messages and less than half is focused on condoms
and other prevention strategies, then it should be only included under
abstinence and be faithful section.

*Strengths and weaknesses*: This indicator is useful in that it tracks
the number of peer and or health educators trained to provide community
outreach services to prevent HIV infection. The indicator captures
increasing capacity to deliver prevention interventions, however, no
conclusion should be drawn regarding the quality of training nor does it
measure the outcomes of the training in terms of competencies of the
individuals trained or their job performance.

**[2.4 Number of hours of technical assistance provided for Condoms and
Other Prevention programmes to: 1) National Government; 2) Local or
Provincial Government; and 3) Other NGOs]{.mark}**

*Definition:* The number of person hours of technical assistance
provided by the PEPFAR-supported partner to improve the implementation
of prevention programmes beyond abstinence and/or being faithful.
Programmes can be implemented by national government entities, local or
provincial government entities, or other NGOs. Technical assistance (TA)
is defined as the identification of need, and delivery of, practical
programmatic support for design, implementation and evaluation of
programmes in the specified area. TA should include regular technical
communications and information dissemination sustained over a period of
time. TA can be provided through a combination of strategic approaches
and dissemination strategies including individualized and on-site peer
and expert consultation, site visits, ongoing consultative
relationships, national and/or regional meetings, consultative meetings
and conferences, conference calls and web-casts, development and
implementation of training curricula.

*Rationale/what it measures:* This indicator measures the amount of
technical assistance provided by USG supported technical experts in the
area of prevention beyond abstinence and/or being faithful programmes to
governmental and non-governmental partners. It reflects capacity
building efforts to improve programmes and develop policies in this
area.

*Inclusions/exclusions:* If the programme is primarily focused on
abstinence/be faithful messages and less than half is focused on condoms
and other prevention strategies, then it should be only included under
abstinence and be faithful section.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator attempts to capture an input into a
process, but does not indicate the quality of the technical assistance
provided or if the intended output was achieved.

## Medical Transmission/ Blood Safety and Injection Safety

**[Programme Overview]{.underline}**

Prevention of HIV transmission through medical practices is receiving
increasing attention. Prevention programmes are implemented to prevent
transmission through blood safety and injection safety programmes.

A national coordinated blood safety programme includes the following
activities: policies, infrastructure, equipment, and supplies; donor
recruitment activities; blood collection, distribution/supply
chain/logistics, testing, screening, and transfusion; waste management;
training; and management to ensure a safe and adequate blood supply.

Activities to promote medically related injection safety include:
policies, training, waste management systems, advocacy,
distribution/supply chain/logistics, appropriate disposal of injection
equipment, and other related equipment and supplies.

**[Indicators]{.underline}**

[]{.mark}

**[3.1 Number of service outlets carrying out blood safety
activities]{.mark}**

*Definition:* The number of service outlets carrying out blood safety
activities. A service outlet refers to the lowest level of service, for
example, a hospital, clinic, or mobile unit. Blood safety activities
include those that support policies, infrastructure, equipment, and
supplies; blood donor recruitment. Activities include; blood collection,
distribution/supply chain/logistics, testing, screening, and/or
transfusion; waste management; training; and/or management to ensure a
safe and adequate blood supply.

The unit of measurement is the site, not the activity. A site will only
count once during a reporting period regardless of the number of ongoing
activities at the site.

*Rationale/what it measures:* This indicator counts the number of
service outlets that receive direct USG support for blood safety
activities. It measures the extent of support for reducing medical
transmission of HIV through blood.

*Inclusions/exclusions:* Sites that do not receive direct USG support
should be excluded.

*Strengths and weaknesses*: This indicator does not consider the quality
of service provision, which would require more in-depth evaluation
efforts like facility surveys. This indicator is not a complete measure
of coverage, as there is no denominator of total facilities. In
addition, this does not capture non-USG supported service outlets.

[3.2 Number of individuals trained in blood safety]{.mark}

*Definition:* The number of individuals trained in blood safety. Blood
safety training may address any of the following specific blood safety
activities: blood safety policies, infrastructure, equipment, and
supplies; blood donor recruitment; blood collection, distribution/supply
chain/logistics, testing, screening, and/or transfusion; waste
management; and management to ensure a safe and adequate blood supply.

Training refers to new training or retraining of individuals and assumes
that training is conducted according to South African or international
standards when these exist the training must follow a curriculum that
indicates the objectives and/or expected competencies. Training may be
knowledge and/or skills and/or competency-based.

*Rationale/what it measures:* The intent of the indicator is to measure
progress toward a creating cadre of professionals trained in blood
safety activities according to South African or international standards.

Each USG agency and USG funded partner counts the number of individuals
trained in blood safety by USG staff (HQ or field-based) or USG funded
partners during the specified reporting period (6 months for semi-annual
report/12 months for annual report). Only participants who complete the
full training course should be counted. Individuals attending more than
one training in a particular program area during the reporting period
should only be counted once.

*Inclusions/exclusions:* Only include individuals who completed the
training in blood safety as operationally defined by the organization.

*Strengths and weaknesses*: This indicator does not measure the quality
of the training, nor does it measure the outcomes of the training in
terms of the competencies of individuals trained, nor their job
performance.

**[3.3 Number of individuals trained in medical injection
safety]{.mark}**

*Definition:* The number of individuals trained in medical injection
safety. Medical injection safety training may address any of the
following specific medical injection safety activities: medical
injection safety policies; appropriate disposal of injection equipment;
waste management systems; and/or other injection safety related
distribution/supply chain/logistics.

Training refers to new training or retraining of individuals and assumes
that training is conducted according to South African or international
standards. The training must follow a curriculum that indicates the
objectives and/or expected competencies. Training may be knowledge
and/or skills and/or competency-based.

*Rationale/what it measures:* The intent of the indicator is to measure
progress toward a cadre of professionals trained in medical injection
safety activities according to South African or international standards.
The assumption is more trained people will result in better services.

Each USG agency and USG funded partner counts the number of individuals
trained in medical injection safety by USG staff (HQ or field-based) or
USG funded partners during the specified reporting period (6 months for
semi-annual report/12 months for annual report). Only participants who
complete the full training course should be counted. Individuals
attending more than one training in a particular program area during the
reporting period should only be counted once.

*Inclusions/exclusions:* Only include individuals who completed the
training in injection safety as operationally defined by the
organization.

*Strengths and weaknesses*: This indicator does not measure the quality
of the training, nor does it measure the outcomes of the training in
terms of the competencies of individuals trained, nor their job
performance.

[3.4 Number of facilities with good waste management and procurement
systems to support injection safety]{.mark}

*Definition:* The number of public and private hospitals with good waste
management and procurement systems to support injection safety in place.
A good waste management and procurement system is determined through
accreditation by the Council for Health Service Accreditation of
Southern Africa (COHSASA).

*Rationale/what it measures*: This indicator measures the quality of
waste management and procurement systems in hospitals. Waste management
and procurement systems are essential for good HIV prevention and AIDS
care service delivery.

*Inclusions/exclusions:* Only hospitals (public and private) that have
been assessed and accredited by COHSASA should be included.

*Strengths and weaknesses*: This indicator does not consider the waste
management and procurement systems of lower level facilities such as
clinics and community health centres. This indicator is not a complete
measure of coverage, as there is no denominator with the total number of
hospitals.

[3.5 Number of public health facilities (clinics and hospitals)
receiving IEC printed material on injection safety and infection
control]{.mark}

*Definition:* The number of public hospitals, clinics or community
health centres receiving printed IEC material from the project on the
following areas: universal and/or standard precautions, adherence to
injection safety standards; use of personal protective equipment, types
of health care waste, appropriate segregation and disposal of health
care waste.

*Rationale/what it measures*: This indicator is one measure of the
information received by facilities on injection safety and infection
control. Personnel working in facilities need to have access to
up-to-date information on injection safety and infection control methods
and this indicator measures access to one source of information.

*Inclusions/exclusions:* Only public health facilities that received IEC
material on injection safety and infection control should be included.

*Strengths and weaknesses*: This indicator does not consider the quality
of the information provided by the IEC printed material, which would
require more in-depth evaluation efforts. This indicator is not a
complete measure of coverage, as there is no denominator with the total
number of hospitals.

[]{.mark}

[]{.mark}

## Prevention of Mother-To-Child Transmission

**[Programme Overview]{.underline}**

Mother-to-child transmission (MTCT) of HIV can occur during pregnancy,
labor, delivery, or after birth, through breastfeeding. Without
intervention, it is estimated that the rate of MTCT is approximately 35%
in developing countries. MTCT can be prevented by administering
prophylactic treatment in the last weeks of pregnancy or at labor and
delivery and by modification of infant feeding practices among
HIV-infected women. Clinical trials have demonstrated that these
interventions can reduce the risk of MTCT to between 2% and 20%,
depending on the interventions used.

One of the PEPFAR goals is the prevention of 7 million HIV infections by
2010. The prevention of HIV infections in infants is an essential
component of this goal. Unlike many prevention efforts, prevention of
mother-to-child transmission (PMTCT) provides an opportunity for
quantification of infections averted through monitoring the number of
women who receive PMTCT interventions of known efficacy.

**[Indicators]{.underline}**

[]{.mark}

**[4.1 Number of service outlets providing the minimum package of PMTCT
services according to South African or international standards]{.mark}**

*Definition:* The number of service outlets, such as antenatal clinic or
other delivery site directly supported with USG resources (i.e. at the
point of service delivery) that provide a minimum package to prevent
mother-to-child transmission of HIV/AIDS. Include only those service
outlets that provide the minimum package of PMTCT services including:

-   Counseling and testing services;

-   ARV prophylaxis to prevent MTCT;

-   Counseling and support for safe infant feeding practices; and

-   Family planning counseling or referral.

In order for a service outlet to be counted as providing the minimum
package of PMTCT services, they must offer all four of the services
listed above.

*Rationale/what it measures:* This indicator is specifically intended to
capture service outlets supported at least in part with USG technical or
financial resources. USG support includes provision of (1) direct
funding; (2) personnel support; (3) materials/commodities; and/or (4)
technical assistance.

*Inclusions/exclusions:* Include only those service outlets that provide
the minimum package of PMTCT services listed above. Include only those
facilities supported at least in part with USG resources.

*Strengths and weaknesses*: This indicator measures the extent of PEPFAR
support for direct PMTCT services. This indicator does not consider the
quality of service provision, which would require more in-depth
evaluation efforts like facility surveys. This indicator is not a
complete measure of coverage, as there is no denominator with the total
number of hospitals, and in most cases, a PMTCT service outlet consists
of a clinic and hospital, with part of the service being offered at the
clinic and part at the hospital.

**[4.2 Number of pregnant women that attended first antenatal care
visit]{.mark}**

*Definition:* The number of pregnant women who attended their first
antenatal care (ANC) visit at a service outlet that offers PMTCT
services supported by USG.

*Rationale/what it measures:* This indicator provides the number of
pregnant women who access ANC services prior to giving birth (at a USG
supported ANC service outlet). This figure can provide an estimate of
the number of women who should be provided with pre-test counseling and
HIV testing and thus serve as a denominator for coverage estimates of
such services.

*Inclusions/exclusions:* Count only those pregnant women who received
ANC services for the first time during the specified reporting period (6
months for semi-annual report / 12 months for annual report), even if
they did not chose to access CT or PMTCT services.

*Strengths and weaknesses*: This indicator is not an expression of
service uptake at a population level, but only the uptake of services at
USG supported PMTCT service outlets. It also does not indicate uptake of
PMTCT services, but provides an estimate as to how many women could
access PMTCT.

[4.3 Number of pregnant women who received HIV counseling and testing
for PMTCT and received their test results]{.mark}

*Definition:* The number of pregnant women who received their HIV test
results and were post-test counseled at a USG directly supported PMTCT
service outlet. A service outlet is the lowest level of service delivery
and USG support includes provision of (1) direct funding; (2) personnel
support; (3) materials/commodities; and/or (4) technical assistance.

*Rationale/what it measures:* This indicator reflects a primary goal of
PMTCT, which is to increase the number of pregnant women who know their
HIV status.

*Inclusions/exclusions:* Count only those pregnant women who received,
at minimum, HIV counseling and testing and received results during the
specified reporting period (6 months for semi-annual report / 12 months
for annual report). This is not dependent on the results; i.e.: this
includes women who test negative as well.

*Strengths and weaknesses*: This indicator is not an expression of
service uptake at a population level, but only the uptake of services at
USG supported PMTCT service outlets. The goal is to track the number of
pregnant women who received their test results, however, not all
programmes are set up to adequately distinguish between those who are
tested and those who receive results. In order to provide good quality
services, all USG funded PMTCT sites should work toward tracking women
through pre-test counseling, testing, post-test counseling, provision of
results, and subsequent interventions.

[4.4 Number of pregnant women provided with a complete course of
ARV]{.mark}

*Definition:* The number of HIV-infected pregnant women who received ARV
prophylaxis and counseling for PMTCT at a USG supported PMTCT service
outlet. ARV prophylaxis may be single dose Nevirapine (SD NVP) or
short-course combination prophylaxis or highly active antiretroviral
therapy (HAART). The PMTCT sites must follow current South
Africa-specific protocols. (Since these may change over time, please
consult the national or provincial Department of Health for PMTCT
guidelines.) Counseling could include, but is not limited to nutrition
advice for both the infant and mother, psychosocial support, and
counseling regarding long-term wellness and ARV treatment options.

*Rationale/what it measures:* This indicator is a measure of the
delivery and uptake of antiretroviral prophylaxis for PMTCT, which is
the key intervention to prevent infection of the child.

*Inclusions/exclusions:* Only HIV-infected pregnant women should be
included in this indicator.

*Strengths and weaknesses*: This indicator is not an expression of
service coverage at a population level, but only the delivery/uptake of
services at USG supported PMTCT service outlets. This indicator does not
distinguish among the different types of prophylaxis (SD NVP,
short-course prophylaxis, HAART). It is recommended to track the
different types of prophylaxis. This indicator may overestimate the
number of women who have received a complete course due to the fact that
it is not always administered at the facility. It also does not
necessarily allow for an estimate of effectiveness if data systems are
not set up to verify this information.

**[4.5 Number of infants receiving an ARV prophylaxis]{.mark}**

*Definition:* The number of infants (born to HIV-infected women) who
received an ARV prophylaxis for PMTCT at a USG supported PMTCT service
outlet.

*Rationale/what it measures:* This indicator is a measure of the
delivery and uptake of ARV prophylaxis for infants, because it is a key
intervention to prevent HIV infection.

*Inclusions/exclusions:* Count only those infants born to HIV-infected
mothers during the specified reporting period (6 months for semi-annual
report / 12 months for annual report). This is not dependent on whether
the mother received an ARV prophylaxis as well, but is a separate data
set.

*Strengths and weaknesses*: This indicator measures the extent of PMTCT
service uptake from first identifying the mother's HIV status to
providing the baby with ARV prophylaxis. It does not, however, measure
the effectiveness of the prophylaxis itself.

6.  **[Number of infants tested by PCR at 6-14 weeks]{.mark}**

*Definition:* The number of infants (born to HIV-infected women) who
were tested for HIV by DNA polymerase chain reaction (PCR) at
*approximately* 6-14 weeks after birth.

*Rationale/what it measures:* This indicator measures the number of
infants who were tested for HIV at 6-14 weeks by PCR, as this is a more
accurate measure of HIV status in an infant. This is also an important
step in the PMTCT intervention and also to link the infant into further
care if needed. If infants are still being breastfed repeat testing will
be necessary to confirm HIV status.

*Inclusions/exclusions:* Count only those infants born to HIV-infected
mothers during the specified reporting period (6 months for semi-annual
report / 12 months for annual report) that received a specific PCR test.
Exclude other testing methods. Also, only count those infants tested
around the 6-14 week after birth timeframe (with a 3 week window on each
side).

*Strengths and weaknesses*: The indicator intends to measure the extent
that babies born to HIV positive women are brought back to the health
facility to be tested for HIV soon after birth. It does not detect the
mode of transmission for babies who test HIV positive.

**[4.7 Number of infants tested at 12 months]{.mark}**

*Definition:* The number of infants (born to HIV-infected women) who
were tested for HIV at *approximately* 12 months after birth. This
indicator is not specifying testing method, so can capture various types
of testing. Approximately indicates that it can be anywhere between 11
and 13 months.

*Rationale/what it measures:* Follow-up testing is an important step in
the PMTCT intervention and also to link the infant into further care if
needed. Follow-up testing is also necessary to monitor the effectiveness
of the PMTCT programme. The reason for conducting the test at 12 months
is that the infant no longer has maternal antibodies to HIV. In most
cases, infants enrolled in the PMTCT programme are weaned at 4-6 months.
HIV transmission from mother-to child usually occurs within the first 12
months after birth. Therefore, testing at 12 months can accurately
detect mother-to-child transmission rates.

*Inclusions/exclusions:* Count only those infants born to HIV-infected
mothers during the specified reporting period (6 months for semi-annual
report / 12 months for annual report) that received an HIV test. Also,
only count those infants tested around the 12 month after birth
timeframe (with a 1 month window on each side).

*Strengths and weaknesses*: This indicator intends to measure the extent
that babies born to HIV positive women are brought back to health
facilities to be tested for HIV. However, it does not capture whether
babies had been previously tested for HIV and therefore cannot detect
the mode of transmission for babies who test HIV positive.

**[4.8 Number of HIV-infected pregnant women referred to: 1) a wellness
programme and 2) a treatment programme]{.mark}**

*Definition:* The number of HIV-infected pregnant women who were
referred for wellness programmes and HIV/AIDS care or treatment
services. Wellness programmes include: symptom diagnosis and relief;
psychological and spiritual support; clinical monitoring and management
(and/or referral for these) of opportunistic infections such as TB/HIV,
malaria and other HIV/AIDS-related complications; culturally appropriate
end-of-life care; and social and material support, such as nutrition
support, legal aid, and housing. A treatment programme would include the
provision of antiretroviral drugs and clinical monitoring.

*Rationale/what it measures:* As soon as women are diagnosed as
HIV-infected, they may need to be referred for a range of wellness
and/or treatment services. The women will stay much healthier if they
have care and support from an early stage. PMTCT may be a method of
identifying women early. This indicator provides an estimate of the
number of women who are referred to such services from the PMTCT
programme.

*Inclusions/exclusions:* Count only HIV-infected pregnant women who were
provided referrals for a wellness programme and/or treatment programme.

*Strengths and weaknesses*: This indicator only counts those who are
referred and does not assess whether the women actually received the
services.

[]{.mark}

**[4.9 Number of pregnant women who received HIV counseling and testing
for PMTCT and received their test results (indirect)]{.mark}**

*Definition:* The estimated number of women who received HIV counseling
and testing and received their results in a PMTCT setting regardless of
their status. Indirect support includes: national, provincial, or
district level policy development; institutional capacity building;
logistics; protocol or guideline development; advocacy; national,
provincial, district level training; or national, provincial, or
district level management information systems.

*Rationale/what it measures:* There are a number of support functions
that are essential for the provision of quality PMTCT services. This
indicator tries to account for all these activities of USG funded
partners by estimating the number of women who received counseling and
testing for PMTCT that benefited from indirect support.

*Inclusions/exclusions:* This is an estimate of the reach on the
indirect support for PMTCT often at provincial or national levels. Only
include those pregnant women who received counseling and testing and
received their test results for PMTCT. They do not have to have received
ARV prophylaxis to be included.

*Strengths and weaknesses*: This indicator captures indirect support at
the provincial or national level that aims to strengthen PMTCT services
that are not at the service delivery level. It does not measure the
quality of the support provided, and it is difficult to determine the
contribution or effect of the support for overall PMTCT services.

[]{.mark}

**[4.10 Number of pregnant women provided with a complete course of
antiretroviral prophylaxis in a PMTCT setting (indirect)]{.mark}**

*Definition:* The estimated number of women who have received ARV
prophylaxis in a PMTCT setting through indirect USG support.  ARV
prophylaxis may be single dose Nevirapine (SD NVP) or short-course
combination prophylaxis or highly active antiretroviral therapy (HAART).
Indirect support includes: national, provincial, or district level
policy development; institutional capacity building; logistics; protocol
or guideline development; advocacy; national, provincial, district level
training; or national, provincial, or district level management
information systems. See page 25 for further detail.

*Rationale/what it measures:* There are a number of support functions
that are essential for the provision of quality PMTCT services,
including ARV prophylaxis. This indicator tries to account for all these
activities of USG funded partners by estimating the number of women who
received ARV prophylaxis within a PMTCT programme that benefited from
indirect support.

*Inclusions/exclusions:* This is an estimate of the reach on the
indirect support for PMTCT often at provincial or national level. Only
include those pregnant women who received ARV prophylaxis. If they have
accessed other PMTCT services, but did not continue all the way through
to receive the ARV prophylaxis, they should not be counted under
indicator 4.10.

*Strengths and weaknesses*: This indicator captures indirect support at
the provincial or national level that aims to strengthen PMTCT services
that are not at the service delivery level. Because it is indirect it is
an estimate, not actual reported data. It also does not measure the
quality of the support provided, and it is difficult to determine the
contribution or effect of the support for overall PMTCT services.

[]{.mark}

**[4.11 Number of health workers trained in the provision of PMTCT
services according to South African or international standards]{.mark}**

*Definition:* The number of health workers who completed, during the
reporting period, a course or training workshop sponsored, co-sponsored,
or conducted by USG funded partners to provide or improve delivery of
PMTCT services. This includes health workers that are newly trained and
those retrained. USG support includes provision of (1) direct funding;
(2) personnel support; (3) materials/commodities; and/or (4) technical
assistance, or similar support by USG funded partners.

To be considered here, the training must contain at least one of the
PMTCT core elements: PMTCT-related counseling and testing, ARV
prophylaxis, infant feeding counseling, and family planning counseling
or referral.

*Rationale/what it measures:* This indicator is specifically intended to
capture training that was supported at least in part with USG technical
or financial resources. The assumption is that training will result in
increased human resource capacity to improve and expand access to
services. This indicator will indicate progress towards this goal.

*Inclusions/exclusions:* Both in-service and pre-service trainings and
workshops are included. Only participants who complete the full training
course should be counted. If the participant is in the middle of the
course, they should be counted in the subsequent reporting period.
Individuals attending more than one training in a particular program
area during the reporting period should only be counted once.

*Strengths and weaknesses*: This indicator does not measure the quality
of the training, nor does it measure the outcomes of the training in
terms of the competencies of individuals trained, nor their job
performance. This indicator simply measures the number trained in PMTCT
as opposed to an indicator such as the percent of health facilities with
trained staff, which indicates coverage. This may be measured through
health facility surveys.

**[4.12 Number of hours of technical assistance provided for PMTCT
programmes to: 1) National Government; 2) Local or Provincial
Government; and 3) Other NGOs]{.mark}**

*Definition:* The number of person hours of technical assistance
provided by the PEPFAR-supported partner to local NGOs, national or
provincial Departments of Health, or other institutions for
strengthening PMTCT services.

Technical assistance (TA) is defined as the identification of need, and
delivery of, practical programmatic support for design, implementation
and evaluation of programmes in the specified area. TA should include
regular technical communications and information dissemination sustained
over a period of time. TA can be provided through a combination of
strategic approaches and dissemination strategies including
individualized and on-site peer and expert consultation, site visits,
ongoing consultative relationships, national and/or regional meetings,
consultative meetings and conferences, conference calls and web-casts,
development and implementation of training curricula.

PMTCT services include: counselling and testing for pregnant women; ARV
prophylaxis to prevent MTCT; counselling and support for safe infant
feeding practices; and family planning counselling or referral. 

*Rationale/what it measures:* This indicator measures the amount of
technical assistance provided by USG technical experts in the area of
PMTCT programmes to governmental and non-governmental partners. It
reflects capacity building efforts to improve programmes and develop
policies in this area.

*Inclusions/exclusions:* Include person hours of technical assistance
provided.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator attempts to capture an input into a
process, but does not indicate the quality of the technical assistance
provided or if the intended output was achieved.

## Counseling and Testing

**[Programme Overview]{.underline}**

Since 2000, the South African NDOH has supported widespread
implementation of a National Programme for HIV counseling and testing
(CT), establishing national policies, procedures, guidelines and
legislating intervention strategies to provide universal access to the
adult population. NDOH and other stakeholders are exploring the use of
routine and diagnostic testing as a means to increase access to CT and
ensure linkages to care and treatment programmes. PEPFAR partners are
encouraged to recommend CT to all clients on a routine basis.

Counseling and testing is a key gateway for HIV prevention, care and
treatment. With the expansion of HIV-related treatment in South Africa
the role of CT in identifying and referring those in need of HIV-related
services is essential. It is imperative to strengthen linkages and
referral networks between CT, TB, PMTCT, STI, family planning,
palliative care and ARV services.

Counseling and testing (CT) includes activities in which both HIV
counseling (pre and post-test) and testing are provided for those who
want to know their HIV status (as in traditional voluntary counseling
and testing (CT)) or, as indicated in other contexts, such as in STI
clinics or TB centres, where HIV diagnosis is confirmed. Counseling and
testing in a PMTCT setting is covered under PMTCT.

**[Indicators]{.underline}**

[]{.mark}

**[5.1 Number of service outlets providing counseling and testing
according to South African or international standards]{.mark}**

*Definition:*

A service outlet refers to the lowest level of service -- where the
testing is actually completed. For example, with regard to clinical
activities, the lowest level for which data exists should be a service
outlet such as a health centre, hospital, clinic, stand alone CT centre,
or mobile unit. Counseling and testing includes activities in which both
HIV counseling and testing are provided for those who seek to know their
status (as in traditional CT) or as indicated in other contexts such as
STI clinics or diagnostic testing. This indicator excludes service
outlets that provide counseling and testing in the context of preventing
mother-to-child transmission. Please refer to indicator 4.1 for more
guidance on reporting the number of service outlets that provide
services to prevent mother-to-child transmission of HIV.

*Rationale/what it measures:* This indicator provides a gross count of
the number of USG supported locations that provide basic counseling and
testing for HIV. It provides a rough sense of coverage of counseling and
testing services. If there is a plan to expand the number of service
outlets, this measure will track the progress of meeting that goal.

*Inclusions/exclusions:* Include only those facilities supported, at
least in part, with USG resources. Counseling and testing for PMTCT
should be included in the PMTCT programme area only. HIV counseling and
testing specifically targeting TB patients should be included in the
TB/HIV programme area only.

*Strengths and weaknesses*: This is purely an output measure. It
provides no sense of the geographical spread of CT services, nor any
relationship to the percentage of the population that is reached by the
service outlet. This indicator does not consider the quality of service
provision, which would require more in-depth evaluation efforts like
facility surveys. This is not a complete measure of coverage, as there
is no denominator of total facilities.

**[5.2 Number of individuals pre-test counseled (disaggregated by
gender)]{.mark}**

[]{.mark}

*Definition:* The number of clients that received individual counseling
prior to testing for HIV at a USG supported CT site (e.g. hospitals,
clinics, stand alone CT centres, mobile unites, etc.).

*Rationale/what it measures:* This indicator reflects the first step in
reaching one goal of CT that is to increase the number of individuals
who know their HIV status. Pretest counselling is an important first
step in learning ones' HIV status.

*Inclusions/exclusions:* Count only those individuals who received HIV
pre-test counseling during the specified reporting period (6 months for
semi-annual report / 12 months for annual report).

*Strengths and weaknesses*: This indicator is not an expression of
service uptake at a population level, but only the uptake of services at
USG supported CT service outlets. The goal is to track the number of
individuals who received pre-test counselling. In order to provide good
quality services, all USG funded CT sites should work toward tracking
individuals through pre-test counseling, testing, post-test counseling,
provision of results, and subsequent interventions.

[]{.mark}

**[5.3 Number of clients who received counseling and testing and
received their test results (disaggregated by gender)]{.mark}**

*Definition:* The number of clients that received HIV test results and
post-test counseling at a USG supported CT site such as hospitals,
clinics, stand-alone CT centres and mobile units. This is a subset of
those who were tested for HIV. This indicator requires a minimum of
post-test counseling, testing, and the provision of test results. This
data should be reported as a total, and then by number of males reached
and number of females reached separately.

*Rationale/what it measures:* This indicator provides a count of those
individuals who have received counseling and testing during the current
reporting period and are now aware of their HIV status. The hope is that
knowledge of one's status leads to appropriate behavior change and
access to services if necessary.

*Inclusions/exclusions:* Only those whose confirmed HIV test status is
known can be counted. If they test and do not return, they are excluded.
If a client does not receive the appropriate post-test counseling, they
also should be excluded.

*Strengths and weaknesses*: Not all those who are tested will return for
results, thus there will be a loss to follow-up. This indicator also
does not indicate quality or coverage of services. It is also limited to
USG-supported sites, and is not a national number.

[]{.mark}

**[5.4 Number of clients who received counseling and testing and
received their test results (indirect)]{.mark}**

*Definition:* The estimated number of individuals who received HIV test
results and post-test counseling through indirect support. Indirect
support includes any of the following: national, provincial, or district
level policy development; institutional capacity building; logistics;
protocol or guideline development; advocacy; national, provincial, or
district level training; and national, provincial, or district level
management information systems. See page 25 for further detail.

*Rationale/what it measures:* There are a number of support functions
that are essential for the provision of quality CT services. This
indicator tries to estimate the results of USG supported partners who
indirectly contribute to increasing access or quality of CT services.

*Inclusions/exclusions:* Count only services that received indirect
support. Those services that received direct support should be counted
in indicator 5.4.

*Strengths and weaknesses*: There may be some facilities that receive
both direct and indirect support. This is also an estimate and not
actual reported data.

**[5.5 Number of HIV-infected individuals referred to a: 1) wellness
programme 2) treatment programme; 3) STI services; 4) TB
services]{.mark}**

*Definition:* The number of individuals identified as HIV-infected
through a CT programme that were then referred for HIV care or
treatment. Wellness programmes could include: symptom diagnosis and
relief; psychological and spiritual support; clinical monitoring and
management (and/or referral for these) of opportunistic infections
(including TB/HIV) including malaria and other HIV/AIDS-related
complications; culturally appropriate end-of-life care; and social and
material support, such as nutrition support, legal aid, and housing. A
treatment programme would include the provision of antiretroviral drugs
and clinical monitoring. STI are facilities that have the capacity to
diagnose and treat sexually transmitted infections. TB services are
those facilities that provide TB diagnostics and treatment.

*Rationale/what it measures:* Once diagnosed as HIV-infected,
individuals may need to be referred for a range of wellness and/or
treatment services. The earlier that HIV-infected individuals access
care and treatment, the longer they will stay healthy. This indicator
provides an estimate of the number of individuals who are referred to
such services.

*Inclusions/exclusions:* Count only individuals tested positive for HIV
who were referred to either: 1) wellness programme 2) treatment
programme; 3) STI services; or 4) TB services. Individuals can be
counted in each of the referral categories.

*Strengths and weaknesses*: This indicator only counts those who are
referred and does not assess whether the individuals actually accessed
or received the services. It is recommended that programmes have an
active referral tracking system to obtain such information. Although
only referrals to wellness, treatment, STI and TB programmes are tracked
in this indicator, partners are encouraged to refer to a wide variety or
appropriate services, including services for individuals who test
negative, and monitor such referrals as part of regular programme
management.

**[5.6 Number of individuals trained in counseling and testing according
to South African or international standards]{.mark}**

*Definition:* The number of individuals trained to provide HIV
counseling and testing services. Training refers to training or
retraining of individuals and must follow a curriculum with stated
objectives and/or expected competencies. An individual should only be
counted once they have completed the training. Individuals that are
mid-way through a training should be counted in the next reporting
period. Individuals attending more than one training in a particular
program area during the reporting period should only be counted once.

This indicator is specifically intended to capture training that was
supported at least in part with USG technical or financial resources.
USG support includes provision of (1) direct funding; (2) personnel
support; (3) materials/commodities; and/or (4) technical assistance, or
similar support by USG funded partners.

*Rationale/what it measures:* Training increases the number of
professionals able to carry out counseling and testing services. It also
should increase quality. This gives some indication of this increased
capacity.

*Inclusions/exclusions:* Only participants who complete a full training
course should be counted.

If a training course covers more than one topic within the CT programme
area, individuals should only be counted once for that training course.
If a training course is conducted in more than one session/training
event, only individuals who complete the full course should be counted.
Do not sum the participants for each training event.

*Strengths and weaknesses*: This indicator does not measure the quality
of the training, nor does it measure the outcomes of the training in
terms of the competencies of individuals trained, nor their job
performance. This indicator simply measures the number trained in CT as
opposed to an indicator such as the percent of health facilities with
trained staff, which may indicate coverage. This may be measured through
health facility surveys.

[]{.mark}

[]{.mark}

**[5.7 Number of hours of technical assistance provided on counseling
and testing to: 1) National Government; 2) Local or Provincial
Government; and 3) Other NGOs]{.mark}**

[]{.mark}

*Definition:* The number of person hours of technical assistance
provided by the PEPFAR-supported partners to local NGOs, national or
provincial Departments of Health, or other institutions for building
capacity to provide HIV counseling and testing services. Technical
assistance is defined as the identification of need, and delivery of,
practical programmatic support for design, implementation and evaluation
of programmes in the specified area. TA should include regular technical
communications and information dissemination sustained over a period of
time. TA can be provided through a combination of strategic approaches
and dissemination strategies including individualized and on-site peer
and expert consultation, site visits, ongoing consultative
relationships, national and/or regional meetings, consultative meetings
and conferences, conference calls and web-casts, development and
implementation of training curricula.

*Rationale/what it measures:* This indicator measures the amount of
technical assistance provided by USG supported technical experts in the
area of counseling and testing to governmental and non-governmental
partners. It reflects capacity building efforts to improve programmes
and develop policies in this area.

*Inclusions/exclusions:* Include person hours of technical assistance
provided specifically for strengthening CT programmes and/or policies.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator attempts to capture an input into a
process, but does not indicate the quality of the technical assistance
provided or if the intended output was achieved.

## Orphans and Vulnerable Children

**[Programme Overview]{.underline}**

Current estimates indicate that in South Africa, 1.1 million children
have been orphaned. The goal of orphans and vulnerable children (OVC)
activities is to provide support aimed at improving the lives of
children and families directly affected by AIDS-related morbidity and/or
mortality. The emphasis of OVC programmes is on strengthening
communities to meet the needs of orphans and vulnerable children
affected by HIV/AIDS, supporting community-based responses, helping
children and adolescents meet their own needs, creating a supportive
social environment. Activities could include training caregivers;
increasing access to education; economic support; targeted food and
nutrition support; legal aid; medical, psychosocial, or emotional care;
and/or other social and material support.

Orphans are defined as children under 18 who have lost either a mother
or father. Vulnerable children are those affected by HIV through the
illness of a parent or principle caretaker. If an HIV-infected OVC is
receiving ART treatment as well as care in an OVC programme, the OVC
should be counted both under treatment ***and*** under OVC. However, an
HIV-infected OVC receiving palliative care services among other services
within an OVC programme should ***only*** be counted under OVC to avoid
double counting under the total care count.

**[Indicators]{.underline}**

[]{.mark}

**[6.1. Number of OVC served by an OVC programme (disaggregated by
gender)]{.mark}**

*Definition:* The number of unique OVC, under 18 years of age, provided
with direct support during the defined reporting period. To be
considered having received direct support, the OVC must receive at least
[three]{.underline} of the following nine services:

-   Assisting with access to health care (including counseling and
    testing);

-   Referral or provision of antiretroviral treatment;

-   Assisting with access to education including school fees, uniforms
    or tutoring;

-   Assisting with access to economic support such as accessing social
    grants, income generation projects;

-   Providing food and/or nutrition support including supplements or
    food gardens;

-   Providing legal assistance, including accessing birth certificates
    and succession planning;

-   Providing or linking OVC to psychosocial support;

-   Providing protection from abuse; and

-   Mobilizing and building capacity of communities to respond to OVC
    needs.

This data should be reported as a total, and then by number of males
reached and number of females reached separately. OVC can be counted in
each of the subset indicators if they receive care in each different
areas within the reporting period.

*Rationale/what it measures:* An OVC should be reached with a
comprehensive package of services. Providing only food to a child in
need is not sufficient, but they should be linked or provided with
services to meet all their needs. This indicator provides a measure of
the number of OVC that are receiving comprehensive services by using a
minimum of three services out of a package of nine.

*Inclusions/exclusions:* Only those OVC who are being served by
programmes that provide at least three types of OVC services are counted
in this indicator. OVC 18 and older should be excluded from this
indicator. Excludes children not considered an orphan or vulnerable
child by the programme and/or community.

*Strengths and weaknesses*: This indicator measures the change in reach
of comprehensive OVC programmes. However, this indicator does not
provide any indication of the quality of the OVC services, including how
many times a child accessed services nor does it indicate the coverage
of a given OVC programme. If an estimate of the target population were
known, then it would be possible to calculate the percentage of the
target population reached through OVC programmes.

**[6.1A Number of OVC receiving increased access to health care (subset
of 6.1)]{.mark}**

*Definition:* Number of OVC receiving increased access to health care.
This includes the referral and/or provision of childhood immunization,
routine exams, clinical monitoring and management and ARV therapy if
necessary.

*Rationale/what it measures:* Ensuring continued access to health care
is a basic need for OVC. Health care is generally free in South Africa
and the OVC may just lack access. This intends to monitor that these
linkages are being made within OVC programmes.

*Inclusions/exclusions:* Include only those OVC who have received direct
support to access health care. Exclude OVC 18 years and older and those
children not considered an orphan or vulnerable by the programme

*Strengths and weaknesses*: This indicator measures the changes in the
reach of OVC programmes that provide access to health care. However,
this indicator does not provide any indication of the quality of the OVC
services nor does it indicate the coverage of a given OVC programme. If
an estimate of the target population were known, then it would be
possible to calculate the percentage of the target population reached
through health care programmes.

[]{.mark}

**[6.1B Number of OVC receiving antiretroviral treatment (subset of
6.1)]{.mark}**

*Definition:* This indicator is specifically measuring the number of
children orphaned or made vulnerable by HIV and AIDS, and are infected
with HIV, who are receiving antiretroviral treatment. The OVC partner
may not be providing ARVs themselves, but should ensure that the OVC
gains access to ARVs as appropriate and assists them to monitor issues
such as adherence and nutrition so the child remains healthy.

*Rationale/what it measures:* In South Africa, ARVs are rolling out at a
national level. It is vital that HIV infected children gain access to
these ARV programs so they are able to be healthy and productive. This
indicator intends to monitor that the linkages are being made between
OVC and ART programmes.

*Inclusions/exclusions:* Include only those OVC (under 18) who are
receiving ARVs. Exclude OVC who are in pre-treatment training or those
who are HIV positive, but are not yet eligible, until they are actually
receiving ARVs. Exclude OVC who are 18 years of age or older.

*Strengths and weaknesses*: This indicator is an indication that
children are gaining access to antiretroviral treatment. However, it
does not capture the total number eligible for treatment and the
percentage of children receiving treatment out of total in need. This
indicator also does not indicate the quality of the treatment program or
adherence to ARVs.

[]{.mark}

**[6.1C Number of OVC receiving support to increase access to education
(subset of 6.1)]{.mark}**

*Definition:* The number of OVC receiving support to access education.
This could include either the provision of school fees or assisting the
child in having school fees waived, providing a uniform, or either
providing tutoring or ensuring that the child can access tutoring. This
could also include advocacy activities aimed at district or provincial
governments to ensure that policies are in place for all children to
access education.

*Rationale/what it measures:* In South Africa, the law stipulates that
all children must have access to free education. Education is also key
to long-term development and success of a child. This intends to monitor
that these linkages are being made within OVC programmes.

*Inclusions/exclusions:* Include only those OVC who have received direct
support to increase access to education. Excludes children 18 and over,
and those children not considered an orphan or vulnerable by the
programme.

*Strengths and weaknesses*: This indicator measures changes in the reach
of educational support programmes for OVC. However, this indicator does
not provide any indication of the quality or the coverage of educational
support programmes. If an estimate of the target population were known,
then it would be possible to calculate the percentage of the target
population reached through educational support programmes for OVC.

**[6.1D Number of OVC receiving access to economic support (subset of
6.1)]{.mark}**

*Definition:* The number of OVC that received access to economic
support. Economic support is broad, but could include such interventions
as accessing social grants or income generation projects. This could
also include advocacy activities to ensure policies are supportive of
OVC.

*Rationale/what it measures:* Many families affected by HIV/AIDS suffer
economic losses. It is essential to monitor the number of OVC that
receive access to economic services. This intends to monitor that these
linkages are being made within OVC programmes.

*Inclusions/exclusions:* Include only those OVC who have received direct
access to economic support. Exclude OVC 18 years and older and those
children not considered an orphan or vulnerable by the programme.

*Strengths and weaknesses*: This indicator measures the changes in the
reach of economic support programmes for OVC. However, this indicator
does not provide any indication of the quality or the coverage of
economic support programmes for OVC. If an estimate of the target
population were known, then it would be possible to calculate the
percentage of the target population reached through economic support
programmes for OVC.

**[6.1E Number of OVC receiving food or nutritional support (subset of
6.1)]{.mark}**

*Definition:* The number of OVC that receive food or nutritional support
could include nutritional supplements, feeding schemes at centres or
food gardens, etc.

*Rationale/what it measures:* Ensuring continued access to food is a
basic need for all OVC, and is key to ongoing development. This
indicator intends to monitor that these linkages are being made within
OVC programmes.

*Inclusions/exclusions:* Include only those OVC who have received direct
support to nutritional or food support. Exclude OVC 18 years and older
and those children not considered an orphan or vulnerable by the
programme

*Strengths and weaknesses*: This indicator measures the changes in the
reach of food and nutritional support programmes for OVC. However, this
indicator does not provide any indication of the quality of the OVC
services nor does it indicate the coverage of a given OVC programme. If
an estimate of the target population were known, then it would be
possible to calculate the percentage of the target population reached
through nutritional support programmes for OVC.

**[6.1F Number of OVC receiving legal assistance (subset of
6.1)]{.mark}**

*Definition:* The number of OVC receiving legal assistance, including
accessing birth certificates or addressing issues of inheritance.

*Rationale/what it measures:* Ensuring access to legal assistance is
important for OVC as many may face difficult legal issues related to
land rights, housing, and other rights that require legal assistance.
This intends to monitor that these linkages are being made within OVC
programmes.

*Inclusions/exclusions:* Include only those OVC who have received direct
support to legal assistance. Exclude OVC 18 years and older and those
children not considered an orphan or vulnerable by the programme

*Strengths and weaknesses*: This indicator measures the changes in the
reach of legal assistance OVC programmes. However, this indicator does
not provide any indication of the quality of the OVC services nor does
it indicate the coverage of a given OVC programme. If an estimate of the
target population were known, then it would be possible to calculate the
percentage of the target population reached through legal assistance
programmes.

[]{.mark}

[]{.mark}

**[6.1G Number of OVC provided with or referred to psychosocial support
(subset of 6.1)]{.mark}**

*Definition:* Number of OVC that are directly provided with the
appropriate psychosocial support care that meets their needs, or, a
referral to the appropriate services that can address the needs. This
includes age appropriate HIV prevention education, grief counseling, and
other activities such as kids clubs and OVC support groups.

*Rationale/what it measures:* Ensuring access to psychosocial support
care is important for OVC as many have experienced significant trauma.
It is an important aspect of overall health. This intends to monitor
that these linkages are being made within an OVC programme.

*Inclusions/exclusions:* Include only those OVC who have received direct
psychosocial support. Exclude OVC 18 years and older and those children
not considered an orphan or vulnerable by the programme.

*Strengths and weaknesses*: This indicator measures the changes in the
reach of psychosocial support care services. However, this indicator
does not provide any indication of the quality of the OVC services nor
does it indicate the coverage of a given OVC programme. If an estimate
of the target population were known, then it would be possible to
calculate the percentage of the target population reached with
psychosocial support.

[]{.mark}

**[6.1H Number of OVC provided with protection from abuse]{.mark}**

*Definition:* Number of OVC that are at risk or have suffered from abuse
that have been referred to protection services, or some type of
protection has been arranged within the community.

*Rationale/what it measures:* There is increasing evidence that some OVC
suffer abuse or are at risk of abuse due to their OVC status, especially
in a child-headed household. It is important that these issues be
addressed as part of a holistic package of services. This intends to
monitor that these linkages are being made within OVC programmes.

*Inclusions/exclusions:* Include only those OVC who have received
protection from abuse in some manner. Exclude OVC 18 years and older and
those children not considered an orphan or vulnerable by the programme

*Strengths and weaknesses*: This indicator measures the changes in the
reach of OVC programmes that provide protection from abuse. However,
this indicator does not provide any indication of the quality of the OVC
services nor does it indicate the coverage of a given OVC programme. If
an estimate of the target population were known, then it would be
possible to calculate the percentage of the target population reached
through abuse protections services.

It is very difficult to identify children who are at risk of or who have
suffered from abuse. While it is very important to provide protection
services for such OVC, their confidentiality must be ensured. For
example, the child must agree to have their name given to a child
protection agency.

**[6.1I Number of OVC benefiting from community mobilization to respond
to OVC needs (subset of 6.1)]{.mark}**

*Definition:* Number of OVC that are receiving services through
programmes that are focused on mobilizing and building capacity of
communities to respond to OVC needs.

Community mobilization activities include:

-   Identifying social groups and mapping existing formal structures or
    networks in order to encourage or promote HIV prevention, care
    and/or treatment interventions and services, such as counseling and
    testing, PMTCT, HIV care and antiretroviral treatment;

-   Building trust with the community by providing a forum to discuss
    their perceived needs for HIV prevention, care and/or treatment
    interventions and services;

-   Developing communication around social networks to engage in
    dialogue with the community which encourages or promotes HIV
    prevention, care and/or treatment interventions and services; and

-   Creating media and events that expose community members to new
    ideas, involving them in problem solving, and encouraging
    innovations that promote HIV prevention, care and/or treatment
    interventions and services.

*Rationale/what it measures:* Strengthening communities is a key
strategy for improving the lives of children and families directly
affected by AIDS-related morbidity and/or mortality.

*Inclusions/exclusions:* Include only those OVC who have received
support through community networks. Exclude OVC 18 years and older and
those children not considered an orphan or vulnerable by the programme.

*Strengths and weaknesses*: This indicator measures the changes in the
reach of community mobilization efforts to respond to OVC needs.
However, this indicator does not provide any indication of the quality
of the OVC services nor does it indicate the coverage of a given OVC
programme. If an estimate of the target population were known, then it
would be possible to calculate the percentage of the target population
reached through community mobilization efforts.

**[6.2 Number of OVC served by OVC programmes (indirect)]{.mark}**

*Definition*: The number of OVC provided with indirect support. Indirect
support is defined as those children reached with [fewer than
three]{.underline} of the following eight services:

-   Assisting with access to health care (including counseling and
    testing);

-   Referral or provision of antiretroviral treatment;

-   Assisting with access to education including school fees, uniforms
    or tutoring;

-   Assisting with access to economic support such as accessing social
    grants, income generation projects;

-   Providing food and/or nutrition support including supplements or
    food gardens;

-   Providing legal assistance, including accessing birth certificates
    and succession planning;

-   Providing or linking OVC to psychosocial support;

-   Providing protection from abuse; and

-   Mobilizing and building capacity of communities to respond to OVC
    needs.

*Rationale/what it measures:* It is intended that OVC will be provided
with a holistic package of services in order to meet all of their needs.
However, there are other interventions that are necessary to implement
OVC programmes such as policy and guideline development, advocacy and
development of materials. Defining direct as more than three and
indirect as less than three distinguishes these types of interventions,
as well as encouraging those providing direct support to consider the
OVC's multiple needs.

*Inclusions/exclusions:* Only those OVC who are being served by
programmes that provide less than three types of OVC services are
counted in this indicator. Exclude OVC 18 years and older and those
children not considered an orphan or vulnerable by the programme

*Strengths and weaknesses*: This indicator measures the changes in the
reach of indirect OVC programmes (i.e., those that provide fewer than
three types of services). However, this indicator does not provide any
indication of the quality of the OVC services nor does it indicate the
coverage of a given OVC programme

**[6. 3 Number of family members of OVC provided with HIV-related
palliative care]{.mark}**

*Definition:* The number of family members of Orphans and Vulnerable
Children (OVC) provided with palliative care services that are directly
supported with USG funds (i.e. at the service delivery level). The
minimum requirements for someone having received palliative care are
that the individual must have received services in at least two
categories of clinical, psychological, spiritual or social services.
Please refer to the palliative care tables in Appendix B for an
illustrative list of palliative care service.

Family member is defined as a legal spouse or common-law spouse (where
legal), same or opposite sex domestic partner, legal guardian, legal
ward, son or daughter (adopted\*, foster\*, step or in-law), brother or
sister (adopted\*, foster\*, step or in-law), parent (includes step or
in-law), grandparent (includes in-law), great-grandparent (includes
in-law), grandchild, great-grandchild, aunt, uncle, niece, nephew,
cousin or member of household of an HIV-infected individual that may or
may not live in the same residence\*\*.

*\*Adopted and foster relationships may include both legal and informal
arrangements.*

*\*\*In the context of palliative care in Africa, home or household does
not mean physical infrastructure in which a person lives, but also
involves the biological, sociological and spiritual roots of an
individual.*

*Rationale/what it measures:* Fundamental to the palliative approach to
HIV care is actively engaging and supporting family members of OVC.
Providing only one category of services is not sufficient, but families
should be linked or provided with services to meet all their needs. As a
result, at least two categories of services are required for a partner
to count that they have delivered HIV-related palliative care services
to OVC. This indicator is the total number of unduplicated family
members of OVC, receiving care from USG supported facilities and/or
community/home-based organizations. It is the goal of the South African
government and PEPFAR to increase access of HIV services in the country.
This indicator monitors progress towards this goal.

*Inclusions/exclusions:* Family members of OVC should be included if
they received HIV-related palliative care in at least two categories of
palliative care (listed in appendix B). Partners should not double count
individuals within a program or service outlet, even if the individual
accesses services on multiple occasions. Individuals receiving non-HIV
related services should be excluded.

Family members who are infected with HIV and receiving HIV-related
palliative care services should be excluded here and counted in
indicator "Number of individuals provided with HIV-related palliative
care (including TB) (disaggregated by gender)". If applicable, the
HIV-infected family member may also be counted in the ARV Services
Program Area.

*Strengths and weaknesses*: Adjusting for overlap between programs is
very difficult, especially when programs are not well linked and patient
confidentiality concerns must be respected. Some overcounting may occur.
This indicator measures the change in reach of comprehensive palliative
care programs. However, this indicator does not provide any indication
of the quality of the services, including how many times PLWHA accessed
services nor does it indicate the coverage of a given palliative care
programme.

[]{.mark}

[]{.mark}

**[6.3 Number of providers/caretakers trained in caring for
OVC]{.mark}**

*Definition:* The number of individuals trained to provide services to
OVC in any of the following areas:

-   Assisting with access to health care (including counseling and
    testing);

-   Referral or provision of antiretroviral treatment;

-   Assisting with access to education including school fees, uniforms
    or tutoring;

-   Assisting with access to economic support such as accessing social
    grants, income generation projects;

-   Providing food and/or nutrition support including supplements or
    food gardens;

-   Providing legal assistance, including accessing birth certificates
    and succession planning;

-   Providing or linking OVC to psychosocial support;

-   Providing protection from abuse; and

-   Mobilizing and building capacity of communities to respond to OVC
    needs.

Training refers to training or retraining of individuals and must follow
a curriculum with stated objectives and/or expected competencies. An
individual should only be counted once they have completed the training.
Individuals that are mid-way through a training should be counted in the
next reporting period. Individuals attending more than one training in a
particular program area during the reporting period should only be
counted once.

*Rationale/what it measures:* This indicator is a measure of OVC
caregivers who have been trained in the delivery of OVC services (one or
more of the eight areas listed above) to OVC. There is a need to
increase the cadre of caregivers available to reach OVC. This gives an
indication of progression towards this goal.

*Inclusions/exclusions:* Include only those persons trained to care for
OVC and who have completed training as operationally defined by the
organization. Do not include individuals trained if it is not related to
OVC care.

*Strengths and weaknesses*: This indicator is useful in that it tracks
the number of individuals trained to provide OVC services. The indicator
attempts to document increasing capacity to deliver OVC services,
however, no conclusion should be drawn regarding the quality of training
nor does it measure the outcomes of the training in terms of
competencies of the individuals trained or their job performance.

[]{.mark}

[]{.mark}

## Palliative Care: Basic Health Care and Support and TB/HIV

**[Program Overview]{.underline}**

Palliative care is patient and family centered holistic care and, at its
core, addresses a person's mind, body, spirit and societal context, in
its approach to HIV care. Under PEPFAR, the palliative approach to HIV
care optimizes the quality of life and alleviates the suffering of
adults and children living with HIV through the active anticipation,
prevention, and treatment of pain, symptoms and suffering from the onset
of HIV diagnosis through death. Palliative care includes and goes beyond
the medical management of infectious, neurological or oncological
complications of HIV and AIDS in order to comprehensively address
symptoms and suffering throughout the continuum of illness. The means by
which palliative care is achieved will vary according to stage of
illness but always with the understanding that improved quality of life
and the provision of holistic care involves addressing an HIV-infected
individual's or family member's clinical and physical needs,
psychological needs, spiritual needs, and social needs.

Given the importance of delivering quality, holistic services for PLWHA,
it is ideal for USG South Africa partners to work in collaboration with
other partners to encourage and ensure the delivery of comprehensive,
family-centered holistic services for PLWHA in all four service delivery
categories of clinical/physical care, psychological care, spiritual care
and social care. It is anticipated that the combination of services will
not only address the care needs of a family but will also build
protective measures to address vulnerability and empower family members
to potentially protect themselves against HIV. The categories include:

-   **Clinical and Physical Care**: Addresses the restoration and
    maintenance of an HIV-infected individual's immune status and the
    mitigation of physical consequences related to HIV disease.

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-   **Psychological Care**: Addresses the non-physical suffering of
    individuals and family members.

-   **Spiritual Care**: Addresses the major life events that cause
    people to question themselves, their purpose and their meaning in
    life.

-   **Social Care**: Assists individuals and family members in
    maintaining linkages to and use of care, preventing HIV infection
    and ensuring adherence to treatment.

**[Indicators]{.underline}**

[]{.mark}

**[7.1. Number of service outlets providing HIV-related palliative care
(including TB)]{.mark}**

*Definition:* The number of USG-supported service outlets that provide
general HIV-related palliative care. Service outlet refers to the lowest
level of service that provides HIV-related palliative care for
HIV-infected individuals including hospitals, clinics, and mobile units.
The minimum requirements for the provision of palliative care are that
the service outlet must be able to provide services in at least two
categories of clinical, psychological, spiritual or social services.
Please refer to the palliative care tables in Appendix B for an
illustrative list of palliative care service.

*Rationale/what it measures:* This indicator measures the expansion of
the number of locations that provide HIV-related palliative care
services that are delivered in accordance with South African standards.
It provides a rough sense of the change in the capacity to provide
palliative care services. This will track progress towards the goal of
expanding access and coverage of palliative care in South Africa.

*Inclusions/exclusions:* This indicator includes the total number of
service outlets that provide HIV-related palliative care supported by
USG. Exclude those not receiving USG resources, including human and
technical resources. Exclude service outlets that do not provide
HIV-related services. Also exclude service outlets that do not provide
HIV-related services in at least two categories of Palliative Care.

*Strengths and weaknesses*: This is purely an output measure. This
indicator does not describe the geographic location or distribution of
service outlets. Although this indicator does attempt to ensure that
service outlets can provide a minimum of at least two categories of
HIV-related Palliative Care services, this indicator does not consider
the quality of service provision, which would require more in-depth
evaluation efforts like facility surveys. This is not a complete measure
of coverage, as there is no denominator of total facilities.

One difficulty with this indicator is that while facility-based or
community-based service outlets in fixed locations are relatively
straight-forward to measure, community-based or home-based outreach
activities are difficult to define as service outlets and are not
captured in this indicator. It is recommended that at country level,
programs monitor which sites provide each of the key interventions:
clinical, psychological, spiritual and social.

**[7.1.A Number of service outlets providing treatment for TB for
HIV-infected individuals in a palliative care setting (subset of
7.1)]{.mark}**

*Definition:* The number of service outlets providing treatment for TB
for HIV-infected individuals (diagnosed or presumed) according to South
Africa standards. This indicator measures the subset of palliative care
service outlets that provide specific TB/HIV care. Service outlet refers
to those that provide treatment to TB for HIV-infected individuals
including hospitals, clinics, and mobile units.

*Rationale/what it measures:* The co-infection rate of HIV and TB is
very high, therefore it is crucial to increase access to TB services.
This indicator measures the progress of a programme to expand the number
of locations that provide TB treatment for HIV-infected individuals
(diagnosed or presumed). It provides a rough sense of the change in the
capacity to provide TB and care services. This will track progress
towards the goal of expanding access and coverage of palliative care in
South Africa.

*Inclusions/exclusions:* Include USG supported service outlets that
provide treatment for tuberculosis to HIV-infected individuals
(diagnosed or presumed).

*Strengths and weaknesses*: This is purely an output measure. This
indicator does not describe the geographic location or distribution of
service outlets. This indicator does not consider the quality of service
provision, which would require more in-depth evaluation efforts like
facility surveys. This is not a complete measure of coverage, as there
is no denominator of total facilities.

One difficulty with this indicator is that while facility-based or
community-based service outlets in fixed locations are relatively
straight-forward to measure, community-based or home-based outreach
activities are too difficult to define as service outlets and are not
captured in this indicator. It is recommended that at country level,
programmes monitor which sites provide each of the key interventions:
medical, psychological, spiritual and social.

[]{.mark}

[]{.mark}

**[7.2. Number of individuals provided with HIV-related palliative care
(including TB) (disaggregated by gender)]{.mark}**

*Definition:* The number of HIV-infected (diagnosed or presumed)
individuals provided with palliative care services that are directly
supported with USG funds (i.e. at the service delivery level). The
minimum requirements for someone having received palliative care are
that the individual must have received at least one form of clinical
care [and]{.underline} one other type of non-clinical care. The four
categories of Palliative Care services are clinical, psychological,
spiritual or social services. Please refer to the palliative care tables
in Appendix B for the list of each type of palliative care service.

*Rationale/what it measures:* People living with HIV/AIDS should be
reached with a comprehensive package of services. Providing only one
category of services is not sufficient; PLWHA should be linked or
provided with services to meet all of their needs. As a result, at least
two categories of services, of which one category must be clinical care
services, are required in order for a partner to count that they have
delivered HIV-related palliative care services. Clinical care services
is a required category in order to address the critical importance of
early identification of HIV status and HIV-related clinical problems
which may compromise an individual's immune status and physical
wellbeing. This indicator is the total number of unduplicated
individuals receiving palliative care from USG supported facilities
and/or community/home-based organizations. It is the goal of the South
African government and PEPFAR to increase access to HIV services in the
country. This indicator monitors progress towards this goal.

*Inclusions/exclusions:* This is not simply the sum of the individuals
served by facility-based palliative care (including TB) and
community/home-based palliative care partners; adjustment for the
overlap in service to the same individuals should be accounted for in
this total. Partners should not double count individuals within a
program or service outlet, even if the individual accesses services on
multiple occasions. An individual will count in separate program areas,
such as someone receiving ART, or reached with a prevention program.
Individuals receiving non-HIV related services should be excluded.
Individuals can be counted in each of the subset categories (see
indicators below) if they receive care in the different areas within the
reporting period.

*Strengths and weaknesses*: Adjusting for overlap between programs is
very difficult, especially when programs are not well linked and patient
confidentiality concerns must be respected. Some overcounting will
occur. However, this indicator does not provide any indication of the
quality of the services, including how many times PLWHA accessed
services nor does it indicate the coverage of a given palliative care
programme.

[]{.mark}

[]{.mark}

**[7.2.A Number of HIV-infected individuals that received treatment for
TB disease (disaggregated by gender) (subset of 7.2)]{.mark}**

*Definition:* The number of HIV-infected (diagnosed or presumed)
individuals who receive treatment for TB disease at service delivery
outlets that are directly supported with USG funds. This treatment
should be in line with national TB programme treatment guidelines. This
data should be reported as a total, and then by number of males reached
and number of females reached separately.

*Rationale/what it measures:* This indicator is the total number of
unduplicated individuals receiving treatment for TB from facilities
and/or community/home-based organizations. Evidence has shown that
previously undiagnosed tuberculosis was detected in a significant
proportion (up to 11%) of HIV-infected clients through routine TB
screening at HIV counseling and testing services. HIV-infected patients
with tuberculosis should be identified and placed on appropriate TB
treatment in order to interrupt TB transmission, and reduce the burden
of TB among HIV-infected clients. This indicator will measure the
implementation of TB and HIV integration and reduce the burden of TB in
HIV-infected clients.

*Inclusions/exclusions:* Only count those who are HIV-infected or
presumed HIV-infected and receiving treatment for TB disease.

*Strengths and weaknesses*: Adjusting for overlap between programmes is
very difficult, especially when programmes are not well linked and
patient confidentiality concerns must be respected. As TB treatment
lasts approximately 6-9 months, this indicator does not measure the
outcome of the TB treatment.

[]{.mark}

**[7.2 B Number of individuals that received post exposure prophylaxis
(subset of 7.2)]{.mark}**

*Definition:* Post Exposure Prophylaxis (PEP) is **short-term**
antiretroviral treatment to reduce the likelihood of HIV infection after
potential exposure. Antiretroviral therapy should be initiated as soon
as possible - within 48 to 72 hours - of sexual, injection-drug use, and
other substantial non-occupational HIV exposure and continued for 28
days.

*Rationale/what it measures:* PEP should be provided to reduce an
individual's risk of becoming infected with HIV after exposure to the
infection.

*Inclusions/exclusions:* An individual who receives PEP after exposure
to HIV, in any context, should be included in this indicator. An
HIV-infected individual given anti-retroviral drugs for the purposes of
PMTCT or long-term ART should not be included in this indicator.

*Strengths and weaknesses*: This indicator demonstrates how many
individuals received PEP, which is an important HIV intervention.
However, it does not demonstrate how many individuals needed PEP and did
not receive it, nor does it demonstrate the efficacy of PEP in
preventing HIV infection amongst the recipients of the prophylaxis.

[]{.mark}

**[7.2 C Number of HIV-infected individuals that received cotrimoxazole
prophylaxis (subset of 7.2)]{.mark}**

  

*Definition:* The number of HIV-infected individuals who received
cotrimoxazole prophylaxis during the reporting period according to the
South African Government guidelines.

*What it measures:* Cotrimoxazole is an important prophylaxis used to
prevent Opportunistic Infections to which HIV-infected individuals are
at risk. In South Africa, cotrimoxazole prophylaxis is a standard
clinical care intervention that should accompany anti-retroviral
treatment services. It is vital that PLWHA gain access to cotrimoxazole
prophylaxis when it is clinically indicated so they are able to be
healthy and productive. This indicator intends to monitor a priority
clinical care intervention delivered by providers to HIV-infected
individuals needing cotrimoxazole prophylaxis in USG-supported sites. 
Because success relies on resources and sufficient staff, this indicator
also measures commitment to HIV/AIDS care and treatment and in
maintaining an uninterrupted supply of cotrimoxazole for prophylactic
use.

*Inclusions/Exclusions:* Only include HIV-infected individuals receiving
prophylactic cotrimoxazole. To be included in this indicator, the
individual must have received prophylactic cotrimoxazole during the
reporting period. Include in this indicator, all individuals on
prophylactic cotrimoxazole regardless of whether or not they are on
anti-retroviral treatment.

*Strengths and weaknesses*: This indicator demonstrates the demand for
cotrimoxazole prophylaxis at sites supported by USG.   This indicator is
useful for assessing progress in providing prophylactic cotrimoxazole to
individuals with HIV/AIDS. It should be noted that service providers may
not be providing appropriate clinical care with prophylactic
cotrimoxazole because of a lack of drug availability at sites, lack of
appropriate health personnel to prescribe or insufficient access to
laboratory monitoring to guide appropriate use of prophylaxis according
to South African standards. 

This indicator does not capture whether the individual received
cotrimoxazole throughout the entire reporting period or for only a short
period of time. This indicator is an indication that PLWHA are gaining
access to prophylaxis, however, it does not show the total need. The
percentage of PWLHA receiving prophylaxis out of total in need of
prophylaxis is not represented in this indicator. This indicator also
does not show quality of the clinical care delivered or adherence to
cotrimoxazole. One difficulty with this indicator is that prevention of
opportunistic infections with prophylaxis and management of
opportunistic infections with treatment are often difficult to delineate
at service outlets.

**[7.3 Number of TB patients counseled and HIV tested and received test
results (disaggregated by gender)]{.mark}**

*Definition:* The number of individuals who are receiving TB treatment
who received HIV pre-test counselling, an HIV test and received their
test results with post-test counselling. This data should be reported as
a total, and then by number of males reached and number of females
reached separately.

*Rationale/What it measures:* Many individuals who are infected with TB
are also infected with HIV. In addition, many individuals do not get HIV
counselling and testing until they have advanced HIV disease and arrive
at a facility that provides treatment. Testing individuals who have TB
for HIV is an opportunity to reach out to many people who may likely be
HIV positive. This indicator measures the extent to which people who are
infected with TB and receiving TB treatment are then tested for HIV so
that they can access HIV care.

*Inclusions/Exclusions:* Count only persons who are receiving TB
treatment and who were counseled, tested and received results for HIV.

*Strengths/Weaknesses:* This is purely an output measure. This indicator
does not consider whether persons identified as being HIV positive are
referred for services and actually receive ARV services. There is no
dominator of the number of people who are receiving TB treatment to get
a measure of the percentage of persons tested for HIV.

[]{.mark}

[]{.mark}

**[7. 4 Number of family members of HIV-infected individuals provided
with HIV-related palliative care]{.mark}**

*Definition:* The number of family members of HIV-infected (diagnosed or
presumed) individuals provided with palliative care services that are
directly supported with USG funds (i.e. at the service delivery level).
The minimum requirements for someone having received palliative care are
that the individual must have received services in at least two
categories of clinical, psychological, spiritual or social services.
Please refer to the palliative care tables in Appendix B for an
illustrative list of palliative care service.

Family member is defined as a legal spouse or common-law spouse (where
legal), same or opposite sex domestic partner, legal guardian, legal
ward, son or daughter (adopted\*, foster\*, step or in-law), brother or
sister (adopted\*, foster\*, step or in-law), parent (includes step or
in-law), grandparent (includes in-law), great-grandparent (includes
in-law), grandchild, great-grandchild, aunt, uncle, niece, nephew,
cousin or member of household of an HIV-infected individual that may or
may not live in the same residence\*\*.

*\*Adopted and foster relationships may include both legal and informal
arrangements.*

*\*\*In the context of palliative care in Africa, home or household does
not mean physical infrastructure in which a person lives, but also
involves the biological, sociological and spiritual roots of an
individual.*

*Rationale/what it measures:* Fundamental to the palliative approach to
HIV care is actively engaging and supporting family members of PLWHA.
Family members of PLWHA should be reached with a comprehensive package
of services. Providing only one category of services is not sufficient,
but families should be linked or provided with services to meet all
their needs. As a result, at least two categories of services are
required for a partner to count that they have delivered HIV-related
palliative care services to family members of HIV-infected (diagnosed or
presumed) individuals. This indicator is the total number of
unduplicated family members of HIV-infected individuals, receiving care
from USG supported facilities and/or community/home-based organizations.
It is the goal of the South African government and PEPFAR to increase
access of HIV services in the country. This indicator monitors progress
towards this goal.

*Inclusions/exclusions:* Family members of HIV-infected individuals
should be included if they received HIV-related palliative care in at
least two categories of palliative care (listed in appendix B). Partners
should not double count individuals within a program or service outlet,
even if the individual accesses services on multiple occasions.
Individuals receiving non-HIV related services should be excluded.

Family members who are infected with HIV and receiving HIV-related
palliative care services should be excluded here and counted in
indicator "Number of individuals provided with HIV-related palliative
care (including TB) (disaggregated by gender)". If applicable, the
HIV-infected family member may also be counted in the ARV Services
Program Area.

*Strengths and weaknesses*: Adjusting for overlap between programs is
very difficult, especially when programs are not well linked and patient
confidentiality concerns must be respected. Some overcounting may occur.
This indicator measures the change in reach of comprehensive palliative
care programs. However, this indicator does not provide any indication
of the quality of the services, including how many times PLWHA accessed
services nor does it indicate the coverage of a given palliative care
programme.

**[7.5 Number of TB cases\*]{.mark}**

*\* This indicator is required for all USAID supported TB programmes and
optional for other USG supported programmes.*

*Definition:* The total number of TB cases diagnosed.

*Rationale/what it measures:* This indicator provides information on the
number of TB cases detected. Because effective treatment of TB patients
reduces TB transmission, early detection is one of the main strategies
of TB control, and the indicator measures the programme's capacity to
identify those sources. Information on true incidence or prevalence of
TB disease is unlikely to be available. Trends over time in case
notification usually indicate changes in programme coverage and capacity
to detect TB cases; at high levels of case detection, the indicator
reflects changes in the prevalence of TB in the community. Additionally,
it provides data for programme planning and M&E purposes, and it should
be used as a measure to guide these activities. For example, an upward
trend in case notification rates can reflect an improvement in programme
performance or, in some cases, the impact of the HIV/AIDS epidemic.

*Inclusions/exclusions:* Only count those who are diagnosed with TB.

*Strengths and weaknesses*: This indicator only captures number of TB
cases reported.

[]{.mark}

[]{.mark}

**[7.6 Number of Pulmonary TB\*]{.mark}**

*\* This indicator is required for all USAID supported programmes and
optional for other USG supported programmes.*

*Definition:* As a subset of the total number of TB cases diagnosed,
report the number of pulmonary TB cases.

*Rationale/what it measures:* Pulmonary TB is likely to be more
infectious than non-pulmonary forms of TB that needs to be tracked
separately. Also, it is important to track over time to see if there is
an increase/decrease in case detection.

*Inclusions/exclusions:* Only count those diagnosed with pulmonary TB.
Exclude other forms of TB.

*Strengths and weaknesses*: This indicator only captures number of TB
cases reported. It also does not give geographic coverage.

**[7.7 Number of new smear positives\*]{.mark}**

*\* This indicator is required for all USAID supported programmes and
optional for other USG supported programmes.*

*Definition:* The total number of individual TB cases reported as new
smear positive pulmonary cases.

*Rationale/what it measures:* The indicator assesses the adequacy of
smear diagnosis for TB suspects, specifically the utilization of
laboratory services by diagnosing clinicians for determining whether or
not a TB suspect has infectious TB. It reflects the development of
programme screening of TB suspects with sputum smear microscopy, as well
as the relative weight of medical diagnosis of pulmonary TB without
microscopy examination or with negative smears. In programme conditions
in countries with medium or high TB burden, over two-thirds of pulmonary
TB in adults should present with positive smears (the remainder being
either culture-positive or culture-negative pulmonary TB). The
proportion of children with smear positive pulmonary TB is quite low.
Although the diagnosis of TB can be made in smear negative individuals
(particularly in children and those who had never been treated), the
absence of bacteriological examination is not an acceptable medical
practice in the diagnosis of pulmonary TB in adults. Under programme
conditions, when microscopy laboratory services are available and
diagnostic criteria are properly applied, pulmonary TB smear positive
cases represent at least 65% of the total pulmonary TB cases in adults
and 50% or more of all TB cases. These proportions may be lower in
populations with high HIV incidence.

*Inclusions/exclusions:* Only count those who were smear positive for
TB. Exclude other forms of diagnosed TB cases.

*Strengths and weaknesses*: The indicator is a direct measure of
programme capacity to identify infectious cases. The number of new
pulmonary smear positive TB cases provides a better comparison and
trends over time between areas, as compared with the number of total
cases, because it uses a single, objective method (sputum microscopy).
However, case notification represents only a subset of the true number
of cases arising in a country because of incomplete coverage by health
services or deficient recording and reporting. Although case
notifications under-represent the true burden of disease, they often
represent the most useful data for estimating incidence.

[]{.mark}

[]{.mark}

**[7.8 Number of successfully treated TB\*]{.mark}**

*\* This indicator is required for all USAID supported programmes and
optional for other USG supported programmes.*

*Definition:* Successful treatment rates include the number of
individuals provided treatment for TB who were either cured of TB plus
those who completed TB treatment. Cured is defined as those individuals
who were initially sputum smear positive for TB, were treated with a
complete course of TB treatment, tested smear negative at or one month
prior to completion and on at least one previous occasion. Completed TB
treatment count includes those who initially tested smear positive,
completed a full course of TB treatment and do not have any
documentation of a subsequent negative TB smear or those with no smear
examined at diagnosis or those who were initially diagnosed with
extra-pulmonary TB and completed a full course of TB treatment.

*Rationale/what it measures:* Evidence has shown that previously
undiagnosed tuberculosis was detected in a significant proportion (up to
11%) of HIV-infected clients through routine TB screening at HIV
counseling and testing services. HIV-infected patients with tuberculosis
should be identified and placed on appropriate TB treatment in order to
interrupt TB transmission, and reduce the burden of TB among
HIV-infected clients. This indicator measures the success rate of TB
treatment programmes in reducing the burden of TB in HIV-infected
clients.

*Inclusions/exclusions:* Only count those who completed treatment for TB
at a USG supported site.

*Strengths and weaknesses*: One important limitation is that success
(and other treatment outcomes monitored routinely in TB programmes) is
an outcome of treatment regimens, not patient results. Although it might
be useful to analyze a cohort of TB patients in terms of survival or
TB-free status at a given point in time \-- after say, 12 or 24 months
\-- the routine TB monitoring system was not designed to facilitate such
an analysis. In the routine TB monitoring system, an outcome is an
irrevocable event (or status assignment) that signals an end of the
current treatment regimen. An end is declared because the regimen was
completed (cured, completed), because the regimen is no longer
applicable (failure, default), or because no information could be
obtained (death, transfer out, and not evaluated). Obviously, some cases
with recorded outcomes of failure or default may go on to be cured
(after re-registration for re-treatment regimens), and some cured cases
may go on to relapse. Some default cases are never seen again and may
therefore have died or spontaneously healed or found treatment
elsewhere. The only status assignment serving both types of analysis
(routine monitoring versus survival analysis) is death. Where there is
interest in monitoring outcomes of patients (as distinct from outcomes
of regimens), more sophisticated relational linkages must be introduced
into the record-keeping system.

[]{.mark}

**[7.9]{.mark}** **[Number of HIV-infected individuals in a palliative
care program that were referred for ART]{.mark}**

*Definition:* The number of HIV infected individuals receiving
palliative care at a USG supported service outlet that were referred to
a treatment programme. A treatment programme includes the provision of
antiretroviral drugs and clinical monitoring.

*Rationale/what it measures:* Once diagnosed as HIV-infected,
individuals may need to be referred for treatment services. Palliative
care is an entry point for treatment and the goal is to increase access
to treatment for those in need. This indicator provides an estimate of
the number of individuals who are currently receiving palliative care
services who are referred on to treatment services.

*Inclusions/exclusions:* Count only HIV infected individuals receiving
palliative care at a USG supported site who were referred to a treatment
programme. Exclude HIV infected individuals already enrolled in a
treatment programme.

*Strengths and weaknesses*: This indicator only counts those who are
referred and does not assess whether the individuals actually received
the services. This indicator is biased, as the individual has already
presented for palliative care services.

[]{.mark}

[]{.mark}

**[7.10 Number of individuals provided with HIV-related palliative care
(including TB) (indirect)]{.mark}**

*Definition:* The number of HIV-infected (diagnosed or presumed)
individuals receiving palliative care services that were indirectly
supported with USG funding. Indirect support includes any of the
following activities: national, provincial, or district level policy
development; institutional capacity building; logistics; protocol or
guideline development; advocacy; national, provincial, district level
training; and national, provincial, or district level management
information systems. See page 25 for further information.

*Rationale/what it measures:* There are a number of support functions
that are essential for the provision of quality palliative care
services. This indicator tries to quantify the indirect inputs that USG
partners make to this process by estimating the number of individuals
who received palliative care services indirectly.

*Inclusions/exclusions:* Only include the estimated number of HIV
infected individuals who received palliative care services. Individuals
must be presumed or diagnosed HIV positive.

*Strengths and weaknesses*: There may be some facilities that receive
both direct and indirect support. Indirect support is an estimate and
not actual reported data.

[]{.mark}

**[7.10A Number of HIV-infected individuals who received treatment for
TB disease (subset of 7.9) (indirect)]{.mark}**

*Definition:* The number of HIV-infected (diagnosed or presumed)
individuals who received treatment for TB that were indirectly supported
with USG funding. This is a subset of 7.9. Indirect support includes any
of the following activities: national, provincial, or district level
policy development; institutional capacity building; logistics; protocol
or guideline development; advocacy; national, provincial, district level
training; and national, provincial, or district level management
information systems.

*Rationale/what it measures:* There are a number of support functions
that are essential for the provision of quality TB care services. This
indicator tries to quantify the indirect inputs that USG partners make
to this process by estimating the number of individuals who received
treatment for TB disease indirectly.

*Inclusions/exclusions:* Only include the estimated number of HIV
infected individuals who received treatment for TB disease. Individuals
must be presumed or diagnosed HIV positive.

*Strengths and weaknesses*: There may be some facilities that receive
both direct and indirect support. Indirect support is an estimate and
not actual reported data.

[]{.mark}

[]{.mark}

**[7.11 Number of individuals trained to provide HIV-related palliative
care (including TB/HIV)]{.mark}**

*Definition:* The number of individuals trained to provide HIV-related
palliative care for HIV-infected individuals (diagnosed or presumed) and
includes those trained in facility-based, community-based and/or
home-based care, including TB/HIV.

Training refers to new training or retraining of individuals and assumes
that training is conducted according to South African or international
standards when these exist. A training must have specific learning
objectives, a course outline or curriculum, and expected knowledge,
skills and/or competencies to be gained by participants. Training on
HIV-related palliative care services may include: a) clinical/medical
including TB/HIV b) psychological, c) spiritual, and/or d) support care
services for HIV-infected individuals and family members.

*Rationale/what it measures:* This indicator is a measure of health
providers who have been trained in general HIV-related palliative care
for HIV-infected individuals. It is an indication of the expansion of
health care workers who are available to provide care.

In many countries, the national AIDS coordination body and/or
professional organizations have defined training standards. This applies
in particular to countries that have introduced certification systems
for HIV/AIDS training. The training must equip trainees with a minimum
set of competencies needed to take an active role in supporting HIV/AIDS
programmes in line with national recommendations and/or guidelines.
Usually the presence of such competencies is assessed based on
successful completion of training and practical experience during the
reporting period.

*Inclusions/exclusions:* This indicator is the total number of
individuals receiving training for palliative care (including those
trained in TB/HIV). Only participants who complete the full training
course should be counted. Individuals attending more than one training
in a particular program area during the reporting period should only be
counted once.

*Strengths and weaknesses*: This indicator is useful in that it tracks
the number of health care providers trained to provide palliative care
to HIV-infected individuals. The indicator attempts to document
increasing capacity to deliver palliative care to HIV-infected
individuals. This indicator does not measure the quality of the
training, nor does it measure the outcomes of the training in terms of
the competencies of individuals trained, nor their job performance.

[]{.mark}

**[7.11A Number of individuals trained to provide treatment for TB to
HIV-infected individuals (subset of 7.11)]{.mark}**

*Definition:* The number of individuals trained to provide treatment for
TB to HIV-infected individuals (diagnosed or presumed) and includes
those trained in facility-based, community-based and/or home-based care.
Training refers to new training or retraining of individuals and assumes
that training is conducted according to South African or international
standards when they exist. A training must have specific learning
objectives, a course outline or curriculum, and expected knowledge,
skills and/or competencies to be gained by participants.

*Rationale/what it measures:* This indicator is a measure of health care
providers who have been trained in the delivery of treatment for TB to
HIV-infected individuals. It measures the number of newly trained or
retrained individuals who are able to deliver treatment for TB to
HIV-infected individuals. This is a subset of the total number trained
for HIV-related palliative care that had specific training on TB/HIV.

In many countries, the national AIDS coordination body and/or
professional organizations have defined training standards. This applies
in particular to countries that have introduced certification systems
for HIV/AIDS training. The training must equip trainees with a minimum
set of competencies needed to take an active role in supporting HIV/AIDS
programmes in line with national recommendations and/or guidelines.
Usually the presence of such competencies is assessed based on
successful completion of training and practical experience during the
reporting period.

*Inclusions/exclusions:* This indicator is the number of individuals
trained to provide treatment for TB to HIV-infected individuals. Only
participants who complete the full training course should be counted.
Individuals attending more than one training in a particular program
area during the reporting period should only be counted once.

*Strengths and weaknesses*: This indicator is useful in that it tracks
the number of health care providers trained to provide treatment for TB
to HIV-infected individuals. The indicator attempts to document
increasing capacity to deliver treatment for TB to HIV-infected
individuals. However, no conclusion should be drawn regarding the
quality of training nor does it measure the outcomes of the training in
terms of competencies of the individuals trained or their job
performance.

[]{.mark}

[]{.mark}

**[7.12 Number of hours technical assistance provided in HIV-related
health care and support]{.mark}**

*Definition:* The number of person hours of technical assistance
provided by the PEPFAR-supported partner to local NGOs, national or
provincial Departments of Health, or other institutions for building
capacity to provide basic health care and support services.

Technical assistance (TA) is defined as the identification of need, and
delivery of, practical programmatic support for design, implementation
and evaluation of programmes in the specified area. TA should include
regular technical communications and information dissemination sustained
over a period of time. TA can be provided through a combination of
strategic approaches and dissemination strategies including
individualized and on-site peer and expert consultation, site visits,
ongoing consultative relationships, national and/or regional meetings,
consultative meetings and conferences, conference calls and web-casts,
development and implementation of training curricula.

*Rationale/what it measures:* Technical assistance is one strategy along
with training and mentoring that may increase the capacity of
organizations to provide basic health care and support for HIV-infected
and affected populations. This indicator measures the amount of
technical assistance provided by USG supported technical experts in the
area of basic health care and support to governmental and
non-governmental partners. It reflects capacity building efforts to
improve programmes and develop policies in this area.

*Inclusions/exclusions:* Include person hours of technical assistance
provided specifically for strengthening HIV related palliative care or
TB/HIV programmes and/or policies.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator attempts to capture an input into a
process, but does not indicate the quality of the technical assistance
provided or if the intended output was achieved.

[]{.mark}

[]{.mark}

**[7.13 Number of hours technical assistance provided for strengthening
TB/HIV services]{.mark}**

*Definition:* The number of person hours of technical assistance
provided by the PEPFAR-supported partner to local NGOs, national or
provincial Departments of Health, or other institutions for building
capacity to strengthen TB/HIV services.

Technical assistance (TA) is defined as the identification of need, and
delivery of, practical programmatic support for design, implementation
and evaluation of programmes in the specified area. TA should include
regular technical communications and information dissemination sustained
over a period of time. TA can be provided through a combination of
strategic approaches and dissemination strategies including
individualized and on-site peer and expert consultation, site visits,
ongoing consultative relationships, national and/or regional meetings,
consultative meetings and conferences, conference calls and web-casts,
development and implementation of training curricula.

*Rationale/what it measures:* Technical assistance is one strategy,
along with training and mentoring, that may increase the capacity of
organizations to provide TB/HIV services for HIV-infected individuals.
This indicator measures the amount of technical assistance provided by
USG technical experts in the area of TB/HIV services to governmental and
non-governmental partners. It reflects capacity building efforts to
improve programmes and develop policies in this area.

*Inclusions/exclusions:* Include person hours of technical assistance
provided specifically for strengthening TB/HIV programmes and/or
policies.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator attempts to capture an input into a
process, but does not indicate the quality of the technical assistance
provided or if the intended output was achieved.

[]{.mark}

[]{.mark}

## Antiretroviral Treatment Services

**[Programme Overview]{.underline}**

With more than 6 million South Africans infected with HIV, the need to
address the medical, social and psychosocial demands in the public and
private sector is ever-increasing. A continuum of care, that includes
treatment, would be focused on ensuring that people know their status
(through HIV counseling and testing), have their opportunistic
infections managed (e.g. through a wellness program), and are assessed
for eligibility for ARV treatment in a timely fashion (e.g. as part of
HIV counseling and testing).

HIV/AIDS treatment services include the provision of antiretroviral
(ARV) drugs and clinical monitoring for antiretroviral treatment (ART)
among those with advanced HIV infection. The number of clients on ART
has subsets of new clients and continuous clients. These are calculated
based on the date at the end of the reporting period (i.e., March 31 or
September 30).

[Definitions commonly used in this section:]{.underline}

*Antiretroviral therapy:* Long-term combination antiretroviral therapy
intended primarily to improve the health of the individual on treatment,
not to prevent mother-to-child transmission.

*ART services:* Activities including the provision of antiretroviral
drugs and clinical monitoring for antiretroviral therapy among those
with HIV infection.

*Pregnant*: A current client is pregnant if she was pregnant at any time
during the reporting period, regardless of the outcome of the pregnancy.

*Sex*: Refers to male or female.

*Age*: Age is divided into three categories: 0-5, \<15, and \>= 15
years. Some facilities collect either 0-4 or 0-5. Either one can be
reported under the 0-5 column. Please note it in your report if you are
reporting 0-4 instead of 0-5.

At the end of the reporting period: The last day of the 6-month or
12-month reporting period.

*This section is divided into two parts: (1) direct treatment services
and (2) activities in support of treatment. The indicators listed in
direct treatment services are collected on a separate template by site
on a quarterly basis. The data reported should reflect the program
activities at that site and related feeder clinics during the reporting
period.*

Indicators: Direct Treatment Services

**[8.1A Number of service outlets providing HIV counseling and
testing]{.mark}**

*Definition:* A service outlet refers to the lowest level of service -
where the testing actually occurs. For example, with regard to clinical
activities, the lowest level for which data exists should be a service
outlet such as a health centre, hospital, clinic, stand alone CT centre,
or mobile unit. This indicator excludes service outlets that provide
counselling and testing in the context of preventing mother-to-child
transmission. Please refer to indicator 4.1 in the SASI manual for more
guidance on reporting the number of service outlets that provide
services to prevent mother-to-child transmission of HIV.

*Rationale/What it measures:* This indicator provides a gross count of
the number of USG supported locations that provide basic counselling and
testing for HIV. It provides a rough sense of coverage of counselling
and testing services. If there is a plan to expand the number of service
outlets, this measure will track the progress of meeting that goal.

*Inclusions/Exclusions:* Counseling and testing for PMTCT should be
included in the PMTCT programme area only.

*Strengths/Weaknesses:* This is purely an output measure. It provides no
sense of the geographical spread of CT services, nor any relationship to
the percentage of the population that is reached by the service outlet.
This indicator does not consider the quality of service provision, which
would require more in-depth evaluation efforts like facility surveys.
This is not a complete measure of coverage, as there is no denominator
of total facilities.

[]{.mark}

**[8.1B Number of service outlets providing HIV-related palliative care
(including TB)]{.mark}**

[]{.mark}

*Definition:* The number of USG-supported service outlets that provide
general HIV-related palliative care. Service outlet refers to the lowest
level of service that provides HIV-related palliative care for
HIV-infected individuals including hospitals, clinics, and mobile units.
The minimum requirements for the provision of palliative care are that
the service outlet must be able to provide services in at least two
categories of clinical, psychological, spiritual or social services.
Please refer to the palliative care tables in Appendix B for an
illustrative list of palliative care service.

*Rationale/what it measures:* This indicator measures the progress of a
program to expand the number of locations that provide HIV-related
palliative care services that are delivered in accordance with South
African standards. It provides a rough sense of the change in the
capacity to provide palliative care services. This will track progress
towards the goal of expanding access and coverage of palliative care in
South

*Inclusions/exclusions:* This indicator includes the total number of
service outlets that provide HIV-related palliative care supported by
USG. Exclude those not receiving USG resources, including human and
technical resources. Exclude service outlets that do not provide
HIV-related services. Also exclude service outlets that do not provide
HIV-related services in at least two categories of Palliative Care.

*Strengths and weaknesses*: This is purely an output measure. This
indicator does not describe the geographic location or distribution of
service outlets. Although this indicator does attempt to ensure that
service outlets can provide a minimum of at least two categories of
HIV-related Palliative Care services, this indicator does not consider
the quality of service provision, which would require more in-depth
evaluation efforts like facility surveys. This is not a complete measure
of coverage, as there is no denominator of total facilities.

One difficulty with this indicator is that while facility-based or
community-based service outlets in fixed locations are relatively
straight-forward to measure, community-based or home-based outreach
activities are difficult to define as service outlets and are not
captured in this indicator. It is recommended that at country level,
programs monitor which sites provide each of the key interventions:
clinical, psychological, spiritual and social.

[]{.mark}

**[8.1C Number of service outlets providing treatment for TB (subset of
palliative care outlets)]{.mark}**

*Definition:* The number of service outlets providing treatment for TB
for HIV infected individuals (diagnosed or presumed) according to South
African standards. This indicator measures the subset of palliative care
service outlets that provide specific TB/HIV care. Service outlet refers
to the lowest level of service that provides treatment to TB for
HIV-infected individuals including hospitals, clinics, and mobile units.

*Rationale/What it measures:* The co-infection rate of HIV and TB is
very high, therefore it is crucial to increase access to TB services.
This indicator measures the progress of a programme to expand the number
of locations that provide treatment for TB for HIV-infected individuals
(diagnosed or presumed) services that are delivered in accordance with
South African standards. It provides a rough sense of the change in the
capacity to provide TB and care services. This will track progress
towards the goal of expanding access and coverage of palliative care in
South Africa.

*Inclusions/Exclusions:* A USG supported service outlet that will count
in this indicator will provide treatment for tuberculosis to
HIV-infected individuals (diagnosed or presumed).

*Strengths/Weaknesses:* This is purely an output measure. This indicator
does not describe the geographic location or distribution of service
outlets. This indicator does not consider the quality of service
provision, which would require more in-depth evaluation efforts like
facility surveys. This is not a complete measure of coverage, as there
is no denominator of total facilities.\
\
One difficulty with this indicator is that while facility-based or
community-based service outlets in fixed locations are relatively
straight-forward to measure, community-based or home-based outreach
activities are too difficult to define as service outlets and are not
captured in this indicator. It is recommended that at country level,
programmes monitor which sites provide each of the key interventions:
medical, psychological, spiritual and social.

[]{.mark}

**[8.1D Number of service outlets providing antiretroviral
treatment]{.mark}**

*Definition:* The number of service outlets that provide ART. A service
outlet refers to the lowest level of service delivery providing ART
including hospitals, clinics, and mobile units. ART services are
activities including the provision of antiretroviral drugs and clinical
monitoring for antiretroviral therapy among those with HIV infection.
South African or international standards refer to national guidelines
and policies to promote ART training and services in a comprehensive
way, linking them with HIV prevention and care and with the
strengthening of health systems. National guidelines and policies are
often based on existing international guidelines, and are generally
agreed upon in a national forum. Without standards, services of unknown
quality and impact can be implemented on an ad hoc basis, making it
difficult to monitor and evaluate efforts.

*Rationale/what it measures:* This indicator measures the progress of a
programme to expand the number of locations in which ART services are
delivered in accordance with South African or international standards.
It provides a rough sense of the change in the capacity within a country
to provide ART services. If there is a plan to expand the number of
service outlets, this measure will track the progress of meeting that
goal.

*Inclusions/exclusions*: Include only those service outlets that are
supported with USG funding at the service delivery level.

*Strengths and weaknesses*: This is purely an output measure. This
indicator does not describe the geographic location or distribution of
service outlets. This indicator does not consider the quality of service
provision, which would require more in-depth evaluation efforts like
facility surveys. This is not a complete measure of coverage, as there
is no denominator of total facilities.

**[8.2 Number of individuals counseled and HIV tested and received test
results (disaggregated by gender)]{.mark}**

*Definition:* The number of individuals who received pre-test
counselling, an HIV test and received their test results with post-test
counselling at an ART facility during the quarter. "Treatment facility"
refers to all levels of service that provide ART including hospitals,
clinics, and mobile units. This data should be reported as a total, and
then by number of males reached and number of females reached
separately.

*Rationale/What it measures:* Many individuals do not get HIV
counselling and testing until they have advanced HIV disease and arrive
at a facility that provides treatment. This indicator provides a count
of the individuals who have been counselled and tested in treatment
facilities.

*Inclusions/Exclusions:* Count only those who are counselled and tested
in treatment facilities.

*Strengths/Weaknesses:* This is purely an output measure. This indicator
does not consider the quality of service provision, which would require
more in-depth evaluation efforts like facility surveys. This is not a
complete measure of coverage, as there is no denominator of total
individuals seen at treatment sites.

**[8.2A Number of TB patients counseled and HIV tested and received test
results (disaggregated by gender) (subset of 8.2)]{.mark}**

*Definition:* The number of individuals who are receiving TB treatment
who received HIV pre-test counselling, an HIV test and received their
test results with post-test counselling. This data should be reported as
a total, and then by number of males reached and number of females
reached separately.

*Rationale/What it measures:* Many individuals who are infected with TB
are also infected with HIV. In addition, many individuals do not get HIV
counselling and testing until they have advanced HIV disease and arrive
at a facility that provides treatment. Testing individuals who have TB
for HIV is an opportunity to reach out to many people who may likely be
HIV positive. This indicator measures the extent to which people who are
infected with TB and receiving TB treatment are then tested for HIV so
that they can access HIV care.

*Inclusions/Exclusions:* Count only persons who are receiving TB
treatment and who were counseled, tested and received results for HIV.

*Strengths/Weaknesses:* This is purely an output measure. This indicator
does not consider whether persons identified as being HIV positive are
referred for services and actually receive ARV services. There is no
dominator of the number of people who are receiving TB treatment to get
a measure of the percentage of persons tested for HIV.

**[8.3 Number of HIV-infected individuals who received pre-treatment
training]{.mark}**

*Definition:* The number of HIV-infected individuals who received
pre-treatment training during the quarter. Report this indicator by
individuals, not by sessions. Pre-treatment training may vary by
facility, but must include adherence counselling and ART literacy.

*Rationale/What it measures:* Pre-treatment training is essential to the
success of ART programmes and on health outcomes for the individual.
This indicator is a measure of the number of HIV-infected individuals
who have completed pre-treatment training prior to initiating treatment.

*Inclusions/Exclusions:* Only individuals who complete pre-treatment
training as defined by the facility should be included.

*Strengths/Weaknesses:* This indicator is useful in that it tracks the
number of people who received pre-treatment training and level of effort
of the ART programme in preparing people for ART. However, since it is
purely an output measure, it does not measure the effectiveness of the
pre-treatment training.

**[8.4 Number of HIV-infected individuals who received ARV adherence
counselling]{.mark}**

*Definition:* The number of HIV-infected individuals who received
adherence counselling training during the quarter. Report this indicator
by individuals, not by sessions.

*Rationale/What it measures:* Adherence is essential to the success of
ART programmes. This indicator is a measure of the number of
HIV-infected individuals who receive adherence counselling prior to
initiating or to reinforce the importance of adherence after already
initiating treatment.

*Inclusions/Exclusions:* Include all individuals who received any
adherence counselling during the quarter.

*Strengths/Weaknesses:* This indicator is useful in that it tracks the
number of people counselled in adherence. However, since it is purely an
output measure, it does not track patient health outcomes as a result of
the adherence counselling.

**[Palliative Care Guidance for indicators 8.5 -- 8.8]{.mark}**

*Note that this is not an indicator but provides guidance for palliative
care for indicators 8.5-8.8.*

*Definition:* The number of HIV-infected (diagnosed or presumed)
individuals provided with palliative care services that are directly
supported with USG funds (i.e. at the service delivery level). The
minimum requirements for someone having received palliative care are
that the individual must have received at least one form of clinical
care [and]{.underline} one other type of non-clinical care. The four
categories of Palliative Care services are clinical, psychological,
spiritual or social services. Please refer to the palliative care tables
in Appendix B for the list of each type of palliative care service.

*Rationale/what it measures:* People living with HIV/AIDS should be
reached with a comprehensive package of services. Providing only one
category of services is not sufficient; PLWHA should be linked or
provided with services to meet all their HIV-related needs. As a result,
at least two categories of services, of which one category must be
clinical care services, are required for a partner to count that they
have delivered HIV-related palliative care services. Clinical care
services is a required category in order to address the critical
importance of early identification of HIV status and HIV-related
clinical problems which may compromise an individual's immune status and
physical wellbeing. This indicator is the total number of unduplicated
individuals receiving palliative care from USG supported facilities
and/or community/home-based organizations. It is the goal of the South
African government and PEPFAR to increase access to HIV services in the
country. This indicator monitors progress towards this goal.

*Inclusions/exclusions:* This is not simply the sum of the individuals
served by facility-based palliative care (including TB) and
community/home-based palliative care partners; adjustment for the
overlap in service to the same individuals should be accounted for in
this total. Partners should not double count individuals within a
program or service outlet, even if the individual accesses services on
multiple occasions. An individual will count in separate program areas,
such as someone receiving ART, or reached with a prevention program.
Individuals receiving non-HIV related services should be excluded.
Individuals can be counted in each of the subset categories (see
indicators below) if they receive care in the different areas within the
reporting period.

*Strengths and weaknesses*: Adjusting for overlap between programs is
very difficult, especially when programs are not well linked and patient
confidentiality concerns must be respected. Some overcounting will
occur. This indicator measures the change in reach of comprehensive
palliative care programs. However, this indicator does not provide any
indication of the quality of the services, including how many times
PLWHA accessed services nor does it indicate the coverage of a given
palliative care programme.

**[8.5 Cumulative number enrolled in HIV care by the beginning of
quarter (disaggregated by age, gender and pregnancy status)]{.mark}**

*Definition:* The cumulative number of HIV-infected individuals enrolled
in a care or wellness programme by the first day of the quarter since
the beginning PEPFAR support at the facility. Include those on ART as
well as those not yet initiated on ART for any reason like having a CD4
count above 200 or having TB, since it is assumed that those on ART are
also receiving some form of HIV care or monitoring in addition to
receiving ARV drugs. This indicator is intended to capture all those who
have ever been enrolled in care and therefore includes those who are
also no longer in care including those who have died or are lost to
follow-up. This data should be disaggregated by age (0-5 years, 0-14
years and 15 and over) and gender (male and female).

*Rationale/What it measures:* This indicator provides a total count of
individuals who have received any type of HIV care by the beginning of
the quarter, regardless of whether they are still receiving care. This
number provides a baseline against which to measure new enrollees during
the quarter.

*Inclusions/Exclusions:* Count all individuals who were enrolled in any
type of HIV care at the beginning the reporting period.

*Strengths/Weaknesses:* This is purely an output measure. It intends to
capture the number of people who were ever enrolled in HIV care at the
facility.

**[8.6 New enrollees in HIV care during the quarter (disaggregated by
age, gender)]{.mark}**

*Definition:* The number of HIV-infected individuals newly enrolled in
HIV care during the quarter. Include those on ART and those individuals
who have not yet initiated ART for any reason like having a CD4 count
above 200 or having TB, since it is assumed that those on ART are also
receiving some form of HIV care or monitoring in addition to receiving
ARV drugs. This indicator should be disaggregated by sex and age and
should be referred to as new clients. This data should be is aggregated
by age (0-5 years, 0-14 years and 15 and over) and gender (male and
female).

*Rationale/What it measures:* This indicator provides a count of
individuals who are newly enrolled in HIV care.

*Inclusions/Exclusions:* Exclude those enrolled in care before the
beginning of the quarter. Count those on ART as well as those not yet
initiated on ART.

*Strengths/Weaknesses:* This is purely an output measure. This indicator
does not consider the quality of service provision. By tracking this
indicator over time, it shows the uptake ART services at the facility.

**[8.7 Cumulative number enrolled in HIV care by the end of the quarter
(disaggregated by age, gender)]{.mark}**

*Definition:* This column automatically sums the \'cumulative number
enrolled in HIV care by the beginning of the quarter\' with the \'new
enrollees in HIV care during the quarter\'. It captures the cumulative
number ever enrolled in HIV care by the end of the quarter and includes
both those who have received care and may or may not be eligible for ART
and those that have died or are lost to follow-up. This data should be
disaggregated by age (0-5 years, 0-14 years and 15 and over) and gender
(male and female).

*Rationale/What it measures:* This indicator provides a total count of
individuals who have received any type of HIV care by the end of the
quarter since the beginning of the quarter, regardless of whether they
are still receiving care.

*Inclusions/Exclusions:* Include all individuals who received care since
the beginning of the programme. Count those on ART as well as those not
yet initiated on ART.

*Strengths/Weaknesses:* This is purely an output measure. This indicator
does not consider the quality of service provision.

**[8.8 Number who received HIV care during the reporting period
(disaggregated by age, gender)]{.mark}**

*Definition:* This indicator captures the number of HIV-infected
individuals who received care at any time within the reporting period.
This indicator is captured for the quarterly, semi-annual and annual
reporting periods. For the purpose of this indicator, care is defined as
any encounter between a staff person and the person in care including
enrolment visits, medical visits, home-based/community-based care,
laboratory visits, visits to the pharmacy or adherence counselling. Only
report the number of individuals, not the number of visits. If a patient
dies in the second month, but received care in month one, they are still
reported here, as they received care at some point in the reporting
period. This data should be disaggregated by age (0-5 years, 0-14 years
and 15 and over) and gender (male and female).

*Rationale/What it measures:* This indicator provides a count of
individuals who received HIV care during the reporting period including
new enrollees and former patients.

*Inclusions/Exclusions:* Count those on ART as well as those not yet
initiated on ART.

*Strengths/Weaknesses:* This is purely an output measure that shows the
service uptake at the facility during the quarter. This indicator does
not consider the quality of service provision.

[]{.mark}

**[8.9 Number in HIV care during the quarter & eligible for ART, but NOT
started ART by the end of the quarter]{.mark}**

*Definition:* The number of HIV-infected individuals who met the
facility\'s definition of being eligible for ART, but who had not
started on ART by the end of the quarter.

*Rationale/What it measures:* This indicator provides a count of
individuals who meet a facility\'s definition of being eligible for ART,
but who have not yet started ART. This indicator measures the unmet need
for ART at the facility.

*Inclusions/Exclusions:* Only include those not yet on ART, but who meet
the eligibility criteria at the facility.

*Strengths/Weaknesses:* This indicator aims to measure the \'waitlist\'
for individuals eligible for ART but not able to start treatment for a
variety of reasons, especially resource constraints at the facility.

**[8.10 Number in HIV care that are receiving treatment for TB disease
(disaggregated gender)]{.mark}**

*Definition:* The number of HIV-infected persons who are receiving
treatment for TB (subset of the total number who palliative care).
Please report on this indicator for each of the columns, i.e. both the
quarter and the year. This data should be reported as a total, and then
separately by number of males reached and number of females reached.
Note that this indicator is also captured for the semi-annual and annual
reporting periods.

*Rationale/what it measures:* This indicator provides a count of
individuals who received treatment for TB during the quarter and during
the year, including new enrollees and former patients.

*Inclusions/exclusions:* Include only HIV-infected individuals who
received treatment for TB during the reporting period.

*Strengths and weaknesses*: This is purely an output measure. This
indicator does not consider the quality of service provision. It
attempts to track the integration of TB/HIV services.

[]{.mark}

**[8.11 Number of HIV-infected individuals receiving cotrimoxazole
prophylaxis]{.mark}**

  

*Definition:* The number of HIV-infected individuals who received
cotrimoxazole prophylaxis during the reporting period according to the
South African Government guidelines.

*What it measures:* Cotrimoxazole is an important prophylaxis used to
prevent Opportunistic Infections to which HIV-infected individuals are
at risk. In South Africa, cotrimoxazole prophylaxis is a standard
clinical care intervention that should accompany anti-retroviral
treatment services. It is vital that PLWHA gain access to cotrimoxazole
prophylaxis when it is clinically indicated so they are able to be
healthy and productive. This indicator intends to monitor a priority
clinical care intervention delivered by providers to HIV-infected
individuals needing cotrimoxazole prophylaxis in USG-supported sites. 
Because success relies on resources and sufficient staff, this indicator
also measures commitment to HIV and AIDS care and treatment and in
maintaining an uninterrupted supply of cotrimoxazole for prophylactic
use.

*Inclusions/Exclusions:* Only include HIV-infected individuals receiving
prophylactic cotrimoxazole. To be included in this indicator, the
individual must have received prophylactic cotrimoxazole during the
reporting period. Include in this indicator, all individuals on
prophylactic cotrimoxazole regardless of whether or not they are on
anti-retroviral treatment.

*Strengths and weaknesses*: This indicator demonstrates the demand for
cotrimoxazole prophylaxis at sites supported by USG.   This indicator is
useful for assessing progress in providing prophylactic cotrimoxazole to
individuals with HIV/AIDS. It should be noted that service providers may
not be providing appropriate clinical care with prophylactic
cotrimoxazole because of a lack of drug availability at sites, lack of
appropriate health personnel to prescribe or insufficient access to
laboratory monitoring to guide appropriate use of prophylaxis according
to South African standards. 

This indicator does not capture whether the individual received
cotrimoxazole throughout the entire reporting period or for only a short
period of time. This indicator is an indication that PLWHA are gaining
access to prophylaxis, however, it does not show the total need. The
percentage of PWLHA receiving prophylaxis out of total in need of
prophylaxis is not represented in this indicator. This indicator also
does not show quality of the clinical care delivered or adherence to
cotrimoxazole. One difficulty with this indicator is that prevention of
opportunistic infections with prophylaxis and management of
opportunistic infections with treatment are often difficult to delineate
at service outlets.

**[8.12 Cumulative number started on ART by the beginning of the quarter
(disaggregated by age, gender and pregnancy status)]{.mark}**

*Definition:* The cumulative number of HIV-infected individuals who had
started on ART by the first day of the quarter since the facility
started receiving PEPFAR funding. This data should be disaggregated by
age (0-5 years, 0-14 years and 15 and over), gender (male and female)
and pregnancy status (at the time of enrolment). Disaggregation of
pregnant women by age is not required.

*Rationale/What it measures:* This indicator is intended to capture all
those who had ever started on ART and therefore includes those who are
also no longer receiving ART. This includes those who have died or are
lost to follow-up.

*Inclusions/Exclusions:* Include all patients at the facility who ever
received ART since the facility started receiving PEPFAR funding
regardless of whether or not they are still receiving ART or the funding
source of the ART drugs.

*Strengths/Weaknesses:* This is purely an output measure. It intends to
capture the number of people who were ever enrolled in ART at the
facility.

**[8.12 Number new on ART during the quarter (disaggregated by age,
gender and pregnancy status)]{.mark}**

*Definition:* The number of HIV-infected individuals who newly started
on ART during the quarter at PEPFAR supported facilities. Include all
patients at the facility regardless of the funding source of the ARV
drugs. New patients do not have to be treatment naïve.\
\
For example, if a woman previously received Nevirapine for PMTCT she
would not be treatment naïve. *Newly initiated* refers to newly
initiated antiretroviral therapy during the reporting period in a
programme directly supported by USG funds.\
\
This data should be disaggregated by age (0-5 years, 0-14 years and 15
and over), gender (male and female) and pregnancy status (at the time of
enrolment). Age represents an individual\'s age at initiation of
therapy. The number of pregnant women is to be shown as a subset of all
new women on ART.

*Rationale/What it measures:* There are three programme indicators that
count individuals receiving antiretroviral therapy at a service outlet
directly supported by PEPFAR funds: new, cumulative, and current. This
particular indicator provides a count of individuals newly initiated on
antiretroviral therapy during a reporting period.

*Inclusions/Exclusions:* If an individual transfers in to the ART
programme with records of continuous ART from another facility or
programme, this person should not be counted as new. If an individual
transfers in without records or has no documented evidence of previous
antiretroviral therapy, this person may be counted as new because
programmes have no choice but to enroll this person as a new client. If
an individual previously on ART in the programme restarts ART after an
interruption in therapy, this person should not be counted as new.\
\
If an individual initiated treatment during the period but died, stopped
ART, or transferred out before the end of the reporting period, this
person should still be counted as new since status at the end of the
period does not affect the fact that the person was still new on therapy
during the period.

*Strengths/Weaknesses:* As the health of ART clients improve and ART
services become available at more locations, transferring patients may
account for an increasing proportion of ART client load in the health
care system and at any given facility. If treatment is not adequately
documented or records are not transferred with a client, clients may be
newly initiated at more than one programme/facility over time. At the
country level, these clients will be double counted in the NEW and
CUMULATIVE client indicators. Double counting of individuals within a
programme area is to be avoided to the extent possible.\
\
Since age and pregnancy status change over time, the comparison of NEW,
CUMULATIVE, and CURRENT clients by age and pregnancy status is
challenging. Because "new" and "cumulative" are states defined at the
start of a programme, it is expected that the characteristics of new and
cumulative clients are recorded at the time they newly initiate or
transfer into a programme. On the contrary, "current" is a state defined
by vital/treatment status at last visit so it is expected that
characteristics of these clients would be updated each time they are
seen by a programme. Combining all children into one age group of \< 15
yrs may not be satisfactory for programme managers. There are different
criteria for starting treatment, as well as different disease burdens,
care needs, and mortality patterns for children of different ages.
Programmes may wish to further disaggregate children by age to follow
programmatically and clinically meaningful differences as follows: 0-18
months, 18 months-5 years, and 6-14 years.

**[8.13 Number on ART who transferred in during the quarter
(disaggregated by age, gender and pregnancy status)]{.mark}**

*Definition:* The number of HIV-infected individuals already on ART who
transferred to the PEPFAR programme at the facility during the quarter.
Include all patients at the facility regardless of the actual funding
source of the ARV drugs. This data should be disaggregated by age (0-5
years, 0-14 years and 15 and over), gender (male and female) and
pregnancy status (at the time of enrolment). Disaggregation of pregnant
women by age is not required.

*Rationale/What it measures:* It is important to keep track of patients
on ART as they move from one facility to another. This indicator
measures the level of movement between facilities.

*Inclusions/Exclusions:* If an individual transfers in to the ART
programme with records from continuous ART at another facility or
programme, this person should be counted as transferred. If an
individual transfers in without records or has no documented evidence of
previous antiretroviral therapy, this person may be counted as new
because programmes have no choice but to enroll this person as a new
client.

*Strengths/Weaknesses:* As the health of ART clients improves and ART
services become available at more locations, transferring patients may
account for an increasing proportion of ART client load in the health
care system and at any given facility. If treatment is not adequately
documented or records are not transferred with a client, clients may be
newly initiated at more than one programme/facility over time. At the
country level, these clients will be double counted in the NEW and
CUMULATIVE client indicators. Double counting of individuals within a
programme area is to be avoided to the extent possible.

**[8.14 Number started on ART programme during the quarter (includes new
and transfers) (disaggregated by age, gender and pregnancy
status)]{.mark}**

*Definition:* This indicator is a sum of the two previous indicators
(new and transferred), which are automatically summed in the
spreadsheet. Sum \'number new on ART during the quarter\' and \'number
on ART who transferred in during the quarter\' to capture all those
started on ART during the quarter at USG funded facilities. This data
should be disaggregated by age (0-5 years, 0-14 years and 15 and over),
gender (male and female) and pregnancy status (at the time of
enrolment). Disaggregation of pregnant women by age is not required. The
number of pregnant women is to be shown as a subset of all women started
on ART.

*Rationale/What it measures:* This indicator provides an overall measure
of the caseload of patients on ART during the quarter.

*Inclusions/Exclusions:* Include all new and transferred patients during
the quarter. This indicator is auto summed in the Data Warehouse.

*Strengths/Weaknesses:* This is purely an output measure. It aims to
capture all new patients starting ART during the specified time period.

**[8.15 Cumulative number started on ART by the end of the quarter
(disaggregated by age, gender and pregnancy status)]{.mark}**

*Definition:* Sum of the \'cumulative number started on ART by the
beginning of the quarter\' with \'number started on ART programme during
the quarter (includes new and transfers)\'. This data should be
disaggregated by age (0-5 years, 0-14 years and 15 and over), gender and
pregnancy status (at the time of enrolment). Disaggregation of pregnant
women by age is not required. The number of pregnant women is to be
shown as a subset of all women on ART.\
\
"Cumulative" refers to the total number of individuals who were ever on
ART since the start of PEPFAR support to the service outlet.

*Rationale/What it measures:* This indicator captures the cumulative
number ever started on ART by the end of the quarter, not adjusting for
loss to follow-up or death.\
\
There are three programme indicators to count individuals receiving
antiretroviral therapy at a service outlet directly supported by PEPFAR
funds: new, cumulative, and current. Collectively, these three programme
indicators, when combined with the required outcome indicator: care &
treatment (percentage of people still alive and on therapy at 6, 12, and
24 months after initiation of treatment) give an overview of the
progress of a programme in achieving targets to begin and maintain
individuals on long-term, antiretroviral therapy.

*Inclusions/Exclusions:* The cumulative indicator is comprised of the
new clients plus those clients who transfer with records into a
programme directly supported by PEPFAR funds. The cumulative number of
clients by the end of any reporting period is the sum of the cumulative
number of clients at the end of the previous reporting period plus the
clients who newly initiate and transfer into the programme during the
reporting period.\
\
The cumulative count never declines over time, as it represents the
total number of individuals who were ever on ART, regardless of whether
they died or otherwise left the programme. The same individual should
never be counted more than once for the cumulative indicator. Thus if an
individual previously on ART in the programme restarts ART after an
interruption in therapy, this person should not be counted again in the
cumulative count as s/he has already been counted. For the cumulative
indicator, age represents an individual\'s age at initiation of therapy
or when s/he transfers into the programme.\
\
Disaggregation of pregnant women by age is not required. The number of
pregnant women is to be shown as a subset of all women on ART.

*Strengths/Weaknesses:* As the health of ART clients improves and ART
services become available at more locations, transferring patients may
account for an increasing proportion of ART client load in the health
care system and at any given facility. If treatment is not adequately
documented or records are not transferred with a client, clients may be
newly initiated at more than one programme/facility over time. At the
country level, these clients will be double counted in the new and
cumulative client indicators. Double counting of individuals within a
programme area is to be avoided to the extent possible.\
\
Since age and pregnancy status change over time, the comparison of new,
cumulative, and current clients by age and pregnancy status is
challenging. Because new and cumulative are states defined by beginning
in a programme, it is expected that the characteristics of new and
cumulative clients are recorded at the time they newly initiate or
transfer into a programme. On the contrary, current is a state defined
by vital/treatment status when last seen, so it is expected that
characteristics of these clients would be updated each time they are
seen by a programme.

**[8.16 Number on ART at the end of the quarter (CURRENT) (disaggregated
by age, gender and pregnancy status)]{.mark}**

*Definition:* The number of HIV-infected individuals who were still on
ART on the last day of the quarter. This number is adjusted for the loss
to follow-up, deaths, and those who stopped ART or transferred out. This
data should be disaggregated by age (0-4 years, 0-14 years and 15 and
over), gender (male and female) and pregnancy status (at the time of
enrolment). Disaggregation of pregnant women by age is not required. The
number of pregnant women is to be shown as a subset of all women on
currently on ART.

*Rationale/What it measures:* There are three programme indicators that
count individuals receiving antiretroviral therapy at a service outlet
directly supported by PEPFAR funds: new, cumulative, and current.
Collectively, these three programme indicators, when combined with the
required outcome indicator: care & treatment (percentage of people still
alive and on therapy at 6, 12, and 24 months after initiation of
treatment) give an overview of the progress of a programme in achieving
targets to begin and maintain individuals on long-term, antiretroviral
therapy.

*Inclusions/Exclusions:* Patients who transfer in, transfer out, or who
restart after interruption of therapy will be counted in the CURRENT
client load, as long as they are on ART at the end of a reporting
period.\
\
A person on ART who initiated ART or transferred in during the reporting
period can be counted as a current client if s/he is on treatment at the
end of the reporting period. Individuals who died, stopped treatment,
transferred out, or were otherwise lost to follow-up during the
reporting period are **not** on ART at the end of the reporting period,
and thus, are not counted as a current client. Note that the difference
between the "cumulative number ever on treatment by the end of the
reporting period" and the "current number on treatment at the end of the
reporting period" should be approximately the number of individuals who
died, who permanently stopped treatment or transferred out, or who were
otherwise lost to follow-up by the end of the reporting period. In order
to measure survival on ART and the number of current clients, all
programmes should collect information on the number of individuals who
are no longer on treatment at the end of a reporting period and the
reason including death, stop treatment, transfer out, or loss to
follow-up.\
\
Patients pick up ARV drugs on variable schedules, and monitoring systems
are not always adequate to flag and follow up each person who misses an
appointment. Thus it may not be possible to get an exact count of
current clients on the last day of the reporting period. The recommended
method for calculating this indicator is to count the number of
individuals who were seen for ARV therapy during the last three months
of the reporting period (i.e., the last quarter) and to subtract those
who were known to have died, stopped treatment, transferred out, or
otherwise been lost to follow-up since the last time they were seen for
a treatment appointment. Those not seen during the last three months are
presumed lost to follow-up. For the current indicator, age represents an
individual\'s age at the end of the reporting period, or when last seen
during the reporting period for an ART appointment. Disaggregation of
pregnant women by age is not required. The number of pregnant women is
to be shown as a subset of all women.

*Strengths/Weaknesses:* Monitoring systems are variable in their ability
to measure exactly the client load at the end of the reporting period,
thus the reported results may include some people who have recently
died, dropped out, transferred out, or been lost to follow-up as well as
overestimate the true number of clients at the end of the reporting
period. Since age and pregnancy status change over time, the comparison
of new, cumulative, and current clients by age and pregnancy status is
challenging. Because new and cumulative are states defined by beginning
in a programme, it is expected that the characteristics of new and
cumulative clients are recorded at the time they newly initiate or
transfer into a programme. On the contrary, current is a state defined
by vital/treatment status when last seen, so it is expected that
characteristics of these clients would be updated each time they are
seen by a programme.

**[8.18 Number of health workers trained to deliver ART
services]{.mark}**

*Definition:* The number of health workers trained in the provision of
antiretroviral drugs and clinical monitoring for antiretroviral therapy
among those with HIV infection. Training refers to training or
retraining of individuals and must follow a curriculum with stated
objectives and/or expected competencies.\
\
Health workers: this includes health workers that have been sufficiently
trained to take up a direct function in support of scaling up clinical
or community-based ART services. There are a variety of health workers
including:\
\
- Physicians and health workers with physician skills, such as medical
officers.\
- Nurses and other health workers with nursing skills, including
midwives and clinical officers.\
- Other health care workers and lay staff in clinical setting.\
- Laboratory technicians and staff.\
- Pharmacy/dispensing staff.\
- Community treatment supporters including peer educators, outreach
workers, volunteers, informal caregivers.\
\
Training refers to new training or retraining of individuals and assumes
that training is conducted according to South African or international
standards when these exist. The training must follow a curriculum that
indicates the objectives and/or expected competencies. Training may be
knowledge and/or skills and/or competency-based.

*Rationale/What it measures:* Building human capacity in health care
delivery systems is of the utmost importance for the delivery of quality
ART services. This indicator measures efforts to train a workforce to
achieve targets in ART service delivery. Included are both certified
clinical and lay health workers who contribute to the development and
implementation of ART services.

*Inclusions/Exclusions:* An individual should only be counted once they
have completed the training. Individuals that are mid-way through a
training should be counted in the next reporting period. Individuals
should only be counted once during a reporting period even if s/he may
have attended several training courses within the same period. If a
training course covers more than one ART topic, individuals should only
be counted once for that training course. If a training course is
conducted in more than one session/training event, only individuals who
complete the full course should be counted. Do not sum the participants
for each training session.

*Strengths/Weaknesses:* This indicator does not measure the quality of
the training, nor does it measure the outcomes of the training in terms
of the competencies of individuals trained, nor their job performance.
This indicator simply measures the number of staff trained in ART
services as opposed to the percent of health facilities with trained
staff, which may be measured through health facility surveys.\
\
This indicator is most useful in the initial phases of a response to
HIV/AIDS, when the cumulative number of trained health professionals is
expected to continuously increase until it reaches a critical mass or
desired ceiling. This indicator does not measure the distribution of
health workers trained to provide ART care services. This indicator does
not disaggregate by the type of health worker trained to provide ART
care services. This indicator does not measure the type, content or
duration of training being counted, or whether the health workers
counted as trained have been counted as trained in a previous period.
Given the importance of human capacity to provide paediatric AIDS
services, countries and/or programmes may wish to collect additional
information on the number of health workers trained to provide
paediatric ART services.

**[8.19 Number of health workers trained to deliver HIV palliative care
(non-ART)]{.mark}**

*Definition:* The number of individuals trained in palliative care
services including symptom diagnosis and relief; psychological and
spiritual support; clinical monitoring and management (and/or referral)
of opportunistic infections including TB/HIV, malaria and other
HIV/AIDS-related complications; culturally appropriate end-of-life care;
and social and material support, such as nutrition support, legal aid,
and housing.\
\
Training refers to training or retraining of individuals and must follow
a curriculum with stated objectives and/or expected competencies.

*Rationale/What it measures:* The intent of the indicator is to measure
progress toward a cadre of professionals trained in palliative (non-ART)
care according to South African or international standards.

*Inclusions/Exclusions:* An individual should only be counted once they
have completed the training. Individuals that are mid-way through a
training should be counted in the next reporting period. Individuals
should only be counted once during a reporting period even if s/he may
have attended several training courses within the same period. If
individuals were trained in both ART care and non-ART palliative care,
they can be included in this indicator and in the above indicator.

*Strengths/Weaknesses:* This indicator does not measure the quality of
the training, nor does it measure the outcomes of the training in terms
of the competencies of individuals trained, nor their job performance.

**[8.19.A Number of individuals trained to provide TB treatment (subset
of 8.19)]{.mark}**

*Definition:* The number of individuals trained in providing TB services
for HIV-infected individuals (diagnosed or presumed).\
\
Training refers to training or retraining of individuals and must follow
a curriculum with stated objectives and/or expected competencies.

*Rationale/What it measures:* The intent of the indicator is to measure
progress toward a cadre of professionals trained to provide TB
treatment.

*Inclusions/Exclusions:* An individual should only be counted once they
have completed the training. Individuals that are mid-way through a
training should be counted in the next reporting period. Individuals
should only be counted once during a reporting period even if s/he may
have attended several training courses within the same period. Note:
this is a subset of the \'number trained in (non-ART) HIV palliative
care\'.

*Strengths/Weaknesses:* This indicator does not measure the quality of
the training, nor does it measure the outcomes of the training in terms
of the competencies of individuals trained, nor their job performance.

**[Cohort table for indicators 8.20-8.23]{.mark}**

*Note that this is not an indicator but is part of a table that provides
information for indicators 8.22-8.25.*

*Definition:* There should be one cohort for the reporting period.
Therefore if they initiated ART in February, March or April, they would
be counted in the September report.

*Inclusions/exclusions:* Include the months when the cohort started on
ART using the following table:

+-------------------+-------------------+------------------------------+
| **Reporting       | **6-month         | **12-month cohorts**         |
| period**          | cohorts**         |                              |
|                   |                   | Patients who started on ART  |
| Patients being    | Patients who      | in the previous year, during |
| reported during   | started on ART in | the months of:               |
| the time quarter: | the preceding     |                              |
|                   | months of:        |                              |
+-------------------+-------------------+------------------------------+
| October 1 -       | Feb, March, April | Aug, September, October      |
| December 31       |                   |                              |
+-------------------+-------------------+------------------------------+
| January 1 - March | May, June, July   | November, December, January  |
| 31                |                   |                              |
+-------------------+-------------------+------------------------------+
| April 1 - June 30 | Aug, September,   | Feb, March, April            |
|                   | October           |                              |
+-------------------+-------------------+------------------------------+
| July 1 -          | November,         | May, June, July              |
| September 30      | December, January |                              |
+-------------------+-------------------+------------------------------+

**[8.20 Number of individuals in cohort (6 and 12 month
cohorts)]{.mark}**

*Definition:* The number of persons who have been on ART for 6 and 12
months.

*Rationale/what it measures:* This indicator provides a measure of the
number of patients who adhere to ART at 6 and 12 months.

*Inclusions/exclusions:* If a person was transferred into the PEPFAR
programme and has records of previous treatment records, including CD4
counts, they can be included in this indicator.

Do not include children under six for this indicator since the
measurement of CD4 counts is different than adult measurement.

*Strengths and weaknesses*: Many patients will have incomplete records
and thus this indicator will only include a select group of clients.

**[8.21 Number in cohort who have CD4+ counts (6 and 12 months
cohorts)]{.mark}**

*Definition:* The number of individuals in the cohort who have CD4+
counts. Baseline CD4 counts should be captured any time during the
three-month period prior to starting ART or within two weeks of starting
ART. The six-month CD4 count should be obtained between 4-7 months after
initiating ART; the 12-month CD4 count should be obtained between 10-13
months after initiating ART.

*Rationale/what it measures:* The intent of the indicator is to measure
the number of individuals on ART who are monitored with CD4+ counts.
CD4+ counts are very important to monitor the clinical progress of
individuals on ART and thus provide an indication of the quality of
services provided.

*Inclusions/exclusions:* Only include those patients on ART who are part
of the cohort.

*Strengths and weaknesses*: Regular monitoring of CD4+ counts for
patients on ART is a key component of an ART programme. This indicator
is an output indicator that indicates the number of patients who have
received CD4+ tests.

**[8.22 Number in cohort who received ARVs for entire time period (6 and
12 month cohorts)]{.mark}**

*Definition:* The number of persons in the six-month cohort who have
received ART every month for the entire six-month period.

*Rationale/what it measures:* This indicator measures of the level of
adherence to ART in the cohort.

*Inclusions/exclusions:* Only include those patients on ART who are part
of the cohort and who have received ARVs for the entire 6 month or 12
month period.

*Strengths and weaknesses*: This indicator intends to measure treatment
adherence. It does not, however, monitor the patient health outcomes
(e.g. increase in CD4+, reduction of viral load).

**[8.23 Median CD4+ count for cohort (6 and 12 month cohorts)]{.mark}**

*Definition:* The median CD4+ count for 6 and 12 month cohorts at
baseline and at 6 or 12 month for the respective cohort.

*Rationale/what it measures:* This indicator measures the mean CD4+
count which indicates positive or negative health outcomes for persons
on ART. Over time, CD4+ counts for persons on ART should increase over
time.

*Inclusions/exclusions:* Only include those patients on ART who are part
of the cohort who have CD4+ counts.

*Strengths and weaknesses*: This indicator aims to show strengths or
weaknesses of an ART programme and is an outcome measure for people on
treatment. However, many facilities that do not have advanced electronic
patient tracking systems may have a difficult time obtaining such data
for a cohort.

**[8.24 Number of patients on each regimen at the end of the quarter (by
age)]{.mark}**

*Definition:* For all current patients on ART, indicate the number of
persons on each regimen. If a person changes regimens during the
quarter, include only the current regimen. A patient should be recorded
in this table, no matter the source of funding for ARV drugs.

*Rationale/what it measures:* Clinical management of HIV disease
requires the monitoring of drug regimens. This indicator measures the
number of patients on each regimen.

*Inclusions/exclusions:* Only include current patients on ART.

*Strengths and weaknesses*: This indicator attempts to identify the
regimen distribution among adults and children and changes over time.

**[8.25 Number of persons who started on ART at the facility in the
PEPFAR programme who were not on ART at the end of the quarter]{.mark}**

*Definition:* Number of persons who started on ART at the facility in
the PEPFAR programme who were not on ART at the end of the quarter and
are thus lost to follow-up.

A person is considered lost to follow-up (LTF) if s/he has not been to
clinic or picked up drugs for at least 3 months. Each category should be
mutually exclusive. Since the reasons listed are not necessarily
mutually exclusive, use this guidance for how to classify persons who
experience multiple events:

-   If patient transferred out, then was lost, count as transferred out.

-   If patient transferred out, then died, count as transferred out.

-   If patient transferred out, then stopped, count as transferred out.

-   If patient stopped ARVs, then died, count as stopped.

-   If patient stopped ARVs, then transferred out, count as stopped.

-   If patient stopped ARVs, then was lost, count as stopped.

As much as possible, over time, a programme should try to re-classify
the persons lost to follow-up as more information becomes available:

-   If patient is lost, then transfers out, count as transferred out.

-   If patient is lost, then dies, count as died.

-   If patient is lost, then stops ARVs, count as stopped.

*Rationale/what it measures:* This intends to get a quarterly update on
the status of all persons on who were started on treatment since the
grantee began support to the extent possible.

The most recent status of persons who started on ART at the facility at
any point since the beginning of the programme is tracked on a table
that indicates the number of people who were on ART at any point since
the launch of PEPFAR support, but who are not on ART at the end of the
quarter. The total should equal the difference between the cumulative
number started on ART and the total number on ART at the end of the
quarter. These numbers are expected to change from one quarter to
another as information is gathered and status can be updated. These
numbers can go down as well as up. Death is a final state, but people
can restart ART after stopping, can transfer back in after having
transferred out, and can return to the programme after being lost to
follow-up.

*Inclusions/exclusions:* Only include those patients no longer on ART.

*Strengths and weaknesses*: This indicator attempts to track health
outcomes of treatment programmes. Tracking deaths, loss to follow-up,
people who are transferred out, and those who stop treatment allows
programme managers to identify strengths and weaknesses in ART services.

***Indicators: Activities in Support of ART Services***

[]{.mark}

**[8.26 Number of HIV-infected individuals provided with ARV treatment
at the end of the reporting period (indirect)]{.mark}**

*Definition:* The estimated number of HIV-infected individuals
indirectly supported by USG that receive ART. 

Indirect support includes any of the following: national, provincial, or
district level policy development; institutional capacity building;
logistics; protocol or guideline development; advocacy; national,
provincial, district level training; and national, provincial, or
district level management information systems.

*Rationale/what it measures:* There are a number of support functions
that are essential for the provision of quality treatment services. This
indicator measures the number of individuals who received treatment
services and benefited from indirect support.

*Inclusions/exclusions:* Count only services that received indirect
support. Those services that received direct support should be counted
in indicators 8.1 to 8.25

*Strengths and weaknesses*: This indicator intends to measure support
for ART services not at the facility level, but on a broader scale. It
is difficult to measure the link between this type of support and
attribution at the facility level.

**[8.27 Number of health workers trained to deliver ART
services]{.mark}**

*Note: This indicator is the same as indicator 8.18, but it is intended
to capture training activities for partners who do not support direct
treatment programmes.*

*Definition:* The number of health workers trained in the provision of
antiretroviral drugs and clinical monitoring for antiretroviral therapy
among those with HIV infection. Training refers to training or
retraining of individuals and must follow a curriculum with stated
objectives and/or expected competencies.

This includes health workers who have been sufficiently trained to take
up a direct function in support of scaling up clinical or
community-based ART services. Type of health workers include:

-   Physicians and health workers with physician skills, such as medical
    officers.

-   Nurses and other health workers with nursing skills, including
    midwives and clinical officers.

-   Other health care workers and lay staff in clinical setting.

-   Laboratory technicians and staff.

-   Pharmacy/dispensing staff.

-   Community treatment supporters including peer educators, outreach
    workers, volunteers, informal caregivers.

Training refers to new training or retraining of individuals and assumes
that training is conducted according to South African or international
standards when these exist. The training must follow a curriculum that
indicates the objectives and/or expected competencies. Training may be
knowledge and/or skills and/or competency-based.

*Rationale/what it measures:* Building human capacity in health care
delivery systems is of the utmost importance for the delivery of quality
ART services. This indicator measures efforts to train a workforce to
achieve targets in ART service delivery. Included are both certified
clinical and lay health workers who contribute to the development and
implementation of ART services.

*Inclusions/exclusions:* An individual should only be counted once they
have completed the training. Individuals that are mid-way through a
training should be counted in the next reporting period. Individuals
attending more than one training in a particular program area during the
reporting period should only be counted once.

*Strengths and weaknesses*: This indicator does not measure the quality
of the training, nor does it measure the outcomes of the training in
terms of the competencies of individuals trained, nor their job
performance.

This indicator simply measures the number of health workers trained in
ART services as opposed to the percent of health facilities with trained
staff, which may be measured through health facility surveys.

This indicator is most useful in the initial phases of a response to
HIV/AIDS, when the cumulative number of trained health professionals is
expected to continuously increase until it reaches a critical mass or
desired ceiling. This indicator does not measure the distribution of
health workers trained to provide ART care services. This indicator does
not disaggregate by the type of health worker trained to provide ART
care services. This indicator does not measure the type, content or
duration of training being counted or whether the health workers counted
as trained have been counted as trained in a previous period. Given the
importance of human capacity in providing pediatric AIDS services,
countries and/or programmes may wish to collect additional information
on the number of health workers trained to provide pediatric ART
services.

**[8.28 Number of hours technical assistance provided for ART
services]{.mark}**

*Definition:* The number of person hours of technical assistance
provided by the PEPFAR partner to local NGOs, national or provincial
Departments of Health, or other institutions for building capacity to
provide ART services. Technical assistance is defined as the
identification of need, and delivery of, practical programmatic support
for design, implementation and evaluation of programmes in the specified
area.

TA should include regular technical communications and information
dissemination sustained over a period of time. TA can be provided
through a combination of strategic approaches and dissemination
strategies including individualized and on-site peer and expert
consultation, site visits, ongoing consultative relationships, national
and/or regional meetings, consultative meetings and conferences,
conference calls and web-casts, development and implementation of
training curricula.

*Rationale/what it measures:* This indicator measures the amount of
technical assistance provided by USG technical experts in the area of
treatment to governmental and non-governmental partners. It reflects
capacity building efforts to improve programmes and develop policies in
this area.

*Inclusions/exclusions:* Include person hours of technical assistance
provided specifically for strengthening ART programmes and/or policies.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator attempts to capture an input into a
process, but does not indicate the quality of the technical assistance
provided or if the intended output was achieved.

## Laboratory Infrastructure

**[Programme Overview]{.underline}**

Development and strengthening of laboratory facilities to support
HIV/AIDS-related activities, including the purchase of equipment and/or
commodities, the provision of quality assurance, staff training, and
other technical assistance.

**[Indicators]{.underline}**

[]{.mark}

**[9.1 Number of laboratories with capacity to perform: 1) HIV tests and
2) CD4 tests and/or lymphocyte tests]{.mark}**

*Definition:* This indicator measures the number of laboratories with
the capacity to perform HIV tests and CD4 tests and/or lymphocyte tests.
Laboratory capacity is defined as the ability to perform (1) HIV tests
and (2) CD4 tests or lymphocyte tests. This refers to both the equipment
and personnel necessary to carry out testing.

*Rationale/what it measures:* This indicator reflects USG efforts to
strengthen capacities of laboratories to perform HIV/AIDS related tests,
diagnostics and monitoring tasks.

*Inclusions/exclusions:* Only include those laboratories that receive
direct USG support.

*Strengths and weaknesses*: This indicator does not measure whether the
sites are actually performing the specified tests. This indicator does
not consider the quality of service provision, which would require more
in-depth evaluation efforts like facility surveys. This is not a
complete measure of coverage, as there is no denominator of total
facilities.

**[9.2 Number of tests performed at USG supported laboratories: 1) HIV
testing; 2) TB diagnosis; 3) syphilis testing; and 4) HIV disease
monitoring]{.mark}**

*Definition:* The number of tests performed at USG supported
laboratories during the reporting period (6 months/ 12 months). Tests
include:

-   HIV testing: Examples include ELISA and simple rapid tests for
    serology and polymerase chain reaction (PCR) for infant diagnostics.

-   TB diagnostics: Acid fast (Ziehl-Neelsen) staining of sputum.

-   Syphilis testing: Rapid Plasma Reagent (RPR), simple syphilis,
    Treponema pallidum hemagglutination assay (TPHA).

-   Sreening and confirmation, and HIV disease monitoring: CD4, viral
    load, Alanin transaminase (ALT), and Creatinine.

*Rationale/what it measures:* This indicator measures the extent to
which USG supported laboratories are expanding laboratory services to
support HIV/AIDS care and treatment services.

This measure should reflect the number of tests performed, not the
number of kits or reagents purchased. Measurement of this indicator is
undertaken by systematically reviewing laboratory records maintained at
each site, as well as USG project records and documents, to count the
number of USG supported laboratories performing tests within each of the
categories listed above. The number of tests should be added within each
category. For example, the number of HIV tests should reflect the sum of
ELISAs, rapid tests, and PCRs.

*Inclusions/exclusions:* Only include tests for laboratories that
receive direct USG support.

*Strengths and weaknesses*: This indicator is an output indicator of
direct support provided to strengthen laboratories in a given country
and for PEPFAR as a whole. Different sub-categories of HIV monitoring
provide an overall picture of USG support. For management purposes,
laboratories may want more detailed information about the tests
performed.

When interpreting this indicator, consideration must be given to factors
within and beyond USG manageable interests. For example, reagent stock
outages and logistical problems greatly reduce the number of tests
performed in labs. Often procurement and logistics are managed
independently.

The ability of laboratory staff to report this information may lag
behind their capacity to perform these tests. As a result, counts may
underestimate laboratory performance. As record-keeping and reporting
capacity of laboratories improve, so will the quality and accuracy of
the indicator estimate.

**[9.3 Number of individuals trained in the provision of laboratory
related activities]{.mark}**

*Definition:* This indicator measures the number of individuals trained
in the provision of laboratory related activities. Training refers to
new training or retraining of individuals and assumes that training is
conducted according to South African or international standards when
these exist. A training must have specific learning objectives, a course
outline or curriculum, and expected knowledge, skills and/or
competencies to be gained by participants.

*Rationale/what it measures:* The indicator measures progress toward
developing and/or maintaining the skills of a cadre of professionals
such that they are able to provide laboratory services according to
South African or international standards.

*Inclusions/exclusions:* Include only those individuals who received
laboratory related training as operationally defined by the
organization.

*Strengths and weaknesses*: This indicator does not measure the quality
of the training, nor does it measure the outcomes of the training in
terms of the competencies of individuals trained, nor their job
performance.

This indicator simply measures number trained in laboratory-related
activities as opposed to the percent of health facilities with trained
staff, which may be measured through health facility surveys.

##  Policy Analysis and System Strengthening

**[Programme Overview]{.underline}**

Other HIV/AIDS-related activities including strengthening policies and
systems to address stigma and discrimination, and to support national
prevention, care, and treatment efforts; other activities to strengthen
systems or build capacity to combat HIV/AIDS, include activities to
support the implementation of national and/or multilateral programmes.
Activities could also include the provision of technical assistance
through small grants or assistance with proposal development,
organizational management, network or coalition building, advocacy,
and/or public/private partnership building.

**[Indicators]{.underline}**

[]{.mark}

**[10.1 Number of local organizations provided with technical assistance
for HIV-related policy development]{.mark}**

*Definition:* The number of local organizations provided with technical
assistance related to policy development.

Technical assistance is defined as the identification of need, and
delivery of, practical programmatic support for design, implementation
and evaluation of policy development activities. TA should include
regular technical communications and information dissemination sustained
over a period of time. TA can be provided through a combination of
strategic approaches and dissemination strategies including
individualized and on-site peer and expert consultation, site visits,
ongoing consultative relationships, national and/or regional meetings,
consultative meetings and conferences, conference calls and web-casts,
development and implementation of training curricula.

Policy activities aim to:

-   Broaden and strengthen political and popular support for HIV/AIDS
    policies and programmes;

-   Improve the operational environment for these programmes, including
    better planning and financing;

-   Ensure that accurate, up-to-date information informs policy
    decisions; and

-   Build in-country and regional capacity to participate in policy
    development.

*Rationale/what it measures:* This indicator measures the number of
local organizations reached by USG technical experts in the area of
policy development.

*Inclusions/exclusions:* Only include [local organizations]{.underline}
(not international organizations) specifically provided with technical
assistance for HIV-related policy development.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator does not indicate the quality of the
technical assistance provided. If the total number of local
organizations is known, then it would be possible to calculate the
percentage of organizations reached with Strategic Information (SI)
technical assistance.

[]{.mark}

[]{.mark}

**[10.2 Number of local organizations provided with technical assistance
for HIV-related institutional capacity building]{.mark}**

[]{.mark}

*Definition:* The number of local organizations provided with technical
assistance related to institutional capacity building.

TA is defined as the identification of need, and delivery of, practical
programmatic support for design, implementation and evaluation of
institutional capacity building activities. TA should include regular
technical communications and information dissemination sustained over a
period of time. TA can be provided through a combination of strategic
approaches and dissemination strategies including individualized and
on-site peer and expert consultation, site visits, ongoing consultative
relationships, national and/or regional meetings, consultative meetings
and conferences, conference calls and web-casts, development and
implementation of training curricula.

[]{.mark}

Institutional capacity building activities may include:

-   Strategic planning: organizations that have a board of directors,
    mission statement, and strategies for the short and long-term (5 -10
    years), including diversification of funding sources and ability to
    write their own grant proposals;

-   Registration: organizations that are officially registered as legal
    entities;

-   Financial management: organizations that have a practical accounting
    system in place and are able to account for all expenditures in
    accordance with USG and in-country audit requirements, analyze unit
    costs, make financial projections, and track expenditures against
    budgets;

-   Human resource management: organizations with an established
    personnel system with checks and balances, for recruiting, paying,
    retaining, training, and supervising adequate numbers of staff at
    all levels of the organization;

-   Networks development: local networks established/strengthened that
    deliver prevention, care and treatment services, monitor
    implementation, and report results;

-   Commodities, equipment and logistics management: organizations that
    have established a system to assess commodity needs, account for
    donated product, ensure adequate drug supply at all times, and
    eventually procure and purchase supplies, equipment, and drugs for
    HIV and AIDS prevention, care and treatment services; and

-   Infrastructure development: laboratories, clinics, and classrooms
    improved or renovated to provide HIV/AIDS training or services.

[]{.mark}

*Rationale/what it measures:* This indicator measures the number of
local organizations reached by USG technical experts in the area of
institutional capacity building.

*Inclusions/exclusions:* Include only [local organizations]{.underline}
(not international organizations) that were provided with technical
assistance specifically for the seven categories listed above.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator does not indicate the quality of the
technical assistance provided. If the total number of local
organizations is known, then it would be possible to calculate the
percentage of organizations reached with SI technical assistance.

[]{.mark}

[]{.mark}

**[10.3 Number of individuals trained in HIV-related policy
development]{.mark}**

[]{.mark}

*Definition:* The number of individuals trained in implementing
programmes related to policy development activities. Training refers to
training or retraining of individuals and must follow a curriculum with
stated objectives and/or expected competencies. An individual should
only be counted once they have completed the training. Individuals that
are mid-way through a training should be counted in the next reporting
period. Individuals attending more than one training in a particular
program area during the reporting period should only be counted once.

Policy activities aim to:

-   Broaden and strengthen political and popular support for HIV/AIDS
    policies and programmes;

-   Improve the operational environment for these programmes, including
    better planning and financing;

-   Ensure that accurate, up-to-date information informs policy
    decisions; and

-   Build in-country and regional capacity to participate in policy
    development.

*Rationale/what it measures:* Supportive interventions strengthen HIV
prevention, care and treatment programmes. This indicator measures the
number of individuals trained in policy development activities. As more
and more individuals are trained in the different policy development
domains, more individuals can be reached with HIV/AIDS services. In
conjunction with indicator 10.1, this gives a picture of the reach of
policy development activities.

The training must equip trainees with a minimum set of competencies
needed to take an active role in supporting HIV/AIDS programmes in line
with national recommendations and/or guidelines. Usually the presence of
such competencies is assessed based on successful completion of training
and practical experience during the reporting period.

*Inclusions/exclusions:* Only participants who complete the full
training course should be counted.

Individuals attending more than one training in a particular program
area during the reporting period should only be counted once.

*Strengths and weaknesses*: The indicator documents any increases in the
capacity to deliver policy development activities. However, this
indicator does not measure the quality of the training, nor does it
measure the outcomes of the training in terms of the competencies of
individuals trained, nor their job performance. This indicator simply
measures number trained in policy development activities as opposed to
the percent of organizations with trained staff.

**[10.4 Number of individuals trained in HIV-related institutional
capacity building]{.mark}**

[]{.mark}

*Definition:* The number of individuals trained in implementing
programmes related to institutional capacity building. Training refers
to training or retraining of individuals and must follow a curriculum
with stated objectives and/or expected competencies. An individual
should only be counted once they have completed the training.
Individuals that are mid-way through a training should be counted in the
next reporting period. Individuals attending more than one training in a
particular program area during the reporting period should only be
counted once.

Institutional capacity building activities may include:

-   Strategic planning: organizations that have a board of directors,
    mission statement, and strategies for the short and long-term (5 -10
    years), including diversification of funding sources and ability to
    write their own grant proposals;

-   Registration: organizations that are officially registered as legal
    entities;

-   Financial management: organizations that have a practical accounting
    system in place and are able to account for all expenditures in
    accordance with USG and in-country audit requirements, analyze unit
    costs, make financial projections, and track expenditures against
    budgets;

-   Human resource management: organizations with an established
    personnel system with checks and balances, for recruiting, paying,
    retaining, training, and supervising adequate numbers of staff at
    all levels of the organization;

-   Networks development: local networks established/strengthened that
    deliver prevention, care and treatment services, monitor
    implementation, and report results;

-   Commodities, equipment and logistics management: organizations that
    have established a system to assess commodity needs, account for
    donated product, ensure adequate drug supply at all times, and
    eventually procure and purchase supplies, equipment, and drugs for
    HIV and AIDS prevention, care and treatment services; and

-   Infrastructure development: laboratories, clinics, and classrooms
    improved or renovated to provide HIV/AIDS training or services.

*Rationale/what it measures:* Supportive interventions strengthen HIV
prevention, care and treatment programmes. This indicator measures the
number of individuals trained in institutional capacity building
activities. As more and more individuals are trained in the different
capacity building domains, more individuals can be reached with HIV/AIDS
services. In conjunction with indicator 10.2, this gives a picture of
the reach of capacity building programmes.

The training must equip trainees with a minimum set of competencies
needed to take an active role in supporting HIV/AIDS programmes in line
with national recommendations and/or guidelines. Usually the presence of
such competencies is assessed based on successful completion of training
and practical experience during the reporting period.

*Inclusions/exclusions:* Only participants who complete the full
training course should be counted.

Individuals attending more than one training in a particular program
area during the reporting period should only be counted once.

*Strengths and weaknesses*: The indicator documents any increases in the
capacity to deliver institutional capacity building activities. However,
this indicator does not measure the quality of the training, nor does it
measure the outcomes of the training in terms of the competencies of
individuals trained, nor their job performance. This indicator simply
measures number trained in institutional capacity building activities as
opposed to the percent of organizations with trained staff.

**[10.5 Number of individuals trained in HIV-related stigma and
discrimination reduction]{.mark}**

[]{.mark}

*Definition:* The number of individuals trained in HIV-related stigma
and discrimination reduction. Training refers to new training or
retraining of individuals and assumes that training is conducted
according to South African or international standards when these exist.

Count all individuals trained, from local organizations or otherwise,
during the reporting period. A training must have specific learning
objectives, a course outline or curriculum, and expected knowledge,
skills and/or competencies to be gained by participants.

HIV/AIDS-related stigma can be described as a "process of devaluation"
of people either living with or associated with HIV and AIDS. This
stigma often stems from the underlying stigmatization of sex and
intravenous drug use---two of the primary routes of HIV infection.
Discrimination follows stigma and is the unfair and unjust treatment of
an individual based on his or her real or perceived HIV status or being
perceived to belong to a particular group.

Stigma and discrimination reduction activities may include:

-   Enhancing practical knowledge to reduce fear of casual transmission;

-   Providing a safe forum to discuss sensitive topics (sex, death, drug
    use, inequity);

-   Finding a common language to talk about stigma;

-   Strengthening the capacity of people living with HIV and AIDS to
    challenge stigma in their lives;

-   Providing a process to determine appropriate and feasible individual
    and community responses to stigma;

-   Providing comprehensive, flexible tools for organizations to
    strengthen staff skills and develop or strengthen interventions to
    reduce HIV-related stigma; and

-   Developing a system to compile and address reported acts of
    discrimination.

*Rationale/what it measures:* Supportive interventions strengthen HIV
prevention, care and treatment programmes. This indicator measures the
number of individuals trained in HIV-related stigma and discrimination
reduction.

The training must equip trainees with a minimum set of competencies
needed to take an active role in supporting HIV/AIDS programmes in line
with national recommendations and/or guidelines. Usually the presence of
such competencies is assessed based on successful completion of training
and practical experience during the reporting period.

*Inclusions/exclusions:* Only participants who complete the full
training course should be counted.

Individuals should be counted only once during a reporting period even
if s/he attended several training courses that would be categorized
under this same indicator during the same period.

*Strengths and weaknesses*: The indicator documents any increases in the
capacity to deliver stigma and discrimination reduction activities and
services. However, this indicator does not measure the quality of the
training, nor does it measure the outcomes of the training in terms of
the competencies of individuals trained, nor their job performance. This
indicator simply measures number trained in stigma and discrimination
reduction as opposed to the percent of organizations with trained staff.

**[10.6 Number of individuals trained in HIV-related community
mobilization for prevention, care and/or treatment]{.mark}**

*Definition*: the number of individuals trained in HIV-related community
mobilization for the prevention, care and/or treatment. Training refers
to new training or retraining of individuals and assumes that training
is conducted according to South African or international standards when
these exist. Count all individuals trained, from local organizations or
otherwise, during the reporting period. A training must have specific
learning objectives, a course outline or curriculum, and expected
knowledge, skills and/or competencies to be gained by participants.

Community mobilization activities include:

-   Identifying social groups and mapping existing formal structures or
    networks to encourage or promote HIV prevention, care and/or
    treatment interventions and services, such as counseling and
    testing, PMTCT, HIV care and antiretroviral treatment;

-   Building trust with the community by providing a forum to discuss
    their perceived needs for HIV prevention, care and/or treatment
    interventions and services;

-   Developing communication around social networks to engage in
    dialogue with the community which encourages or promotes HIV
    prevention, care and/or treatment interventions and services; and

-   Creating media and events that expose community members to new
    ideas, involving them in problem solving, and encouraging
    innovations that promote HIV prevention, care and/or treatment
    interventions and services.

*Rationale/what it measures:* Supportive interventions strengthen HIV
prevention, care and treatment programmes. This indicator measures the
number of individuals trained in HIV-related community mobilization for
prevention, care and/or treatment.

The training must equip trainees with a minimum set of competencies
needed to take an active role in supporting HIV/AIDS programmes in line
with national recommendations and/or guidelines. Usually the presence of
such competencies is assessed based on successful completion of training
and practical experience during the reporting period.

*Inclusions/exclusions:* Only participants who complete the full
training course should be counted.

Individuals should be counted only once during a reporting period even
if s/he attended several training courses that would be categorized
under this same indicator during the same period.

*Strengths and weaknesses*: The indicator documents any increases in the
capacity to deliver prevention, care and/or treatment services through
community mobilization. However, this indicator does not measure the
quality of the training, nor does it measure the outcomes of the
training in terms of the competencies of individuals trained, nor their
job performance. This indicator simply measures number trained in
community mobilization as opposed to the percent of organizations with
trained staff.

## Strategic Information

**[Programme Overview]{.underline}**

Strategic information (SI) includes activities related to HIV/AIDS
surveillance, health management information systems (HMIS) and
monitoring and evaluation (M&E), including development of improved tools
and models for collecting, analyzing, and disseminating HIV/AIDS
behavioral and biological surveillance and monitoring information;
facility surveys; other monitoring and health management information
systems; assisting countries to establish and/or strengthen such
systems; targeted programme evaluations (including operations research);
developing and disseminating best practices to improve programme
efficiency and effectiveness; planning/evaluating national prevention,
care and treatment efforts; analysis and quality assurance or
demographic and health data related to HIV/AIDS; and testing
implementation models, for example to support the development or
implementation of Global Fund proposals.

**[Indicators]{.underline}**

[]{.mark}

**[11.1 Number of local organizations provided with technical assistance
for strategic information]{.mark}**

[]{.mark}

*Definition:* The number of local organizations provided with technical
assistance for strategic information activities. Local organizations
include national government entities, local or provincial government
entities, or other NGOs.

Technical assistance (TA) is defined as the identification of need, and
delivery of, practical support aimed at improving the collection,
reporting and use of SI including development of M&E plans, indicator
definitions and data collection forms. TA should include regular
technical communications and information dissemination sustained over a
period of time. TA can be provided through a combination of strategic
approaches and dissemination strategies including individualized and
on-site peer and expert consultation, site visits, ongoing consultative
relationships, national and/or regional meetings, consultative meetings
and conferences, conference calls and web-casts, development and
implementation of training curricula.

*Rationale/what it measures:* This indicator measures the number of
local organizations reached by USG technical experts in the area of
strategic information, which is critical to improving the quality of
programmes and measuring the progress of activities.

*Inclusions/exclusions:* Include organizations that were provided with
technical assistance specifically for strengthening Strategic
Information (M&E, HMIS, and surveillance) policies and/or programmes.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator does not indicate the quality of the
technical assistance provided. If the total number of local
organizations is known, then it would be possible to calculate the
percentage of organizations reached with SI technical assistance.

[]{.mark}

[]{.mark}

**[11.2 Number of individuals trained in strategic information]{.mark}**

*Definition:* The number of individuals trained in M&E, HMIS and/or
surveillance. Topics may include: developing or improving M&E models,
methods and tools for collecting, analyzing, and disseminating and using
data; establishing or improving information systems; developing or
improving programme monitoring, planning and/or conducting targeted
evaluations including operations research; monitoring and disseminating
best practices to improve programme efficiency and effectiveness; and
improving data quality.

Training refers to training or retraining of individuals and must follow
a curriculum with stated objectives and/or expected competencies. An
individual should only be counted once they have completed the training.
Individuals that are mid-way through a training should be counted in the
next reporting period. Individuals should only be counted once during a
reporting period even if s/he may have attended several training courses
within the same period.

*Rationale/what it measures:* This indicator is a measure of individuals
who have been trained in strategic information. It measures the number
of newly trained or retrained individuals who are able to perform SI
functions.

The training must equip trainees with a minimum set of competencies
needed to take an active role in conducting strategic information tasks.
Usually the presence of such competencies is assessed based on
successful completion of training and practical experience during the
reporting period.

*Inclusions/exclusions:* Only participants who complete the full
training in SI, as operationally defined by the organization, should be
counted.

*Strengths and weaknesses*: This indicator is useful in that it tracks
the number of individuals trained to conduct strategic information
functions. The indicator attempts to document increasing capacity to
perform SI functions, however, no conclusion should be drawn regarding
the quality of training nor does it measure the outcomes of the training
in terms of competencies of the individuals trained or their job
performance.

**[11.3 Number of hours of technical assistance provided for strategic
information]{.mark}**

*Definition:* The number of hours of technical assistance provided by
the PEPFAR-supported partner to improve the collection, reporting and
use of SI by local organizations including national government entities,
local or provincial government entities, or other NGOs. Technical
assistance for SI is defined as assistance aimed at improving the
collection, reporting and use of SI including development of M&E plans,
indicator definitions and data collection forms.

*Rationale/what it measures:* This indicator measures the amount of
technical assistance provided by USG technical experts to local
organizations in the area of strategic information, which is critical to
improving the quality of programmes and measuring the progress of
activities.

*Inclusions/exclusions:* Include person hours of technical assistance
provided specifically for strengthening SI in programmes and/or
policies.

*Strengths and weaknesses*: Technical assistance can cover a wide
variety of areas. This indicator attempts to capture an input into a
process, but does not indicate the quality of the technical assistance
provided or if the intended output was achieved.

# Appendix A: Glossary of Key M&E Terms

**Abstinence only:** Activities or programmes that *only* promote the
importance of abstinence in reducing the prevention of HIV transmission
among unmarried individuals; Decision of unmarried individuals to delay
sexual activity until marriage; Development of skills in unmarried
individuals for practicing abstinence; and adoption of social and
community norms that support delaying sex until marriage and that
denounce forced sexual activity among unmarried individuals.

**Abstinence and faithfulness:** Activities or programmes that promote
abstinence combined with the importance of faithfulness in reducing the
transmission of HIV among individuals in long-term sexual partnerships;
Elimination of casual sex and multiple sexual partnerships; Development
of skills for sustaining marital fidelity; Adoption of social and
community norms supportive of marital fidelity and partner reduction
using strategies that respect and respond to local customs and norms;
and adoption of social and community norms that denounce forced sexual
activity in marriage or long-term partnerships.

**Activity:** Specific actions or events implemented with the intention
of reaching a given audience. Activities are what the programme or
project does for the purpose of achieving its objectives. A given
activity---when frequently repeated---constitutes an intervention or
strategy (e.g., mass media programming, in-school life skills
education). [^1]

*Synonym: Intervention*

**Analysis:** The process of systematically applying statistical
techniques and/or logic to interpret, compare, categorize, and summarize
data collected in order to draw conclusions.

**Assessment and Planning:** The collection of information and data
needed to plan programmes and initiatives. These data may describe the
needs of the population and the factors that put people at risk, as well
as the context, programme response, and resources available (financial
and human).

*Also: Needs Assessment*

**Baseline:** The status of services and outcome-related measures such
as knowledge, attitudes, norms, behaviors, and/or condition prior to an
intervention.

**Baseline data:** Data describing the situation prior to intervention
of a programme or project that serve as the starting point for measuring
or demonstrating changes in that situation and the performance of the
programme or project.

**Behavior Change: Community Outreach:** Community outreach behavior
change activities outside of mass media, medical transmission, and STI
management, aimed at preventing HIV transmission. This could include
community mobilization, peer education, classroom, small group and/or
one-on-one information, education, and communication (IEC) and behavior
change communication (BCC) messages/programmes to promote avoidance of
or reduction of HIV risk behaviors, and the social marketing and/or
promotion of condoms. This includes work with high risk group such as
intravenous drug users (IDUs), men who have sex with men (MSM),
commercial sex workers (CSWs), and PLWHA, as well as activities
(including training) to promote abstinence until marriage, delay of
first sex, faithfulness, partner-reduction, and related social and
community norms.

**Case Study:** A detailed review of a unique or important programme
that captures the background, process, outcomes, successes, failures and
lessons learned. The case study may include either qualitative or
quantitative data or both. The case study provides an opportunity to
explore a single programme in-depth, but places the onus on the
investigator to provide clarity, organization and scholarship to the
investigation.[^2]

**Clients served**: Count of people receiving services, disaggregated by
sex.

**Conceptual Framework:** A framework that links trends in HIV
prevalence to broad social and economic determinants through a set of
biological and behavioral factors having a direct effect on HIV
transmission.[^3]

Comprehensive M&E systems do all of these things, of course, but they
are also able to:

-   Conduct [formative assessments and research]{.underline} to support
    the conceptualization and design of new HIV/AIDS interventions and
    programmes;

-   Conduct [cost analysis]{.underline}, [cost-effectiveness
    analysis]{.underline} and [sustainability analysis]{.underline}; and

-   Generate and use more [strategic information]{.underline} in order
    to answer targeted evaluation and monitoring questions by linking
    various data sets from surveillance, population surveys, the HMIS,
    facility surveys, operations research, targeted evaluations, and
    other special evaluation studies.

**Cost-Effectiveness Analysis:** Cost-effectiveness analysis is an
estimate of inputs in monetary terms and outcomes in non-monetary
quantitative terms (e.g., reduction in HIV prevalence). A
cost-effectiveness analysis involves assessing the gains (effectiveness)
and resource input requirements (costs) of alternative ways of achieving
a specified objective. The results are usually expressed in terms of
cost per unit of effectiveness for each alternative. The alternative
with the lowest cost per unit of effectiveness is the most
cost-effective and is generally preferred on grounds of economic
efficiency.[^4]

Cost-effectiveness analysis helps managers and planners make decisions
about the use of their budgets and funding. With this information
decision makers can make choices about how to allocate their funds and
decide whether or not the funds are being spent appropriately and
whether they should be re-allocated.

**Country Operational Plan:** State Department Global AIDS Coordinator's
Office (OGAC) work plan for the President's Emergency Plan for AIDS
Relief.

**Coverage:** The extent to which a programme reaches its intended
target population, institution, or geographic area.

**Data Collection and Analysis Plan:** A plan for collecting and
analyzing the relevant and needed data to report on programme indicators
and to assess impact of the programme.

**Data Sources:** Documents, databases, organization or surveys that
will provide raw information or final figures for programme indicators.

**Disease Surveillance:** The ongoing systematic collection, analysis,
and interpretation of data to describe diseases and their transmission
in populations. These data can contribute to predicting future trends
and targeting needed prevention and treatment programmes.

**Dissemination Plan:** A document that entails identifying the audience
to receive programme information; communication strategies and a time
line.

[]{.mark}

**Economic Evaluation:** Economic evaluations use applied analytic
techniques to identify, measure, value, and compare the costs and
outcomes of alternative interventions.

**Effectiveness:** A measure of the extent to which a programme achieves
its planned results (goals, purposes and outputs).

**Efficiency:** A measure of how economically or optimally inputs
(financial, human, technical and material resources) are used to produce
outputs.

**Evaluability Assessment:** An approach used to determine a programme's
readiness to be monitored and/or evaluated.

*Synonym: Evaluability.*

**Evaluable Questions:** Monitoring and evaluation questions that are
typically based on stated programme objectives. These questions will
determine what M&E data will be needed, as well as necessary data
collection methods.

*Synonym: Evaluation questions*

**Evaluation:** Evaluation is the use of social research methods to
systematically investigate a programme's effectiveness. It involves
developing study designs; it sometimes requires control or comparison
groups; it involves measurements over time; and it can involve special
studies. More precisely, evaluation is a rigorous, scientifically based
collection of information about programme activities, characteristics,
and outcomes that determine the merit or worth of a specific programme.
Evaluation studies are used to improve programmes and inform decision
about future resource allocations.

**Facility-Based Management Information Systems (MIS):** Data management
systems that facilitate the assessment of service uptake and coverage
for facility-based interventions.

*Synonym: Health Information System (HIS); Health Management Information
System (HMIS)*

**Facility Survey:** A site inventory of all elements required to
deliver services such as basic infrastructure, drugs, equipment,
test-kits, registers, and staff trained in the delivery of the reference
service. The units of observation are facilities of various types and
levels in the health system and will normally include both public and
private facilities in the sample frame of sites.

*Also:* *Service Provision Assessment*.

*Synonym: Inventory*

**Feasibility:** The coherence and quality of a programme strategy that
makes successful implementation likely.

**Fiscal Year**: The USG fiscal year is defined as the period from
October 1 -- September 30.

**Formative Evaluation:** A type of process evaluation undertaken during
programme implementation to furnish information that will guide
programme or project improvement. A formative evaluation focuses on
collecting data on programme or project operations so that needed
changes or modification can be made to the programme or project in its
early stages. Formative evaluations are used to provide feedback to
programme managers and other personnel about the programme components
that are working and those that need to be changed.

**Formative Needs Assessment:** Process conducted during the planning or
re-planning stage of a programme in order to identify programme needs
and resolve issues before a programme is widely implemented. During a
formative needs assessment the following issues are explored:

-   Identifying the need for interventions;

-   Defining realistic goals and objectives for interventions;

-   Identifying feasible programme strategies; and

-   Setting programme targets.

*Synonym: Needs Assessment*

**Goal:** A broad statement of a desired, long-term outcome of a
programme. Goals express general programme intentions and help guide a
programme's development. Each goal has a set of related, more specific
objectives that, if met, will collectively permit programme staff to
reach the stated goal.

*Also see: Objective*

*Synonym: Ai.*

**Impact Assessment:** Is the measurement of the health, economic status
and quality of life of the target population. Impact assessment focuses
on population-based measures. Certain study designs---called
experimental designs---allow us to evaluate cause-and-effect with
relative precision. With this type of design, we are able to measure the
amount of change attributable to the intervention, eliminating the
possibility that confounding factors unrelated to the programme
influenced the results obtained. We can answer the question, "What would
have happened in the absence of our programme?"[^5]

**Impact Evaluation:** Impact evaluations look at the rise and fall of
disease incidence and prevalence as a function of HIV/AIDS programmes.
Impact on entire populations seldom can be attributed to a single
programme or even several programmes.

**Impact Monitoring:** In the field of public health, impact monitoring
is usually referred to as "disease surveillance" and is concerned with
the monitoring of disease prevalence or incidence. This type of
monitoring collects data at the jurisdictional, regional, and national
levels.

**Indicators**: A quantitative or qualitative measure of programme
performance that is used to demonstrate change and which details the
extent to which programme results are being or have been achieved.
Indicators can be measured at each level: input, process, output,
outcomes and impact.

**Input/Output Monitoring:** Input and output monitoring involve the
basic tracking of information about programme inputs, or resources that
go into a programme, and about outputs of the programme activities. Data
sources for monitoring inputs and outputs usually exist naturally in
programme documentation, such as activity reports and logs, and client
records, which offer details about the time, place, and amount of
services delivered, as well as, the types of clients receiving services.

*Also: Process Monitoring.*

**Logic Model:** A programme design, management, and evaluation tool
that describes the main elements of a programme and how these elements
work together to reach a particular goal, such as prevention of HIV in a
specific population. The basic elements in describing the implementation
of a programme and its effects are: inputs, activities, outputs,
outcomes, and impacts. A logic model graphically presents the logical
progression and relationship of these elements.

*Synonym: Logical Framework, Logframe Matrix, Roadmap, Theory of Action,
Concept Map, Model of Change, Blueprint, Theoretic Underpinning,
Rationale, Causal Chain, Programme Theory, Chain of Causation, Programme
Hypothesis, M&E Pipeline.*

**Monitoring:** Monitoring is fundamentally the routine process of data
collection and measurement of progress toward programme objectives. It
involves tracking what is being done and routinely looking at the types
and levels of resources used, the activities conducted, the products and
services generated by these activities, including the quality of
services, and the outcomes of these services and products.

As elaborated by UNAIDS, monitoring is the routine tracking and
reporting of priority information about a programme and its intended
outputs and outcomes. This is likely to include monitoring of inputs and
outputs through record-keeping and regular reporting systems as well as
health facility observation and client surveys.

Monitoring within a comprehensive M&E/SI system can also include the
tracking of short-term programme outcomes (immediate outcomes), as well
as intermediate outcomes and long-term impact. Such data frequently come
from surveillance systems that track disease occurrence (impact) and
risk behaviors (intermediate outcomes) using the same data collection
system over time; and is typically performed at both the district and
the national levels.[^6]

**Monitoring and Evaluation (M&E) Work Plan:** A comprehensive planning
document for all monitoring and evaluation activities within a national,
USG, UNAIDS or HIV/AIDS/Health/Nutrition/Population programmes. This
plan documents the key M&E questions to be addressed, what indicators
are collected, how, how often, from where and why they will be
collected; baselines, targets and assumptions; how they are going to be
analyzed/interpreted and how/how often reports will be developed and
distributed on the evolution of these indicators.

*Synonym: Performance Monitoring Plan.*

**Monitoring and Evaluation (M&E) System:** Fundamentally, an M&E system
is a data system that tracks what is being done and whether programmes
are making a difference. It enables programme managers to calculate how
to allocate resources in order to achieve the best overall result. A
strong M&E system that includes or is linked to a surveillance system
can effectively addresses three key strategic questions that would be
answered by the surveillance system: 1) What is the trend in HIV
prevalence, especially among young people or other vulnerable
populations? 2) If HIV prevalence among vulnerable populations increases
or decreases, can this be attributed to changes in sexual behavior or
other main determinants? 3) If sexual behavior or other main
determinants change, can this be attributed to interventions?[^7]

**Objective:** A statement of desired, specific, realistic, and
measurable programme results.

*Also, see: Goal*

*Synonym: (Performance) Target.*

**Operations Research:** Operations research or operations evaluation
applies systematic research techniques to improve programme outputs and
outcomes, such as service delivery, service quality, and coverage. This
type of research and evaluation analyses only those factors that are
under the control of programme managers, such as improving the quality
of services, increasing training and supervision of staff, and adding
new service components. Operations research can be designed to assess
the accessibility, availability, and quality of services, and the
cost-effectiveness and sustainability of programmes.

*Synonym: Operations Evaluation*

**Outcome Evaluation:** This is a type of evaluation that is concerned
with determining if, and by how much, programme activities or services
achieved their intended outcomes. Whereas outcome monitoring is helpful
and necessary in knowing whether or not outcomes were attained, outcome
evaluation attempts to attribute observed change to the intervention
tested; describe the extent or scope of programme outcomes; and indicate
what might happen in the absence of the programme. Outcome evaluations
are methodologically rigorous and require a comparative element in its
design, such as a control or comparison group.

**Outcome Monitoring:** Outcome monitoring is the basic tracking of
variable that have been adopted as measures or indicators of the desired
programme outcomes. For national AIDS programme outcome monitoring is
typically conducted through population-based surveys to track whether or
not desired outcomes have been reached. Outcome monitoring may also
track information directly related to programme clients, such as change
in knowledge, attitudes, beliefs, skills, behaviors, access to services,
policies, and environmental conditions.

**Palliative Care (non-ART care) Services/Programmes**: All clinic-based
*and* home/community-based activities aimed at optimizing quality of
life of HIV-infected (diagnosed or presumed) clients and their families
throughout the continuum of illness by means of symptom diagnosis and
relief; psychological and spiritual support; clinical monitoring and
management of opportunistic infections including TB and malaria and
other HIV/AIDS-related complications; culturally appropriate end-of-life
care; social and material support, such as nutrition support, legal aid,
and housing; and training and support for caregivers. Given the need to
independently track TB prevention, care, and treatment in an HIV
palliative care setting, totals for palliative care are made up of the
two service categories below: Basic Health Care and Support, and TB/HIV.

**Participatory Approach:** A broad term for the involvement of primary
and other stakeholders in an undertaking (e.g. programme planning,
design, implementation, monitoring and evaluation).

*Also: Participatory M&E Planning and Implementation.*

**Policy Analysis and System Strengthening (Capacity Building):** Other
HIV/AIDS-related activities including strengthening policies and systems
to address stigma and discrimination, and to support national
prevention, care, and treatment efforts; other activities to strengthen
systems or build capacity to combat HIV/AIDS, including activities to
support the implementation of national and/or multilateral programmes.
Policy analysis could include the provision of technical assistance
through small grants or assistance with proposal development,
organizational management, network or coalition building, advocacy,
and/or public/private partnership building.

**Policy Evaluation:** Assessments of application and effectiveness of
national, sub-national, district or other policies.

**Prevention of Mother-to-Child Transmission Services:** Activities
aimed at providing the minimum package of services for preventing
mother-to-child transmission including:

-   Counseling and testing for pregnant women.

-   Providing ARV prophylaxis to prevent MTCT.

-   Counseling and support for safe infant feeding practices.

-   Providing family planning counseling or referral.

**Problem Statement:** A statement that describes the nature and extent
of the problem to be addressed by an intervention, including factors
that put a population at risk. These factors may be related to
knowledge, attitudes, beliefs, behaviors, skills, access to services and
information, policies, and environmental conditions. The problem
statement often results from assessment and planning activities.

**Process Evaluation:** A type of evaluation that focuses on programme
implementation, adding a dimension to the information that was tracked
in input/output monitoring. Process evaluations usually focus on a
single programme and use largely qualitative methods to describe
programme activities and perceptions especially during the developmental
stages and early implementation of the programme. These assessments may
also include some quantitative approaches, such as survey about client
satisfaction and perceptions about needs and services. In addition, a
process evaluation might provide understanding about a programme's
cultural, socio-political, legal, and economic contexts that affect the
programme.

*Also: Formative Evaluation; Mid-term Evaluation*

**Programme:** A combination of interventions or activities that an
organization establishes as a fundamental part of its structure and
mission. Programmes tend to focus on a specific area such as HIV/AIDS or
reproductive health, and operate over the long-term. Organizations
develop programmes consistent with their mission and policies.[^8]

**Project:** A combination of interventions or activities that an
organization establishes in response to specific circumstances or needs.
Projects tend to have a defined duration (e.g., 3-5 years). If a project
is of particular importance to an organization, it may evolve into a
programme. [^9]

**Proxy Indicator:** A proxy measure is an indirect measure to obtain
data that is indicative of the desired result. For example, it is too
difficult to obtain information on whether a condom is actually used, so
the number of condoms distributed is used as a *proxy* measure. Or, a
project could count the number of individuals post-test counseled, to be
the number counseled and tested. Although the testing wasn't done
on-site, if a patient is being post-counseled, it can be assumed the
testing was done.

**Qualitative Methods:** Qualitative methods such as interviews, focus
groups, direct observation, and abstraction of written documents (such
as programme records) can provide an understanding about social
situations and interaction, as well as people's values, perceptions,
motivations, and reactions.

*Also: Interviews; Focus Groups*

**Quantitative Methods:** Surveys and questionnaires used to
systematically collect information for a carefully selected sample of
individuals and households; provides data for evaluating achievement of
outcomes.

**Response Assessment:** Also called a response analysis, a response
assessment looks at the responses specifically as they relate to the
priority areas identified in the situational analysis and it includes a
map of the ongoing (and past) activities that have addressed HIV/AID, a
determination of what interventions are working, which ones are not,
what needs improvement, and where gaps have appeared in the response to
date; and an examination of the problems faced by people living with
HIV/AIDS.[^10]

**Rapid Assessment Process (RAP):** An approach used for understanding
perceptions, beliefs, practices, and behaviors of groups of individuals
to plan or correct prevention activities mid-course. A combination of
qualitative methods may be used instead of, or supplementary to,
quantitative survey methods.

*Synonym: Rapid Assessment*

**Results Framework:** A framework that lays out and links programme
strategic objectives to overall objectives which arrive at the goal of
the programme; usually depicted with the main programme goal at the top
of the page, each of the main objective in its own box under the goal
and the results feeding into each other from the bottom (result 1) to
the top.

**Service outlets/programmes:** USG supported (see below). A service
outlet refers to *the lowest level of service*. For example, with regard
to clinical activities, the lowest level for which data exists should be
a service outlet such as a hospital, clinic, or mobile unit. For
programmes such as prevention efforts implemented through mass media or
community outreach, the level at which the programme is counted is the
level at which funds are obligated. For example, a national mass media
programme is counted only once. However, if the USG is independently
funding mass media programmes at the provincial level, each province's
programme should be counted. Both terms (service outlet/programmes) are
used to account for the different formats through which activities are
delivered, i.e., prevention programmes and health care service outlets.

**Situational Assessment:** A process that describes the magnitude and
dynamics of the problem in terms of the people who are most vulnerable
and why they are most vulnerable, the number of people at risk and how
they interact in ways that increase their vulnerability to HIV
infection; and the social, economic, political, cultural and legal
issues associated with the epidemic.[^11]

*Synonyms:* *Situational Analysis; Needs Assessment*

**"SMART" approach to writing objectives:** A tool to determine whether
or not objectives will be measurable and useful to programme planning.
***S**pecific:* Identifies concrete events or actions that will take
place. ***M**easurable:* Quantifies the amount of resources, activity,
or change to be expended and achieved. ***A**ppropriate**: ***Relates to
the overall problem statement and desired effects of the programme.
***R**ealistic:* Provides a realistic dimension that can be achieved
with the available resources and plans for implementation.
***T**ime-based:* Specifies a time within which the objective will be
achieved.

**Stakeholder:** Person, group, or entity that has a role and interest
in the goals/objectives and implementation of a programme.

**Surveillance:**

**Behavioral:** Repeat cross-sectional surveys of behavior in a
representative population.

**Sero or Biological:** system to track infection levels (i.e. HIV) in
populations accessed through "watch post" institutions (i.e. ANC). These
institutions are generally already drawing blood or performing other
biological tests for another purpose. Where blood (or other biological
specimen are taken) is taken for other purposes, leftover sera can be
stripped of all identifying markers and tested for infections (i.e. HIV)
without the consent of the individual concerned.

**Second Generation Surveillance:** Systems that monitor HIV/AIDS risk
behaviors, using them to warn of or explain changes in levels of HIV
infection. This type of surveillance uses data from behavioral
surveillance to interpret data gathered from sero-surveillance efforts.

**Sustainability (of a programme):** Sufficient likelihood that
political and financial support will exist to maintain the programme
while the evaluation is being conducted.

**Sustainability Analysis:** Sustainability analysis is a method to find
a strategy that will produce an acceptable level of services at a cost
the programme can afford while minimizing the threats to sustainability,
i.e., the threats to maintaining a programme at a specified level of
service. Sustainability analysis involves a financial assessment and a
strategic assessment.

The [financial assessmen]{.underline}t assesses the effects of the
factors on future revenues and expenses, and how to project revenues and
expenses over a period of time. (In one sustainability analysis computer
programme, a computerized "what if" analysis allows one to change one's
assumptions or mix of services and immediately see the effects on
projected revenues and expenditures.)

The [strategic assessment]{.underline} assesses ten factors that have
been shown to be the most frequent potential threats to sustainability -
or opportunities to enhance sustainability. These ten factors include:

-   Population size and composition.

-   Target group knowledge, attitudes, behaviors, and practices.

-   Service quality.

-   Management support.

-   Organizational capacity.

-   Political commitment.

-   Personnel resources.

-   Revenues.

-   Expenditures.

-   Environmental factors.

**Strategic Information**: Activities related to HIV/AIDS surveillance,
HMIS and M&E, including development of improved tools and models for
collecting, analyzing, and disseminating HIV/AIDS behavioral and
biological surveillance and monitoring information; facility surveys;
other monitoring and health management information systems; assisting
countries to establish and/or strengthen such systems; targeted
programme evaluations (including operations research); developing and
disseminating best practices to improve programme efficiency and
effectiveness; planning/evaluating national prevention, care and
treatment efforts; analysis and quality assurance or demographic and
health data related to HIV/AIDS; and testing implementation models, such
as those developed to support implementation of Global Fund proposals.

**Strategic Planning:** A process for making informed, evidence-based
decisions about how most efficiently and effectively to achieve a
measurable change toward a defined and specific goal. More specifically,
it involves identifying clearly articulated goals, objectives, targets,
and the strategies and broad-based activities that will be required to
achieve them over time.

**Targets:** Time framed benchmarks to be met by the programme during
and after implementation; measured by the indicators of the programme.

**Trained:** Count of persons trained in a particular programmatic area.
Training refers to new training or retraining of individuals and assumes
that training is conducted according to South African or international
standards when these exist.

**Treatment Services**: Activities including the provision of
antiretroviral drugs and clinical monitoring for ART among those with
advanced HIV infection in either an ART setting.

**USG Supported:** Any HIV service outlet/programme that receives at
least some of its funding or support from the USG. It is likely that
country service outlets/programmes will be supported by a mixture of
funds from varied sources, including the USG. Because we cannot separate
USG clients from other clients in an USG funded service or programme,
all clients of an USG supported service or programme should be counted
toward USG prevention, care, and treatment goals. In
multi-service/programme institutions, please count clients for the
service or programme component that is being funded. For example, if the
USG is contributing funds to support a PMTCT clinic in a large hospital,
all clients in that PMTCT clinic should be counted as USG clients,
regardless of other funding received by the clinic. However, if the
hospital is providing ARVs in another clinic that does not receive USG
funds, clients in that clinic should *not* be counted as part of an USG
supported programme. If, for example, a programme receives USG funding
for PMTCT and Global Fund funding for Counseling and Testing, only the
PMTCT clients will be reported and the service outlet is counted under
PMTCT. However, if the programme receives both USG and Global Fund
funding for PMTCT, it is acceptable to report all clients served in
PMTCT, as it would be very difficult to divide the clients served in
some way.

**Validity:** The extent to which a measurement or test accurately
measures what is intended to be measured.

[]{.mark}

# 

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# Appendix B: Illustrative Examples of HIV-Related Palliative Care Services for Adults and Children

  ----------------------- ----------------------- ------------------------
                          **CLINICAL/PHYSICAL     []{.mark}
                          CARE**                  

  Entrance & Adherence to Nutrition               Skin Problems
  Antiretroviral                                  
  Treatment                                       

  Entrance to             Routine nutritional     Provision of Gentian
  Antiretroviral Therapy  assessment and          Violet/ointments/other
  (ART)                   monitoring              treatments to reduce
                                                  HIV-related skin
                                                  diseases

  ART placement           Provision of            Provision of symptom
                          micronutrient           management\* related to
                          supplementation         skin diseases and/or
                          according to WHO        swelling
                          guidelines)             

  Routine clinical        Provision of targeted   Bowel/Bladder Care and
  monitoring (for those   nutrition               Genital Problems
  on ART)                 supplementation         
                          according to WHO        
                          criteria                

  Routine clinical        Provision of targeted   Referral and prevention
  monitoring (for those   therapeutic nutritional of diarrheal disease,
  in need but not yet on  feeding (WHO criteria)  constipation or
  ART)                                            incontinence

  Routine clinical        Promotion of exclusive  Provision of symptom
  monitoring (for those   breastfeeding until     management\* related to
  not yet in need of ART) weaning                 diarrheal diseases,
                                                  constipation or
                                                  incontinence

  Provision of Post       Support for             Provision of Oral
  Exposure Prophylaxis    appropriate, safe       Rehydration Salts and/or
                          complementary feeding   zinc for diarrheal
                          practices               disease

  Provision of side       Support for formula     Referral and prevention
  effect management       feeding if AFASS        of genital problems
  related ART medications criteria met            (e.g. general infection,
                                                  STI management, etc.)

  Provision of symptom    Support for early       Provision of symptom
  management\* related to weaning if AFASS        management\* related to
  ART                     criteria met            genital problems
                                                  (including management of
                                                  genital discharge)

  Treatment and           Provision of side       Respiratory Problems
  Prevention of           effect management       
  Opportunistic           related to nutrition    
  Infections                                      

  Provision of            Provision of symptom    Treatment of HIV-related
  cotrimoxazole           management\* related to respiratory illnesses
  prophylaxis             nutrition (includes     
                          loss of appetite,       
                          control of              
                          nausea/vomiting)        

  Provision of            Physical Care           Provision of symptom
  prophylaxis for                                 management\* related to
  candidiasis (e.g.                               cough, breathlessness or
  Diflucan)                                       respiratory disease

  Provision of Isoniazid  Provision of symptom    Other Clinical/Physical
  (INH) prophylaxis for   management\* for        Care
  TB                      physical problems       

  Treatment of            Provision of wound care Appropriate use of
  Opportunistic           (prevention and         universal precautions to
  Infections including    treatment)              protect the client and
  Sexually Transmitted                            caregiver from
  Infections (STI)                                transmitting HIV disease
  (excluding TB)                                  

  Support for TB          Provision of oral care  Psychiatric assessment
  treatment adherence     (prevention and         and psychiatric
                          treatment)              treatment of HIV-related
                                                  mental disorders

  Provision of side       Correct positioning and Treatment and prevention
  effect management       prevention and          of HIV-related
  related to              treatment of            malignancies
  Opportunistic           contractures in muscles 
  Infections, STI and TB  and joints              
  therapies                                       

  Provision of symptom    Routine monitoring of   Clinical treatment of
  management\* related to vital signs             other HIV-related
  Opportunistic                                   diseases
  Infections                                      

  Treatment and           Pain Management         Additional Pediatric
  Prevention of Malaria                           Considerations

  Provision of            Screening for pain      Referral for early
  insecticide-treated bed                         infant diagnosis (DBS)
  nets                                            

  Provision of            Assessment of pain      Appropriate child
  intermittent                                    survival interventions
  presumptive treatment                           within HIV services
                                                  (e.g. immunizations)

  Other interventions to  Treatment Step 1 (WHO   Routine growth and
  prevent or treatment of analgesic ladder)       development monitoring
  malaria in HIV-infected                         
  individuals                                     

  Provision of symptom    Treatment Step 2 and 3  Other routine pediatric
  management\* for        (WHO analgesic ladder)  HIV care interventions
  malaria                                         

  Provision of side       Referral for pain       
  effect management       management              
  related to malaria                              
  medications                                     

                          Provision of side       
                          effect management of    
                          pain medications        
  ----------------------- ----------------------- ------------------------

*Notes: HIV-Related Palliative Care is grouped in 4 categories:
Clinical/Physical Care, Spiritual Care, Psychological Care, and Social
Care; HIV-Related Palliative Care services may be provided in facility
and community and home based settings; Education and Counseling related
to each of the above service delivery elements is an integral component
of palliative care service delivery.*

*\*Symptom management may include screening, assessment, care, and
treatment with appropriate symptom relieving-medications or therapies.*

  ----------------------- ----------------------- ------------------------
  **SPIRITUAL CARE**      **PSYCHOLOGICAL CARE**  **SOCIAL CARE**

  Spiritual Support       Emotional Support       Social Support

  Screening of spiritual  Screening of emotional  Screening of social
  problems related to HIV problems related to HIV problems related to HIV
  disease                 disease                 disease

  Assistance with         Participation in        Linking to food security
  spiritual assessment    HIV-related support     interventions, income
                          groups                  generation activities,
                                                  livelihood strengthening
                                                  interventions, etc.

  Visitation by spiritual Basic assistance with   Linking to education,
  mentors, pastors,       HIV-related agitation,  safe water and
  healers, imams,         fears, loss, worries,   sanitation systems and
  priests, rabbis, etc    sadness, stigma-related other wrap around
                          issues or difficulties  programs
                          with sleeping           

  Participation in        Future life planning    Development of People
  spiritual support                               Living with HIV/AIDS
  groups                                          (PLWHA) support groups
                                                  or People Affected by
                                                  AIDS (PABA) support
                                                  groups

  Participation in        Mental Health Care      Inclusion of
  religious               (non-psychiatric care)  gender-specific care
  events/ceremonies                               activities (e.g. male
                                                  involvement, screening
                                                  for violence, etc.)

  Participation in        Screening and           Assistance in accessing
  traditional healers     assessment for          legal services or child
  groups                  psychological problems  protection interventions
                          by a trained            
                          professional            

  Provision of prayer or  Provision of counseling Assistance in accessing
  guided meditation       and/or psychotherapy    government grants/social
                          for psychological       welfare support
                          problems by a trained   
                          professional            

  Preparing for and       Provision of            Community mobilization
  coping with death and   medication(s) that      and promotion of
  the dying process       address psychological   awareness of HIV and
                          problems                AIDS prevention,
                                                  counseling/testing, care
                                                  or treatment services

  Spiritual Counseling    Other Psychological     Household and Family
                          Care                    Support

  Provision of life       Support for disclosure  Assistance with house
  review and assessment   of HIV status           cleaning, maintaining a
                                                  hygiene and safe home
                                                  environment or household
                                                  repairs

  Counseling related to   Support for HIV risk    Assistance with meal
  hopes, fears, meaning   reduction behavior      preparation, proper food
  and purpose, guilt and                          storage, cooking or
  forgiveness                                     feeding

  Assistance with life    Provision of adherence  Assistance with
  completion tasks        counseling for          miscellaneous errands
                          Anti-Retroviral         for the client or family
                          Treatment and           
                          opportunistic infection 
                          medication              

  Other spiritual-related Assistance with social  Provision of comfort
  counseling by trained   interaction or          measures for the client
  spiritual counselors or therapeutic play        or family (e.g. quality
  healers                                         communication and
                                                  culturally-appropriate
                                                  therapeutic touch,
                                                  empathy and affection)

                          Assistance with         Assistance with
                          bereavement assessment  assessments on household
                                                  and family support
                                                  (including genogram
                                                  development, economic
                                                  planning, etc)

                          Provision of            Preparing for and coping
                          bereavement counseling  with death and the dying
                                                  process

                          Assistance with         Efforts to reduce
                          succession planning     HIV-related stigma

                          Preparing for and       Provision of measures
                          coping with death and   that facilitate
                          the dying process       self-care and care for
                                                  caregivers both
                                                  physically and
                                                  emotionally

                                                  Supervision, mentorship
                                                  and financial/incentive
                                                  support for caregivers

                                                  Training on the use of
                                                  Universal Precautions at
                                                  the household level

                                                  Assistance client
                                                  hygiene, bathing, or
                                                  changing of
                                                  linens/clothes

                                                  Referral or provision of
                                                  family planning
                                                  interventions

                                                  Referral for testing and
                                                  counseling - pre and
                                                  post
  ----------------------- ----------------------- ------------------------

*Notes: HIV-Related Palliative Care is grouped in 4 categories:
Clinical/Physical Care, Spiritual Care, Psychological Care, and Social
Care; HIV-Related Palliative Care services may be provided in facility
and community and home based settings; Education and Counseling related
to each of the above service delivery elements is an integral component
of palliative care service delivery.*

*\*Symptom management may include screening, assessment, care, and
treatment with appropriate symptom relieving-medications or therapies*

# []{.mark} {#section-15 .para-text}

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# Appendix C: Sample M&E Frameworks

**1. Results Framework -- USG**

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 35%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 27%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><strong>Activity</strong></td>
<td colspan="4"><strong>Impact</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Mitigate the Impact of HIV/AIDS in South Africa</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Morbidity and Mortality Figures due to AIDS</p></li>
<li><p>Life expectancy</p></li>
</ul></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="4"><strong>Outcomes</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Achievement of 2-7-10 Goals for South Africa (Reaching 500,000
with treatment)</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>% of goal reached (X number of individuals receiving treatment/
500,000)</p></li>
</ul></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><strong>Outputs</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Expansion of Treatment Service Delivery in South Africa</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of Individuals Receiving ARVs (Directly and Indirectly
with USG support)</p></li>
<li><p>Number of Individuals on ARVs for a 12 month continuous
period</p></li>
</ul></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="4"><strong>Input</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="4"><ul>
<li><p>Trained Staff</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of Individuals Trained to Administer Treatment (or in any
other specific area)</p></li>
</ul></td>
</tr>
</tbody>
</table>

**Note:** Because of the large scope of the USG/SA programme, we can use
national level indicators to assess outcome and impact. Each partner
should narrow the indicators to the province, district or sub-district
in which you are working.

**2**. **Results Framework -- Training at Partner Level**

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 35%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 27%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><strong>Activity</strong></td>
<td colspan="4"><strong>Impact</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Improving quality of life for HIV+ individuals in South
Africa</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>% of HIV + individuals eligible for treatment in South Africa (or
could go to a more specific geographical area that you are working in,
i.e.: province), who are receiving treatment</p></li>
<li><p>Morbidity and mortality for the same geographic area.</p></li>
</ul></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="4"><strong>Outcomes</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Increased competency of staff to deliver treatment</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>% of individuals trained who are applying their skills six months
after the training (follow-up survey)</p></li>
</ul></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Expansion of service delivery in treatment</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>% of facilities in a specified geographic area who have trained
staff (you could use sub-district, district or province depending on
reach of your training programme)</p></li>
</ul></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Better quality service delivery in treatment</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>% of facilities that have increased quality of service (The SA
treatment accreditation criteria could be used or criteria could be
developed – this would require a baseline and endline, which may or may
not be feasible)</p></li>
</ul></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><strong>Outputs</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Trained Staff</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of Individuals who completed training to provide treatment
(or in any other specific area)</p></li>
</ul></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="4"><strong>Input</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="4"><ul>
<li><p>Money</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>US$/SA Rand Allocated to Training in FYXX</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="4"><ul>
<li><p>Human Resources</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of individuals who initiated or registered for
training</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="4"><ul>
<li><p>Development of Training Materials</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of hours spent developing materials</p></li>
<li><p>US$/SA Rand spent specifically on material development</p></li>
</ul></td>
</tr>
</tbody>
</table>

# 

1.  **Results Framework -- Treatment**

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 35%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 27%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><strong>Activity</strong></td>
<td colspan="4"><strong>Impact</strong></td>
<td colspan="3"><strong>Indicators</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="4"><ul>
<li><p>Improved quality of life for HIV+ individuals and their families
in South Africa (or at the level at which you are working)</p></li>
</ul></td>
<td colspan="3"><ul>
<li><p>% on treatment who have returned to work</p></li>
<li><p>life expectancy</p></li>
</ul></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="3"><strong>Outcomes</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="3"><ul>
<li><p>Make treatment more readily available for HIV+ individuals in
South Africa (or at the level at which you are working)</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>% of those eligible for treatment who are receiving ARVs</p></li>
</ul></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="3"><ul>
<li><p>Increased adherence to treatment</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of HIV+ individuals who have been on ARVs for a continuous
6 months</p></li>
<li><p>Number of HIV+ individuals who have been on ARVs for a continuous
12 months</p></li>
<li><p>% of total that initiated treatment who reached the 6 or 12 month
mark</p></li>
</ul></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="3"><ul>
<li><p>Improved health of HIV+ patients</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>mean CD4 count for patients receiving ARVs</p></li>
</ul></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"><strong>Outputs</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"><ul>
<li><p>Initiation of Treatment Programmes</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of HIV+ individuals receiving ARVs</p></li>
<li><p>Number of facilities that your organization is supporting a
treatment programme</p></li>
</ul></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"><ul>
<li><p>Ensuring that HIV+ Individuals are receiving a comprehensive
package of services</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of HIV+ individuals (not on ARVs) who are receiving
palliative care</p></li>
<li><p>Number of HIV+ individuals (on ARVs) who are receiving palliative
care</p></li>
</ul></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="3"><strong>Input</strong></td>
<td colspan="4"><strong>Indicators</strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="3"><ul>
<li><p>Human Resources</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>Number of individuals who completed training in treatment service
delivery</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="3"><ul>
<li><p>Money</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>US$ or SA Rand Allocated to Treatment Programmes in FYXX</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="3"><ul>
<li><p>Procurement of Necessary Supplies</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>% of funding spent on ARV drugs</p></li>
<li><p>%of funding spent on Salaries for nurses, doctors</p></li>
</ul></td>
</tr>
</tbody>
</table>

Note: Depending on the focus of your programme, quality of service
indicators could be added at the outcome level.

# 

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# Appendix D: Indicator Protocol Reference Sheet 

Template Sheet

  ----------------- ------------- ------------- -----------------------------------
  **Indicator                                   
  Protocol                                      
  Reference Sheet**                             

  Name of                                       
  Indicator:                                    

  Result to Which                               
  Indicator                                     
  Responds:                                     

  Level of                                      
  Indicator: Input                              
  Output Outcome                                
  Impact                                        

  Is this a PEPFAR                              
  Core Indicator:                               

  **Description**                               

  Definition:                                   

  Unit of Measure:                              

  Disaggregated by:                             

  Justification and                             
  Management                                    
  Utility:                                      

  **Plan for Data                               
  Acquisition**                                 

  Data Collection                               
  Method:                                       

  Data Source:                                  

  Frequency and                                 
  Timing of Data                                
  Acquisition:                                  

  Estimated Cost of                             
  Data Acquisition:                             

  Individual                                    
  Responsible:                                  

  Location of Data                              
  Storage:                                      

  **Data Quality                                
  Issues**                                      

  Known Data                                    
  Limitations and                               
  Significance:                                 

  Actions Taken or                              
  Planned to                                    
  Address this                                  
  Limitation:                                   

  Date of Initial                               
  Internal and                                  
  External Data                                 
  Quality                                       
  Assessments:                                  

  Date of Future                                
  Data Quality                                  
  Assessments:                                  

  **Plan for Data                               
  Analysis, Review                              
  & Reporting**                                 

  Data Analysis:                                

  Presentation of                               
  Data:                                         

  Review of Data:                               

  Reporting of                                  
  Data:                                         

  **Other Notes**                               

  Baselines:                                    

  Targets:                                      

  Other:                                        

  **Performance                                 
  Indicator                                     
  Values**                                      

  **Year**          **Target**    **Actual**    **Notes**

                                                

                                                

                                                

                                                

  **This Sheet Last                             
  Updated On:**                                 

                                                
  ----------------- ------------- ------------- -----------------------------------

# 

# 

# 

# 

# 

# Appendix E: Data Quality Tools 

####### 

**Compiling the Data Quality Plan**

**1. Why do I need a Data Quality Plan?**

It is essential that any data that is being collected and reported be of
the best possible quality. This because decisions, related to the
effectiveness and efficiency of any project, are based on the data
collected during monitoring and evaluation. In order to ensure data
quality and to avoid unnecessary and costly data repairs, a Data Quality
Plan (DQP) is constructed in support of the Monitoring and Evaluation
Plan (MEP) and in line with the Indicator Information Sheets (IIS). The
DQP forms the basis for ensuring that the five critical elements of data
quality, namely: validity, reliability, timeliness, precision and
integrity, are given due regard during the planning for monitoring and
evaluation and activity rollout. The DQP is an essential record of how
the project managed its data quality issues and as such is an excellent
source of information for the Auditor during a Data Quality Audit (DQA).

**2. What is the significance of the 'Items' in column A?**

The items listed in column A are broadly related to the Indictor
Information Sheets but contextualized to address specific data quality
issues that must be considered at operational level when planning the
monitoring and evaluation activities.

**3. What 'Explanations' are required in column B?**

This is where the implementing partner explains how the requirements for
data quality are realized operationally. For example: data quality, in
terms of validity, is always dependent on the partner having a specific
definition for the indicator they are reporting on. Although the
indicator is defined in the IIS, it is important for the partner to
explain the definition in terms of their programme, and to indicate what
data is included or excluded during data collection in order for them to
prove validity.

**4. What is meant by 'Source / Records' in column C?**

All implementing partners must be able to prove, during a DQA, that they
have a data quality management system, which enables them to report data
that is accurate, valid and reliable. In order to save the implementing
partner and the auditor time it is always a good idea to list the ready
sources of evidence / records which would demonstrate the information
given in the DQP. This could be a list of document types, or record
numbers, or references to academic works, or even a reference to a
filing location.

**5. How and why should I do a 'Risk Type' analysis as required in
column D?**

All data has an associated quality risk and sometimes the cost of
managing the risk outweighs the additional benefit to be gained from
improving the data quality. The use of a risk matrix enables the
implementing partner to establish those elements within the data
management system, which pose the greatest data quality risk so that the
appropriate controls can be put in place to minimize the impact of a
risk being realized in practice. Use the matrix given below to establish
the data risk. Identify the probable frequency with which an error in
the data could arise and assign the appropriate value. Identify how
serious the error would be in terms of the overall effect on the quality
of the data and assign an appropriate value. Multiply the two values
together to get the risk score. Review the score against the risk
analysis table below and take the appropriate actions.

Risk Matrix

  --------------- --------------- ------------- --------------- --------------
  **Overall       **Probability                                 
  Effect on Data  of Error                                      
  Quality**       Occurring**                                   

                  *(4) -          *(3) -        *(2) -          *(1) -
                  Constantly*     Frequently*   Occasionally*   Unlikely*

  *(4) -          **16**          **12**        **8**           **4**
  Catastrophic*                                                 

  *(3) --         **12**          **9**         **6**           **3**
  Critical*                                                     

  *(2) -          **8**           6             **4**           **2**
  Marginal*                                                     

  *(1) -          **4**           **3**         **2**           **1**
  Negligible*                                                   
  --------------- --------------- ------------- --------------- --------------

##### 

Risk Analysis Table

  --------- ------------ --------------------------------------------------
  **Risk    **Risk       **Remedial Action**
  Score**   Type**       

  **9 -     **High       Establish contingency plan to reduce risk, verify
  16**      Risk**       and validate *prior to each reporting episode*,
                         maintain strict audit trail.

  **4 - 8** **Medium     Establish contingency plan to reduce risk, verify
            Risk**       and validate *prior to annual return*, maintain
                         strict audit trail.

  **1 - 3** **Low Risk** No immediate action required; risk could be
                         managed through normal internal audit processes.
  --------- ------------ --------------------------------------------------

**6. Where can I get more information to help me understand Data
Quality?**

ADS Chapter 203 -- Assessing and Learning
\[http://www.usaid.gov/pubs/ads/200/\]

TIPS 12: Guidelines for Indicator and Data Quality
\[http://www.dec.org/usaid eval/#004\]

Data Quality Plan Table XX of XX

  --------------------------------------------------------------------------------
  **A. ITEM**         **B. EXPLANATION**                    **C. SOURCE / **D.
                                                            RECORDS**     RISK
                                                                          TYPE**
  ------------------- ------------------------------------- ------------- --------
  **1. Desired                                                            
  Outcome**                                                               

  *Indicator:*                                                            

  **2. Measure of                                                         
  Validity**                                                              

  *Unit of measure:*                                                      

  *Operational                                                            
  definition:*                                                            

  *Definitional                                                           
  inclusions:*                                                            

  *Definitional                                                           
  exclusions:*                                                            

  *Definitional                                                           
  bias:*                                                                  

  *Desegregations:*                                                       

  *Operational                                                            
  justification:*                                                         

  *Source of data:*                                                       

  **3. Measure of                                                         
  Reliability**                                                           

  *Collection                                                             
  methodology:*                                                           

  *Collection                                                             
  instrumentation:*                                                       

  *Sampling                                                               
  frameworks:*                                                            

  *Collection                                                             
  personnel:*                                                             

  *Collection bias:*                                                      

  *Analysis                                                               
  methodology:*                                                           

  *Arithmetic                                                             
  manipulations:*                                                         

  **4. Measure of                                                         
  Timeliness**                                                            

  *Frequency of                                                           
  collection:*                                                            

  *Reporting                                                              
  frequency:*                                                             

  *Collection:                                                            
  Collation:                                                              
  Reporting time                                                          
  lags:*                                                                  

  **5. Measure of                                                         
  Precision**                                                             

  *Source error:*                                                         

  *Instrument error:*                                                     

  *Sampling error:*                                                       

  *Transcription                                                          
  errors:*                                                                

  *Manipulation                                                           
  errors:*                                                                

  *Total margin of                                                        
  error:*                                                                 

  **6. Measure of                                                         
  Integrity**                                                             

  *Cost of                                                                
  collection:*                                                            

  *Source integrity:*                                                     

  *Collector                                                              
  integrity:*                                                             

  *Anti-tampering                                                         
  controls:*                                                              

  *Data cleaning:*                                                        

  *Hard copy                                                              
  storage:*                                                               

  *Electronic                                                             
  storage:*                                                               

  *Internal audit:*                                                       

  *External audit:*                                                       
  --------------------------------------------------------------------------------

**Data Quality Audit**

**Self-Evaluation Tool**

  -------------------------------------- --------------------------------
  **Contract No:**                       **Review No:** of

  **Auditor:**                           **Audit Date:**

  **Partner:**                           **Activity(ies):**

  **Representative:**                    **Indictor Sheet Ref:**
  -------------------------------------- --------------------------------

**Table One: Previous Data Quality Audits**

  -------------------------------------------------------------------------------
  **Criterion**                  **Yes**   **No**   **Add any comments you feel
                                                    are required**
  ------------------------------ --------- -------- -----------------------------
  Have you been subject to a                        
  Data Quality Audit in the                         
  past?                                             

  If applicable, were any                           
  significant areas of                              
  non-compliance raised during                      
  the audit that related                            
  specifically to data practices                    
  in your organization?                             

  If yes, what were they, and                       
  how have they been addressed?                     
  -------------------------------------------------------------------------------

**Table Two: Indictor Information Sheets**

  -------------------------------------------------------------------------------
  **Criterion**                  **Yes**   **No**   **Add any comments you feel
                                                    are required**
  ------------------------------ --------- -------- -----------------------------
  **Indicator Information Sheets                    
  (IIS)**                                           

  Do you have a copy of the IIS?                    

  Have you **fully** implemented                    
  the IIS for the data                              
  collection for which you are                      
  responsible?                                      

  If not, please state reason.                      

  Has your organization                             
  developed and implemented a                       
  Data Quality Plan that enables                    
  you to meet the requirements                      
  of the IISP?                                      

  If yes, has this process been                     
  documented?                                       

  If yes, has this process been                     
  subject to internal review?                       

  If yes, has this process been                     
  subject to external review?                       
  -------------------------------------------------------------------------------

**Table Three: Evaluation of implementation of the IIS and DQP**

  -------------------------------------------------------------------------------
  **Criterion**                  **Yes**   **No**   **Add any comments you feel
                                                    are required**
  ------------------------------ --------- -------- -----------------------------
  **Definition**                                    

  Are the precise definitions as                    
  given in the IIS and DQP                          
  applied consistently in the                       
  data collection process?                          

  If not, please state reasons.                     

  **Desegregation**                                 

  Is the source data                                
  desegregated according to the                     
  criteria given in the IIS and                     
  DQP?                                              

  If not, please state reasons.                     

  Does data manipulation need to                    
  take place for desegregation                      
  for reporting purposes?                           

  If yes, please state how                          
  manipulation typically takes                      
  place.                                            

  **Data collection                                 
  methodology**                                     

  Have specific procedures been                     
  developed for data collection                     
  as per the IIS and DQP?                           

  If not, please state reasons.                     

  Has source data been tested                       
  for validity?                                     

  Has source data been tested                       
  for reliability?                                  

  Has source data been tested                       
  for integrity?                                    

  Have updated IIS been                             
  submitted to the reporting                        
  authority?                                        

  If not, please state reasons.                     

  Has data been collected at the                    
  stated frequency?                                 

  If not, please state reasons.                     

  Has cost of data collection                       
  been as per the estimated cost                    
  given in the IIS and DQP?                         

  If not, please state reasons.                     

  Has any analysis of the data                      
  been conducted by your                            
  organization?                                     

  If yes, please state the                          
  typical type of analysis e.g.                     
  descriptive statistics,                           
  inferential statistics, etc.                      

  **Data quality issues**                           

  Have any issues arisen that                       
  make you think that there may                     
  be a problem with data                            
  quality?                                          

  If yes, please state what you                     
  think the problem is, and                         
  whether the problem may be of                     
  a general nature, or of a                         
  specific nature.                                  

  Have any of the data                              
  limitations that are mentioned                    
  in the IIS and DQP resulted in                    
  higher than expected margins                      
  of error?                                         

  If yes, please state how this                     
  has been addressed and                            
  reported.                                         

  **Data storage**                                  

  Is source data / primary data                     
  still accessible for review?                      

  If not, please state where the                    
  source data can be accessed                       
  from and how quickly.                             
  -------------------------------------------------------------------------------

##### Table Four: General data quality issues

  -----------------------------------------------------------------------
  **Please raise any general data quality issues, positive or negative,
  that you think are relevant.**
  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

# Appendix F: Results of FY 05 Data Quality Audit: Recommendations for Partners and USG

The South Africa USG HIV/AIDS task force commissioned a local contractor
to conduct Data Quality Audits (DQA) for a sample of USG South Africa
partners / grantees. Data Quality Audits are a vital component within
any monitoring and evaluation program and are an ideal tool to establish
and verify the quality of both the data management system (DMS) and the
data itself. Maintaining a strong DMS ensures that the data that are
being used for decision making are both valid and reliable. The primary
objectives of the DQA initiative were to:

-   Build Capacity. All the audits were not handled as 'cold-fact'
    audits but on a 'consultancy' type basis where guidance and
    capacity-building formed an important part of the audit, especially
    in the light of understanding how a DMS should function. As part of
    the DQA process, the integrity and quality of the partner/grantee
    Data Management System (DMS) was assessed. The auditor was able to
    establish and identify risks to data quality and provide
    recommendations to both partners/grantees and USG to reduce such
    risks.

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-   Verify Reported Data. The USG task force also wanted to ensure that
    the data that are reported to OGAC are both valid and reliable by
    establishing that indicator definitions are interpreted accurately
    and consistently across partners/grantees.

In FY05, 24 USG partners/grantees received a data quality audit. The
reported data from the FY 05 semi-annual report was audited. This report
summarizes the findings of the DQA activities.

***Partner Recommendations***

The measures given below are recommended to improve the systems in
general for the partners / grantees of the USG. Partners / grantees
should:

-   Ensure that the correct number of adequately experienced data
    management personnel is employed.

-   Operationally define all their reported indicators and ensure that
    these are integrated into the daily business of the organization and
    are well-known and understood by all data management personnel.

-   Invest sufficient resources into M&E in the form of, for example, a
    dedicated M&E person.

-   Ensure that their M&E system is sustainable and maintained through,
    for example, ensuring succession planning.

-   Always utilize the automatic form generated by the DW for data
    capture.

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-   Ensure that all the reported indicators have documented definitions
    that have been operationalized according to the everyday operation
    of the organization. It should be ensured that all data management
    personnel are familiar with and understand these definitions.

-   Ensure that wording used on all collection / collation / reporting
    tools are identical within each organization and that the wording is
    unambiguous.

-   Use the same tools, if at all possible, throughout their DMS,
    preferably right from collection through to reporting. If this is
    not possible then partners / grantees should determine the
    inter-tool Reliability to ensure that the same data is reported from
    all sites.

-   Design and document a MER Plan that includes:

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-   Specific procedures for the methodology of the handling of all data
    including given timelines for data capture where appropriate.

-   The recording of the dates of all various stages within the DMS in
    order to be able to determine areas of possible time delays.

-   A fully completed IPRS for each contracted PEPFAR indicator.

-   Succession planning to ensure the sustainability of the DMS.

-   The creation of a verifiable audit trail of the entire DMS.

-   Version control of all written documents.

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```
-   Implement internal data quality control systems at all levels to
    minimize transcription, manipulation and other data errors.

-   Utilize collation tools, in for example MS EXCEL, to ensure
    consistency and to provide a verifiable audit trail for collation
    processes.

-   Provide the MER Plan and all data handling methodologies to all data
    collectors in perhaps the form of a training session so that they
    can understand the entire DMS better and thus produce improved
    quality data.

-   Validate data to the primary data source on a regular basis -- it
    would be acceptable to use a sampling technique. These regular
    validations could, in fact, form part of the MER Plan.

-   Ensure that the reported data from the sites is all of the stated
    reporting period to avoid Timeliness as well as to a certain degree
    Validity and Reliability issues.

-   Identify the strengths and vulnerabilities of their DMS through
    regular, formalized internal reviews of the DMS so that the DMS can
    be improved upon. All data quality issues should be reported to the
    USG.

-   Ensure that there is more than one (1) final data handler and
    reporter to minimize the risks to Integrity, all partners / grantees
    should If this is not possible due to resources, then the final
    reporter should copy all data handlers when the final report is
    submitted to the USG.

-   Keep data, especially primary data sources, secure to minimize risk
    to Integrity.

-   Invest sufficient resources into M&E in the form of for example a
    dedicated M&E person.

***USG Recommendations***

-   Develop the conventions / parameters for all the indicators,
    especially for the direct and indirect definitions, to ensure
    standardization across all partners / grantees. It may even be
    advisable to provide exemplars for all indicators to avoid any
    misunderstanding of the set conventions / parameters.

-   Ensure that the definitions being used by their partners / grantees
    are suitably matched to these broader indicator 'umbrella'
    definitions so that the partners / grantees report data that is the
    'intended measure'.

-   Set margins of acceptable error for quantitative indicators and
    distribute these to the partners / grantees.

-   Provide training to all partners / grantees on:

    -   the basics of total quality management with a focus on DMS and
        DQS so that they can understand the importance of the five (5)
        data quality criteria.

    -   on basic statistics and the use thereof in the methods and
        procedures in the analysis of data. There should be an emphasis
        on the use of the analysis of data for the monitoring, and thus
        improvement, of the program.

-   Utilize the delivery of quality data and the security of the data,
    from the primary source to the reported data, as the essential
    criteria for the acceptance of partners / grantees to PEPFAR
    funding.

-   Plan regular DQA of partners / grantees on a rotational basis so
    that all partners / grantees have the benefit of the capacity
    building component of the DQA.

# 

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# Appendix G: Additional M&E Resources 

***General***

[http://www.bja.evaluationwebsite.org/html/useful_links/index.html#Evaluation
Related](http://www.bja.evaluationwebsite.org/html/useful_links/index.html#Evaluation Related)

This site provides extensive links to evaluation-related government
agencies, associations, listservs, non-profit organizations,
foundations, research centres, journals and on-line publications, how-to
documents, as well as standards, assessment, measurement, instruments,
data and statistics.

<http://www.gao.gov/special.pubs/erm.html>

This site contains an extensive list of evaluation research and
methodology publications.

<http://www.cdc.gov/eval/resources.htm>

This site offers links to many resources on evaluation.

Adamchak S, et al. A Guide to Monitoring and Evaluating Adolescent
Reproductive Health Programmes, Tool Series 5. FOCUS on Young Adults.
2000.

Bertrand JT and Escudero G. Compendium of Indicators for Evaluating
Reproductive Health Programmes (Volume I). Chapel Hill, NC: MEASURE
Evaluation Project. 2002.

Bertrand, JT Magnani RJ, Rutenberg N. Evaluating Family Planning
Programmes: with Adaptations for Reproductive Health. Chapel Hill, NC:
The EVALUATION Project. 1996.

Patton MQ, editor. Utilization-focused evaluation. 2nd edition. Beverly
Hills (CA): Sage Publications; 1986. p. 177-217

Bertrand JT, Magnani RJ, Rutenberg N. Handbook of Indicators for Family
Planning Programme Evaluation. Chapel Hill, NC: The EVALUATION Project.
1994.

Centres for Disease Control and Prevention. Update: HIV Counseling and
Testing Using Rapid Tests. MMWR Vol. 47/No. 11. March 27, 1998.

Family Health International. Behavioral Surveillance Surveys -
Guidelines for Repeated Behavioral Surveys in Populations at Risk of
HIV. Arlington, VA.
[www.fhi.org/en/aids/impact/bss/bssguide/bssguidelinesfull.pdf](http://www.fhi.org/en/aids/impact/bss/bssguide/bssguidelinesfull.pdf).
2000.

Family Health International. Evaluating Programmes for HIV/AIDS
Prevention and Care in Developing Countries. Arlington, VA. 2001.

Family Health International and UNAIDS. Meeting the behavioral
data-collection needs of national HIV/AIDS/STD programmes. Proceedings
from a joint IMPACT/FHI/UNAIDS workshop. \[Co-authored by Pisani, E.,
Brown, T., Saidel, T., Rehle, T. and Carael, M.\] Arlington, VA and
Geneva, Switzerland, 1998.

Fisher A et al. (2002). Designing HIV/AIDS Intervention Studies. An
Operations Research Handbook. New York: The Population Council.

Mertens, T., and Carael, M. Evaluation of HIV/STD prevention, care and
support: An update on WHO\'s approaches. *AIDS Education and
Prevention*, 1997; 9:133-145.

Rossi P et al. (1999). Evaluation. A systematic Approach. Thousand Oaks:
Sage Publications.

Rugg, D., and Mills, S. Development of an integrated monitoring and
evaluation plan. In Rehle, T., Saidel, T., Mills, S., Magnani,R.(Eds.)
*Evaluating Programmes for HIV/AIDS Prevention and Care in Developing
Countries.* Arlington, VA: Family Health International, available
December 2000.

Special Programme for Research and Training in Tropical Diseases.
Tuberculosis disease information. [United Nations Development Programme
(UNDP)](http://www.undp.org/), the [World
Bank](http://www.worldbank.org/) and the [WHO](http://WHO/),
[www.who.int/tdr/diseases/tb/diseaseinfo.htm. Accessed February
2003](http://www.who.int/tdr/diseases/tb/diseaseinfo.htm. Accessed February 2003).

United Nations Programme on HIV/AIDS (UNAIDS)-00.17E. National AIDS
Programmes -- A Guide to Monitoring and Evaluation. Geneva: UNAIDS.
2000.

United Nations Programme on HIV/AIDS-Best Practice Digest. AIDS: The
Fear Syndrome.
[www.unaids.org/bestpractice/digest/files/aids3.html](http://www.unaids.org/bestpractice/digest/files/aids3.html).
Accessed February 2003.

United Nations Programme on HIV/AIDS-Best Practice Digest. HIV
Prevention in Drug Using Populations. Geneva: UNAIDS.
[www.unaids.org/publications/documents/ specific/
injecting/una99e1.pdf](http://www.unaids.org/publications/documents/ specific/ injecting/una99e1.pdf).
1999.

United Nations Programme on HIV/AIDS/ World Health Organization --
(2000.5/00.03E). Guidelines for Second Generation HIV Surveillance.
Geneva. 2000.

United States Agency for International Development. Handbook of
Indicators for HIV/AIDS/STI Programmes. USAID Bureau for Global
Programmes, Field Support and Research. First Edition. Washington, DC:
2000.

United States Agency for International Development. HIV/AIDS Indicators
database. Washington, DC.
[www.measuredhs.com/hivdata/ind_detl.cfm?ind_id=75&prog_area_id=13](http://www.measuredhs.com/hivdata/ind_detl.cfm?ind_id=75&prog_area_id=13).
Accessed February 2003.

World Health Organization. Blood Safety.
[www.who.int/hiv/topics/blood/safety/en/](http://www.who.int/hiv/topics/blood/safety/en/).
Accessed January 2003.

World Health Organization. Establishing a Blood Transfusion Service.
[www.who.int/bct/Main_areas_or_work/BTS/Blood_Tservice.htm](http://www.who.int/bct/Main_areas_or_work/BTS/Blood_Tservice.htm).
Accessed February 2003.

World Health Organization. Global Plan to Stop TB, Phase 1: 2001 to
2005, Chapter 7. Geneva: WHO.
[www.stoptb.org/GPSTB/default.asp](http://www.stoptb.org/GPSTB/default.asp).
2002.

World Health Organization. Global TB/HIV Working Group-2nd Meeting -
Durban, South Africa-14-16 June 2002.
[www.who.int/gtb/whats-new/durban](http://www.who.int/gtb/whats-new/durban).
Accessed March 2003.

World Health Organization. Guidelines for the Management of Sexually
Transmitted Infections.
[www.who.int/docstore/hiv/STIManagemntguidelines/who_hiv_aids_2001.01/001.htm](http://www.who.int/docstore/hiv/STIManagemntguidelines/who_hiv_aids_2001.01/001.htm)
Accessed February 2003.

World Health Organization. Guidelines for Sexually Transmitted
Infections Surveillance --

UNAIDS/WHO Working Group on Global HIV/AIDS/STI Surveillance. Geneva.
[www.who.int/hiv/pub/me/GuidelinesforSTISurveillance1999_English.pdf](http://www.who.int/hiv/pub/me/GuidelinesforSTISurveillance1999_English.pdf).
1999. Accessed March 2003.

World Health Organization. Harm Reduction Approaches to Injecting Drug
Use.
[www.who.int/hiv/topics/harm/reduction/en/](http://www.who.int/hiv/topics/harm/reduction/en/).
Accessed February 2003.

World Health Organization. HIV/AIDS: Testing and Counseling.
[www.who.int/hiv/topics/CT/testing/en](http://www.who.int/hiv/topics/vct/testing/en).
Accessed January 2003.

World Health Organization. Joint HIV/Tuberculosis Interventions.

[www.who.int/hiv/topics/tb/tuberculosis/en](http://www.who.int/hiv/topics/tb/tuberculosis/en).
Accessed January 2003.

World Health Organization. Policy Statement on Preventive Therapy
against Tuberculosis in people living with HIV. Meeting of the Global
Tuberculosis Programme of the WHO and UNAIDS, 1998.
[www.who.int/gtb/publications/TB_HIV_polstmnt/technical_annex.html#\_drug](http://www.who.int/gtb/publications/TB_HIV_polstmnt/technical_annex.html#_drug).
Accessed March 2003.

World Health Organization. Preventing and Treating Sexually Transmitted
and Reproductive Tract Infections.
[www.who.int/hiv/topics/sti/prev/en/](http://www.who.int/hiv/topics/sti/prev/en/).
Accessed January 2003.

***Measurement methods or tools***

AIDS Module DHS (MEASURE DHS+).
[www.cpc.unc.edu/measure/guide/tools/dhsaids/dhsaids.pdf](http://www.cpc.unc.edu/measure/guide/tools/dhsaids/dhsaids.pdf).
Accessed May 2003.

Family Health International HIV/AIDS/STD Behavioral Surveillance
Surveys.
[www.cpc.unc.edu/measure/guide/tools/fhibss/fhiyouth.pdf](http://www.cpc.unc.edu/measure/guide/tools/fhibss/fhiyouth.pdf).
Accessed May 2003.

Logistics Indicator Assessment Tool.
[www.deliver.jsi.com/pdf/g&h/liatword.pdf.](http://www.deliver.jsi.com/pdf/g&h/liatword.pdf. )
Accessed May 2003.

MEASURE Blood Safety HIV/AIDS Prevention Indicators Survey.
[www.cpc.unc.edu/measure/guide/tools/measureblood/measureblood.pdf](http://www.cpc.unc.edu/measure/guide/tools/measureblood/measureblood.pdf).
Accessed May 2003.

MEASURE Training Manual for Conducting the Service Provision Assessment.
[www.cpc.unc.edu/measure/cmnht/t6/training.pdf](http://www.cpc.unc.edu/measure/cmnht/t6/training.pdf).
Accessed May 2003.

MEASURE Service Provision Assessment Survey.
[www.cpc.unc.edu/measure/guide/tools/spa/spa.pdf](http://www.cpc.unc.edu/measure/guide/tools/spa/spa.pdf).
Accessed May 2003.

UNAIDS/MEASURE HIV/AIDS General Population Survey-Household.
[www.cpc.unc.edu/measure/guide/tools/unaidspopulation/household.pdf](http://www.cpc.unc.edu/measure/guide/tools/unaidspopulation/household.pdf).
Accessed May 2003.

UNAIDS/MEASURE HIV/AIDS General Population Survey-Individual.
[www.cpc.unc.edu/measure/guide/tools/unaidspopulation/individual.pdf](http://www.cpc.unc.edu/measure/guide/tools/unaidspopulation/individual.pdf).
Accessed May 2003.

UNAIDS/MEASURE HIV/AIDS General Population Manual.
[www.cpc.unc.edu/measure/guide/tools/unaidspopulation/unaidspopulation.pdf](http://www.cpc.unc.edu/measure/guide/tools/unaidspopulation/unaidspopulation.pdf).
Accessed May 2003.

UNAIDS. *Tools for Evaluating HIV Voluntary Counseling and Testing*.
Geneva, May 2000.

UNICEF/UNAIDS/WHO. *Local Monitoring and Evaluation of the Integrated
Prevention of Mother to Child Transmission in Low-income Countries*.
Geneva: UNICEF/UNAIDS/WHO. March 3, 1999.

WHO Protocol for the Evaluation of HIV/AIDS Care and Support-Draft.
[www.cpc.unc.edu/measure/guide/tools/whocare/whocare.pdf](http://www.cpc.unc.edu/measure/guide/tools/whocare/whocare.pdf).
Accessed May 2003.

WHO Guidelines for Sexually Transmitted Infections Surveillance.
[www.who.int/emc-documents/STIs/docs/STI%20Guidelines.html](http://www.who.int/emc-documents/STIs/docs/STI Guidelines.html).
Accessed May 2003.

WHO Guidelines for second generation HIV Surveillance.
[www.who.int/hiv/topics/GuidelinesforSGS2000_5_E.pdf](http://www.who.int/hiv/topics/GuidelinesforSGS2000_5_E.pdf).
Accessed May 2003.

Protocol for the Assessment of STI Case Management.
[www.cpc.unc.edu/measure/guide/tools/stiassessment/stiassessment.pdf](http://www.cpc.unc.edu/measure/guide/tools/stiassessment/stiassessment.pdf).
Accessed May 2003.

***Developing a Logic Model***

[www.insites.org/documents/logmod.htm](../www.insites.org/documents/logmod.htm)

*Everything You Wanted to Know About Logic Models But Were Afraid to
Ask.*

Connie C. Schmitz, Professional Evaluation Services, Minneapolis, MN
&Beverly A. Parsons, InSites, Boulder, CO

This article provides an easy-to-understand description of logic models.
It explains why logic models are developed, who should be involved in
development, what logic models are based upon, and other relevant
topics.

[www.uwex.edu/ces/pdande/Evaluation/logicmodels.htm](../www.uwex.edu/ces/pdande/Evaluation/logicmodels.htm)

*Logic Model,* University of Wisconsin-Extension (UWEX)

This Website provides a brief historical account of the logic model
usage. Also provided are PowerPoint presentations that illustrate
essential components of logic models. A bibliography is included on this
site.

[www.bja.evaluationwebsite.org/html/documents/stop1‑4.html#chap2](../www.bja.evaluationwebsite.org/html/documents/stop1%1E4.html#chap2)

*Evaluation Guidebook, Projects Funded by S.T.O.P. Formula Grants under
the Violence Against Women Act*. Martha R. Burt, Adele V. Harrell, Lisa
C. Newmark, Laudan Y. Aron, Lisa K. Jacobs (December 1997)

Chapter two of this guidebook is dedicated to the development of logic
models. Steps for goal setting and objectives are described, as well as,
instructions for developing a diagram for specific factors.

[www.bja.evaluationwebsite.org/html/documents/evaluation_strategies_p3_7.html](../www.bja.evaluationwebsite.org/html/documents/evaluation_strategies_p3_7.html)

Developing a Logic Model. Harrel, A*.* (n.d.). *Evaluation Strategies
for Human Services Programmes*. Washington DC: The Urban Institute

In this article key points for developing a logic model are discussed,
and an example with a diagram is given.

[www.national.unitedway.org/outcomes/cmtyout1.pdf](../www.national.unitedway.org/outcomes/cmtyout1.pdf)

*Achieving and Measuring Community Outcomes: Challenges, Issues, and
Some Approaches*. (April 1999)

> This PDF formatted article, created by the United Way, describes how
> to develop logic models, strategies and challenges surrounding using
> logic models, indicators for success, and other pertinent information
> concerning logic models.

[www.open.org/\~westcapt/evaluate.htm](../www.open.org/~westcapt/evaluate.htm)

*Building a Successful Prevention Programme Western Regional Centre for
the Application of Prevention Technologies*. *Step 7: Evaluation*

> This Website provides a plethora of information on building, planning
> and using a logic model for evaluation. Links to several evaluation
> tools and measures, including worksheets, sample questionnaires, and
> case studies.

***Creating a Budget for Evaluation***

[www.the‑aps.org/education/promote/plnbudget.html](../www.the%1Eaps.org/education/promote/plnbudget.html)

*Promoting Effective Programme Evaluation Expert Advice: Evaluation Tips
and Resources*

The American Physiological Society posted suggestions, made during the
May 1998 Evaluation Exploration Conference, for planning an evaluation
budget. The plan shows examples of itemized evaluation activities and
attached expenses. A budget worksheet is also included.

***Evaluability Assessment***

Stahler GJ and Tash WR. *Innovative Approaches to Mental Health
Evaluation*. New York/London: Academic Press, Inc., 1982

The findings of three evaluability assessments are illustrated in
Chapter 8 of this book. Conditions under which successful evaluability
assessments are discussed.

Fisher RJ and Peters L. The role of evaluability assessment in mental
health programme evaluation. *Canadian Journal of Community Mental
Health*, 4(2): 25-34. Fall 1985

This article describes evaluability assessment as a methodology designed
to increase the appropriateness and utilization of evaluation studies.
Three case studies in different mental health settings (a day programme,
a home care programme, and a counseling programme) are presented which
illustrate the various implications and benefits of evaluability
assessment and underscore the recommendation that programme evaluation
should almost always begin with an evaluability assessment.

Leviton LC, Collins CB, Laird BL, and Kratt PP. Teaching evaluation
using evaluability assessment. *Evaluation*, 4(4): 389-409. 1998

> While this article is largely about how to introduce students to the
> field of evaluation by using the technique of evaluability assessment,
> it also includes relevant sections on understanding the logic of
> programme delivery and the development of a programme model. The
> authors argue that evaluators will practice more optimally useful
> evaluation if they are skilled in eliciting and describing programme
> logic.

[^1]: Bertrand, Jane T., and Manuel Solis. Evaluating HIV/IADS
    Prevention Projects: A Manual For Nongovernmental Organizations.
    **MEASURE Evaluation Manual Series, No. 10.** Carolina Population
    Center, University Of North Carolina At Chapel Hiss. July 2000.
    (Translation To English 2004).

[^2]: Master Glossary, The Synergy Project APDIME Toolkit Retrieved On
    July 23 From:
    [Http://Www.Synergyaids.Com/Apdime/Mod_1_Assess/Assess_Index.Htm](http://www.synergyaids.com/apdime/mod_1_assess/assess_index.htm)

[^3]: Alan Johnston, Senior DDU Specialist MEASURE Evaluation Project.
    Poster At The International Aids Conference 2000 Durban, South
    Africa, Entitled: \"Interpreting HIV Trends For Policymakers: Using
    An Intermediate Variables Framework As A Policy Advocacy Tool.\"  

[^4]: Creese A, Parker D. Cost Analysis in Primary Health Care, A
    Training Manual For Program Managers. Who, Geneva, 1994.

[^5]: Bertrand, Jane T., and Manuel Solis. Evaluating HIV/Aids
    Prevention Projects: A Manual for Nongovernmental Organizations.

[^6]: UNAIDS. National AIDS Programs -- A Guide to Monitoring and
    Evaluation. Geneva, 2000.

[^7]: UNAIDS/WHO Working Group on Global HIV/AIDS/STI Surveillance.
    *Initiating Second Generation HIV Surveillance Systems: Practical
    Guidelines.* UNAIDS/WHO, Geneva, 2002.

[^8]: Bertrand, Jane T., And Manuel Solis. Evaluating HIV/Aids
    Prevention Projects: A Manual for Nongovernmental Organizations.

[^9]: Ibid

[^10]: The Synergy Project. HIV/AIDS Programming Toolkit, Version 1.0.
    Washington, Dc, 2000.

[^11]: Ibid.