Cabrini-2013-Program-Report-FINAL

Your support this year has also allowed us to make a dream come true...a new Social Service Department is now serving homesteads facing situations which Health Care and Child Care have o

Program Report

2012-2013

(01 October 2012 – 30 September 2013)

College, Cabrini Health Australia, Cabrini Mission Foundation, Centers for Disease Control and Prevention, ELMA Foundation, ICAP (Columbia University), Missionary Sisters of the Sacred Heart, PACT, PEPFAR (US Government), SAFAIDS, Sahee Foundation, Solon Foundation, United States Agency for International

Development, and individual donors worldwide.

TABLE OF CONTENTS

1 Letter from Executive Director 4

2 Letter from Deputy Executive Director 5

3 Executive Summary 6

4 Organization information 7

History 7

Vision / Mission / Values 9

Staff and Leadership 9

5 Situation in Swaziland 11

6 Programmatic Overview 13

Health Care 14

Service Delivery 14

Program Impact 22

Key Accomplishments 23

Strategic Partnerships 25

Child Care 27

Assessments 27

Service Delivery 27

Program Impact 32

Key Accomplishments 33

Strategic Partnerships 36

Social Services 36

Program Development 37

Service Delivery 38

Impact and Expansion 39

Agriculture 40

Food Security Programming 40

Program Transition 40

7 Monitoring and Evaluation systems 41

8 Organizational Development 43

Identified Emerging Issues 43

Strategic Priorities 46

Becoming a “Social Service Organization” 47

Future Projects 48

9 Get involved 50

10 Appendices 51

Cabrini Health Care Analysis of Services 52

Clinical Cascade Results and Exits 56

Cabrini Impact Mitigation Analysis of Services 57

1 LETTER FROM EXECUTIVE DIRECTOR

Dear Friends of Cabrini Ministries,

I greet you with joy from the Lubombo Lowveld of Swaziland

It is truly a year of joy for the people of this region because this

summer we are experiencing rain – lots of life giving rain For

those of you who are familiar with the 20 year drought this area

has endured, you know how important this is The changes here

go deeper than the weather Everywhere I look, I see the new

joy that accompanies lives being restored!

I also greet each of you with thanksgiving and gratitude for your prayers, interest and supportfor the people of this area As you read this report I am sure you will also give thanks with

me for the enormous work being done by this small faith-based and community-based

organization You will see what your support, interest and prayer have wrought and where you have brought this area over the last 10 years: from grave sickness, death, poverty and abandonment, to life and hope for today and for the future

In this last year, Cabrini Ministries has continued its work with the HIV/AIDS and TB afflicted people of the area, as well as the orphaned and vulnerable children whom this great pandemic has produced Despite the daily struggles and real risks, we are moving from acutecare to chronic care as more people are alive and working We are moving to more children being able to live with their families and guardians due to the increasing stability of some homesteads We are moving from emergency support to once again dreaming about what the future can hold Your support this year has also allowed us to make a dream come true a new Social Service Department is now serving homesteads facing situations which Health Care and Child Care have observed and reported, but have not been able to adequately address The family unit has truly become the center of our work

God’s great love is poured out like a river in the desert and the desert has become a place of life

Many blessings to each of you

Sr Diane DalleMolle, MSC

2 LETTER FROM DEPUTY EXECUTIVE DIRECTOR

My Dear Friends,

It’s been a great year of us working together to fulfill the mission of

Restoring Life and Rekindling Hope It takes so many people to

make our work possible and we are deeply grateful to all of you for

your interest, prayers, donations and support Without you our

Cabrini family here on the ground couldn’t continue this work of

love

Cabrini Ministries in this past year realized our desire of opening a Social Service

Department The impact of this movement is immense As a Catholic faith-based

organization we continually think about how we can best serve and love the people in this area with HIV/AIDS, TB and those impacted by these diseases Our underlying framework utilizing a psychosocial approach to care allows us to compliment the significant gains that have been made in the scientific world regarding HIV In Swaziland there has been a steady upward trajectory in health care delivery More people know their HIV status, more eligible people are on treatment, and families and communities are starting to stabilize

Despite all the scientific advances there are still a large number of families who lack the necessary resources – physical, emotional, intellectual or spiritual – to adhere to treatment regimens Many factors converge to contribute to this challenge, including poverty,

education, and social beliefs Our Social Service Department is able to assess the challenges and barriers that families face in trying to manage adherence and the lack of governmental social welfare supports The interventions of the Social Service Department creates a safety network to alleviate these struggles by providing food, health care, child protection, legal assistance, and individualized human rights advocacy, to name just a few supports As families become stronger and more cohesive, they rely less on Cabrini Ministries’ help and steadily move to a more independent functioning

I am proud of the steady quality improvements in Cabrini Ministries over the years The most important factor in all of this is the staff at Cabrini Ministries, who each day grows in itsown capacity to love as Jesus loved and to know what it means to love

United in this work of love,

Sr Barbara Staley, MSC, LCSW

3 EXECUTIVE SUMMARY

For over 40 years the Cabrini Sisters have been serving in Swaziland During that time, their work has always been driven by a connection to the community and a willingness to focus onthe most pressing needs During the past decade, that work has been dedicated to helping those people infected and affected by HIV/AIDS and Tuberculosis This care delivery has largely been carried out through Cabrini Ministries’ work in Health Care and Child Care.The commitment to the community and its needs has never changed, yet this year represents asignificant period of transition for the organization The work of Cabrini Ministries is

moving from crisis care to chronic care The primary focus is still on keeping people alive and ensuring that they are cared for, but now more people are able to think about transitioningtoward the future – a luxury many in the area haven’t had for over a decade

The most concrete example of this transition is the recent formation of the Social Service Department Originally designed to address the community needs that exist between our work in Health Care and Child Care, today the nascent department is providing a solid framework for addressing the holistic needs of the community we serve

In this report, you will read about the impact of the Social Service Department as well as the on-going efforts of our existing departments The programmatic year for Cabrini runs from October 1st through September 30th and this report seeks to draw together a detailed overview

of significant activity that has occurred in this period It pulls from a variety of data sources and reports to present a broad understanding of the organization and its impact

While it is impossible to capture the breadth of what Cabrini does by simply looking at statistics, the following figures provide a quick snapshot of what has happened this past year:

 A total of 2,806 individuals received direct care from Cabrini

 Our Health Care staff provided clinical services for 1,932 clients

o 872 HIV+ patients were given access to life-saving ARV medicine including

123 new initiations

o 89% of those initiated on ART were alive and on treatment one year later

 874 Orphans and vulnerable children were served through Cabrini Child Care

o 151 of those received a full complement of comprehensive services

o 333 healthy child physicals were conducted at area schools

 The Social Service Department assessed 1,067 individuals on 131 homesteads

o 177 interventions have already been initiated

 In addition to the Social Service Department, several new initiatives have been

launched: a Medical Circumcision Clinic, on-site laboratory services, expanded community health education, outreach academic enrichment, enhanced OVC support groups and new strategic partnerships

4 ORGANIZATION INFORMATION

Cabrini Ministries Swaziland is a Catholic faith-based and community-based not-for-profit

organization (Section 21: R7/26820) working

in the Lubombo lowveld of Swaziland to show God’s love in action through service Cabrini Ministries is based at St Philip’s Mission and operates for the good of the larger community including the chiefdoms of Mamba,

Ngcamphalala, and Gamedze with recent expansion into Shongwe, Mkweli and Nceka.Our work is fundamentally about meeting the psychosocial needs of our community which includes addressing issues of health, nutrition, education, and protection, as well as ensuring mental and spiritual wellbeing Service

delivery is primarily achieved through three integrated departments: Health Care, Child Care and Social Service Individual interventions are necessary, but can only be adequately assessed and understood in the context of family and community This contextual

understanding of the people served by Cabrini is the core of Cabrini Ministries’ effectiveness

in responding to and providing for the many challenges experienced by the people we serve

Unfortunately, as the millennium came to a close,

Swaziland was faced with a triple crisis of drought,

unemployment and – most damaging – the HIV

pandemic In the span of less than a decade, an

entire generation of Swazis had been devastated and

the social fabric of the country began to unravel

Bright young people who had been educated

through the hard work and sacrifice of their families

along with the support of the sisters were dying just

as their working lives were beginning Families

were left without their children and consequently the social safety net they had expected to exist in their later years of life

Sr Anne Maria counsels a child

in the early 1980s

In 2002, in response to the crisis, a strategic decision was made to refocus the apostolic mission of the Missionary Sisters of the Sacred Heart All resources, human and financial, were shifted to respond deliberately to the havoc caused by HIV and TB With the support and encouragement of the local leaders, a free hostel was established to care for orphans and vulnerable children of the area Initially, 50 children were enrolled, 98 showed up on the firstday and none were turned away The work in health care moved from the clinic-based to home care-based since most clients were simply too sick to travel What started as

emergency palliative care eventually evolved into a systematic approach of educating, testing,and linking to care In 2006, Cabrini Ministries was officially incorporated as a Swazi not-for-profit organization

In recent years, the southern Lubombo region of Swaziland remains an area remarkably underserved by care providers The ongoing impact of HIV, along with the co-morbidity of

TB and the resulting number of parentless children is compounded by continued years of drought and high unemployment These realities intensify the problems already associated with poverty, food insecurity, and low levels of education of the people living in these remoterural chiefdoms

Since its inception, Cabrini Ministries has established a strong track record demonstrating creativity, determination and competency in responding to community needs The

organization provides health care services of the highest quality to the people in the

catchment area and maintains on-going cooperative partnerships with families and neighbors

in the care and upbringing of children orphaned or vulnerable due to HIV/TB

In the last decade, Cabrini has served over 6,000 people living with HIV and/or TB and provided care to over 1,500 orphans and vulnerable children What began as just a few

people doing what they could to help their neighbors has evolved into a full service

organization deeply rooted in the community, providing comprehensive integrated care as well as targeted care to thousands

of others In 2013, a Social

Service Department was launched

in order to better meet the

multi-faceted needs of the homesteads

receiving services from the

organization and to enhance the

quality of care provision

Vision / Mission / Values

VISION:

Restoring life… kubuyisela imphilo

MISSION:

Sharing the love of Jesus Christ through

 Health Care Services for HIV, AIDS and TB at the homesteads and access to health care and supportive services for HIV, AIDS, and TB

 Care of orphans, vulnerable children and extended families/guardians

 Economic strengthening and skills development of local people through employment

VALUES:

 Quality Care Kunakekela ngelizinga lelisetulu

Staff and Leadership

Cabrini currently has 55 staff members and operates with the following service departments:

Health Care Outreach, Child Care and Social Services They are supported by work in Administrative Services, Maintenance, and Transportation Of the current staff members

who are employed, all but five are African, with the vast majority coming from the catchmentarea served by the organization

Executive Team

The Executive Team of Cabrini is comprised of five staff members who are responsible for decisions related to the day-to-day operations of the organization The members are:

 Sr Diane Dalle Molle – Executive Director

 Sr Barbara Staley – Deputy Executive Director

 Mr Pius Mamba – Cultural Liaison

 Mr Bongani Khumalo – Director of Health Care Outreach

 Mr Mzamo Sikhondze – Director of Human Resources

Board of Directors

The official board of Cabrini Ministries is comprised of members of the Provincial Council ofthe Stella Maris Province of the Missionary Sisters of the Sacred Heart of Jesus However, the duties of advisement and oversight of the organization have been delegated to a local Swazi Board comprised of the following members:

 Nathi Gumede (Chairperson)

Executive Director, Conciliation Mediation and Arbitration Commission

 Mavis Dlamini (Vice Chair)

Head Teacher, Duze High School

 Langalakhe Dlamini (Head of Finance Committee)

Finance Manager, Swaziland National Provident Fund

Social Welfare Advisor, Health Finance and Government

Cabrini Children perform traditional Swazi Dance.

5 SITUATION IN SWAZILAND

Swaziland is a small land-locked country in Southern Africa extending roughly 175 by 135 kilometers (110 by 85 miles) and having a population of approximately 1.1 million The country is considered to be Africa’s last true monarchy with King Mswati III ruling the country

By technical definition, Swaziland is a middle-income country with a per capita income of

$5,246.1 However, 63% of the population lives on less than $2/day with 37% living on less than $1/day.2 This illustrates the significant gap between the rich and poor in this small country The poorest 20% of the population account for only 1.4% of the national

consumption and Swaziland as a whole consistently ranks as one of the 25 worst countries in the world for income inequality.3 The unemployment rate has risen in the last five years and currently stands at 66.3% with even higher rates in the rural areas.4

The health situation in Swaziland is

even worse The country holds the

unfortunate distinction of leading the

world in HIV rates as well as

incidence of Tuberculosis According

to a recent national survey, 31% of

Swazis ages 18-49 are infected with

HIV and every year 2.38% of

previously uninfected people will

contract the disease.5 Swaziland

yearly has 1,350 new cases of TB for

every 100,000 people; compare that

to the world average of 122.6

While the deadly diseases of HIV and TB receive the most attention, Swaziland’s health and sanitation systems face challenges as well Even though basic health services are available for most of the population, the country has an infant mortality rate of 7.9% and an under-five mortality rate of 10.4%.7 One in ten children born in Swaziland won’t live to see their sixth birthday Only 53.8% of Swazis have access to adequate sanitation facilities and in the rural

areas of the country, 40% lack access to adequate drinking water sources.8

1 World Bank, 2012 Swaziland is ranked 112 out of 180 when adjusting for Purchasing Power Parity.

2 Swaziland MDG Progress Report, 2012.

3 Based on GINI coefficient

4 Swaziland MDG Progress Report, 2012.

5 SHIMS Report, Columbia Univeristy.

6 WHO Global TB Report, 2013 Other rates for reference include: Africa as a whole – 220, Australia – 6, United States – 4, Europe – 5.

7 Swaziland MDG Progress Report, 2012.

8 MICS Survey, 2011.

Recent statistics paint a worrying social picture as well The HIV crisis has overwhelmed the social safety net of the country with a significant amount of children becoming orphaned or vulnerable in a short period of time This, coupled with the lack of wage earners, makes for a dangerous situation.

Currently, 45.1% of Swazi children are officially classified as orphaned or vulnerable Of these children, 38% do not

have their basic needs met.9 Less than one in four children live with both their biological parents Protections that are considered basic in many areas of the world are lacking from daily life for Swazi children: 42% of children ages 5-14 engage in child labor activities and 89% are regularly subjected to violent forms of discipline.10

The combination of economic, social and health factors impacting the country of Swaziland have produced a complicated situation, but it is not without hope In the fight against HIV, Swaziland has reached the tipping point – the rate of new initiations on life-saving drugs is higher than the rate of new infections.11 In the economic arena, new opportunities are

emerging For the lowveld in particular, sugar cane holds the potential to be an economic engine Even technology is changing for the better as more and more Swazis are connected

to the internet even in the most remote areas

The next ten years promise to be pivotal in the history of Swaziland Either the devastation caused by the HIV crisis will prove too much to overcome, or the country will find its footingand restore stability

Despite the ongoing challenges, this country

certainly has reason to be hopeful Cabrini

Ministries is committed to partnering with our

community, and country as a whole, to turn the

corner on this desperate situation

9 Ibid Defined as having a minimum of one meal a day, two pairs of clothing and one pair of shoes.

10 Ibid.

11 AVAC 2013 Annual Report.

6 PROGRAMMATIC OVERVIEW

The goal of Cabrini Ministries, as a Catholic faith-based and community-based organization,

is to form a relationship with each family and individual it serves Who are these family-ies? What are the health problems, social problems, financial difficulties with which they struggle daily? Over the years, Cabrini Ministries has come to know the strengths and challenges of each of the families and individuals it serves, creating a covenant bond of faithful service Cabrini Ministries is committed to being faithful and persevering in helping these HIV, TB and poverty stricken communities become healthier and stronger

It is the great desire of Cabrini Ministries to love the people of this area with the same faithfulcovenant love God has for each of us We express this love during all our encounters through

a relationship based on respect and dignity – while encouraging those who have defaulted to adhere to their medications; while teaching and supporting families about protecting the rights of women and children; while reuniting and strengthening families who have been overwhelmed by sickness, death and loss

For the past decade Cabrini Ministries has focused its work on responding to the crisis caused

by HIV/AIDS and TB and the devastating corollaries of these illnesses Historically, this has taken the form of health care services for adults and children and impact mitigation measures aimed primarily at orphans and vulnerable children

The last year has brought a marked

transition from providing emergency

care to focusing on comprehensive

and integrated social, child care and

health services for families and

children in chronic conditions of

illness, abandonment, abuse, and

poverty The communities we serve

are awakening from a dark night of

debilitating illness and death to new

beginning of working, caring for

their children and having hope for a

Cabrini Ministries has worked intensively in this last year to consider all of these changes as

we reshape our existing programs and develop new ones in order to meet the growing and emerging needs of the communities we serve

Health Care

The primary objective of the Health Care Program is: To provide a comprehensive,

community based, integrated health care to children and adults living with HIV/AIDS and

TB over their lifetimes.

The primary point of service for Cabrini Health Care is the

Cabrini Drop-in Clinic located on St Philips Mission This

facility serves as the hub for HIV/TB work for the entire

catchment area

Upon coming to the clinic, clients are checked in, their vital

signs are taken and they receive education and psychosocial

support which is offered by our trained staff They then

meet with a treatment support counselor before visiting a

skilled nurse who specializes in HIV/TB care and

treatment All clients, regardless of the purpose of their

visit, receive a TB screening Basic medical care is also

provided for those who participate in the HIV Testing and Counseling program For clients that are in relatively good health, but for whom transportation is a problem, we provide drivers to bring them to the clinic

The following services are offered on-site:

HIV Test and Counseling

During an average month, 30-40 individuals come to Cabrini’s on-site facility to find out their HIV status If clients are negative for HIV and TB, they are counseled on strategies to maintain their negative status and encouraged to come back for regular testing If they are positive, clients receive a full complement of support care services so they are prepared for the treatment journey ahead HIV Testing and Counseling is also regularly offered at

community events

Support Care (adherence counseling, support groups, health education, etc.)

Cabrini’s Health Care Services are not just focused on the medical aspects of care Every client, whether new or returning, is provided with psychosocial support and health education activities

Pre-ART / ART Initiation and Treatment

The center of Cabrini’s HIV program is treatment Cabrini nurses are trained and equipped toinitiate clients on life-saving anti-retroviral treatment as well as pre-treatment antibiotic prophylaxis (cotrimoxizole) Clients receive refills at regular intervals ranging from weekly

to quarterly, along with clinical assessments and personalized care

Ongoing supportive Health Care

Because HIV suppresses the immune system, it often leads to a wide range of other health issues Cabrini integrates care for opportunistic infections and other complicating disorders, into its regular continuum of care Clients who are HIV or TB positive are guaranteed access

to the best comprehensive care possible

Connection to Sexual and Reproductive Health Services

Cabrini works with other organizations to connect our clients with the services they need including access to sexual and reproductive health interventions

Food by Prescription

For clients who are clinically malnourished (as determined by body mass index), Cabrini provides emergency food services as part of its comprehensive care provision

Transportation to Other Services

Because Cabrini’s Health Care focus is on HIV and TB, not all treatment options are

available onsite However, because of the covenantal relationship our organization has with its clients, we are committed to connecting patients to other clinics that can provide the services they need On a weekly basis, clients are transported to other hospitals, and in emergency situations, they are provided with transportation to the closest emergency care facility

The Drop-in Clinic also functions as the primary location for all missed appointment follow

up and Health Care data collection/analysis

Community Health Outreach

In addition to extensive care and treatment for Cabrini

clients, several community health outreach activities

have been implemented:

Homestead Visits

Often, clients are too sick to make it into the clinic for their refills and appointments In thesecases, Cabrini sends nurses into the catchment area to provide clinical support for the most vulnerable These sessions are designed to provide the same level of care offered at the clinic, but are utilized in the most dire of situations Nearly every day, a nurse is out doing these visits During homestead visits, patients are provided with treatment (pre-ART, ART,

TB, opportunistic infections etc.) as well as psychosocial support through nutritional

supplements, spiritual uplift and counseling

Remote Refill Locations

Cabrini’s catchment area is approximately 50km in length and width and covers terrain with only rudimentary dirt roads Because of this, many clients find it difficult to come to the clinic for regular service In order to alleviate this burden, Cabrini initially began offering a

In the last year, 1 in 3 Cabrini patients received care away from the clinic This includes remote refill locations and home

Patients line up outside a Remote Refill location awaiting care

shuttle service to clients in remote locations However, as the number of clients served steadily increased, it became essential to create a new solution The result was mobile refill stations Every week, a nurse, counselor and support staff member head to a remote section

of the catchment area on a regular schedule to provide medication refills and on-site clinical care We currently have four refill locations throughout the region: Bhadlane, Mconcwane, Ncandweni and Sinyamantulwa These sites provide the same services as the drop-in clinic (HIV testing and counseling, TB screening, treatment, care and support), but are mobile and are designed to meet the needs of clients in the most effective way possible

Missed Appointment Follow up (including partner clinics)

Cabrini recognizes that initiating a person on treatment is only effective if that person

remains on treatment For this reason, the organization employs one of the most aggressive missed appointment tracking protocols in the country:

 Missed appointments are identified at the end of each day

 Clients are contacted immediately to inform them of their appointment status

 After 3 days of tracking, a register is opened for the client

 If phone calls are not effective, a default tracker is sent to client’s home

 If client has not returned in 7 days, they are classified as a defaulter

 Follow up continues until client returns or refuses treatment

 After 90 days, if client does not return, they are considered lost to follow up as per national protocols; however, Cabrini continues to track them

 Tracking data is collected and analyzed on a quarterly basis

Cabrini has found that this level of client tracking

is very time and resource intensive, but has resulted in return rates much better than the national average It also provides insights into our clients’ needs and challenges that would not be possible otherwise

In addition to tracking regular Cabrini clients, Cabrini has entered into partnership with two government clinics (Sinceni and Siphofaneni) to provide default tracking and community linkage support These clinics lie on the outer edge

of the Cabrini catchment area and many of the households our organization serves have clinical ties with the institutions In the last year, Cabrini employees followed up with 342 unique clients from these government clinics

Targeted Programming

In order to address specific health care needs, targeted programs have been established to focus on the most significant barriers to a healthy community Cabrini’s targeted programs include: Tuberculosis Care, Prevention of Mother to Child Transmission, Medical

Circumcision, and Community Education

Tuberculosis Care

While Tuberculosis Care is integrated into the comprehensive health approach Cabrini

implements, its impact necessitates a focused effort on prevention, case finding, diagnosis and treatment TB is one of the leading causes of death among HIV+ patients In order to decrease its effects, Cabrini has implemented the following systems:

Case Finding

The cornerstone of any TB program is case finding Regular patients are screened for

symptoms of TB at every visit Additionally, patients who are suspect for TB are encouraged

to have other members of their homesteads tested to identify if the disease has spread TB screening has also been incorporated into everyday aspects of Cabrini programming such as homestead assessments and healthy child physicals

If a patient is identified as being a TB suspect, they are coached through giving a sputum sample for testing If other identification measures such as a chestX-ray are needed, Cabrini arranges for those In FY13, roughly 10% of TB suspects were identified as having the disease

TB Prevention

Preventing the spread of Tuberculosis is always preferable to treating the disease Cabrini takes a multi-pronged approach to prevention that includes medical as well as behavioral interventions

From a medical side, Cabrini offers its clients access

to TB prophylaxis (isoniazid) In the last year, 103 high-risk clients received this preventative care to reduce their risk of contracting the disease

In addition to medical interventions, Cabrini also provides existing clients with alternative living arrangements to prevent the spread of the disease on their homestead In instances where a TB-positive client would have to live in the same dwelling as non-infected family members, Cabrini provides alternative living arrangements so the individual can be cared for while decreasing the risk of transmission

Treatment and Support

In Swaziland, it is estimated that 15,000 people each year will contract Tuberculosis A standard treatment regimen is six-months long, and Cabrini provides this service to over 130 individuals per year Unlike with HIV on its own, treatment failure bears additional

significant risk – namely the development of Multi-Drug Resistant Tuberculosis (MDR-TB) which can take up to three years of expensive treatment to cure and has a much higher mortality rate Therefore, Cabrini not only provides the treatment, but also focused support for TB clients This includes ongoing observation and intentional orientation to the treatment

process and the risks of non-adherence In the last 3 years, Cabrini has not had any clients default on TB treatment This not only guarantees better outcomes for the clients, but also

reduces the risks of MDR-TB which can have devastating effects on the community as a whole

Transportation for MDR-TB Clients

Due to the high risk and intensive treatment regimen for MDR-TB clients, a government hospital has been established to care for these patients Clients of Cabrini who are suspect of having MDR-TB are provided transport to the government hospital in order for them to receive the best care possible If appropriate, these clients can continue their treatment at home with Cabrini nurses serving as treatment supporters

Prevention of Mother to Child Transmission (PMTCT)

Cabrini has implemented a comprehensive education and support program to guide

prospective mothers in maximizing the potential for babies to be happy, healthy and HIV negative This requires a dedicated approach to care and support Once an HIV positive client in our catchment area is found to be pregnant or intending to become pregnant, a Cabrini nurse consults with her to discuss options She is encouraged to attend a support group with other expectant and new mothers These groups are led by nurses and include lessons and open discussions about PMTCT issues Food supplements and at-home care are provided as needed In addition to support care, participants receive ongoing clinical

assessment and support, nutritional support, treatment of opportunistic infections,

prophylaxis, ART treatment for those with advanced HIV, and ante-natal care in cooperation with partner

organizations

In the last year, 49 new expectant mothers were reached through our PMTCT program These new clients joined the nearly 100 other mothers who were already being supported through PMTCT programming Of those, 27 newborns from this year with known HIV statuses, only 2 became HIV positive representing a rate of 7.4% While any child becoming HIV positive at birth is tragic, it should be noted that this rate is significantly lower than average the mother to child transmission rate of 25%

Medical Circumcision

Studies have shown that men who are circumcised have a 60% lower chance of contracting HIV; this ultimately reduces the spread of the disease.12 These encouraging statistics have prompted a nationwide effort to increase Medical Circumcision (MC) In partnership with two other NGOs in the country, Cabrini opened a local MC clinic to meet the needs of men who are willing to participate in this prevention strategy In the last six months, over 500 school aged children have been encouraged to participate, and ongoing community dialogues have occurred Roughly 60 new clients have undergone the procedure at the Cabrini’s MC Clinic

As the program establishes itself, Cabrini will continue to work with local service providers

to increase the uptake of this service

Community Education

Cabrini firmly believes that successful prevention and treatment strategies must be built on education and community engagement In addition to the on-going education which occurs during routine clinic sessions, Cabrini hosts regular community education sessions in a variety of settings and targeting a diverse audience

on HIV treatment, palliative care, TB infection control, and encouragement for TB screening and HIV testing

Traditional Healers

12 AVAC, VMMC Talking Points, 2011.

The clients Cabrini serves are deeply enmeshed in the traditional belief systems of the area This includes the regular consultation of Traditional Healers for spiritual, social and health related issues An informal survey revealed that over 80% of Cabrini’s clients see a

Traditional Healer at least once before, during or after medical treatment Despite potential differences in values, beliefs and approaches to illness, we feel it is essential to work with these Traditional Healers so that the clients can best be served

Currently, regular meetings occur

in all three chiefdoms with the Traditional Healers These are facilitated by a local nurse who isalso trained in the traditional practices The focus of the meetings has been on education Cabrini has provided training on how ARVs work and the unique health concerns of HIV positive patients There has also been education on reducing risk in their own practices and

identifying warning signs of HIV and TB Referrals and continuing education are always encouraged

Traditional Leaders

Because the work of Cabrini Ministries is within a setting of traditional chiefdoms, it is essential that strong working relationships be maintained with the chief and the traditional structures Since 2012, Cabrini has offered quarterly education and dialogue sessions with the traditional leaders of each chiefdom Topics include HIV/AIDS and TB education, Medical Circumcision, Treatment adherence and child protection By reaching the people who have the most influence in the community, we can ensure the issues are taken seriously The leaders are not expected to teach their people but to direct them towards healthy living for the common good of their chiefdoms Because traditional values and cultural norms are involved, the process is always deliberate and respectful Change does not come quickly and will take years of building trust to see the full benefits of these efforts

Healthy Living Advocacy Days

On a quarterly basis, the Health Care Department hosts an education day in different

communities in its catchment areas for current HIV+ patients The clients invited to the day are those who are most adherent in caring for themselves and have seen the value of entering into treatment They are encouraged to bring a relative or neighbor who has not yet tested The day consists of education on positive living, health related discussions, encouragement for testing for newcomers The day ends with a full meal and time for socializing These well attended events have sought to recognize and encourage those who have adopted a healthy life style and also to education new community members about positive living

Program Impact

In FY13, the Cabrini Health Care Program served 1,932 unique clients This includes 1,590 clients from Cabrini Clinic and outreach as well as 342 from the government clinics in Siphofaneni and Sinceni Over 20,000 services were provided to these patients A full overview of this service provision is available in the appendices, but the following figures provide a glimpse at the overall impact of the program

 1,932 total clients served (1,399 of these were HIV+)

o 1,590 through Cabrini Clinic (Drop-in Clinic, Remote refill clinic and home visits)

o 342 through Government Clinics

 617 individuals received HIV Testing and Counseling

 327 clients received Pre-ART services

 872 received ART services

 123 were initiated on ART

 130 clients with tuberculosis received treatment

o 58 were newly initiated on treatment this year

o 6 new MDR-TB clients were identified

 87 clinically malnourished patients received therapeutic food supplements through theWHO’s Food by Prescription program

 103 clients received TB prophylaxis (INH)

 89% of clients initiated on ART are known to be alive and on treatment 12 months after initiation

 631 clients received CD4 results

 969 missed appointments were followed up on

o 492 from Cabrini

o 477 from Government Clinics

 80.5% of clients who missed appointments returned to care

o 95.9% of Cabrini Clients returned to care13

 Over 400 individuals engaged in community education events

o 130 individuals participated in events at the chiefdom level

o 131 participated in HIV testing events

o 91 Rural Health Motivators attended trainings

o Over 100 traditional healers participated in dialogues

 49 new mothers were enrolled in programming designed to prevent mother to child transmission of HIV

13 Lower rates for Government Clinics are due to employee transitions as well as difficulties experienced while transitioning to a new data tracking system.

Key Accomplishments

Alive and on Treatment Rates

The greatest measure of success in the Health Care Department is the number of patients whoremain healthy and productive When working in the field of HIV, this success is most often measured by looking at the proportion of clients who are alive and on treatment one year aftertheir initiation In Swaziland, the alive and on treatment rate has historically been around 80% in other words, even when enrolled on life-saving anti-retroviral treatment, one in fiveclients still either default on treatment or die Over the last 3 years, Cabrini’s Alive and on Treatment Rate has hovered around 90% Many factors that influence this figure

In 2011, Swaziland experienced a stock-out of CD4 reagent which is essential for monitoring the advancement of HIV in the body Without these test results, clients were unwilling to initiate on treatment.14 This delay in initiation led to a decrease in new initiations, which in turn meant that people started treatment later All across the country, this decrease in

initiations was noted

In response to this issue, Cabrini was proactive to ensure patients had the best chances for survival Health Care employees advocated at the highest levels of government for

restocking of the vital CD4 reagents Nurses participated in a national program to allow them

to provide initiations (rather than having to wait on a doctor) Initiations were done when possible on clinical staging rather than CD4 count Eventually a point of care CD4 machine was acquired in order to perform the labs on-site

14 In Swaziland, standard treatment is to start ART at a CD4 level of 350.

As the chart above illustrates, the lack of lab work resulted in decreased initiations and consequently decreased rates of clients being alive and on treatment However, once

corrective measures were put into place, the rate rose higher than ever before It is currently projected to end the year at nearly 95%!

Keeping people on treatment is not only essential for the health of individuals, but also for the health of the country as a whole Clients on treatment are less likely to transmit the disease and individuals who remain healthy are better able to support their family and their community

Launch of MC Clinic and Laboratory

Cabrini realizes that quality health care services must also be accessible in order to be

effective This approach has resulted in numberous partnerships regular expansion of of-care services This ensures our clients are as close as possible to the care that they need Inthe last programming year, two such expansions have occurred: the launch of an on-site laboratory and the launch of a Medical Circumcision Clinic

point-Laboratory

Cabrini has always partnered with government clinics to provide laboratory services to our clients However, the faster laboratory results can be obtained, the faster proper treatment can be initiated Therefore, this year, Cabrini launched its own mini-laboratory For now its primary function is providing rapid CD4 counts for clients while they wait This allows clinicians to quickly pursue the best treatment course of action In coming months, the services offered are expected to expand

MC Clinic

Medical Circumcision holds the promise

of reducing HIV transmission rates in high prevalence countries such as Swaziland Because of this, Cabrini has been active in encouraging clients and other men from the area to be

circumcised In collaboration with several local and international agencies, Cabrini launched a “Clinic in a Box” which is designed to provide rapid deployment of MC services This semi-permanent structure was constructed to quickly provide the necessary structure to carry out circumcision procedures Cabrini

currently oversees recruitment and education, and in the future is looking to expand into providing the point-of-care service itself

Area Hospitals and Clinics

Serve as referral locations for clients who need services not regularly provided by Cabrini Ministries

Family Life Association of Swaziland

Provides access to Sexual and Reproductive Health services for Cabrini patients This includes access to care and support as well as education

PACT / ICAP / PEPFAR

Financial and technical assistance around a wide variety of issues Also supports area

organization provide assistance to Cabrini

URC

Training and technical assistance

US Ambassador James and a Ministry of Healthy

representative officially open the MC Clinic.

Community Health Motivators

Connect clients with local services and also assist with missed appointment follow up and defaulter tracking

Cabrini Health Australia

Provide financial and technical assistance Coordinate with area staff to host extensive healthy child physicals and work with clinicians to improve quality of care

Child Care

The primary objective of the Child Care program is: To Raise orphans and Vulnerable Children in partnership with their guardians in local communities to help them develop into happy, healthy, and independent Swazis

Cabrini Ministries provides

comprehensive care for those in the most

desperate situations as well as targeted

support for individuals and families only

requiring specific assistance Service

delivery is based upon on-going

assessments of a client’s situation and all

interventions are designed with the larger

family and community in mind

Assessments

Cabrini’s work with Orphans and Vulnerable children takes into account a person’s needs andstrengths when designing an appropriate intervention All clients who receive services through the department undergo an assessment process to ensure the services provided are tailored to their situation We believe that the best care comes from a person’s own

community and family and therefore, an emphasis is always placed on utilizing all resources available

Needy families are identified through local community leaders and self-referral The assessment evaluates not only the financial situation, but also issues of health, protection, education and access to non-material resourcesand services These evaluations provide the basis for future interventions and take into account the situation of the entire family Because these assessments are with high risk and high need individuals and families and address sensitive issues, the work often takes several hours as staff members engage in psychosocial care and support throughout the assessment process

On-going assessments for current comprehensive care clients are being performed to determine if, and when, it

is possible to transition these children into a care situationthat is supported on their own homesteads

Service Delivery

The Child Care program at Cabrini provides services across six domains of care: Shelter, Nutrition, Health, Education, Legal / Protection, Economic Strengthening and

Psychosocial Support These domains are based on the national Quality Service Standards for Child care and are integrated into Programs, Events and One-Time Services which are

delivered through the department As a result of the organization embracing an approach to service where caring for the whole family unit is understood as the best way to assist the individuals in that family, the work of Child Care is increasingly being done in collaboration with Health Care and Social Service

In addition to nutritional support for children

enrolled in comprehensive care, emergency

food provisions are available for families who

need short-term support Growth monitoring

and appropriate follow up is also included in

the provision of nutritional care for those

served by Cabrini

Health

The Cabrini Clinic provides access to health care services for children with chronic

conditions Additional health services are available for community children through regular physicals and referral to care and treatment, either through Cabrini or in collaboration with another service provider

Education

The Child Care Department provides access to education both as a direct provider and as a liaison with traditional educational structures As a direct provider, Cabrini offers a Bridge School as well as after-school tutoring services and special events In connection with the national education system, Cabrini helps students overcome issues related to access by assisting with schools fees, uniforms, boarding costs, etc We advocate on educational rights

and act as parentis in locus.

Legal / Protection

Cabrini’s work in Legal and Protection is carried out in partnership with the Social Service Department and commonly includes assisting children in obtaining legal documents such as birth certificates, parent’s death certificates, identity cards, etc Cabrini also regularly works with area entities in issues of child protection This includes responding to reports of rape or abuse and helping victims navigate the way forward Cabrini also provides training and

sensitization on child protection issues to staff, children’s guardians and the community at large.

Economic Strengthening

Various programs in the Child Care department connect children with opportunities to

increase their skills and provide the ability to live a sustainable life on their own This includes access to education and trade programs, hands-on job training, and technical skills development in areas such as agriculture and handicraft

Psychosocial Support (PSS)

Psychosocial support is care designed to influence the

individual and social environment of a person and

includes social, spiritual, emotional and psychological

elements For Cabrini, this work is at the heart of all

activities and interventions PSS is not an activity in

and of itself – rather, it is a methodology that Cabrini

embraces on all levels

Comprehensive Care Programs

Individuals with the greatest level of need and least availability to services and support may qualify for comprehensive care services In the last year, over 150 children received this type

of care Even when comprehensive services are offered by Cabrini, a partnership with the client’s homestead is critical to our collaborative model of care Cabrini staff may have a parental role with these children, but it is only part of the co-parenting relationship as the person’s homestead is expected to also provide leadership and support This is monitored andencouraged through regular meetings with the guardians

Hostel

The free on-site hostel for orphans and

vulnerable children is the most intensive

program of care Participants receive

support in a co-guardian structure wherein

children spend the school year in the Cabrini

hostel with 24 hour care, and then during

school breaks they return to their families

and/or homesteads Shelter is provided 9+

months a year along with daily meals All

participants receive regular primary health

care, including checkups and screenings and

additional health referrals are made when

necessary All children participate in education enhancement activities outside of school four days per week Additionally, if necessary, school fees, uniforms, etc are provided Each child receives legal and/or protection services through assessment for and assistance with essential documents (birth certificates, parents’ death certificates, IDs, etc.) Through the residential childcare staff and case management workers, all children receive ongoing

emotional and social support This is delivered through prayer, counseling, support groups and ongoing love; this aspect of our psychosocial approach is deeply integrated into all aspects of the program Some students in this group are offered economic strengthening opportunities through the skills training programs In the last year, 107 students were stayed

at the hostel

Aftercare / Supported Independent Living

Not all children who receive comprehensive care live on-site Cabrini also cares for students

in a variety of off-site living situations Cabrini pays for many of these students to attend boarding or trade schools as they continue their education Additionally, older students may participate in life transition activities that provide them with safety net of care while still adjusting to life on their own All services offered to the Hostel participants are also offered

to these Aftercare participants Last year, 41 students received Aftercare support

Respite Care

Cabrini’s respite care program is essentially a short-term enrollment in the hostel All

services are provided as described above, but participation is not anticipated to be long-term Respite care is often offered in cases of abuse while the formal process to find a safe

placement is handled through the appropriate channels Individuals with short-term, yet intense, health care needs have also received this service Services in this area are expected

to expand as the Social Service Department extends its reach in the community

Targeted Support Programs

The vast majority of children served by Cabrini fall into the category “Targeted Support.” These children have specific needs as identified in the assessment process and thus are enrolled in programs and activities that adequately address their situation Even if a program does not regularly include some service areas, if they are needed by the children, it is offered

on an individual basis So, if a student is receiving support for education costs, but also has health issues that need to be addressed, Cabrini will assist in that area as well

Academic Support & Sponsorship

Students who are enrolled in our Academic

Support program are usually children who have

their basic needs met, but require support for

things like school fees and uniforms Even with

expanding assistance from the Swaziland

government, many families simply cannot

afford to send their kids to school since regular

tuition costs can easily be several month’s

salary for a general laborer Because most

children in our catchment area struggle with

more than just academic problems, these

children are also assessed for nutritional, health and protection needs Students’ progress is regularly monitored by the Education staff Last year 121 students received this support.

Bridge School

The Cabrini Bridge School was created to facilitate accelerated learning for students who showed great academic potential, but whose age was not appropriate for their grade level Older students who began school later than normal are given the opportunity to work throughmultiple years of school in the course of one academic year so they can catch up to their peers Originally only offered to existing comprehensive care clients, in the last year, we expanded this program to include students from neighboring communities as well Currently eleven students are enrolled in this program

Life Skills Camps

Cabrini’s work with orphans and vulnerable children is not just about delivering services, but also about providing positive environments where youth can learn, experience love, be safe and ultimately thrive This atmosphere is encouraged and facilitated through Cabrini’s inter-term camps We have observed that the most significant issues our children face present when they are away from school, including teen pregnancy and abuse For the past three years Cabrini has offered these short-term camps during the four annual school term breaks This year, the camps’ content included career planning, emotional literacy and developing a positive outlook on life By providing a safe environment, the risks to children during these breaks are reduced These camps are offered to both students regularly in Cabrini

programming as well as area children who are interested This also serves as a way for us to expand our reach into the community During the most recent camp, over 140 students participated

Healthy Child Physicals

For the past three years, Cabrini’s Health Care

and Child Care Departments have partnered

with nurses and doctors from Cabrini Health

Australia to provide physicals for children at

area schools These health outreach activities

provide the only connection with medical care

some of these students ever receive The

health checkups include assessments for

malnutrition and common conditions, as well

as TB screening and the opportunity for HIV

testing Basic clinical care is offered when

possible; for clients with more complicated issues, a referral and access to care is provided

We make sure to follow up with all at-risk clients Nearly 700 unique children have received this access to care in the last two years

CARE Tutoring & Outreach Education

As part of its comprehensive care package, Cabrini provides educational enrichment

opportunities for students living on-site This program is known as CARE: Cabrini

Arithmetic and Reading Enhancement Math and language skills have consistently been identified as areas where students struggle, thus the intentional focus of the program In order to deliver high-quality educational services, several educators and tutors are employed While initially these teachers worked exclusively with the students at the hostel, in the last fewyears this program has been expanded to children from area communities as well

Through partnerships with local schools, Cabrini’s Arithmetic and Reading Enhancement program was attended by over 200 students These students have their basic needs met on their homesteads, but needed some additional instruction outside the regular school day By focusing services towards those who need them the most, the impact of Cabrini’s existing work has expanded

Therapy and Support Groups

In addition to academic enrichment groups, Cabrini also regularly offers theraputic and psychoeducation support groups These groups provide a safe environment for peers to learn and engage on important issues In the past year, groups have been created around art-

therapy and life transition support These groups are led by trained staff and volunteers in theareas of their expertise

One Time Services

Not all needs encountered by Cabrini need to be addressed through programmatic

interventions Sometimes, a one-time service is all that is necessary to allow a family to get through a difficult situation Therefore in addition to the programs outlined above, Cabrini regularly offers short-term care provisions in all domains: Shelter, Nutrition, Health,

Education, Legal / Protection, Economic Strengthening and Psychosocial Support