SACBC ART Program: a Snapshot

Over the past ten years the SACBC AIDS Office has provided ARV treatment, and initiated over  45 000 patients on treatment.  The programme is entering its final phase with donor funding drawing to a close by the end of May 2014.  Many patients have been transferred to clinics of the Department of Health, and currently the SACBC AIDS Office remains active in six places.


 THE SACBC ART PROGRAM: AN OVERVIEW AS OF 1 OCTOBER 2013

Johan Viljoen

A. INTRODUCTION

The SACBC’s ARV treatment program began in February 2004 with funding obtained from Cordaid (Netherlands). Five home based care projects were selected. At each project a doctor and a professional nurse were appointed to manage the program. The nurse would test patients and draw blood for CD4, viral load and full blood count tests. Blood samples were transported by courier to a laboratory in Gauteng. Program sites were informed of test results by email. Patients with CD4 counts below 200 would be initiated on ART. The doctors wrote the required prescriptions and emailed them to a pharmaceutical distributor in Gauteng. A month’s supply of ARV’s, individually packaged per patient, would be delivered by courier to the program site. Caregivers followed patients up for adherence. This was the first time that ART was provided outside a hospital, clinic or private medical practice – a completely innovative approach, making ART available in remote, resource-poor settings.

In 2004 SACBC was chosen to be the South African implementing partner of AIDSRelief – a PEPFAR funded consortium lead by CRS, providing ART in 9 countries. The program was expanded to an additional 17 implementation sites, bringing the total number of sites to 22. The first PEPFAR funding was received in June 2004, and the first new sites began enrolling patients in August of the same year. MOU’s were signed between SACBC and the National Department of Health, as well as each Provincial Department of Health in each province where the program was implemented.

The second phase of PEPFAR emphasized local ownership of programs. SACBC was the first PEPFAR program globally considered to have the capacity to be a direct recipient of PEPFAR funding. It began receiving direct PEPFAR funding in March 2009.

SACBC’s intention was to make ART available through Catholic health care facilities to patients who wouldn’t have been able to access ART otherwise. During this period, the government’s ARV roll out began expanding. Where the government began providing ART at clinics near an SACBC ART site, patients were transferred to the government program, and the SACBC ART site was closed down.

The second PEPFAR grant was due to end in May 2013. In 2011, SACBC began negotiating with provincial Departments of Health and District Offices in places where it had ART sites, to determine the future of its ART sites after the end of PEPFAR. In places where the government had the capacity to absorb SACBC patients, these were transferred to the government, and the SACBC site was closed down. In places where the government lacked the capacity to absorb SACBC patients (six sites in total), it began providing ARV drugs and laboratory tests to the SACBC ART sites.

In February 2013 a no-cost extension was approved by the US government, in terms of which funding will continue until May 2014. This gives SACBC the chance to finalize the future of its last six ART sites. The process has been complex – SACBC differs from most other PEPFAR partners in the sense that it didn’t work in government facilities from the beginning, but used PEPFAR funds to purchase ARV’s, to be provided in the Church’s own health care facilities.

SACBC looks back with gratitude at what has been achieved with US government funding. A total of 45 237 patients have been initiated on ART since the program began in 2004.

B. TREATMENT SITES CLOSED BEFORE 1 MAY 2013

1.1. Name and Location: Thembalethu, Malelane, Mpumalanga
1.2. Brief Description: A home based care project that serves a rural population consisting largely of Mozambican refugees and their descendants, on the border between South Africa, Mozambique and Swaziland.
1.3. Date of Closure and Number on ART: Closed December 2005. By then 99 had been initiated on ART.
1.4. Resolution: All patients were transferred to Tonga Hospital and Shongwe Hospital when these began providing ART. The site was subsequently closed.

2.1. Name and Location: Good Samaritan Hospice, Bethulie, Free State
2.2. Brief Description: A hospice and home based care program in Bethulie,a small rural town in the southern Free State.
2.3. Date of Closure and Number on ART: Closed January 2006, by which time 96 patients had been initiated on ART.
2.4. Resolution: The government clinic in Bethulie started to provide ART. All patients were transferred to the government, and the Good Samaritan ARV treatment program was terminated.

3.1. Name and Location: Philisa, Bethal, Mpumalanga
3.2. Brief Description: A home based care program serving the township of Bethal – a coal mining town in Mpumalanga, with a large migrant population.
3.3. Date of Closure and Number on ART: Closed February 2008, 584 patients had been initiated on ART
3.4. Resolution: From the start of the program all patients received ART in Bethal’s government hospital. The project provided patient support services and follow-up. It was closed as a cost saving measure – all patients remain on ART in the government program.

4.1. Name and Location: Bela Bela HIV Project, Bela Bela, Limpopo
4.2. Brief Description: An HIV program providing counseling and home based care in the township of Bela Bela – a small town in Limpopo Province, known for its mineral springs.
4.3. Date of Closure and Number on ART: Closed June 2009, with a total of 780 patients initiated on ART
4.4. Resolution: When the Bela Bela Provincial Hospital began providing ART, all the project’s patients were transferred to the hospital, and the project’s ARV treatment services were terminated.

5.1. Name and Location: Sinosizo, Groutville, KZN
5.2. Brief Description: A home based care project serving the community of Groutville – one of the townships of Stanger, about 70 km north of Durban.
5.3. Date of Closure and Number on ART: Closed February 2008, 417 patients had been initiated on ART.
5.4. Resolution: When the government clinic in Groutville began providing ART, all the patients were transferred to the government clinic, and the project was closed.

6.1. Name and Location: Sinosizo, Kokstad, KZN
6.2. Brief Description: A home based care program serving the poverty-stricken rural areas of the former Transkei homeland. Patients received ARV drugs from the government hospital at Lusikisiki – the project provided patient follow-up and support.
6.3. Date of Closure and Number on ART: Closed May 2009
6.4. Resolution: The project was terminated as a rationalization measure, with patients continuing their treatment in the government hospital.

7.1. Name and Location: Bisdom Vigsministerie, Keimoes, Northern Cape
7.2. Brief Description: A home based care program serving the poverty-stricken rural areas of the Kalahari Desert. Patients received ARV drugs from the government hospitals at Keimoes and Kakamas – the project provided patient follow-up and support.
7.3. Date of Closure and Number on ART: Closed February 2009, 200 patients had been initiated on ART
7.4. Resolution: The project was terminated as a rationalization measure, with patients continuing their treatment in the government hospital.

8.1. Name and Location: St Mary’s Hospital, Mariannhill, KZN
8.2. Brief Description: A 200 bed Catholic hospital serving the Outer West District of Metropolitan Durban – an area with vast informal settlements on the periphery of the city, a population of about 750 000, and an HIV prevalence above 40%.
8.3. Date of Closure and Number on ART: St Mary’s Hospital ceased being part of SACBC program in May 2009 – at that stage it had 8 215 patients on ART.
8.4. Resolution: The Hospital was fully accredited as an ARV roll out site by the South African government in August 2003, thereby receiving ARV drugs from the Department of Health. With the start of the second period of PEPFAR funding (in 2008), St Mary’s Hospital became a direct recipient of PEPFAR funding.

9.1. Name and Location: Good Shepherd Hospice, Middelburg, Eastern Cape
9.2. Brief Description: An in-patient hospice in the small town of Middelburg (situated in South Africa’s arid Karoo region), also operating a home based care program in the neighboring township – a community known for having serious problems of substance abuse and alcoholism.
9.3. Date of Closure and Number on ART: Closed February 2009, 310 patients had been initiated on ART, and 96 patients at its satellite clinic in Cradock.
9.4. Resolution: At the beginning of 2009 the local government hospital in Middelburg began providing ARV’s. All Good Shepherd Hospice’s ARV patients were transferred to the Hospital, and the Hospice’s ART program was terminated.

10.1. Name and Location: Sizanani, Bronkhorstspruit, Gauteng
10.2. Brief Description: An in-patient hospice, home based care project and ARV clinic serving three rural communities outside Bronkhorstspruit, 50 km east of Pretoria.
10.3. Date of Closure and Number on ART: The site closed in May 2011. By then a total of 1755 patients had been initiated on ART.
10.4. Resolution: Formerly Bronkhorstspruit was in the Metsweding Municipality of Gauteng Province. Due to maladministration, the Metsweding Municipality was dissolved. After the 18 May 2011 Local Government Elections, Metsweding Municipality was incorporated into the Tshwane Metropolitan Council. During negotiations, Tshwane made it clear to SACBC that it is not their policy to provide ARV drugs to NGO’s, and that the Department’s clinics in the area had the capacity to absorb Sizanani’s patients. In July 2011 Sizanani was requested by SACBC to transfer out all their patients to government clinics. This was done, and the ARV treatment project was closed at the end of May 2012.

11.1. Name and Location: Thabang Society, Parys, Free State
11.2. Brief Description: A small clinic in Tumahole township, outside the Free State town of Parys.
11.3. Date of Closure and Number on ART: The site closed in April 2011. By then, 970 patients had been initiated on ART.
11.4. Resolution: In 2009 all government clinics in Tumahole started providing ARV’s. SACBC ceased funding Thabang Society after 31 May 2011. It had to transfer its patients to government clinics.

12.1. Name and Location: Vicariate ARV Project, Mtubatuba, KZN
12.2. Brief Description: The project provided treatment to patients in Mkhanyakude District in northern KwaZulu/Natal, bordering on to Swaziland and Mozambique – a vast, very poor rural area (no running water, no roads, no electricity) that used to have the highest HIV prevalence in the country for many years. It operated 15 outreach points in the areas around Mtubatuba, Hlabisa and Kosi Bay, using local Churches as “treatment centres”.
12.3. Date of Closure and Number on ART: The site closed in April 2012. By then a total of 2 177 patients had been initiated on ART.
12.4. Resolution: Because of the publicity generated by Mkhanyakude District having had South Africa’s highest HIV prevalence for many years, the government invested considerable sums of money to upgrade health infrastructure in the area. All local clinics now provide ART. During meetings between the projects, the KwaZulu/Natal Department of Health and SACBC, it was agreed that all 535 patients in the Kosi Bay area would be transferred to the government before the end of May 2011. Patients in the Mtubatuba and Hlabisa areas would be transferred to their nearest government clinic at a rate of at least 75 per month. By the end of May 2012 all SACBC ART patients had been transferred to the government, and the project was closed.

B. TREATMENT SITES CLOSED IN MAY 2013

1.1 Name and Location: Kurisanani (St Scholastica Clinic) Tzaneen, Limpopo
1.2 Brief Description: Kurisanani is a Diocesan program, with three satellites, all three serving rural communities: St Joseph’s Clinic is in the Sibasa area, near Thohoyandou, in the Vhembe District, St Scholastica Clinic is in the village of Senwamakgope, near Modjadjiskloof, and Mothupa Clinic operating from the grounds of the government clinic in Mothupa. Both of these are located in the Mopanie District.
1.3 Number on ART: By the end of November 2012, St Scholastica had 204 patients on treatment.
1.4 Resolution: The Mopanie District Office of the Limpopo Department of Health decided that all patients at St Scholastica Clinic are to be transferred to Kgapane Hospital. This process was completed and the site closed in May 2013.

2.1 Name and Location: Hope for Life, Winterveldt, Gauteng
2.2 Brief Description: The site had two clinics – Hope for Life served Winterveldt – a large informal settlement 35 km northwest of Pretoria, formerly part of the Bophuthatswana Homeland, and now under the Tshwane Metropolitan Council (Gauteng Province). Bertoni Clinic is situated in Mmakau, about 20 km further away, in North West Province. Both Clinics operated under the auspices of the Sisters of Mercy.
2.3 Number on ART: By the end of 2012, Bertoni had 400 patients on ART, and Winterveld had 1 157 on ART. The two sites have initiated a combined total of 2667 patients on ART.
2.4 Resolution: In the cases of both Winterveldt and Bertoni, the respective Departments of Health (North West and Gauteng) indicated that they would not be able to provide ARV drugs. Bertoni’s patients were transferred to Hoekfontein Clinic. The transfer was completed by the middle of February 2013, and the site has closed. Despite resistance by Winterveld patients towards being transferred to government facilities, the process was completed, and the Winterveldt Hope for Life Clinic closed as scheduled in May 2013.

3.1 Name and Location: Holy Cross Home, Pretoria, Gauteng
3.2 Brief Description: A residential in-patient hospice in Pretoria, run by the Holy Cross Sisters.
3.3 Number on ART by 31 January 2012: 96. However, Holy Cross had initiated a total of 653 patients on ART since the beginning of the program.
3.4 Resolution: Before the transfer out of patients began, Holy Cross had over 400 patients on ART – mostly hospice patients who were initiated on treatment whilst in residential palliative care. After the Tshwane Metropolitan Council indicated that it was not able to provide Holy Cross with ARV’s, the transfer out of patients began. By the end of January 2013, Holy Cross had only 96 ART patients. The transfer out of patients was completed by April 2013, and Holy Cross’s ARV Clinic terminated operations in May 2013.

4.1 Name and Location: St Francis, Boksburg, Gauteng
4.2 Brief Description: Founded by the Franciscans, St Francis is one of South Africa’s first residential hospices for people with AIDS, and home for HIV positive orphans, situated in Boksburg, in the Ekhuruleni Municipality east of Johannesburg. It has a satellite clinic at Reiger Park – both serve sprawling urban slums in the industrial heartland of the country.
4.3 Number on ART: Since beginning operations, St Francis has initiated a total of 2 463 patients on ART.
4.4 Resolution: The Ekhuruleni District Office of the Gauteng Department of Health visited St Francis on various occasions, tentatively indicating that they would be interested in providing the facility with ARV drugs. It has proven impossible to arrange follow-up meetings with them. As a result, SACBC instructed St Francis to begin transferring out patients. By 31 January 2013 it had only 210 ART patients. The transfers out was completed by the end of April 2013, and the facility’s ARV clinic terminated operations in May 2013.

5.1 Name and Location: Inkanyezi, Orange Farm, Gauteng
5.2 Brief Description: A home based care program started by the Missionaries of Africa (the White Fathers) in Orange Farm – a sprawling slum to the south of Johannesburg.
5.3 Number on ART: Since beginning operations, Inkanyezi has initiated a total of 1143 patients on ART.
5.4 Resolution: The City of Johannesburg District of the Gauteng Department of Health indicated a willingness to provide Inkanyezi with ARV drugs, during meetings in June 2012. It has subsequently proven to be impossible to arrange follow-up meetings with them. Consequently, SACBC instructed Inkanyezi to transfer out all its patients to government clinics. By 31 January 2013, Inkanyezi had 197 patients left. These were also transferred out, and the site ceased operating in May 2013.

6.1 Name and Location: Centocow Mission, Creighton, KZN
6.2 Brief Description: A large mission founded by the Mariannhill Fathers more than a century ago at the foothills of the Drakensberg Mountains in southern KwaZulu/Natal. Its hospital (St Apollinaris Hospital) was taken over by the government during the 1980’s. The hospital still has a close relationship with the local Mission, which is now run by Pauline Fathers from Poland. The area is extremely rural, densely populated and desperately poor, with no running water or electricity, no sanitation, no roads and no employment opportunities. All patients on treatment receive their ARV drugs from the government in the hospital. SACBC provides the hospital’s ARV Clinic with staff (doctors, nurses, counselors, data capturers and pharmacists), and patient support and follow up. SACBC also funds the community outreach, which provides patients with their drugs near the places where they stay.
6.3 Number on ART by 31 January 2013: 1 726. However, since the beginning of the program Centocow has initiated a total of 5 903 patients on ART.
6.4 Resolution: SACBC funding to the program was terminated in May 2013. SACBC could withdraw from Centocow without putting continuation of treatment for patients at risk, because all patients are already receiving their ARV drugs from the government. It continues as an ARV clinic of the KZN Department of health at St Apollinaris Hospital.

C. TREATMENT SITES BEING CONTINUED DURING NO-COST EXTENSION

1.1 Name and Location: Tapologo, Rustenburg, North West
1.2 Brief Description: Tapologo has a 30 bed residential hospice and a network of 13 outreach sites, serving the Bojanala District – a platinum mining area surrounding Rustenburg, that has numerous destitute informal settlements of migrant workers (mostly from Mozambique, Lesotho and Eastern Cape) who come there in search of employment at the mines.
1.3 Number on ART : Tapologo has initiated a total of 4 543 patients on ART since the program began. By 31 August 2013 it had 645 patients on ART.
1.4 Future Prospects: The Management of Rustenburg Hospital as well as the Bojanala District Office of the North West Department of Health met with SACBC and Tapologo on several occasions. The Hospital is anxious to incorporate Tapologo as a down-referral clinic. It will provide Tapologo with ARV drugs and laboratory tests. The Hospital is unable to absorb Tapologo’s patients as referrals – it already has more than 12 000 patients on ART. Discussions with the Bojanala District Office have been complicated. There have been indications that an MOU would be signed – nothing came of this. SACBC consequently instructed Tapologo to begin transferring out patients. The latest indications are that an MOU will be signed, and that Tapologo will receive ARV drugs and laboratory tests from the government. It will therefore continue to be funded for the duration of the no-cost extension, until there is certainty regarding the Department of Health’s intentions.

2.1 Name and Location: Nazareth House, Johannesburg, Gauteng
2.2 Brief Description: An in-patient hospice, home for abandoned HIV positive orphans and ARV clinic run by the Nazareth House Sisters, and serving the immigrant (mostly Zimbabwean and Congolese) population of Johannesburg’s inner-city slums (Hillbrow, Berea and Yeoville).
2.3 Number on ART: 476 by 31 August 2013. But a total of 3 520 patients have been initiated on ART since the program began.
2.4 Future Prospects: Nazareth House’s situation is complicated by the fact that most of its patients are undocumented immigrants – who do not qualify for ARV treatment from the South African government (the government only provides ART to foreigners with valid asylum seeker permits or refugee status). Clinics in the Johannesburg inner city are congested, and find it difficult to absorb Nazareth house’s patients. In June last year, the City of Johannesburg District of the Gauteng Department of Health undertook to begin providing Nazareth House with ARV drugs by November of that year, if Nazareth House took over Aurum’s GP patients. Even though Nazareth House did this, the Department failed to provide it with ARV drugs. Nazareth House will continue to be funded for the period of the no-cost extension, in the hope that the Department will honor its agreement and start providing ARV drugs. In the meantime it is transferring out as many patients as possible, so that it can close down at the end of May 2014 if the Gauteng Department of Health does not provide it with ARV drugs and laboratory tests.

3.1 Name and Location: Siyathokoza Clinic, Botshabelo, Free State
3.2 Brief Description: Siyathokoza comprises of two clinics in Botshabelo – a township 50 km east of Bloemfontein, where people forcibly removed during the Apartheid era were resettled. One clinic is run by the Holy Family Sisters, and the other is run by the Holy Cross Sisters.
3.3 Number on ART: 1 013 by 31 August 2013 – with a total of 1 629 having been initiated on ART since the program began.
3.4 Future Prospects: The Clinic enjoys good working relationships with the local government hospital, which provides it with all of its laboratory tests. The Free State Department of Health agreed to start providing Siyathokoza Clinic with ARV drugs from June 2011, effectively making it a down-referral clinic of the government hospital. The District Manager of the Free State Department of Health expressed a strong interest in the continuation of Siyathokoza’s services – surrounding government clinics are too congested to be able to absorb its patients. In a meeting held in February between the Department, Siyathokoza, SACBC and Aurum (PEPFAR’s new District Partner), Aurum (on the recommendation of the District Manager) agreed to begin paying all Siyathokoza’s staff salaries from its HR budget from 1 April 2013. In February 2013 Siyathokoza obtained an NPO certificate. It will now begin to fund-raise for all non-drug, laboratory or staff expenses, and is able to continue operating. Until then, it will continue to be funded by the SACBC’s no-cost extension.

4.1 Name and Location: Newcastle ARV Project, Newcastle, KZN
4.2 Brief Description: The project was started at Rosary Clinic – a clinic run by the Newcastle Dominican Sisters, serving the population of Blaauwbosch – an informal settlement outside the coal-mining town of Newcastle, in northern KwaZulu/Natal. It draws many patients from the two adjoining townships – Madadeni and Osizweni. In 2010 the Amajuba District (in which Newcastle falls) had the highest HIV prevalence in South Africa. Rosary Clinic was taken over by the KwaZulu/Natal Department of Health in 2008. Since then, the ARV project has been operating from a park home on the Catholic Church property next door to Rosary Clinic.
4.3 Number on ART: 1 537 by 31 August 2013, with a total of 2 522 having been initiated on ART since the program began.
4.4 Future Prospects: The Amajuba District Office of the KwaZulu/Natal Department of Health started to provide the project with ARV drugs from Madadeni Hospital in 2010. It transferred out all its patients who live outside the catchment area of Rosary Clinic to their nearest government clinics. The project receives ARV drugs, opportunistic infection drugs and laboratory tests from Madadeni Hospital for its patients living in Blaauwbosch – effectively making it the “ARV Clinic” of Rosary Clinic, and the down-referral ARV clinic of Madadeni Hospital for its patients living in Blaauwbosch. During the winter of 2013, the park home from which the ARV Clinic operates was transferred from the Church grounds where it stood, to the grounds of Rosary Clinic. It is now physically situated in the Department of Health’s premises. When the no-cost extension comes to an end, it will continue functioning as the ARV clinic of the department of Health’s Rosary Clinic. Negotiations are ongoing regarding the future of staff, when the Department fully takes over at the end of May 2013.

5.1 Name and Location: Blessed Gerard Care Centre, Mandini, KZN
5.2 Brief Description: Blessed Gerard Care Centre is a 30 bed in-patient hospice and a home for 40 abandoned HIV positive orphans, situated in Mandini, Ilembe District, about 90 km north of Durban. It was founded by a Benedictine priest, and is the South African service branch of the Order of Malta.
5.3 Number on ART: 657 by 31 August 2013.
5.4 Future Prospects: Meetings between Blessed Gerard Care Centre, SACBC and the KwaZulu/Natal Department of Health were held at the Centre in the middle of May 2011. The Department was impressed by the superb facilities. It was also made clear that neither the local government district hospital (Stanger Hospital) nor the local clinic (Sundumbili Clinic) were able to take on Blessed Gerard’s patients as down-referrals, due to overcrowding at these facilities. The Department of Health agreed to provide Blessed Gerard Care Centre with ARV drugs, laboratory tests and treatment for opportunistic infections, effectively making it a down-referral ART clinic of Stanger Hospital. It began receiving ARV drugs from the Department in April 2012, and laboratory tests from the Department in April 2013. The Order of Malta is already fundraising in Germany, to enable Blessed Gerard Care Centre to continue paying staff salaries after May 2014.

6.1 Name and Location: Kurisanani (St Joseph’s Clinic, Sibasa, Vhembe District, Limpopo, and Holy Family Clinic, Mothupa, Mopanie District, Limpopo)
6.2 Brief Description: Kurisanani is a Diocesan program, with three satellites, all three serving rural communities (see paragraph B 1 above): St Joseph’s Clinic is in the Sibasa area, near Thohoyandou, in the Vhembe District. It is run by the Holy Spirit Sisters. Holy Family Clinic operated from a park home on the grounds of the Tzaneen Catholic Cathedral. During negotiations with the Mopanie District of the Limpopo department of health, the Department indicated that its greatest need was in the village of Mothupa, about 40 km from Tzaneen. Subsequently, all the patients at Holy Family Clinic were transferred to Van Velden Hospital in Tzaneen. The park home was moved to the premises of the government clinic in Mothupa, and staff began seeing the government clinic’s ARV patients, as well as enrolling new ones. It receives all its ARV drugs and laboratory tests from the government. Patients requiring treatment for opportunistic infections are simply referred to the government clinic on the same premises.
6.3 Number on ART by 31 August 2013: 737 at St Joseph’s Clinic, and 1 127 at Holy Family Clinic.
6.4 Future Prospects: The Limpopo Department of Health has been very accommodating. Following brief negotiations with the Vhembe District, it was agreed that St Joseph’s Clinic would become a down-referral treatment site of Tshilidzini Hospital (the local district hospital). An MOU was signed in March 2011, and the first consignment of ARV drugs was received in the first week of May 2011 – a two month supply for all St Joseph’s patients. Since then supplies have never faltered. During a meeting on 14 December 2012, the Limpopo MEC for Health undertook to provide St Joseph’s with a subsidy to pay staff salaries. In February 2013, NHLS at Tshilidzini Hospital agreed to do all St Joseph’s laboratory tests. St Joseph’s will continue to be funded during the SACBC’s no-cost extension, until it has secured the subsidy from the Limpopo Department of Health to pay its staff.

Holy Family is operating on the Department of Health premises at Mothupa, as the ARV wing of Mothupa Clinic. After the end of May 2014, it will be taken over fully by the government, and will become an integral part of Mothupa Clinic. The Professional Nurse who used to run Holy Family Clinic has already been taken over by the department – she works for the Department but runs the Holy Family ARV Clinic. Negotiations are continuing with the Department to determine the future of Holy Family’s other employees.


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