This activity also relates to activity 8277-Laboratory Infrastructure. The interaction of TB and HIV is increasing the burden of both these prevalent infections. The National TB Reference Laboratory (NTRL) of Uganda supports the National TB program to achieve its aim of TB case finding and management mainly by supporting sputum smear microscopy services country wide. The key roles of the NTRL are to provide training, supervision, Quality Assurance (QA) with an emphasis on External Quality Assurance (EQA) of the district laboratories and NGOs supporting CB-DOTS programs. It also provides limited reference support to the districts in the diagnosis and monitoring of extremely difficult cases, as well as support for national TB drug resistance surveillance.The NTRL attempts to strengthen and intensify screening for TB in all HIV/AIDS infected patients, as well as encourage HIV screening for TB patients. The realization of these goals depends on nationwide coverage of an EQA system at HIV prevention, care, and treatment sites, as well as training and re-training in basic TB diagnostic procedures and in establishing a system that encourages and provides all TB patients with access to HIV screening. NTRL expects TB /HIV integrated activities to lead to increased detection and treatment of TB among persons with HIV/AIDS (PLWHA) attending HIV prevention, care and treatment sites. In addition, an increased number of TB patients will have their HIV status established.

TB/HIV co-infection will be reduced by the provision of quality acid-fast bacilli (AFB) smear diagnostic services. Quality AFB smear diagnostic services will be achieved through the implementation of an EQA scheme coupled with targeted supportive supervision as well as refresher trainings that will be conducted at a newly equipped training laboratory at the NTRL. Improvement of human resource development in qualitative and quantitative aspects will improve accessibility to TB diagnostics services for PLWHA.

In FY06 the NTRL introduced EQA in Central, Eastern and North Western Zones and strengthened EQA in Kampala, South Western and South Eastern Zones through re-visiting of areas with inadequate e.g, slides not collected or technical problems performance. Feedback reports were provided to the District TB and Leprosy Supervisors (DTLS) to further encourage them to continue collecting slides and to address administrative problems concerning forwarding of slides and transmission of feedback reports to the health facilities. Ninety laboratory personnel, 1 Zonal TB Supervisor, 10 District TB/Leprosy Supervisors and 10 District Laboratory Focal Persons were trained in EQA. Supervision visits were conducted. Three staff were recruited for the central laboratory. One Vehicle, 10 Microscopes, office equipment, 2 computers, laptop, LCD projector, slide boxes and generator were procured. Standard Operational Procedures and EQA Guidelines were drafted, printed and disseminated.

FY 07 will focus on further strengthening the EQA System through increased supervision as well as continued training-and re-training of laboratory personnel. EQA will be expanded to the remaining 4 zones. The main focus will be on decentralization of the EQA System by identification of laboratories to perform first and second tier-level quality control. This will demand training of 100 laboratory staff and facilitating the Laboratory Focal Persons of Districts/Regions to carry out support supervision and problem-oriented supervision. A laboratory coordinator will be hired to oversee the day to day activities, prepare and submit and follow up EQA reports to peripheral laboratories, as well as compile budgets, ensure accountability and prepare quarterly reports.

NTRL will also focus on better patient care TB and HIV co-infected patients by initiating drug susceptibility surveillance to identify multi-drug resistant (MDR) TB. For FY 07 NTRL wants to complete the protocol to establish a system for sample transport, as well as piloting drug surveillance in one identified district. In order to ensure flow of work and the provision of rapid test results, NTRL will introduce the MGIT System. This will enable NTRL to expand laboratory diagnosis by culturing samples and subsequently increase diagnosis of TB in HIV/AIDS.

This activity also relates to activity 8278-Palliative Care:TB/HIV and RPSO's Laboratory Infrastructure activity. AMREF is funded to improve staffing capacity at Health Center III [HC III] and strengthen laboratory services at Health Centre IV [HC IV] and above in Uganda. In particular, AMREF focuses on improving district laboratory staffing levels at HC III to enable them upgrade to Laboratory Assistants; improving the status of the electrical and water system facilities at the Laboratory Assistants' training schools, strengthening capacity of laboratory staff, Clinicians and Counselors serving at Ministry of Health (MoH), UPDF, Police, Prisons and FBO laboratories at HC IV and above; and supporting strengthening of the Central Public Health Laboratory's internal and external quality control system. Based on the National Laboratory Assessment Survey, Ministry of Health [2004], and through support supervision, AMREF identified 18 laboratories that required immediate capacity building in order to offer HIV counseling and testing, and other key tests related to OI diagnosis for people living with HIV, such as TB screening. In FY06, AMREF rehabilitated 18 laboratories and provided supplementary equipment to 85 laboratories based on Ministry of Health (MoH) standards, thus improving laboratory capacity to offer HIV testing to support VCT, TB screening and other key tests related to opportunistic infections diagnosis. The equipment included microscopes-binocular, colorimeters-digital, cuvettes-electrical, centrifuges-electrical and manual, autoclave-externally heated, Neubauer counting chamber, glasses for counting chamber, micro liter pipettes-automatic, pipette tips for micro liter pipettes, Sahli haemoglobinometer, Sahli haemoglobinometer tubes, Sahli HB meter pipettes, Tally Counters-multi key, Spirit lamps, Wire loop holder, Erythrocyte Sedimentation Rate [ESR] Westergrene Stand, ESR tubes, Hot plates, Kerosene stoves. Structured in-service training for 126 laboratory staff, 128 clinicians and 165 counselors was conducted; follow-up of these health workers was carried out at their stations of work to consolidate practical skills. 14 laboratory staff from 13 remote districts are sponsored for a three year laboratory technicians' course in three Medical Laboratory Training Schools in Kampala. An ELISA reader and washer were purchased for the Central Public Health Laboratory (CPHL) of MoH to support HIV/AIDS quality control. All these activities were aimed at ensuring the provision of services that are of reliable quality and are available without interruption. During FY06, 74 persons attended Training of Trainers' course; these trainers carry out refresher training and support supervision of laboratory staff. 70 participants (Regional Laboratory Coordinators, District Laboratory Focal Persons, representatives from Faith-Based Organizations, Army, Police, and Prisons) from 56 districts attended a course in management and preparation of quality control materials for HIV, TB, parasites, standard white blood cell total, differential counting, computation of total lymphocyte count. Quality control materials were prepared and distributed to 55 laboratories, whose results were acceptable. 37 motor cycles were procured for the District Laboratory Focal Persons to facilitate support supervision. Three laboratory textbooks were provided to 97 laboratories at HC IV level, district hospitals level and regional hospital level in 19 districts; 12 HC III laboratories in the conflict districts of Gulu, Pader and Kitgum, each received one reference text book. A training officer was appointed to scale up laboratory services at HC III level in these districts through supervision and on-site training. To fulfill MoH's, human resource plan of re-profiling low cadre staff to become more skilled, 49 non professional staff from HC III are currently sponsored for the laboratory assistants' course in nine Medical Laboratory Training Schools in-country. Refrigerators, distillers, overhead projectors, LCD projectors, computers, colorimeters, binocular microscopes, automatic power regulars were some of the equipment that was provided to these training schools. Diagnostics, chemicals and supplies were also provided. AMREF will continue to strengthen skills of health workers (laboratory personnel, clinicians, counselors) at HC III and above, as well as improve the laboratories' capacity nationwide to offer HIV testing to support VCT, TB screening and other key tests related to opportunistic infections diagnosis that is of reliable quality. Supplemental equipment will be distributed to 50 laboratories, all based on the MoH standards. Health care workers will have their skills strengthened; 100 clinicians on appropriate utilization of and planning for laboratories, 80 laboratory staff in essential new technology for testing HIV and related conditions, and planning for laboratories; 120 counselors on new initiatives on counseling and the role of the laboratory in counseling. In order to build the staffing capacity, sponsorship for 19 Laboratory Technicians [14 continuing students and 5 new students in FY07] and 124 Laboratory Assistants [49 continuing students and 75 new students] will be continued. 550 essential reference books will be provided to 180 laboratories nation wide, including the virtual districts of the Army, Prisons and Police forces. To further strengthen competencies of the trained health workers, quarterly support supervision will be conducted. Two

regional monitoring and advocacy meetings will be conducted to enhance stake holder support. The conflict districts of Gulu, Kitgum and Pader have extremely poor laboratory services with a high indication of need for HCT services. On-site training and support supervision will be conducted in those districts to scale up laboratory services in health centre IIIs, where the majority of the population goes for health services