This activity relates to 8313-CT and 8550-Palliative Care; TB/HIV.

In September 2005, Kumi District Local Government received USG funding to implement a Full Access Homebased HIV Confidential Counseling and Testing Program using Outreach Teams in Kumi District, Uganda. The overall goal of this program is to provide counseling and testing services to the entire population residing in Kumi district and refer all those testing HIV positive to sources of ongoing psychosocial support, basic preventive and palliative care, and treatment services.

This activity is closely linked to activity 4046, Counseling and Testing and Palliative care: (TB/HIV). In implementing this activity, Kumi District Directorate of Health Services proposes to work with USG, MOH, indigenous NGOs, CBOs, FBOs and local communities. This activity compliments the HBCT activities whose overall goal is to identify HIV positive clients and refer them to appropriate sources of Care, Treatment and Psychosocial support services within the District. The key components of this activity include strengthening the referral systems in the District including public and NGO health units to be able to provide basic preventative and palliative care. It also focuses on building a local and coordinated indigenous capacity of NGOs, FBOs and CBOs to provide on going psychosocial support and effectively respond to HIV/AIDS issues at the communities. This activity targets all HIV positive clients identified through the home based counseling and testing activities of this project. With an estimated prevalence of HIV in Kumi at 6%, an approximate 7,200 clients will be identified by March 2008. In the Financial Year (FY06), under this activity, 1,177 HIV+ clients were identified through the home based counseling and testing project activities. 407 Males and 1,177 females and were referred for basic care services to the health facilities in the District. Four thousand one hundred and twenty three (4,123) were couples of which 119 were discordant and 125 were concordant positive. Of those referred for basic care 566 have been enrolled on cotrimoxazole prophylaxis and 517 have received basic care starter kits which comprise of safe water vessel, insecticide treated mosquito nets. Cotrimoxazole was procured and distributed to public and NGO health facilities within the District. Starter kits were supplied to the program by Population Services International (PSI). 57 Health Unit Incharges and HBCT core teams were trained by PSI in provision of Basic HIV Care Package. The trained health workers thereafter conducted full site training of other health workers in provision of basic care package services. HIV positive clients also identified by other partners and HIV/AIDS organizations like TASO, AIC and Facility-Based HCT (Static outreach) Sites in the district have received starter kits and cotrimoxazole from the health facilities.

In the FY07, the funds under this activity will be used for procurement of commodities including lab supplies, cotrimoxazole for prophylaxis, safe water vessels, mosquito nets, patient care kits, training of health workers and community care givers in caring for HIV positive clients and supporting the District Health System in managing and monitoring the HIV positive clients referred for care. Every HIV positive client will receive a referral form that will be presented at the nearest health facility where basic care is provided. In order to ensure that HIV positive clients receive basic health care, Cotrimoxazole and starter kits (safe water vessel and insecticide treated mosquito nets) will be procured and distributed to health facilities in the District from HCIII, HCIV and Hospitals where prophylaxis will be initiated and kits given to clients by health workers. Community Resource Persons (CORPs) will be responsible for re-supply of cotrimoxazole and ensure clients are using safe water vessels and insecticide treated nets correctly and consistently in their homes. To effectively implement and ensure that all HIV positive clients and discordant couples receive adequate and qualitative basic care and psychosocial support, health workers and community support groups will be trained on provision and proper use of basic care commodities and psychosocial support services. The Health Facilities in the district will be supported and supplied with necessary logistics and supplies so as to be able to diagnose, and treat Opportunistic Infections (OIs), and provide quality care to all HIV infected persons. Eligible clients will be offered CD4 cell counts and referred for anti retroviral therapy at service outlets within the district. The District Health Team will be responsible for quality assurance of the basic health care component at the health facilities. Local community groups and structures as Post Test Clubs (PTCs) and Peer Support Social Groups (PPSGs) will be formed and supported to mobilize communities for basic care services and provide psychosocial support services to HIV positive clients. The community support groups will also play a vital role in fighting against stigma and discrimination in the

communities. Persons with HIV/AIDS (PHA) Networks will work closely with PTCs and PPSGs for enhanced mobilization and provision of continuous and ongoing psychosocial support to people living positively. Using prevention-with-Positives interventions, a team comprising PHAs will be constituted to follow-up HIV+ clients and discordant couples in their homes to provide adequate psychosocial support and ensure adherence to utilization of basic care services and commodities by clients. For sustainability, health workers and care givers will be trained on Palliative and Community and Home-Based Care (CHBC) to clients. Patient care kits will be procured and distributed through the care givers to the clients in their homes. PHA peer educators will also be trained to supplement efforts of the care givers. To effectively realize a coordinated and enhanced indigenous capacity to respond to HIV/AIDS prevention and treatment activities in the District, collaborative working mechanisms will be established with NGOs, FBOs, CBOs, PHA Networks and health institutions through capacity building and sub granting to ensure adequate and quality service is provided to the population. Radio talks shows, spots and Information, Education and Communication (IEC) materials shall be produced and used to supplement efforts to mobilize communities to take up services.

This activity relates to 8314-Palliative Care;Basic Health Care and Support, 8313-CT.

In September 2005, Kumi District Local Government received USG funding to implement a Full Access Home Based HIV Confidential Counseling and Testing Program using Outreach Teams in Kumi District, Uganda. The overall goal of this program is to provide counseling and testing services to the entire population residing in Kumi district and refer all those testing HIV positive to sources of ongoing psychosocial support, basic preventive and palliative care, and treatment services.

TB/HIV will be a new activity in FY07. In this program, Kumi District Directorate of Health Services is working with USG, MOH, indigenous NGOs, CBOs, FBOs and local communities to provide palliative care specifically on TB/HIV to clients identified through the ongoing HBCT program. The overall goal of the Full Access Home Based Confidential Counseling and Testing program is to identify HIV positive clients and refer them to appropriate sources of care, treatment and support services within the district. The key components of this activity include strengthening the referral systems in the district including public and NGO health units to be able to provide basic preventive and palliative care and TB/HIV collaborative services. In addition, support will be provided to CBOs to establish/expand and strengthen indigenous sources of ongoing psychosocial support in the communities. The target population for this activity includes all HIV positive clients identified through the counseling and testing activities of this project. The prevalence of HIV infection in Kumi district is about 6%. It is expected that approximately 7,200 people will be identified with HIV by March 2008.

During FY06, Five hundred forty eight (548) TB (all types) patients were registered in Kumi District. One hundred forty six (146) were counseled for HIV/AIDS, 107 were tested and received results. Sixty seven (63%) TB patients tested positive, of which 48 were started on Cotrimoxazole and 16 on ART.

In FY07, funds under this activity will be used for enhancing TB/HIV Collaborative activities including referral of all HIV positive clients for TB screening and treatment as appropriate, and CT for people diagnosed with TB, procurement of commodities including lab supplies, training of health workers and Community Resource Persons (CORPS) on TB/HIV integration, improving TB/HIV reporting and surveillance systems, strengthening the role of PHAs in facilitating referral, adherence and improving linkages from CT to TB screening. A counselor will initiate referral of an HIV positive client for TB screening at a health facility nearest to the client. Screening and Sputum examination will be conducted at the facility by trained health service provider. If a client has TB, treatment will be initiated at the health facility and then referred back home for CB-DOTS. For clients who present to the health facility with TB and have not had CT, treatment will be initiated and HCT will be done. Those that test HIV positive will be provided with Basic Care including Cotrimoxazole prophylaxis and referred for CB-DOTS. In order to ensure that the HIV+ clients receive TB screening, laboratory supplies will be procured and supplied in all the health units in the district from HC III, HCIV and hospitals. All HIV positive clients as well as discordant couples will receive follow up counseling and other Prevention With Positives (PWP) interventions and each HIV positive client will receive a referral form to go to the nearest health unit for TB screening with follow-up by the CORPS. In order to ensure successful integration of TB/HIV services, health unit staffs as well as community resource persons will receive training on TB diagnosis and management, records management, and logistics and commodities management. In addition an assessment of all health units in the district will be conducted to identify infrastructure and staffing needs and provided with additional staff, infrastructure, logistics and supplies as required to be able to provide care for the medical needs of HIV-infected people. The District Health Team will be responsible for the supervision and quality assurance of TB/HIV integration at the health facilities. A major component of this program will be community mobilization and is linked to HCT and Basic Palliative care. To strengthen the follow-up of clients on CB-DOTs, CORPs and HIV/AIDS Peer Educators will be used to ensure that clients adhere to treatment so as to minimize the default rate which is a national concern, more so if a client is on ARVs, CB-DOTs and Cotrimoxazole Prophylaxis. The CORPs and PHA Peer Educators in this program are already trained in mobilization for HCT and Basic Palliative Care. Regular reviews will be conducted with CORPs and Peer Educators to assess the progress of the program at the community. TB/HIV programs will be integrated into HCT and Basic Palliative Care mobilization strategies which include use of CORPs, Peer

Psychosocial Support Groups (PPSGs), Persons With HIV/AIDS Peer Educators, PHA Networks and Radio. NGOs, FBOs and CBOs will also play a vital role in sensitizing and mobilizing communities to take up TB/HIV services. IEC packages for TB/HIV integration will also be reprinted and distributed in the communities.

plus ups: Funding will be used to improve capacity of the district to implement TB/HIV integration activities, ensuring that the Health center 3 health facilities are equiped and have trained staff to conduct TB screening. In addition routine counseling and testing provided at all the 16 sites so as to ensure that TB patients are counseled and tested. Supervision and coordination of TB/HIV activities will be supported. Ensure that eligible TB patients are receive HIV treatment. Referral mechanisms for CD-DOTS for TB will be strengthened. Service delivery sites will be facilitated to institute TB infection control plans.

This activity relates to 8314-Palliative Care;Basic Health Care and Support, 8550-Palliative Care;TB/HIV.

In September 2005, Kumi District Local Government received USG funding to implement a Full Access Home Based HIV Confidential Counseling and Testing Program using Outreach Teams in Kumi District, Uganda. The overall goal of this program is to provide HIV counseling and testing services to the entire population residing in Kumi district and refer all those testing HIV positive to sources of ongoing psychosocial support, basic preventive and palliative care, and treatment services. This program also aims at reducing transmission of HIV through preventive counselling and testing and the key components of this activity include mainly, human resource development (staffing & training), procurement, quality assurance and community mobilization. From the inception of the program (October 2005) the following achievements have been registered: Staff recruitment both administrative and field staff including community own resource persons, Procurement of office equipment and supplies, laboratory HIV Test Kits and consumables, staff development whereby several trainings were conducted such as 3 weeks training on basic HIV/AIDS and counselling skills for counsellors and laboratory technicians, 1 week training in the provision of Home Based Counselling and Testing, a two days training of Health Unit in-charges and management staff on counseling and testing and Community Owned Resource Persons (CORPS) training on home based HIV counseling and Testing (HCT) and Community Mobilization. Sensitization meetings for the district LC V Council and Sub-county leaders were also conducted. Weekly Radio Talk shows were conducted and daily radio Spots and are still on-going. Film Shows were done at the sub county level and HIV/AIDS IEC materials were distributed in the communities.

Sixteen (16) outreach teams have been established comprising a counselor and a laboratory assistant. The teams are based at each sub county in the district and are supported by 8 supervisors based at the health sub-districts. 237 community mobilizers were also established at the parish level to assist with community mobilization activities for the program. It is anticipated that by March 2008, 80,000 households will be reached with home based HCT services, and at least 150,000 adults and children at risk of getting HIV will receive HCT services.

From February 2006 up to July 2006, 25,467 clients have been counselled and tested. In FY07, Kumi District Directorate of Health Services [DDHS] will continue to develop and strengthen the process of implementing a full access door-to-door confidential counseling and testing services to the entire population residing in the district. The implementation of the program is mainly the responsibility of the HIV counselors, laboratory technicians, supervisors and community own resource persons (CORPS). The CORPS will continue with the registration of households within their parishes and also assist the outreach teams to mobilize communities for Home based counseling and testing services. They will receive re-training to improve their skills in HIV counseling and community mobilization. Each CORP will be expected to conduct community education seminars at the parish level. Community mobilization is an important on-going activity which determines the success of this program. Communities are being mobilized and sensitized about the program using the appropriate media channels in the district such as daily radio spots, weekly talk shows and occasionally having print messages in the local news paper (Etop). Other available opportunities to pass on information to the communities will be used for example during community meetings at the churches or mosques. Sensitization meetings for sub-county leaders will be done for 5 sub-counties that were not covered at the beginning of this program (Atutur, Kidongole, Kolir, Malera and Bukedea). The program plans to involve all HIV/AIDS implementing partners in the District and lower level councilors to advocate and mobilize communities for HB-CT services. People Living with HIV/AIDS (PHAs) will be used to give testimonies as a way of encouraging those who fear to test come forward and accept to take an HIV test. Post Test Clubs (PTCs) and Peer Psychsocial Support groups will also be used for mobilizing communities as they play a vital role in the reduction of stigma, discrimination and can facilitate disclosure. The outreach team comprising the counselor and laboratory technician will continue with the routine activities such as giving household education to all members of the household they have visited, conducting either couple or individual counseling, HIV testing and filling of data forms, counselor and laboratory registers plus making referral of HIV positive clients to Health units for basic care and treatment. The teams will also continue to collect Dry Spot Blood (DBS) to be taken to the National Reference laboratory for quality

assurance. In order to improve their efficiency and quality of home based (HCT), the teams will be retrained to improve knowledge and skills in couple and child counseling. The outreach teams will be supervised regularly by the supervisors together with the program coordinator and laboratory technologist who will visit each team at their sub counties to ensure that they offer quality HIV counseling and testing services according the counseling protocol and HIV testing algorithm. Procurement of laboratory commodities and other consumables is another very important activity in this program that will be on-going. Other HCT logistics to be procured will include fuel, office supplies and stationery, referral cards, client cards and IEC materials. Data management will be strengthened to inform program is progress and performance. We shall continue to hold monthly review meetings to share problems/challenges field teams face. Monthly meetings between CORPS and supervisors will also be held at the health Sub-district level whereby issues concerning CORPS' work are discussed especially challenges faced while mobilizing communities for HB-CT.

Advisory committee meetings are also going to continue in FY07 because this is the policy making body and overseer of the program. In implementing this program, the office of the District Directorate of Health Services plans to collaborate with all HIV/AIDS implementing partners (CBOs, FBOs & NGOs) in the district thus encouraging building of partnership with existing establishments and local communities. On quarterly basis therefore all the stakeholders/implementing partners will be invited to attend a coordination meeting. Refresher trainings for supervisors and outreach teams will be conducted to up date them as there are always new ideas coming up. Retreats will also be held at least once a year to reduce burnout.

This activity relates to 10036, 10083, 10084, 10102-Strategic Information.

PEPFAR supports an ongoing door-to-door home-based counseling and testing (HBCT) activity for an entire district population in Kumi, Eastern Uganda. Identified HIV-positive persons receive a basic care package (bed nets, condoms, a safe water vessel, a referral mechanism for co-trimoxazole prophylaxis, and informational material for "positive living") and are referred for further care. It is anticipated that this intervention results in a reduction in HIV exposure and a subsequent fall in the rate of new HIV infections (HIV incidence).

Scientific data on the effectiveness of such programs on a population level are not available; further, evaluations comparing HBCT to other VCT delivery modes are scarce. We intend to evaluate this large activity to inform policy decision making. We will examine whether HBCT and provision of the basic care package leads to safer sex behavior, a reduction in new HIV infections and clinical malaria, and a decrease in all-cause mortality. In addition, we plan to compare the effectiveness of HBCT (in reducing HIV incidence and risk behavior) to that of other VCT mechanisms (in a district without HBCT).

We will collect data from approximately 100,000 clients during the HBCT session on sexual behavior and household mortality, diagnose (and treat) clinical malaria, and collect left-over HIV-positive blood on filter paper. Using the serological BED HIV-1 incidence assay, we will test all HIV-positive specimens to identify new (recent) HIV infections and estimate the HIV-1 incidence for the 12 months preceding the HBCT session.

Approximately 12 months after the first HBCT session, field teams will re-visit a sub-sample of the district population (approximately 30,000) a second time. During the second HBCT session, the same intervention package will be re-offered to all (HIV-pos and HIV-neg) household members and the same outcomes (sexual behavior, household mortality, clinical malaria, HIV incidence) will be measured again. We will examine whether the intervention provided through the first HBCT session led to a decline in the measured outcomes and examine possible determinants for a change in these outcomes.

For additional information, please refer to supporting documents in this COP on Public Health Evaluations Study Background Sheets.