plus ups: Stock out of HIV test kit is a great challenge and expansion of the PMTCT national program. Througth the National Medical Stores, thes funds will be used to procure, store and distribute HIV test kits for the PMTCT program. The HIV test its will include: determine HIV 1/2+ Buffer), Screenng: stat -pak HIV1/2 (30% confirmation: unigold HIV 1/2 (2% tie-breaker). The procurement wil also include other accessories such as vacutainers, needles, needle holders, pippettes and racks

Table 3.3.01:

plus ups: "$600,000 of the Plus Up funds will go towards the procurement of cotrimoxazole. This will be a specifically designated cotrimoxazole stock for PHA. It will supplement the existing Ministry of Health supply, and prioritize USG partners. These funds will be provided to the National Medical Stores, which has in the past ably procured and distributed a national stock of prophylactic cotrimoxazole. The NMS will collaborate with the Joint Medical Stores to ensure supply to both public, FBO and NGO health facilities.

"HIV/AIDS Preventive care products There is overwhelming evidence attesting to the effectiveness of preventive care, including chemoprophylaxis, use of bed nets and safe water in delaying HIV disease progression and consequently improving the quality of life for PHA. However, access to these commodities remains low in Uganda. This activity is aimed at expanding access to and ensuring availability of prophylactic cotrimoxazole countrywide. "

Targets

Target Target Value Not Applicable Number of service outlets/programs providing malaria care and/or  referral for HIV-infected clients (diagnosed or presumed) as part of general palliative care Total number of service outlets providing HIV-related palliative care  (excluding TB/HIV) Total number of individuals provided with HIV-related palliative care 30,000
(excluding TB/HIV) Total number of individuals trained to provide HIV-related palliative  care (excluding TB/HIV)

Table 3.3.07: Program Planning Overview Program Area: Palliative Care: TB/HIV Budget Code: HVTB Program Area Code: 07 Total Planned Funding for Program Area: $ 8,178,183.00

Program Area Context:

Uganda is among the 22 countries in the world with the highest Tuberculosis (TB) burden. TB remains the leading cause of morbidity and mortality for people living with HIV/AIDS. In FY07, a key goal for the Emergency Plan in Uganda will be to increase the number of HIV positive TB patients receiving Palliative Care (PC) and antiretroviral treatment (ART). Treating these patients is part of USG's comprehensive approach to support national priorities.

Ugandans face an estimated 3 % annual risk of infection. The annual incidence of TB is 175 per 100,000 and the TB mortality rate is 6.2 %. In 2005, 41,809 TB cases were reported and 50 % of TB patients were co-infected with HIV. Analysis of the 2005 TB reports indicate that Uganda has only achieved a 50.2 % case detection rate of new smear positive TB and 70.4 % treatment success rate. This is significantly below the global case detection and treatment success rates of 70 % and 85 % respectively. Uganda has adopted and implemented the Community Based Directly Observed Treatment Short Course (CB-DOTS) strategy and all districts have now implemented the core DOTS components. However, patient coverage is still low. Reasons for low coverage include delays in drug procurement and distribution, the suspension of the Global Fund (GF) due to mismanagement, shortage of health personnel, and a lack of support supervision. National External Quality Assurance (EQA) to improve the quality of sputum microscopy has been expanded to cover four of the nine zones in Uganda.

TB remains the leading cause of morbidity and mortality for people living with HIV/AIDS (PHAs). In 2003, 30 % of all deaths among PHAs were attributed to TB. Based on these recent experiences with TB/HIV co-infection, it has become apparent that new strategies are needed to improve the integration of TB and HIV services to reduce the TB burden in PHAs. In response to this need, the Ministry of Health (MOH), with support from USG and other development partners, developed and earlier this year launched the TB/HIV integration policy guidelines and communication strategy. USG strategies are consistent with MOH policy guidelines and WHO approaches to TB/HIV integration, which emphasize reducing the burden of TB among PHAs through an integrated approach to management of TB/HIV and a decentralized service delivery and referral system.

Significant progress has been made in integrating TB and HIV management in Uganda. TB/HIV reporting systems have been developed and modified. TB registers capture information on HIV counseling and testing (CT), provision of Cotrimoxazole prophylaxis, and antiretroviral therapy (ART) to TB/HIV co-infected patients. In addition, indicators for TB screening among HIV-positive clients have been developed and are captured in the HIV registers. Training of health workers on TB/HIV integrated activities and use of these registers has so far been conducted in 38 districts. In addition all districts have TB/HIV focal person to coordinate these activities, monitor and provide quarterly reports on the TB/HIV indicators. Despite these improvements, there is still a long way to go in integrating TB and HIV management in Uganda. The 2005 biannual reviews conducted by International Union Against TB and Lung Disease (IUATLD) and Global TB Drug Facility (GDF) mission found that lack of knowledge on TB/HIV collaborative activities hindered the integration of TB and HIV services. Other obstacles to the integration of TB and HIV services included poorly equipped labs, lack of trained personnel and limited support supervision from the district.

In FY06, USG's financial and technical assistance complemented the World Health Organisation (WHO), IUATLD, the German Leprosy and TB Relief Association (GLRA), and the Canadian International Development Agency (CIDA) support to the MOH. During this year, USG supported more than 20 districts and partners and more than 270 service outlets to implement integration of TB/HIV activities, including CT for people diagnosed with TB, and TB screening and treatment for HIV positive patients. USG provided TB treatment directly to a total of 5,867 HIV positive people. Isoniazid preventive therapy (IPT) was recommended and supported in 16 sites. Even though WHO recommends IPT, and the MOH TB/HIV integration policy guidelines support its provision in facilities with the requisite capacity, the limited human resource and organizational capacity in public health facilities remains a challenge to nation wide scale up

of IPT implementation.

Further support was provided to MOH to increase service efficiency and to increase competence in TB/HIV diagnosis and case management, laboratory services, logistics management systems, and TB/HIV reporting systems. HIV/AIDS care and treatment organizations, including the two biggest teaching hospitals, were supported to screen and treat all HIV patients (including children) for TB. In health facilities that provide TB treatment, HIV positive TB patients were linked to services that provided co-trimoxazole prophylaxis and those who were eligible for ARVs were linked to HIV treatment programs. USG will continue to support these integrated TB/HIV activities in FY07.

In FY07, USG aims to directly treat 15,711 HIV positive TB patients and also contribute to the implementation of the national TB/HIV integration policy and communication strategy. This will be achieved through consolidated and coordinated TB/HIV integration training of health workers and supporting partners to develop joint TB/HIV plans. Linkages to CT programs for TB patients will be strengthened so as to ensure that at least 80 percent of TB patients are screened for HIV. In addition, all the expected 231,613 HIV positive clients in the USG supported sites will be screened for TB and referred or diagnosed and treated as appropriate. In FY07 it is expected that 425 USG supported sites will provide TB treatment. All HIV care settings are mandated to have a tuberculosis infection control plan which includes administrative, environmental and personal protection measures to reduce transmission of tuberculosis in health care and congregate settings. Decentralized HIV/TB service delivery will be strengthened by building on existing CB-DOTS programs that are funded with infectious disease resources. The role of PHAs will also be strengthened so as to facilitate referrals and adherence to treatment; and improve linkages between CT and TB screening. USG will also support expanded services in Uganda's conflict affected districts.

Program Area Target: Number of service outlets providing treatment for tuberculosis (TB) to 440 HIV-infected individuals (diagnosed or presumed) in a palliative care setting Number of HIV-infected clients attending HIV care/treatment services that are 20,523 receiving treatment for TB disease Number of HIV-infected clients given TB preventive therapy 2,390 Number of individuals trained to provide treatment for TB to HIV-infected 5,016 individuals (diagnosed or presumed)

Table 3.3.07:

This activity also relates to 8350-Lab.

In September 2004, National Medical Stores (NMS) was awarded funding by the United States Government through CDC to purchase, distribute and track HIV/AIDS-related laboratory supplies reagents and HIV test kits and accessories for all Health Center III facilities and above to the District Hospitals level. Under this funding FBO, NGO and private-not-for-profit health facilities are provided these HIV-related commodities through a partnership with the Joint Medical Stores (JMS). National Medical Stores is a parastatal organization responsible for the management of the national distribution-chain management of essential medicine kits, antiretroviral medicines, TB medicines, contraceptives and other basic medical and laboratory supplies. In FY05 the National Laboratory Logistics System for HIV/AIDS-related laboratory commodities was developed and is now fully functional with the first two push cycles distributed to the health units country wide in FY06.

Using the Navision 3.7 commodity tracking software, NMS has the ability to generate shipment and consumption reports of HIV/AIDS test kits and laboratory supplies tracked directly to each health facility. In addition, this logistics system allows for the integration of donated test kits and accessories from other sources, such as the Global Fund into the routine supply system for health commodities, thus providing a comprehensive mechanism to track current stock and forecast procurement. With the USG funding assistance, NMS capacity to ensure the country's health commodity distribution system has been strengthened to handle the HIV/AIDS-related commodities and their timely delivery countrywide by equipping National Medical Stores with additional transport vehicles, warehouse equipment, and central and district cold-chain boxes. This is leveraged by additional funding sources that provided an electrical mobile cargo side loader of appropriate specification that will be installed at the Dispatch Bay, thus enabling faster dispatch of palletized district orders of HIV/AIDS related commodities.

Following the national HIV testing algorithm, National Medical Stores has to-date procured a total of 1,600,00- persons HIV tests and distributed 1,200,000 -persons test kits. To ensure a continuous supply, 600,000 persons tests is expected in the country by mid-November 2006 and the procurement order for the distribution cycle is in process. In FY07, the number of HIV test kits to be procured by National Medical stores will be increased to approximately 2,000,000 persons-tests which will provide for 40% of the MOH forecasted national testing requirements of 5,000,000 persons tests. To address the national "Know your status " drive, MoH requires an additional 2,000,000 persons tests. With challenges faced by other test kits providers, e.g. the Global Fund, the USG is currently perceived as the "solution" to this deficit. In addition an assessment of the national logistics system for HIV/AIDS laboratory supplies and accessories will be conducted to inform the plan for system strengthening.

plus ups: To support the increased demand for HCT services generated by the expansion of new HCT approaches such as provider initiated HCT; door to door HCT and partner/family HCT. The National Medical Stores (NMS) will prpcure and distribute HIV test kits and associated supplies to ensure a continous national supply

This activity also relates to 8351 CT.

In September 2004, National Medical Stores (NMS) was awarded funding by the United States Government through CDC to purchase, distribute and track HIV/AIDS-related laboratory supplies and reagents for all Health Center III facilities and above to the District Hospitals level. Under this funding FBO, NGO and private-not-for-profit health facilities are provided these HIV-related commodities through a partnership with the Joint Medical Stores (JMS). National Medical Stores is a parastatal organization responsible for the management of the national distribution-chain management of essential medicine kits, antiretroviral medicines, TB medicines, contraceptives and other basic medical and laboratory supplies. In FY05 the National Laboratory Logistics System for HIV/AIDS-related laboratory commodities was developed and is now fully functional with the first two push cycles distributed to the health units country wide in FY06.

Because the national system had not previously provided HIV/AIDS-related laboratory supplies, to initiate the supply chain NMS prepared ‘essential packages' of laboratory reagents and supplies according to the laboratory functioning of each Health Facility and ‘pushed' these packages through two-cycles in order to create demand. Following the third cycle ‘push' to take place in November-December 2006, health facility laboratory managers, who have received training in logistics management, will prepare orders from a list of predetermined HIV/AIDS-related laboratory reagents and supplies, up to the limit of ‘credit' as determined by the Ministry of Health and in respect to funds available. As with the existing essential drug supply ‘pull-system', health facilities will use a standard order form to place orders for the approved range of HIV/AID-related laboratory supplies every two months. These orders will be packed per facility and delivered together with the essential drugs. The National Medical Stores delivers packed and palletized orders to the District Drug warehouse from where the commodities are collected by the Health Facility.

Using the Navision 3.7 commodity tracking software, NMS has the ability to generate shipment and consumption reports of HIV/AIDS-related laboratory supplies and test kits tracked directly to each health facility. In addition, this logistics system allows for the integration of donated stocks of laboratory reagents and supplies from other sources, such as the Global Fund into the routine supply system for health commodities, thus providing a comprehensive mechanism to track current stock and forecast procurement. With the USG funding assistance, NMS capacity to ensure the country's health commodity distribution system has been strengthened to handle the HIV/AIDS-related commodities and their timely delivery countrywide by equipping National Medical Stores with additional transport vehicles, warehouse equipment, and central and district cold-chain boxes. This is leveraged by additional funding sources that provided an electrical mobile cargo side loader of appropriate specification that will be installed at the Dispatch Bay, thus enabling faster dispatch of palletized district orders of HIV/AIDS related commodities.

In FY07 USG funding to National Medical Stores will support sustaining the supply channel for HIV/AIDS-related laboratory reagents and supplies as well as HIV test kits and associated materials. The National Medical Stores and Joint Medical Store will review and expand the laboratory needs within the scope of the project to cater for the pediatric HIV/AIDS needs as well as supplies to the eighteen (18) regional referral hospitals country-wide with the goal to meet at least 30% of facility requirements. Additional accessories will be procured for CD4 and CD8 monitoring for the patients receiving Anti Retro Viral Treatment. As counseling and testing services are increased in FY07, the need for laboratory reagents and supplies will increase, especially those used for monitoring patients on ART and HIV positive populations, not yet eligible for ART. A substaintial amount of laboratory reagents and commodities were supplied by the Global Fund in previous financial years, but given the challenges it is facing, this may not be possible. As a result, the USG is currently viewed as a potential back stop for this deficit. An assessment of the laboratory logistics system for HIV/AIDS-related supplies and accessories will be undertaken to inform a plan for system strengthening.

Plus ups: Currently USG is funding the purchase and distribution of most laboratory commodities in the health sector and this is having a significant effect on technician motivation and moral and hence on service delivery. However, it is estimated that the current laboratory commodities credit-line meets only 50% of the actual commodities needs. Additional funding of US$ 200,000 is required for NMS to extend the laboratory

credit-line to additional health facilities; to facilitate more regular deliveries of commodities; to procure additional instrumentation and commodities to broaden access to the minimum diagnostic package and to expand the availability of reconstituted reagents, especially stains used in the diagnosis of malaria and TB on which both the TB and malaria control programs and more recently PMI, heavily depend.