Protecting Families Against HIV/AIDS (PREFA) is a Non-Governmental Organisation supported by USG to promote comprehensive, holistic PMTCT activities in Uganda. PREFA has core PMTCT activities as well as supporting 2 sub-partners, Tororo District Hospital (TDH) and the Islamic Medical Association of Uganda (IMAU), in Wakiso District.

In FY 06, PREFA successfully carried out its core activities and supported its 2 sub-partners to provide PMTCT services through 20 outlets that were providing the minimum package of PMTCT according to national and international standards.

In FY07, PREFA will continue working with these 2 sub-partners in innovative new projects and comprehensive PMTCT services that include the four pillar approach (primary prevention; family planning; provision of ARV prophylaxis; care and support) in Uganda. PREFA's core activities will support comprehensive PMTCT services in Kampala and Kayunga districts. 31 health centers and 2 hospitals (of which 5 are new sites), will be supported to provide routine counseling and testing for PMTCT targeting pregnant women, their partners and families. Clients will receive a comprehensive PMTCT package including MCH (focused antenatal care, maternity and post-natal), opt-out routine HIV counseling and testing (HCT) services, quality obstetric care, ART ( prophylaxis for mother and baby according to revised national policy or treatment according to client eligibility), client and family member follow-up through home and clinic visits, basic health care package (BCP), as well as referral of clients and their immediate family members for further care and treatment to other institutions including PIDC, MJAP and Reach Out Mbuya.

This funding will also support training of 422 health workers in provision of PMTCT, pediatric care and counselling, reproductive health including family planning, home-based HIV testing and counselling, integration of reproductive health and PMTCT, community awareness and mobilization, and training of 50 trainers/supervisors in PMTCT as well as refreshing the 362 counselors and health workers in the newly revised PMTCT policy. In addition, activities will include general HIV care and support services, quality assurance of HIV testing, HIV outreach testing, filling critical human resource gaps, and purchase of a buffer stock of HIV test kits, ARVS (for PMTCT), logistics and supplies, and community mobilization activities including film and radio sensitization; refreshing and supporting 170 community counselling aides who perform mobilization, sensitization, counselling and referral. In collaboration with the MoH PREFA will evaluate access to early infant diagnosis and its effects on infant feeding decisions in addition to assessing the feasibility of AZT+NVP implementation at a district facility level.

Overall, funding will support CT to 5,381 ANC clients, provide ARV prophylaxis to 3,680 HIV infected pregnant women. PREFA will liaise with the MoH and other stakeholders for the development and dissemination of revised training manuals, and user hand books, as well as appropriate community IEC methods and materials for PMTCT. PREFA will also work to improve the ongoing activities, and practice new innovations and best practices at Kangulumira model site in Kayunga district. The program, M&E, Finance, and training officers will provide regular technical support (including periodic support supervision) to all partner PMTCT programs.

The sub-partner Tororo District Hospital (TDH) will provide comprehensive PMTCT services to pregnant women and their partners within their antenatal/MCH setting, as well as at 8 outreach health centers (2 new ones). Clients will receive the comprehensive PMTCT services according to the revised national policy, follow up clients through home and clinic visits, home based HCT to increase access to HIV services by family members, and provide the basic health care package, as well as referral of the client and her family members for further care and treatment to TASO - Tororo and TDH ART clinic. Funding will support staff capacity building including training of 35 health workers in pediatric care and ART services, care and support services, procurement of test kits and lab equipment, reagents and supplies especially strengthening early infant testing; support facility-, outreach- and home-based implementation of the program, with a particular emphasis on improving TDH's capacity for infant treatment, care, support and follow up; and program administration. TDH will provide CT to 12,000 ANC clients, provide ARV prophylaxis to 700 HIV infected pregnant women. The program will also sensitize 30 TBAs on PMTCT and monitor their contribution to service delivery.

The second sub-partner is Islamic Medical Association of Uganda (IMAU) who will provide

comprehensive PMTCT services at Saidina Abubakar Islamic Hospital (SAIH) in Wakiso district. SAIH will provide PMTCT services including HIV Testing to pregnant women and their male partners, provision of anti-retroviral (ARV) drugs to the HIV infected mothers, their infants and their partners. IMAU will also conduct community education and mobilization that target adult men and women, and people living with HIV/AIDS using health fairs as well as outreach and home visits. The project will provide follow up services for PMTCT clients and their families. This funding will support care and support, purchase of HIV test kits, ARVS (for PMTCT), equipment, logistics and supplies as well as above mentioned community work. The hospital and related health facilities' target is to provide counseling and testing to 2,000 ANC clients, provide ARV prophylaxis to 160 HIV infected pregnant women, and training of 30 traditional birth attendants in PMTCT service provision. All three organizations will contribute to PREFA's vision of improving access to high quality HIV/AIDS services using a family approach through provision of PMTCT services, appropriate referral of HIV affected clients for treatment, care and support, as well as through sustaining an elaborate community sensitization, mobilization, and follow up program.

In FY07, PREFA will evaluate the acceptability and feasibility of offering daily AZT to pregnant women in one district hospital and two health centers (HC) IV as of the 28th week of their pregnancy in addition to SD-NVP in labor, as well as SD-NVP and 1-week course of AZT to their baby as a means to further reduce MTCT. Results will inform implementation of this strategy at a time when the national program is considering adding AZT to its standard PMTCT drug supply.

In addition, PREFA will conduct an assessment to: •assess factors determining accessibility of PCR testing to the target population; •find out how knowledge of the infant's HIV sero status affects/influences infant feeding practices.

Please refer to the supporting documents in this COP for the PHE Background Sheet.

*Implement a comprehensive PMTCT program in 90 sites including HC III levels within 15 districts. Key strategies include: Strengthen MCH services where PMTCT services are integrated; provide routine opt-out CT for pregnant mothers attending ANC; provide effective ARV prophylactic regimens (including HAART and combination ARV prophylactic regimens); provide basic prventive care for HIV+ pregnant women and ensuring that there is a system for linking PMTCT mothers and infants into the ART clinics. Postnatal care services will be strengthened and expanded with the integration of early infant HIV diagnosis services and infant feeding counseling; and a system will be put in place for following up PMTCT clients through PNC and the community. The program will support recruitment of 3 officers based at the central level to support the coordination and strenghtening of family planning integration, Communication and linkage. Districts will conduct routine supervision at all sites.

This activity relates to 10036, 10038, 10084, 10102-Strategic Information.

Daily cotrimoxazole or trimethoprim-sulfamethoxazole (TMP-SMZ) prophylaxis has been established and is recommended by WHO as a safe and effective way to reduce morbidity and mortality among both HIV-infected adults and infants. Currently, most HIV-exposed infants in resource-constrained settings do not have access to early testing by PCR, thus the majority of infants receive TMP-SMZ for up to a year of life or more, independent of their HIV status. This measure has the added advantage of being very inexpensive and of being very easy to implement. However, the current introduction of early infant testing strategies in sub-Saharan Africa will elicit a new situation where TMP-SMZ will be stopped for a majority of infants who will turn out to be HIV-negative after being weaned, if following current guidelines. As TMP-SMZ may have protective effects against malaria and other major infections in normal children, and as HIV-exposed, uninfected infants are known to have a greatly elevated risk of mortality compared to non-exposed infants, this practice could adversely affect the health and survival of HIV-exposed but uninfected children. We propose to compare rates of mortality among uninfected HIV-exposed infants who continue to take TMP-SMZ up to 18 months of age independent of their HIV status, as compared to HIV-uninfected infants who stop TMP-SMZ once confirmed HIV negative (i.e., 6 weeks or more after complete cessation of breastfeeding). Secondary outcomes will include incidence of malaria, diarrhea and pneumonia, growth pattern as measured by weight for height indices and self-reported rates of hospitalization as a measure of morbidity.

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