This activity relates to 8379-Palliative Care;TB/HIV, 8380-ARV services, 8377-M&S, 8376,8381-Lab, 8375,8382,8383,8384,9108-SI.

The Home-Base AIDS Care (HBAC) project is a public health evaluation designed to answer key operational questions to inform the scale-up of ART in rural Uganda. The Ministry of Health (MOH), The AIDS Support Organization (TASO) and USG are partners in this important activity. The program involves provision of ART and three-years of follow-up for 1000 people, using a home-based approach to service delivery. The project will compare the effectiveness of three different ART monitoring systems: a clinical/syndromic approach using lay workers; the syndromic approach with CD4 laboratory monitoring; and, the syndromic approach with both CD4 and viral load monitoring. Protocols have been developed for lay workers to do weekly drug delivery and monitoring using motorcycles to cover a 100km radius. All family members in HBAC were offered VCT and care and treatment as needed. HBAC has developed counseling protocols and behavioral interventions for ART literacy, adherence, and prevention of HIV transmission. The clinical, behavioral, social and economic impact of ART is being monitored and evaluated and results will be disseminated and shared with MOH and ART stakeholders. USG also uses HBAC as a venue for training Ugandans in ART service delivery, as well as in key components of SI, including data analysis and data dissemination. CDC-Uganda staff provide training for all HBAC clinical care providers and patients in basic care services. High level technical staff were involved in overseeing the implementation of the preventive basic care package, including cotrimoxazole prophylaxis. Several of these staff were also involved in the original operational research activities that has defined the basic care package for HIV positive people in Uganda. In FY06 more than 1,500 individuals were served with HIV-related palliative care.

In FY07, the results of the 3 year evaluation of the study will be disseminated locally and through scientific publications. However, plans are in place to extend the study for an additional 3 years in order to fully answer important operational research questions relating to the impact of using clinical monitoring alone, in particular to determine precise definitions of treatment failure. In addition to this HBAC technical assistance, key staff will continue to work with the MOH and the PEPFAR Uganda ART Working Group in promoting the use of basic care services for all HIV+ patients in the country, and provide technical knowledge for ART delivery. Through HBAC, more than 4,000 individuals [including TB patients] will receive HIV-related palliative care.

This activity relates to 8378-Palliative Care;Basic Health Care and Support, 8380-ARV Services, 8375,8382,8383,8384,9108-SI, 8376,8381-Lab, 8377-M&S

The Home-Base AIDS Care project is a public health evaluation designed to answer key operational questions to inform the scale-up of ART in rural Uganda. MOH, TASO and USG are partners in this important activity. The program involves provision of ART and three-years of follow-up for 1000 people, using a home-base approach to service delivery. The project will compare the effectiveness of three different ART monitoring systems: a clinical/syndromic approach using lay workers; the syndromic approach with CD4 laboratory monitoring; and, the syndromic approach with both CD4 and viral load monitoring. Protocols have been developed for lay workers to do weekly drug delivery and monitoring using motorcycles to cover a 100km radius. All family members in HBAC were offered VCT and care and treatment as needed. HBAC has developed counseling protocols and behavioral interventions for ART literacy, adherence, and prevention of HIV transmission. Technical assistance and training from high level CDC-Uganda and CDC-Atlanta staff in TB screening, diagnosis and treatment is provided to all HBAC staff working with HIV positive patients. A major focus of HBAC care includes diagnosis and treatment of TB for all patients who are enrolled on ART. Clinical staff are trained on tools to screen for TB and provide treatment for those co-infected with HIV and TB (approximately 6-10 % of all HIV positive patients in Uganda). HBAC staff are supported in the providing educational sessions to patients, their family members and the community about the links/risks of TB and HIV co-infection.

In FY07, high level CDC technical assistance will continue to support HBAC TB activities. HBAC TB activities will continue to play an important role in HBAC, including developing a screening algorithm for identifying people on ART who have a high probability of having TB. This could potentially be useful in programs throughout the country and elsewhere. As the incidence of TB for existing HBAC clients will have decreased because of prolonged use of ART, resulting in fewer of these patients developing TB in HBAC in FY07. However, we anticipate initiating up to an additional 500 clients on ART in FY07 in order to assess the impact of proposed program changes on adherence and virologic suppression. As well, HBAC has proposed to evaluate the effectiveness of using isoniazid preventive therapy along with ART in reducing the incidence of TB among these 500 clients.

This activity relates to 8378-Palliative Care;Basic Health Care and Support, 8379-Palliative Care;TB/HIV, 8375,8382,8383,8384,9108-SI, 8376,8381-Lab, 8377-M&S.

The Home-Base AIDS Care project is a public health evaluation designed to answer key operational questions to inform the scale-up of ART in rural Uganda. MOH, TASO and USG are partners in this important activity. The program involves provision of ART and three-years of follow-up for 1000 people, using a home-base approach to service delivery. The project will compare the effectiveness of three different ART monitoring systems: a clinical/syndromic approach using lay workers; the syndromic approach with CD4 laboratory monitoring; and, the syndromic approach with both CD4 and viral load monitoring. Protocols have been developed for lay workers to do weekly drug delivery and monitoring using motorcycles to cover a 100km radius. All family members in HBAC were offered VCT and care and treatment as needed. HBAC has developed counselling protocols and behavioral interventions for ART literacy, adherence, and prevention of HIV transmission. ART services in HBAC include provision of cotrimoxazole prophylaxis and basic preventive care, OI treatment, and adherence and prevention counseling. Technical leadership by CDC-Uganda staff for HBAC ART services is provided by a team of very experienced epidemiologists, behavioral and laboratory scientists comprising of expatriate direct hires and Ugandan technical staff. In addition, US CDC has recruited well-trained and very experienced clinicians, nurses and counselors who provide day-to-day patient care, nursing and counseling services to patients enrolled in the ART program. They have together developed and adapted ART treatment, nursing and counseling protocols and guidelines to ensure that high quality Home-Based ARV treatment services are provided through HBAC. The HBAC technical team has also been heavily involved in training staff from other PEPFAR ART programs who frequently come for field practice and in-service training. ARVs are delivered weekly to clients homes by field officers who collect basic clinical information required for clinical monitoring. Subjects also visit the HBAC clinic if acute medical problems develop. In FY06, more than 1031 patients received ARV services, of which 20 were new patients.

In FY07, HBAC will build on FY06 activities. An additional 543 patients, including 10 children will be recruited on ART. 333 patients will be part of Arm D - a group of patients who would have clinical monitoring but who would initiate ART with monthly home visits, rather than weekly.

This activity relates to 8378-Palliative Care;Basic Health Care and Support, 8379-Palliative Care;TB/HIV, 8375,8382,8384,9108-SI, 8380-ARV Services, 8381-Lab, 8377-M&S.

In FY06 the CDC Uganda laboratory continued to offer high quality HIV related services, these included serological testing for HIV, HHV8, HSV2, and Hepatitis B, CD4+ and CD8+ cell counting, full hematology, serum chemistry and viral load testing. The laboratory also introduced PCR techniques to diagnose HIV from dried blood spots collected from infants. Testing services were provided for CDC studies and for partners who had no established laboratory capacity of their own. The CDC laboratory also provided technical assistance and training for laboratory staff to USG implementing partners and to MOH facilities in order to enhance national laboratory services capacity.

During FY06, the CDC laboratory started to assist in health service policy development and the restructuring of CPHL to take on a central role in improving the standards of testing in health service laboratories, including HIV testing services. In addition to expanding this initiative in FY07, the need for laboratory management training will also be addressed as well as continuation of the roll out training program for rapid testing.

In FY07 CDC laboratories will continue to support partners by providing services where they are not available and will also continue to assist in building capacity in both partner laboratories as well as MOH laboratories. Skills, such as PCR for the national HIV infant testing programs will be disseminated to other laboratories with capacity so the program can be extended to cover a greater proportion of the population. This will entail provision of technical training in the CDC laboratories, follow up and support supervision to ensure quality of testing and enrollment on external Quality assurance programs.

In order to integrate services and technical assistance the laboratory works closely with the MOH Laboratory technical committee (LTC) and with the health laboratory service sector. This included the Ministry of Health, in developing a national laboratory health service policy, the Ministry of Education and Sport to support laboratory technician training schools, the Central Public Health Laboratory (CPHL) to develop its role in coordination of reference laboratory and laboratory support programs, the National TB/Leprosy Laboratory (NTLP) to provide quality assurance programs and re-establishing a HIV Reference Laboratory (HRL). The laboratory also works closely with the National Medical Stores for commodity procurement.

The CDC laboratory will continue to provide high-end diagnostic services required for eligibility screening and monitoring of patients on ART, as well as developing, validating and monitoring new, appropriate approaches to diagnostic testing. The laboratory will upgrade its procedures to obtain College of American Pathologists (ACP) accreditation, thus ensuring that testing procedures and results meet internationally acceptable standards.

This activity relates to 8378-Palliative Care;Basic Health Care and Support, 8379-Palliative Care;TB/HIV, 8375,8382,8383,8384,9108-SI, 8376-Lab, 8380-ARV Services, 8377-M&S.

The HBAC laboratory staff in Tororo have been provided with technical assistance and on-the-job training by CDC-Uganda laboratory staff. Under the direction of the CDC laboratory Director, a significant level of effort by the Entebbe Laboratory staff is to provide on-going assistance to HBAC. In addition, the HBAC lab staff have been trained to provide laboratory monitoring for all patients on ART according to the HBAC study protocol. Additionally, HIV testing is provided for patients and family members in their homes through home-based VCT provided by trained lay providers. Quality assurance is conducted using dried blood spots. Other tests are conducted on site in Tororo with quality assurance provided by the main CDC laboratory in Entebbe.

In FY06 viral load, complete blood counts, and CD4 counting were performed on all routine blood samples which are collected on a quarterly basis. An additional 200 subjects were screened for inclusion in HBAC with viral load, CBC, CD4 counting, liver function and serum creatinine tests.

In FY07, CDC Laboratory staff will continue to provide high level technical assistance. Lab activities will be expected to increase somewhat in FY07 due to the addition of up to 500 new clients to be initiated on ART.

This activity relates to 8378-Palliative Care;Basic Health Care and Support, 8379-Palliative Care;TB/HIV, 8375,8382,8383,9108-SI, 8376,8381-Lab, 8380-ARV Services, 8377-M&S.

The CDC Informatics Unit provides technical assistance for the development and implementation of strategic information systems to the country office and national prevention, care and treatment implementing partners. These service providers, who are key recipients of PEPFAR funds, are given direct, hands-on support by the informatics team to design strategic information systems tailored to meet the specific needs of the programs and to build institutional capacity across the organization. The team actively engages partner management and clinic staff at all levels to build consensus and develop applicably standards for effective information system development. Strategic information program interventions range from the design of patient care records, clinic management and logistics system to the integration of monitoring and evaluation of national indicators between the MOH HMIS and the PEPFAR program.

In following activities initiated in FY05 and FY06, the Informatics Unit will focus on the following key areas in FY07: investigate and where applicable develop computer related capabilities such as biological patient recognition, computer power sources, and hand held computers which support our public health partners, support the MOH resource center development of computer capacity for national data collection and reporting; connectivity and computer infrastructure from internet access to specific network topology design and implementation; applications development for the creation of standard information systems and tools for management and clinic facilities; development and design of SI collection instruments; data entry and management; analysis and reporting of SI; and, information and infrastructure security and maintenance. Training in each of these areas will also be developed and supported either directly by the CDC Informatics team or through utilization of outside resources and partners. The goal of training and technical support provided will be to build capacity in partners to implement and maintain their own HMIS with limited on-going technical support from CDC. Technical assistance will also be provided in the interconnectivity of MIS for all partners into the national HMIS and USG systems where required or relevant. Finally, the CDC Informatics Unit will conduct on-going SI needs assessments of partners to ensure informatics resource growth to match needs necessitated by increasing care and prevention activities. The increases in demand reflect the success in implementing initial programs since the partners have used these initial systems and by passed the systems capacity. This activity works closely with MEEPP to maximize synergies and avoid duplication.

This activity relates to 8378-Palliative Care;Basic Health Care and Support, 8379-Palliative Care;TB/HIV, 8373,8375,8382,8384,9108-SI, 8376,8381-Lab, 8380-ARV Services, 10176,10178-M&S. The current CDC/HHS team is compromised of highly trained personnel, including 19 physicians, 4 PhDs, and 14 Masters-level staff in addition to the many with numerous years of program experience. CDC/HHS senior staff includes internationally recognized experts in HIV/AIDS care, treatment and prevention as well as in informatics and laboratory science. Several senior CDC/HHS staff has worked in HIV/AIDS programs in Uganda since the 1980s and has worked with both MOH and NGOs in building Uganda's response. In addition, CDC/HHS staff have years of experience in development, implementation and dissemination of operational evaluations. The current staffing pattern is filled by nine technical experts, thirty-six program officers, five financial executives, one hundred and sixty administrative, support and field officers, and six contractors. Forty-six percent of these staff are fully dedicated to the implementation of the Home-Based AIDS Care targeted evaluation activities at the Tororo field station.

Through the initiation of Emergency Plan activities, CDC/HHS full-time equivalent (FTE) technical and administrative program staff has remained constant at six FTEs by depending on contract personnel to assist with the implementation of expanded programs. This contract personnel mechanism has become increasing problematic. To ensure programs are fully maintained, CDC/HHS is proposing three additional FTE positions in FY07. Two epidemiologists technical positions, one for a generalist/behavioral scientist and on for epidemiologist/treatment advisor will provide oversight and direct technical assistance to the Ministry of Health (MOH) and our implementing partners to develop sustainable systems that will address the national program priorities. Also, one programme manager will be recruited to direct the implementation of our expanded portfolio under the Emergency Plan. In FY07, eighty-five percent of proposed funding will be executed through cooperative agreements through twenty-five partners and sub-partners.

The CDC/HHS-Uganda team is well equipped to manage and support our partner activities, as well as to directly implement key components of the USG Emergency Plan strategy. CDC/HHS technical staff work in four major areas: program technical support, laboratory, informatics, and epidemiology/behavioral evaluation. The Program team works closely with PEPFAR partners to provide high-level technical assistance for program implementation as well as to provide management supervision. The Laboratory team provides senior technical support to the national Central Public Health Laboratory and Reference Laboratories as well as to our laboratory units of all treatment partners. In addition, the CDC laboratory implements over half of high level HIV testing in-country while building capacity by training national and NGO sector laboratories to conduct these tests in their own facilities, and, has developed less expensive CD4 and viral load testing technologies as well as validations of new HIV testing technologies. The Informatics team works very closely with Ministry of Health Resource Center in the development and implementation of the national Health Management Information System. This unit also provides direct technical assistance to implementing partners on applications development, data management, data analysis, connectivity, hardware and software needs, as well as providing extensive training opportunity to strengthen institutional capacity. The Epidemiology and Behavioral teams conduct scientific targeted evaluations on topics such as the impact of ART on morbidity, mortality, HIV transmission and household economics, evaluation and implementation of a basic preventive care package including cotrimoxazole prophylaxis and a safe water vessel, and ART adherence studies. The Program team works across all technical teams to ensure that program and evaluation results as well as scientific evidence are used in supporting the MOH to develop evidence-based policy and implementation guidelines for HIV/AIDS programs. In addition to their technical roles and responsibilities all program staff and selected laboratory, informatics, epidemiology and behavioral staff are actively involved in the management and operations of the recently established USG technical workgroups. CDC/HHS staff chair two of the six technical workgroups and act co-chair for the remaining four.

Approximately six-five percent of the in-country operations and staffing costs are covered through GAP funding. The balance from GHAI funds is for operations of and direct technical assistance level of effort staff provide to the Home-Based AIDS Care targeted evaluation, as well as technical assistance for the implementation of proposed public

health evaluations, the MOH of surveillance, laboratory services support to the central public health laboratory, the national reference laboratory, and our implementing partners. The associated International Cooperative Administration Support Services are outlined in Activity #10176 and Capital Security Cost Sharing are outlined in Activity #10178.