AIDS Information Centre-Uganda (AIC) is a Non-Governmental Organization established in 1990 to provide the public with Voluntary Counseling and Testing (VCT) services on the premise that knowledge of one's own sero-status is an important determinant in controlling the spread of HIV. AIC mandate has expanded to include HIV Counseling and Testing (HCT) which is mainly provided through outreach services. AIC also uses HCT as an entry point for the provision of and referral to HIV/AIDS services including prevention of HIV transmission, treatment of opportunistic infections, Prevention of Mother to Child Transmission (PMTCT), antiretroviral therapy (ART) referral and other care and support services.

According to the 2005 Uganda HIV sero-behavioural survey, 79% of Ugandans don't know their HIV sero-status due to various reasons which include limited access to HCT services. The survey also indicated that 40% of HIV sero-positive Ugandans are in partnership with an HIV-negative spouse and most of these have never been tested and do not know that they are living in a discordant relationship. AIC records show that their clientale have a higher sero-prevalence, 18%-19% as compared to national figure of 6.4%.

In FY07, AIC will continue to provide and increase access to HCT services that promote the integration of relevant and appropriate HIV/AIDS services, including palliative services to make static sites one-stop service centers. As Uganda is one of the world's high-burden countries with tuberculosis (TB) with an estimated incidence rate of 2.2% per year, and an incidence of smear positive TB of 175 cases per 100,000 population per year [WHO, 2006]. TB treatment and prophlyxis will also be emphasized. At present an estimated 50% of TB patients are co-infected with HIV [MOH-NTLP, 2004].

In FY07 AIC in collaboration with the Ministry of Health, will continue to contribute to implementation of the Uganda National policy on TB/HIV integration and the National TB/HIV Communication Strategy with an aim of reducing morbidity and mortality related to TB among persons living with HIV. AIC proposes an approach that maximizes coverage with quality TB/HIV Counseling and Testing services to the most vulnerable populations so as to ensure the highest possible impact with available resources. Community participation in the program is recognized as key in identifying the best solutions and ensuring sustainability. AIC will scale up provision of TB/HIV collaborative activities from 4 to 7 static centers. It is expected that 221,000 clients seek HCT services at the 7 AIC static centers and that AIC supported public health units will be screened for TB disease. All HIV negative clients that are suspected to have TB disease will be evaluated as well. This will be implemented by integrating key TB screening questions in the HCT data collection tool. Using the HCT tool, client data collected , will be captured and entered into the AIC Management Information System. At the four branches of Kampala, Jinja, Mbale and Mbarara (where there is appropriate personnel and laboratory facilities) an estimated 390 clients with active TB will be identified and put on treatment, of these 350 will likely be HIV positive. It is also estimated that 598 clients will be diagnosed with latent TB and treated with Isoniazid Preventive Treatment (IPT). Emphasis will be put on ensuring that active TB is ruled out before they are started on IPT. At the other three branches of Soroti, Kabale and Arua, an estimated 300 clients with a high index of suspicion for active TB, will be referred to nearby hospitals and other public health units for further evaluation for TB disease. Clients will be counseled on TB drug adherence and encouraged to complete their INH. AIC will collect bio-data from the clients to facilitate client follow-up. If a defaults while on treatment for less than six months, then TB home visitors will follow them up. Clients will also be supported to identify treatment supporters according to the National Tuberculosis and Leprosy Treatment Guidelines.

This intervention will be linked to Basic HIV Care and Palliative Care also funded under PEPFAR. Eligible clients will be initiated on cotrimoxazole prophylaxis and offered comprehensive basic care packages as elaborated under that section. An estimated 1,500 clients who will have been diagnosed with TB disease will be screened for HIV to establish their HIV sero-status. This will be done at associated public health institutions identified. The clients found to be HIV positive will be evaluated for ARTeligibility and those eligible will be referred for treatment. All clients will be counseled on TB treatment adherence, nutrition and encouraged to complete their treatment. In this first year, AIC proposes to implement this activity in three public health units.

Full project implementation will require, six medical counselors, four medical officers and

three laboratory technicians to be hired. Additional client data collection tools will be procured to facilitate data collection, and quality service provision. Drugs and laboratory reagents will be accessed from Ministry of Health, where not available they will be procured. An overall estimated target of 221,200 clients will be provided with palliative care including HIV/TB. This target will include all the 121,200 clients whoseek HCT services at AIC main branches and 100,800 clients that will seek services at AIC supported health facilities. AIC in close collaboration with the Ministry of Health will conduct monitoring and support supervision visits to project sites. This will be conducted at two levels; from AIC headquarters to the regional centres and from the regional centres to the health units collaborating with AIC and communities. It is expected that each of the seven regional centres will be visited bi-annually. The supervision teams will comprise of staff from AIC, and MOH. The visits will be aimed at monitoring the project progress.

In collaboration with MOH and other key partners, IEC materials on TB prevention will be developed/adapted and distributed to AIC supported clients. TB/HIV education messages will be incorporated into the AIC counseling protocols. These protocols will be used both at AIC static and outreach sites. Clients accessing HCT services at AIC supported public health facilities will also be screened for TB disease and referred for treatment as appropriate. In addition with other stakeholders AIC will support/ strengthen the functions of the district TB/HIV focal persons whose role is to ensure coordination and implementation of planned TB/HIV collaborative activities in the districts.

Finally, AIC will support targeted supervision and on-the-job training to 168 health workers from public health facilities; orientation for six laboratory technicians; and, TB training for fifteen AIC medical staff. Also 40 community health workers will be oriented in latent TB treatment. An overall estimated target of health service providers trained will be 229.

plus up Funding will be used to scale up TB/HIV integration activities to 2 more regional hospitals and public health facilities. Referral mechanisms to lower level facilities will be strengthened including the CD-DOTS for TB. Capacity will be built in the public health facilities to ensure routine counseling and testing for the TB patients. Subsequent linkage to care and treatment for those found to be HIV positive clients will be implemented and monitored. Tech and financial support will be provided to the public health facilities to train health workers and equip the facilities with Lab equipment and supplies to implement screening for TB among HIV positive clients and routine counseling and testing for TB patients. Support for supervision will be provided to the regional hospitals. Service delivery sites will be facilitated to institute TB infection control plans.

This activity relates to 10038, 10083, 10084, 10102-Strategic Information.

Substantial PEPFAR funds are being used for the provision of voluntary counseling and testing (VCT). In Uganda and other sub-Saharan African countries, VCT guidelines often recommend re-testing of HIV-negative clients after 3-6 months to rule out the possibility of "window period infections", i.e., shortly after infection onset but before the appearance of HIV antibodies. Scientific literature suggests that this period is just 2-4 weeks long. At the AIDS Information Center (AIC), 33% of all testing during 2002-2005 was performed for this purpose, implying that substantial resources are spent to identify a potentially very small group of HIV-infected clients.

We propose to evaluate the utility of repeat-testing for VCT clients who initially tested HIV-negative. The objective is to estimate the likelihood of HIV-negative clients actually being HIV-infected and the potential costs saved by discontinuing this policy.

Routine client questionnaire data will be analyzed to determine the proportion of repeat testers who likely repeat-test due to repeated risk behavior and who return because of the counseling message recommending repeat testing.

Left-over blood specimens from VCT clients frequenting AIC centers already are routinely collected and stored for further testing with informed consent. Approximately 100,000 HIV-negative blood specimens will be pooled in small batches and tested for HIV DNA/RNA. The number and proportion of first-time HIV-seronegative testers actually infected will be determined. Testing and total program costs to identify such persons will be estimated. Identified seronegative but virus-positive VCT clients will be contacted for retesting and re-counseling. A sufficiently large sample size provided, risk factors (using the routine questionnaire data) for truly incident HIV infections will be evaluated.

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