This activity also relates to activities in HIV/AIDS Treatment/ARV Services, Laboratory Infrastructure, Prevention Abstinence and Being faithful, Palliative Care - Basic Health care & support, Palliative care-TB/HIV, Orphans and Vulnerable Children, and Strategic Information. AIDSRelief (AR) is a comprehensive HIV care and treatment program, providing ARV drugs, preventive, palliative, curative, social and ARV services to HIV positive people, their families and communities. Its goal is to ensure that people living with HIV/AIDS have access to ART and high quality medical care. AR is a consortium of five organizations with CRS as prime; Constella Futures Group and the Institute of Human Virology (IHV) providing technical assistance. AR works through 15 Local Partner Treatment Facilities (LPTFs), many of which are in rural and underserved areas.

Procurement of ARV drugs follows USG grant guidelines and National Drug Authority regulations and agrees with National Treatment Guidelines. AR's procurement system encompasses cost effectiveness through global procurement orders & contracts with a regional pharmaceutical procurement company; local sustainability is supported through the Joint Medical Stores (JMS) for warehousing and distribution. AR substitutes innovator proprietary ARVs with FDA approved generic equivalents. Over 60% of drugs used in the program are generically bioequivalent. All the drugs are purchased at Access prices. For generics AR has negotiated prices even lower than those offered under the Clinton Foundation agreement with selected pharmaceutical companies. The Pharmaceutical Management team manages in-country operations with a Therapeutic Drug Committee (TDC) of clinicians, pharmacists, strategic information advisors and program managers. The TDC reviews drug utilization patterns across all LPTFs, assesses scale-up progress and develops required technical support plans. The TDC will be replicated at all LPTFs to ensure ARV SCM is clinically informed and logistically supported.

The Logistic Management Information System (LMIS) used, includes a web-based enterprise inventory and financial management system that allows drug tracking from procurement to dispensing, interfacing with the ART Dispensing Software developed by MSH RPMPlus Program installed at LPTFs. This permits continuous modulation of patient enrollment to reflect ARV availability and to ensure a guaranteed and continuous supply of drugs for each patient initiated on therapy.

AR Uganda will provide ARV drugs to maintain the 10,700 people started on treatment and this will be supported by both local centrally funded funds. ARV services are provided to additional 1300 patients on treatment with non-USG funded drugs making a total of 12,000 patients. The funding scenario will only allow replacement of patients who have died or transferred to another program (March 2007-February 2008). AR will, however, also look into options of enrolling additional number of patients if at all possible. AR will continue to procure adult 1st line, alternative 1st line, and 2nd line therapies for both adults (9845) and children (855). Standard Operating Procedures (SOPs) have been developed in accordance with national guidelines that guide supply chain activities from product selection, forecasting, procurement and drug use monitoring. AR will ensure excellent supply chain management and uninterrupted ARV provision through local capacity building at critical points within the supply management chain. Emphasis will be made on strengthening all these systems, especially at LPTF level. AIDSRelief will also work closely with the Government of Uganda, the USG team in-country, and other partners and programs to harmonize and strengthen pharmaceutical supply chain systems.

IHV will participate in the periodic review of National Treatment Guidelines in order to assist in the selection of regimens most appropriate to the Ugandan context. Choice of regimen is guided by most recent evidence to ensure that the most effective & durable regimen available within the national guidelines with the best possible toxicity and resistance profile. Current choice of primary regimen for AR sites consists of Truvada (TVD) combined with Nevirapine (NVP) or Efavirenz (EFV).Kaletra and Combivir (AZT/3TC) will be substituted in case of intolerance or toxicity. Alternative regimens including Stavudine (D4T) and Lamivudine (3TC) are also procured to be used for patients with both renal insufficiency and anemia. The choice of regimen is based on the more favorable pharmacokinetic and safety profile and is supported by extensive clinical evidence. This is also designed to preserve optimal therapeutic choices for second line regimens.

AIDSRelief site activation process includes a 2- week on site program with both didactic

and clinical preceptorship activities. AIDSRelief has and will continue to support its sites with frequent on-site mentoring, quarterly focus group meetings and access to a web based site on which difficult cases can be discussed. This process is designed to provide LPTFs with ongoing clinical technical assistance and to keep them abreast with the latest developments in the care of HIV patients.

AIDSRelief is a comprehensive and integrated HIV program that provides prevention, ARV drugs and services as well as palliative care to HIV positive people & their families. AIDSRelief is a consortium of five organizations with Catholic Relief Services as the lead agency responsible for overall coordination and management of consortium activities, Constella Futures Group leading the Projects Strategic Information systems which provide essential clinical and programmatic information and Institute of Human Virology providing guidance and informing the establishment of treatment, adherence and care protocols. AIDSRelief program in Uganda will continue to maintain 12,000 patients on treatment by February 28, 2008 as well as will provide care services to 17.170 HIV positive patients. AIDSRelief services will be offered through 15 Points of Service (POS), distributed through out Uganda. The cost of ARV drugs in FY07 will be at $7,000,000 without any possibility of creating a buffer stock. However, the $3,667,621 early funding requested from country-funding COP07 will help the 6-months in advance order in such a way that not shortfall in the provision of ARV drugs will be created at the beginning of next project year. AIDSRelief feels strongly that the integrity of the ARV pipeline must be maintained in a way that ensures uninterrupted access to anti-retroviral therapy (ART). ARV drugs must be in place by February 28, 2007 to guarantee that there are no stock outs at AIDSRelief-supported Local Partner Treatment Facilities (LPTF) in Uganda. ARV procurement cycle from the moment an order is placed till the patient receives drugs takes about 6 months hence the early funding of this activity is critical. This approach also helps with securing all the drugs needed for the regimen mixes used as well as provides the opportunity for getting lower prices. In order to reduce ARV costs, AIDSRelief will also continue with procuring FDA-approved generics which are part of the current treatment regimen.

This activity also relates to activities HIV/AIDS Treatment/ARV Drugs, Laboratory Infrastructure, Prevention Abstinence and Being faithful, Palliative Care - Basic Health care & support, Palliative care-TB/HIV, PMTCT, Orphans and Vulnerable Children, and Strategic Information. AIDSRelief (AR) is a comprehensive HIV CARE program, providing ARVs, preventive, curative, palliative care and ARV services to HIV positive people and their families. Its goal is to ensure that people living with HIV/AIDS have access to ART and high quality medical care. AIDSRelief is a consortium of five organizations. Catholic Relief Services is the lead agency responsible for overall coordination and management of consortium activities, Constella Futures Group leads the Projects Strategic Information activities and the Institute of Human Virology guides and informs the establishment of treatment, adherence and care protocols. Based on its successes and lessons learned and with the support from central funding, the AIDSRelief program in Uganda will maintain 12,000 patients on ART. AR will also provide care services to 17,170 HIV positive patients. New patients will be added into the program based on treatment spaces" being opened if a patient dies or is transferred out of the AR program. Services will be offered through 15 Local Partner Treatment Facilities (LPTFs), distributed through out Uganda. The Children's Aid Fund is a sub-grantee supporting 5 of these sites. AR has demonstrated considerable programmatic success to date. This has been verified through results from a quality assurance/quality improvement (QA/QI) set of activities which includes viral load testing from a 15% sample of patients who have been on therapy for longer than 9 months, plus chart abstractions and adherence questionnaires. Results indicate an overall viral suppression rate (< 400 copies/ml) of 86%. AR believes that its drug regimen and comprehensive program, especially strong LPTF mentorship/preceptorship, adherence and community activities have contributed towards this.

FY07 funding for the provision of ARV services at 15 LPTFs will support staff, laboratory reagents, medicines to treat opportunistic infections, other supplies, logistical support, quality assurance, Technical Assistance (TA), supervision, provision of infrastructure (as needed), and training of clinicians and other HIV care providers and community outreach. Training will be carried out through a mentorship/preceptorship model in the 15 LPTFs and will be directed at medical/clinical officers (59), nurses (67), adherence counselors (113) and the community workers. The results of the QA/QI have been shared with all LPTFs. In year 4 of the program, AIDSRelief will provide supportive supervision through hands-on preceptorship to continue to assist the LPTFs to developing the internal capacity to implement quality assurance and quality improvement on-site. This will include further viral load sampling for those patients who have been on treatment for longer than 9 months together with chart abstraction and an adherence questionnaire. AIDSRelief will help to create networks of providers among the LPTFs, and to link these facilities with other sites providing ART services. AIDSRelief will actively promote learning across LPTFs, through periodic web-based/CD learning in order to provide LPTFs with the most up to date HIV information. Those enrolled in care will be provided with Cotrimoxazole and treatment of OIs. Therapeutic feeding for severely malnourished HIV+ patients will be provided. LPTFs will be encouraged to form PLHA support groups. Sensitization of key community leaders will be key.

Had funding been available Year 4 was planned to be a growth year for the provision of pediatric and family centered services reaching an estimated 19,000 patients with treatment. Under the current local and central funding scenario, patient treatment numbers will be maintained through replacement for those who have died or transferred out of the program. No additional children will be started on ART. AR will however strengthen skills among clinical staff in the areas of pediatric HIV knowledge and pediatric counseling. The AIDSRelief program will devote resources to developing strong adherence programs which has been demonstrated as a key component of good clinical outcomes. Adherence to ART is one of the critical factors to achieving durable viral suppression. The program will work to adapt existing, locally appropriate IEC and BCC materials, as well as to identify gaps in these media and develop materials as needed. In northern Uganda there are examples of hospital/CBO linkages which provide excellent adherence support at community level. AIDSRelief, because of its work through partners who are firmly embedded within communities has the ability to support increased capacity and involvement of communities. This would also have been an important and cost effective component of Year 4 activities had sufficient funds been made available.

Coordinated by Constella Futures (CF), Strategic Information (SI) activities incorporate program level reporting, enhancing the effectiveness and efficiency of both paper-based and computerized patient monitoring and management (PMM) systems, assuring data quality and continuous data quality improvement, and using SI for program decision making across LPTFs. AR has built a strong system using in-country networks and available technology at 15 LPTFs in COP06. AIDSRelief will carry out regular site visits and reviews to ensure continued quality data collection, data entry, data validation and analysis, dissemination of findings; data management & continuous quality improvement. This information will be used to provide the regular USG, OGAC and MOH reports as well as input to LPTF QA/QI activities.

Sustainability lies at the heart of the AR program. To date, AR, through its comprehensive programming, has been able to increase access to quality care and treatment, while simultaneously strengthening health facility systems themselves through human resource support, equipment, financial training and improvements in health management information. In addition, AR has strengthened referral linkages between health facilities themselves, and significantly among these facilities and their communities. In Y4 AR will further build on this foundation to work both at national network and LPTF levels to identify and begin to implement a sustainability plan for the future. The focus will be on building health care treatment networks where different services will be provided by different providers under the same geographic location. Focusing on building the institutional, technical, financial and political capacity of AIDSRelief sites will help create the conditions for the long term support to patients on treatment and care.