EGPAF has extended for 2 years and will undertake the FY07 TBD PMTCT and ARV Services Activities

entitled "Family HIV/AIDS Care".

The Elizabeth Glaser Pediatric AIDS Foundation (Foundation) supports the Uganda National PMTCT

program to prevent HIV infection among infants identified through the PMTCT program and to provide care

and support and access to HIV treatment services for families. The Foundation directly supports districts to

provide VCT, ARV prophylaxis, psychosocial support, community mobilization, training, adequate counselor

and laboratory technician staff, upgraded laboratory facilities and counseling rooms, management

information systems and strengthened MCH/family planning (FP) services.

Key objectives of the Elizabeth Glaser Pediatric AIDS Foundation in Uganda during FY08 will include the

following:

•Support scale up of PMTCT services to 50% of the HC III and increase population coverage to 70% in the

districts where the Foundation works

•Based on the Foundation's lessons learned in Uganda, improve uptake of HIV counseling and uptake of

ARV prophylaxis by HIV-positive pregnant women and their exposed infants.

•Promote the integration of HIV/AIDS care into PMTCT/MCH at all sites providing ART and strengthen sites

to offer complex ARV regimens for PMTCT and enrollment of PMTCT mothers and their family members

into longitudinal care.

•Pilot the use of aluminum foil pouches for the repackaging of nevirapine suspension to increase the uptake

of the infant ARV dose based on a draft proposal being finalized in collaboration with UMOH. Discussions

are underway to increase the availability of prophylactic Zidovudine suspension for infants born to mothers

on complex PMTCT regimens;

•Train midwives at all sites to provide rapid HIV testing and PMTCT services in labor and delivery as the

majority of maternity units do not have regular access to laboratory personnel

•Train midwives in all districts to provide HIV care including staging and screening to initiate treatment.

•Complete the Integrated Infant and Young Child Feeding Policy in collaboration with the UMOH.

•Improve male involvement and partner HIV testing to test 10% of male partners of ANC clients. The

Foundation's technical advisors are collaborating with other partners to develop a service provision package

for men within the PMTCT program and the Foundation discussing a pilot with WHO to include rapid

syphilis testing with the PMTCT package as a way to improve partner testing;

•Improve coordination between PMTCT services and ART services by introducing a patient tracking system

at all implementing health facilities,

•Promote pediatric HIV/AIDS care through the clinical pediatric mentorship program using experts from

regional hospitals are trained in pediatric HIV/AIDS care, given trainer skills and supported to mentor lower

cadre health workers to offer pediatric care.

•Strengthen skills of lower level facility personnel to provide pediatric ART through a training package

developed with the UMOH Child Health Department, comprising of pediatric counseling, modified IMCI

(HIV) and Early Infant HIV diagnosis components.

Key Program Activities:

•Increasing program coverage for PMTCT. by increasing the number of service points in the supported

districts. All health facilities offering antenatal and maternity services will be targeted for the establishment

of PMTCT services. The current MOH strategic plan calls for the establishment of static PMTCT services at

sub-county level (Health Center III) and program expansion will reflect this trend. This approach aims to

bring services closer to people by creating more static sites instead of relying on referrals for PMTCT.

Outreach services will be extended to lower level health facilities (Health Center II) that do not have the

capacity to offer maternity services.

•Increase the uptake of the maternal/infant dose of ARVs ("missed opportunities"). The revised MOH policy

now allows dispensation of NVP any time after 14 weeks of gestation. Foundation supported sites will

implement this new policy. Towards the end of 2007, the Foundation's Uganda program will pilot the

repackaging of Nevirapine suspension for the infant to enable mothers to administer the infant ARV dose to

newborn babies delivered outside the health facility. Lessons learned from this pilot will be rolled out in

FY08 to improve infant dosing which remains the weakest part of the PMTCT cascade.

•Establish longitudinal follow-up of HIV-positive mothers within MCH including during well-child visits. The

provision of care and support services to eligible individuals improves the uptake of all other PMTCT

services. HIV care and treatment services will be strengthened through the development of mechanisms to

offer continuum of care to HIV-positive mothers and their families. Capacity will be built to support the

identification of HIV-exposed infants and their enrollment into continuum of care programs. The follow-up of

HIV exposed infants will take place alongside their mothers within the MCH clinic.

•Family Support Groups will continue to form a critical avenue for the provision of psychosocial support to

communities and families infected and affected by HIV/AIDS. Ariel Clubs have been started to address the

needs of HIV infected children. There are currently 80 family support groups and ten children's groups.

During FY08, the Foundation will develop the capacity of these groups to leverage and manage additional

financial and material resources from other organizations. Through a process of resource mapping these

groups will be linked to civil society organizations that provide complementary services e.g. income

generation, social, and nutritional support..

•A clinical mentorship program to support pediatric HIV/AIDS care has been set up in the 5 regional

hospitals and will be strengthened and expanded to cover more districts. This is done in conjunction with

partner organizations providing ART services.

Training. The Foundation's technical advisors will continue to direct and conduct training activities in the

supported district programs. Using a mentoring approach the technical advisors will reinforce skills

development among health facility staff with an aim of improving program quality and uptake. The technical

development of MOH staff will ensure sustainable and continuing capacity to provide critical PMTCT

services.

In FY2008, the Foundation will train up to 600 health workers, primarily targeting health workers in the

Maternal and Child Health departments as well as program management staff. Clinicians, nursing/midwifery

and laboratory staff will be trained as integrated teams for HIV/AIDS patient care. Training activities will

reflect the expanded nature of the PMTCT program with a strong bias towards integrating preventive and

treatment aspects of HIV/AIDS. Special emphasis will be made towards longitudinal aspects of maternal

and pediatric HIV/AIDS care. Crucial knowledge and skills in adherence monitoring will be included in the

training activities.

Activity Narrative: Planned trainings include a special training developed by the Foundation in collaboration with the Child

Health Department of UMOH and the Clinton Foundation, which is aimed at equipping service providers

with knowledge and skills to identify HIV infected children and offer pediatric HIV/AIDS care.

The Foundation will also train peer mothers and fathers to support newly identified HIV positive women and

their partners to facilitate their involvement in the provision of HIV/AIDS care both. Peer mothers and fathers

(PLHA) will be identified through the family support groups and encouraged to be involved in community

mobilization, sensitization, and home visits at community level and counseling, and other services at facility

level.

There will also be training of trainer courses in infant and young child feeding which is in line with the

revised UMOH Infant Feeding Policy, Health Sub district (HSD) teams will be involved in the training to build

their training and supervision roles. Trainings will also be conducted in HIV/AIDS care to further strengthen

links to care and treatment and provide a continuum of care in the MCH department.

Family planning will be strengthened as an integral part of PMTCT and HIV/AIDS control through training

courses developed in 2006 by Foundation's Uganda program to provide family planning counseling to

PMTCT clients. Technical support will be provided in the form of job aides and coordinating the forecasting

and ordering of family planning supplies.

The Elizabeth Glaser Pediatric AIDS Foundation (Foundation) supports the Uganda National PMTCT

program to prevent HIV infection among infants and utilizes the PMTCT program as a point of identification

of HIV-infected and affected individuals to provide care and support and access to HIV treatment services

for families. The Foundation works closely with the Uganda Ministry of Health (UMOH) and other PMTCT

and treatment partners in Uganda to coordinate support and maximize coverage of PMTCT and treatment

services.

The Foundation directly supports districts to provide VCT, ARV prophylaxis , psychosocial support,

community mobilization , training, adequate counselor and laboratory technician staff, upgraded laboratory

facilities and counseling rooms, management information systems and strengthened MCH/family planning

(FP) services.

Within the Foundation's Uganda Program, among the 8,230 HIV-positive women identified during the past

six months, only 31% were screened and staged for ART eligibility. At the moment, anti-retroviral drugs

(ARVs) are primarily offered only at the hospital level, while most women and children are identified at the

primary care level within health centers. While many Ugandan health centers have been authorized to

provide care and treatment (including ARVs), they are unable to do so given inadequate training and

supervision, lack of a regular ARV supply and other logistical challenges.

To address these critical gaps, the Foundation will conduct an innovative comprehensive care and

treatment program within the defined operational areas. The Foundation's comprehensive family care

model components include community level linkages to increase identification of HIV exposed children and

their families, PMTCT services, care and treatment with an emphasis on pediatric care and an innovative

psychosocial support effort that includes children's support groups. By providing support for care and

treatment the Foundation will integrate affordable, family-based quality HIV/AIDS care and ART services

into health care facilities through ensuring that a continuum of services is available and accessible: from

PMTCT, to care and treatment, to psychosocial support via a Family Care Model.

Key objectives of the Elizabeth Glaser Pediatric AIDS Foundation in Uganda during FY08 will include the

following:

•To establish model Family HIV Care Clinics within twenty MOH Health facilities. As a result at least 10,000

individuals will be enrolled in HIV comprehensive care and 1,000 will be initiated on ART by the end of

FY08.

•To establish linkages with a wide range of existing community-based programs to increase the follow up of

HIV exposed children and patients enrolled into HIV care and treatment.

•To establish functional linkages between TB and HIV care within the Foundation supported health facilities.

•To document and share the lessons learned and support the scale-up this comprehensive health center

model.

•Establish twenty Family HIV Care Clinics at facilities where PMTCT services are available, Family Support

groups are active, but where there are inadequate ARV and opportunistic infections supplies and, as a

result family care and treatment is unavailable. All the selected sites will be accredited by the MOH to start

providing HAART but have had limited success in developing efficient care and treatment services. The

provision of technical and commodity support will strengthen training of services providers, reporting and

forecasting of drug requirements, standardization of operating procedures, and the establishment of quality

improvement systems. The Foundation will support these Family HIV Care Clinics to provide family-based

care whereby the pediatric patient and caretaker (often her mother who was identified in PMTCT program

in antenatal clinic) as well as other family members, receive a joint appointment and make one trip to the

family clinic where they all receive clinical services. Routine HIV counseling and testing of infants and

children will be strengthened to support the identification of HIV exposed and infected children. HIV

counseling and testing will cover both outpatient and inpatient wards at the selected health facilities as well

as the surrounding communities. TB clinics will be specifically targeted for routine HIV counseling and

testing. The possibility of providing HIV care and treatment within the TB will also be explored. As stock outs

of important medications have unfortunately been a common occurrence, the Foundation will purchase

ARVs to provide a backup supply and avoid stock outs. A major component of expansion activities will be

ensuring that quality laboratory services are available in each center providing ART. Referral laboratory

services will be utilized for the monitoring of patients receiving HIV care and treatment. Where possible the

Foundation will explore the possibility of improving and equipping laboratory facilities (especially at district

hospitals) for optimal patient care. Each site will be assessed and needed upgrades in these areas will be

developed.

Key Program Activities

•Community mobilization will be carried out to create an environment in which HIV-affected individuals and

families proactively seek out appropriate care and services. The Foundation will work with local

organizations and community leaders to create educated and empowered communities that fully utilize and

build on existing resources. While specific mobilization efforts will depend on the needs of each community,

emphasis will be placed on a family approach to HIV care and treatment. Messages to the community will

specifically promote the possibility of early infant diagnosis of HIV and the usefulness of pediatric ART. Peer

educators will provide a key linkage between the health facilities and the surrounding communities.

•A clinical mentorship program to support pediatric HIV/AIDS care has been set up in 5 regional hospitals

and will be strengthened and expanded to cover districts supported under the care and treatment initiative.

This program will support the on job training of health workers providing HIV care and treatment using an

approach jointly developed for the Ugandan setting by the Foundation, MOH, ANNECA and the Pediatric

Infectious Disease clinic at Mulago hospital.

•The Foundation will work to ensure that sites provide quality clinical care services, and that they are

prepared to rapidly increase their service coverage. Antiretroviral treatment will be provided in accordance

with Uganda treatment guidelines and the procurement and ARV distribution will utilize the MOH systems.

Collaboration will be sought from other USAID funded programs e.g. QAP to design quality improvement

interventions of HIV care and treatment and provide ongoing technical guidance in this critical area.

•The Foundation's technical advisors will continue to direct and conduct training activities in the supported

district programs. Using a mentoring approach the technical advisors will reinforce skills development

among health facility staff with an aim of improving program quality and uptake. The technical development

of MOH staff will ensure sustainable and continuing capacity to provide critical PMTCT services. The

Foundation plans to train up to 200 health workers during this work plan period. The training strategy will

Activity Narrative: primarily target health workers in both the inpatient as well as outpatient setting as well as program

management staff. Clinicians, nursing/midwifery and laboratory staff will be trained as integrated teams for

HIV/AIDS patient care. The latter approach will increase the versatility of HIV clinical care teams within the

health facilities thereby supporting task shifting and the integration of key HIV services within the different

points of care.

•Develop and implement SOPs and strengthen outreach to assure that (75%) of exposed infants receive

CTX prophylaxis. Training activities will reflect the integral nature of the HIV/AIDS care with a bias towards

family based care of HIV. Crucial knowledge and skills in ART compliance and adherence monitoring will be

included in the training activities. The capacity of teams at health sub district/district/regional levels will

further be built by involving all the trained trainers in supervisory roles.