PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
The Uganda Virus Research Institute (UVRI) is a department within the Ugandan Ministry of Health (MOH),
and has been dedicated to conducting research on viral diseases since 1936. In the area of HIV/AIDS,
UVRI conducts research on the isolation and characterization of HIV strains, the epidemiology and
molecular epidemiology of HIV before and after the introduction of ART, comparing modalities of delivering
ART, HIV vaccines and microbicides, and PMTCT. UVRI also assists in the implementation of national sero-
behavioural surveys, and provides the MOH with HIV surveillance data from ante-natal clinic (ANC) and STI
clinics. UVRI is mandated by MOH to perform Quality Assurance/Quality Control (QA/QC) of all HIV
serological testing sites, both public and private. With USG funding assistance, the HIV Reference and
Quality Assurance Laboratory at UVRI has established a national laboratory QA program focused
specifically on HIV-related testing. This activity focuses on ensuring that the lay and the community health
workers in addition to counselors and lab staff that obtain samples for testing are providing quality service to
the client, obtain and provide quality samples following biosafety guidelines. These three cadres of staff
after proper training in rapid HIV testing nationwide will provide high quality results to inform prevention,
care, and treatment of HIV/AIDS.
Of the targeted 93 staff, 78 (Regional Laboratory Coordinator-RLC and District Laboratory Focal Persons
(DLFPs) were trained in QA/QC, because 15 were not available. In-service training in QA/QC was provided
only to 98 staff due to unreliable transport. Five SOPs for laboratory safety, sample processing, rapid HIV
laboratory testing, Elisa HIV testing, rapid syphilis testing and proficiency panel preparations for HIV were
reviewed, updated and distributed. Unfortunately there was no input from other stakeholders. Prepared and
distributed 700 proficiency testing panels to 216 testing sites. Unreliable transport was a limiting factor.135
internal controls were prepared and 15 test runs performed where they have been incorporated. Re-testing
was carried out on 1,435 samples from 34 sites including National Referral Hospitals, Regional Referral
Hospitals, and District Hospitals, Health Center IV, Health Center III and private facilities. Results have
been returned within 6 weeks. Concordance positive rates have ranged from 50% to 100%, while negative
rates have ranged from 82.4% to 100%. PT results at all these sites were 100%. Obtaining quality samples
for re-testing proved difficult. However, 36 discordant tests were resolved and results returned within 6
weeks. Compiled an inventory of 216 sites, held 216 sensitization meetings with the staff at the sites
regarding quality assurance, 700 distributed Proficiency Testing (PT) panels, collected 216 PT results and
provided corrective action when required, provided 17 out 216 support supervision visits in collaboration
with RLCs and DLFPs, distributed 1085 SOPs and other information tools, provided 216 formal reports
disseminating the findings of support supervision to 216 testing sites. The UVRI cold room has been
equipped to handle additional samples. Adherence to SOPs was assessed at these sites and revealed
availability of 77.8%, accessibility of 86.7%; two thirds displayed the SOPs, 79.2% understood them, and
80.6% of the sites followed them. 203 out of 216(94%) testing sites implemented the National Testing
Algorithms. Sites were further assessed for compliance with good clinical laboratory practice, waste
disposal and availability of requirements to conduct HIV testing. There is however a high demand for
counseling and testing as from the unmet need for HCT (UDHS 2006). Strategies include both client and
provider initiated HIV counseling and testing services and Ministry of Health [MOH] intends to scale up HIV
counseling and testing to all Health Center III by year 2010. There is need to further scale up through
training of service providers and ensuring quality control for HIV testing.
In FY 2006, MOH developed an HIV prevention strategy which places special emphasis on HIV testing
especially for the epidemic drivers (fishermen, commercial sex workers, discordant couples, those with
multiple sexual partners, transactional sexual relationships, etc). This calls for increased testing at health
facilities, home and through outreach/mobile clinics. UVRI shall ensure quality HIV testing is offered to
individuals through training, support supervision and continuous assessment of laboratories for QA/QC in all
laboratories testing for HIV, TB, STI and Malaria. It has been estimated that 1/3 of clients that seek HIV
testing are dually infected with TB. Thus all HIV testing sites are encouraged to offer TB diagnostics
especially to those clients with productive coughs. Through these means we shall support the TB, and
malaria strategic plans. The GFATM round three, phase one, targeted to test 2,200,000 people by the end
of June 2008, and, an additional 58,000 started on ART. Extra effort is required in counseling and testing to
achieve this target and more but ensuring high quality of the results. To achieve this, there is need to task
shift by training lay and community health workers in quality HIV testing throughout the country. By
maintaining and developing strong linkages with key service providers and trainers, UVRI shall support
integrated training especially in the diagnostics of HIV, malaria, syphilis and tuberculosis thus maximizing
benefits out of the available resources. The training provided to this cadre of personnel will ensure provision
of high quality support supervision.
UVRI shall maintain and develop new partnerships with PEPFAR funded partners e.g. CPHL/MOH,
AMREF, NUMAT, MJAP, JCRC, NMS, MUWRP, RHSP, RTI and other stakeholders in laboratory services
and CT to ensure sustainability of internal and external quality assurance at regional and district levels
using Regional Laboratory Coordinators (RLCs) and DFLPs as change agents. In collaboration with these
stakeholders and others especially Ministry of Health Quality Assurance Unit and Community Service
Organizations, UVRI shall identify suitable candidates for training in QA/QC. During support supervision
visits to the testing sites in collaboration with CPHL/MOH, Malaria Control Program, National Leprosy and
Tuberculosis Program and other stakeholders, UVRI shall identify needs in infrastructure, staffing,
laboratory management, commodity availability, storage capacity, recording keeping, availability and
implementation of SOPs, M&E tools and customer service satisfaction. UVRI will provide QC/QA of HIV
serology to TB sites that offer HIV testing. Supply chain management of HIV commodities, will be
addressed to avoid duplication. UVRI will draw up a consumption plan of HCT commodities and work with
NMS to ensure their availability. Buffer stock will be budgeted for to avoid any disruption of services. Due to
the scarcity of trained laboratory staff and the need to get millions of people counseled and HIV tested,
MOH has decided to provide quality training to non-laboratory staff including PHAs to conduct HIV rapid
testing. Despite this approach only 12% of the entire population knows their HIV status. UVRI in
collaboration with CPHL will continue to train lay and community health workers in quality HIV testing
through support supervision to ensure they provide quality results. In collaboration with RLCs and DLFPs,
UVRI shall develop a strategy to achieve this and shall emphasize during training the need for these groups
providing complementary services to coordinate their activities. The UVRI clinic shall continue providing
apprenticeship to both counselors and laboratory trainees. Training sessions for personnel at CT sites will
Activity Narrative: emphasize the need for QA/QC in whatever service they render. The SOP for counseling and testing will be
integrated for the benefit of the counselors, phlebotomists, and laboratory staff. UVRI shall prepare and
distribute Dried Tube Serum (DTS) to all testing sites for proficiency testing and obtain the results later by
means yet to be agreed upon. QA/QC testing will be conducted on samples obtained from CT and PMTCT
sites. Samples yielding discordant results in the field retested at UVRI and the results returned within six
weeks. These outcomes will be used to measure the effect of pre-analytical and analytical QA/QC training
on the quality of results provided to clients. Medical waste generated at UVRI will be disposed of using
disinfectants, incineration and sharps containers as appropriate. Hospitals will be requested to support other
testing centers in their area of jurisdiction for incineration of medical waste. These issues will be
emphasized during training and support supervisory visits. The funding in this programme area will increase
gender equity by ensuring that both male and female staff are equally represented in the various activities,
and courses promote females who are currently fewer in the counseling and testing profession in the
country.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13322
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13322 12494.08 HHS/Centers for Uganda Virus 6443 3440.08 Laboratory $400,000
Disease Control & Research Institute Quality
Prevention Assurance-
Cooperative
Agreement
12494 12494.07 HHS/Centers for Uganda Virus 4816 3440.07 Laboratory $350,000
Emphasis Areas
Gender
* Increasing gender equity in HIV/AIDS programs
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $130,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.14:
UVRI is a department within Ministry of Health (MOH), & has been dedicated to conducting research on
viral diseases since 1936. It conducts research on the isolation & characterization of HIV strains, & on the
epidemiology & molecular epidemiology of HIV before & after the introduction of ART; evaluates HIV
vaccines & microbicides; & compares modalities of delivering ART & PMTCT programs. UVRI also helps
implement national sero-behavioural surveys, & provides the MOH with HIV surveillance data from ANC &
STI clinics. UVRI is mandated by MOH to provide QA to all public & private HIV serological testing sites.
With USG funding, the HIV Reference & QA Lab at UVRI has established a national lab QA program for HIV
serologic testing. This activity focuses on ensuring that the lay, community health workers, counselors & lab
staff that obtain samples for testing are providing quality services, obtain & provide quality samples
following biosafety guidelines.
The UVRI cold room has been equipped; 78 of 93 staff (RLC & DLFPs) were trained in QA/QC because 15
were not available. 5 SOPs for lab safety, sample processing, rapid HIV lab testing, Elisa HIV testing, rapid
syphilis testing & PT panel preparations for HIV were reviewed, updated & distributed. 700 PT panels were
prepared & distributed to 216 USG & non USG supported testing sites. 135 internal controls were prepared
& 15 test runs performed where they have been incorporated. Re-testing was carried out on 1,435 samples
from 34 sites ranging from national, regional, district hospitals to HC IVs & III & private facilities; results
were returned in 6 weeks. We compiled an HIV testing inventory, distributed PT panels, collected PT
results & provided corrective action, provided support supervision with RLCs & DLFPs, distributed other
information tools, provided formal dissemination on support supervision to 216 testing sites. Sites were
further assessed for compliance with GCLP, waste disposal & availability of requirements to conduct HIV
testing. Strategies to increase HCT include both client & provider initiated HIV CT & MOH plans to scale up
HIV CT to all HC IIIs by 2010. There is need to further scale up training of service providers & ensuring
quality control for HIV testing.
While the existing M&E plan will guide implementation of activities, partnerships will be established with
government structures at district level through the health facility hierarchy including NGOs & uniformed
services. This will entail combined training of both lab & non lab including lay & community health workers,
support supervision visits, provision of DTS as PT panels & continuous assessment of labs for QA/QC
services in labs testing for HIV, TB, STI & malaria, thus supporting the TB & malaria National Strategic
Plans. MOH in collaboration with UAC has launched new preventive strategies to drive the HIV prevalence
below 6.4% & prevent an increase in new infections. There is now an urgent need to have high-quality HIV
serological testing in all labs across the country, including UNHCR sites, funded by WHO. Working with
MOH, particularly the QA Unit, the training coordination unit at CPHL & lab supervisors, we shall continue to
identify labs currently conducting HIV serological testing & the tests/algorithms used, at HCT, ANC &
PMTCT programs, in the private & public sector. Based on the inventory of HIV-testing labs, we shall
develop a QA plan that takes advantage of supervisory visits conducted by CPHL, NTLP, QA Unit of MOH,
Area Supervision Teams & other stakeholders to distribute DTS PT panels, & to meet reporting
requirements. Labs failing to meet QA criteria will be visited & remedial action taken. Testing algorithms for
use in the field & for QC at UVRI will be continuously monitored & new algorithms evaluated. With the
expanded LIMS & linked to databases at CPHL & MOH sharing of information, logistics management &
training needs will be easily coordinated, in line with the Uganda National Quality System Guidelines.
Activities include the preparation & distribution of PT panels, resolving discordant results & evaluation of
new HIV testing kits & algorithms. We shall work with the MOES to include quality assurance of HIV testing
in the curriculum of lab training institutions. Apprenticeships will be provided to both counselors & lab
trainees at the UVRI clinic. We shall work with the DFLPs to ensure that their activities are incorporated in
the annual district plan. Medical waste at UVRI will be disposed of using disinfectants, incineration & sharps
containers as appropriate. In collaboration with MOH & CPHL sites will be requested to support other
emphasized during training & support supervisory visits. UVRI shall work with MOH & HSC to recruit project
staff into Public Service thus allowing long term sustainability of QA/QC for the country; other efforts include
training provided to RLCs & DLFPs, supervisory visits, training in preparation & characterization of DTS PT
panels, their distribution & interpretation of the results. We shall coordinate activities with CPHL for training
in rapid HIV testing, EID & support supervision; & with NMS to ensure the availability of supplies. Regular
communication will be provided to labs in Uganda to highlight the role of the National HIV QA Lab, share
lessons learned, identify problems/issues for which assistance is required, & allow for dialogue about recent
news & innovations in HIV lab services. Working together with national regulatory authorities especially
NDA, we shall expedite the approval of new HIV rapid tests, including saliva-based tests. We shall procure
new HIV serologic assays & related instruments, evaluate their performance, & disseminate the findings.
This funding will increase gender equity by ensuring that both male & female lab staff are equally
represented in the various activities, & courses promote females who are currently fewer in the lab
profession in the country.
The development of HIV drug-resistance (HIVDR) is recognized as a serious threat to the efficacy of current
ART, & will compromise PEPFAR efforts to provide long-term treatment in sub-Saharan countries. Drug
resistance (DR) is likely to have a greater influence on the long term success of ART programs than any
other single factor. Emergence of resistance to one or more ARV drugs is a reason for therapeutic failure in
the treatment of HIV. In addition, resistance to one ARV drug sometimes confers a reduction in or a loss of
susceptibility to other or all drugs of the same class. Patients with HIVDR must switch treatment regimens,
reducing treatment options & significantly raising medication costs. Resistance is usually the result of sub-
optimal regimens, or inconsistent use resulting from poor adherence &/or interrupted drug supply. The
optimum time for minimizing the emergence & transmission of resistance is when treatment initiatives are
still in the early stages & first-line regimens are widely used. Prevention, surveillance & monitoring of drug
resistance are critical to the success of clinical & public health HIV/AIDS programs. WHO has developed
standardized strategies, protocols, & guidelines for the prevention of HIVDR in resource-limited settings that
are designed to be implemented alongside treatment programs. As part of this strategy, many African
countries including Uganda have set up National HIVDR prevention, surveillance & monitoring programs in
collaboration with WHO-AFRO. The major principles of containment of HIVDR include: appropriate ARV
drug access, proper prescribing & usage, drug adherence, reduction of HIV transmission, & appropriate
programmatic response based on the results of monitoring & surveillance. The WHO plan also includes
periodic evaluations of early warning indicators (EWI) which have been shown to correlate with early
emergence of DR. EWIs include poor drug supply continuity, inappropriate prescribing practices, & poor
adherence among clients among others. A consensus workshop on the prevention of DR was held in
Activity Narrative: Kampala in January 2007. A National HIVDR Monitoring Plan, developed with support from WHO, has been
endorsed by MOH & UAC. Under the plan, UVRI, working closely with the MOH-ACP & other partners, was
mandated to coordinate these activities, which include: 1) creation of a National HIVDR Data Center in
collaboration with MOH Resource Center; 2) establishing a National Drug Resistance Reference Lab 3)
program management, data coordination, & administration; 4) establishing a National HIVDR Working
Group (HIVDR WG) within the MOH & as part of the National ART Committee. The plan addresses key
areas within the National Strategic Plan for HIV/AIDS, 2007/8-2011/12, & is relevant to PEPFAR goals. The
national HIVDR WG is comprised of MOH, CDC, MRC, WHO, UVRI & PEPFAR-supported treatment
partners including JCRC, IDI, CRS, TASO & MJAP. With funding from WHO, the HIVDR WG conducted a
pilot survey in 2007 to collect EWI at 41 treatment sites. The sites were selected from different geographical
regions, represented different levels & modes of ART service delivery, & were supported by a range of
funders. The indicators evaluated included prescribing practices, proportion of patients lost to follow-up,
number of patients on first line ART, appointment keeping, adherence, & drug supply continuity. The results
of this pilot were presented at the Uganda National AIDS Conference the WHO-AFRO HIV DR meeting in
Namibia, & to various key partners, including the PEPFAR country team. UVRI, through support from WHO
& MRC, conducted a study in Entebbe to determine whether resistant viruses were transmitted to recently
infected individuals. No resistant viruses were identified. These results were published & presented at
various meetings including UAC & the International AIDS Society meeting in Sydney, 2008. The HIVDR WG
recommended that this activity be repeated in 2008. Plans exist for these threshold surveys to be conducted
among teenage pregnant females in Kampala & funding is being sought from PharmAccess. With funding
from MRC & GFATM, UVRI established the National HIV Drug Resistance Reference Lab which was
accredited by WHO. This is one of few accredited labs in Africa, & plans are underway to make it a regional
reference lab. With support from WHO, MRC, & the European Developing Countries Partnership (EDCTP),
the facilities & equipment have been upgraded, including the purchase of an additional Beckman Coulter
capillary sequencer & DNA/RNA extractor, & an ABI sequencer. The UVRI lab has provided training in drug
resistance testing for other technicians & scientists, including one from Zambia, & has also provided testing
of samples from other sub-Saharan African countries.
The DR WG continues to make efforts to secure funding from other sources to support HIVDR lab services,
& for expansion of EWI & acquired resistance surveys. One of the major challenges to implementation of
the national plan has been the absence of a dedicated HIVDR secretariat or center that can develop,
implement, & coordinate efforts, & a lack of adequate funding to perform EWI surveys & DR monitoring.
This funding will support dedicated staff & provide resources to coordinate national activities & enable drug
resistance prevention & monitoring. The proposed activities include: coordinating HIVDR prevention,
monitoring & surveillance at both national & institutional levels, supporting the national HIVDR Working
Group, monitoring emerging & transmitted HIVDR, & supporting the National HIVDR Reference Lab & other
labs to perform HIVDR testing, surveillance & monitoring. A Coordinating Center for HIVDR Prevention,
Monitoring & Surveillance shall be established at UVRI in close collaboration with the MOH-ACP. The terms
of reference of the HIVDR WG include: 1)to coordinate & implement of the National HIV Drug Resistance
(HIVDR) Prevention, Surveillance & Monitoring Plan; 2) to collect & analyze HIVDR EWIs; 3) to develop &
coordinate implementation of the country protocol for monitoring HIVDR in representative sentinel ART
sites; 4) to regularly perform HIVDR threshold surveys to evaluate transmitted resistance in specific
geographic areas; 5) to continue building capacity for genotyping & other activities to support HIV DR
surveillance & monitoring within the country; 6) to provide to other countries an example of implementation
of a national HIVDR strategy, including elements recommended by WHO; 7) to develop & collect
information on activities & programs which will contribute to minimizing HIVDR; 8) to collect & disseminate
information on, & help coordinate all HIVDR public health & research activities in the country; 9) to ensure
all activities follow country & international ethical standards designed to promote the well-being & health of
individuals & communities; 10) to prepare & disseminate annual HIVDR reports & recommendations. An
important component of the WHO & National Plan is the sentinel monitoring of HIVDR emerging during
treatment, & the relationship of resistance to ART program factors. We plan to follow WHO protocol
guidelines by evaluating adult cohorts from time of initiation of ART up to 12 months later, or at viral failure
or switch to a second line regimen. An assessment of routinely collected adherence measures will be made.
In FY2009, we will perform monitoring at 3-5 pilot sites, with possible expansion in subsequent years
subject to availability of funds. According to WHO protocols, 100 individuals newly initiating ART at each
site will be followed. Site selection will be made by the HIVDR working group based on geographic region,
type or level of clinical service, & funder (PEPFAR, GFATM, MOH, other). A protocol will be developed
following WHO guidelines, & reviewed by relevant IRB's. DR survey results will be used to develop
recommendations for improvement of outcomes & program planning, to help inform recommendations for
optimal first & second line regimens, & develop criteria for drug switching. This funding will support the
National HIVDR reference lab through continued participation in testing proficiency panels, QA/QC,
provision of supplies, training of lab staff & preparation for accreditation in genotypic testing using DBS. The
lab will develop SOPs for training, specimen collection, handling, shipment & storage; ensure observance of
GCLP, & assist in accreditation of other labs. The lab team will create a National Data base for resistance
marker sequencing, by working with WHO HIVResnet. Initially, viral loads will be determined in the labs of
the different partners at UVRI with the aim of establishing viral load measurements within the National
HIVDR Reference Lab.
Continuing Activity: 13323
13323 4709.08 HHS/Centers for Uganda Virus 6443 3440.08 Laboratory $325,000
8367 4709.07 HHS/Centers for Uganda Virus 4816 3440.07 Laboratory $325,000
4709 4709.06 HHS/Centers for Uganda Virus 3440 3440.06 Laboratory $170,000
Estimated amount of funding that is planned for Human Capacity Development $210,743
Table 3.3.16:
specifically on HIV-related testing.
The development of HIV drug-resistance (HIVDR) has been recognized as a serious threat to the efficacy of
current antiretroviral therapy (ART), and will compromise the efforts of PEPFAR to provide long term
treatment, not only in Uganda but also in other sub-Saharan countries. Drug resistance is likely to have a
greater influence on the long term success of ART programs than any other single factor. The emergence of
resistance to one or more antiretroviral drugs is one of the more common reasons for therapeutic failure in
the treatment of HIV. In addition, the emergence of resistance to one antiretroviral drug sometimes confers
a reduction in or a loss of susceptibility to other or all drugs of the same class. Patients with drug resistance
must switch treatment regimens, reducing treatment options and significantly raising medication costs,
assuming appropriate 2nd line drugs are available at all. Resistance is most often the result of sub-optimal
regimens, or inconsistent use due to poor adherence and/or interrupted drug supply. The optimum time for
minimizing the emergence and transmission of resistance is when treatment initiatives are still in the early
stages and first-line regimens are widely used (WHO,2003). Therefore, prevention, surveillance and
monitoring of drug resistance are critical to the success of clinical and public health HIV/AIDS programs.
WHO has developed a standardized strategy and protocols for the prevention of HIVDR in resource limited
settings, designed to be implemented alongside treatment programs. As part of this strategy and in
accordance with WHO guidelines, many African countries including Uganda have set up National HIVDR
prevention, surveillance and monitoring programs in collaboration with WHO-AFRO. The major principles of
containment of HIVDR include: appropriate ARV drug access, proper prescribing and usage, drug
adherence, reduction of HIV transmission, and appropriate programmatic response based on the results of
monitoring and surveillance. The WHO and Uganda HIV DR Monitoring Plan includes periodic evaluations
of early warning indicators (EWI) which have been shown to correlate with early emergence of drug
resistance. EWI include poor drug supply continuity, inappropriate prescribing practices, poor adherence
among clients, among others.
Prevention of ART resistance is most important in countries such as Uganda where first and second line
treatment options are limited. A consensus workshop on prevention of DR was held in Kampala in January
2007. A National HIVDR Monitoring Plan was developed with support from WHO, and has been endorsed
by the MOH and Uganda AIDS Commission. Under the plan, the Uganda Virus Research Institute (UVRI),
working closely with the MOH-ACP and other partners, was identified to coordinate these activities
including: 1) the creation of a National HIV drug resistance Data Center in collaboration with the MOH
Resource Center; 2) the establishment of a national drug resistance reference laboratory; 3) the
coordination of all activities (program management, data coordination, and administration); 4) the
establishment of a National HIVDR working group (HIVDR WG) within the MOH and as part of the National
ART Committee. The plan addresses key areas of care and treatment within the National Strategic Plan for
HIV/AIDS, 2007/8-2011/12, and is relevant to PEPFAR goals. The national HIVDR WG is comprised of
individuals with different expertise and from different organizations including the MOH, CDC, Medical
Research Council, WHO, UVRI and PEPFAR-supported treatment partners including JCRC, IDI, Catholic
Relief Services, TASO and MJAP. With some funding from WHO, the HIVDR WG conducted a pilot survey
in 2007 at 41 treatment sites to collect EWI. The sites were selected from different geographical regions,
represented different levels and modes of ART service delivery, and were supported by a range of funders.
The indicators included prescribing practices, percentage of patients lost to follow up, patients on first line
ART, appointment keeping, adherence, and drug supply continuity. The preliminary findings of this study
indicated that 71% of sites started all patients on appropriate first line drugs, 85% of sites had less than
20% loss to follow up during the first year, and 71% retained more than 70% clients on first line ART during
the first year. Most worrying, however, was the observation that only 19 sites reported no drug stock outs in
any quarter in the previous year. The results of this pilot were presented at the Uganda AIDS Conference
(UAC), the WHO-AFRO HIV DR meeting in Namibia, to various key partners, and to the PEPFAR country
team. UVRI, through support from WHO and MRC, conducted a study in Entebbe to determine whether
resistant viruses were transmitted to recently infected individuals. No resistant viruses were identified.
These results were recently published (Ndembi et al. AIDS Research & Human Retroviruses 2008; 24
(6):889-895), and presented at various meetings including the national UAC meeting and the International
AIDS Society meeting in Sydney, 2008. The HIVDR WG recommended that this activity be repeated in
2008. Plans exist for these threshold surveys to be conducted among teenage pregnant women in
Kampala. Funding for this activity is being sought from PharmAccess. With funding from MRC and the
Global Fund, UVRI established the National HIV drug resistance reference laboratory and was accredited
by WHO; this is one of few laboratories in Africa that are accredited. The UVRI laboratory has provided
training in drug resistance testing for other technicians and scientists, including one from Zambia, and has
also provided testing for samples from other sub-Saharan African countries. The DR WG is making efforts
to secure additional funding from other sources to implement the National plan.
In FY 2009, The USG country team will support the implementation and evaluation of Early Warning
Indicators, as part of the National HIVDR prevention activities and as part of the HIV DR working group
activities. An assessment of EWI will support ART program practices and country planning to minimize the
unnecessary emergence of HIV drug resistance. This evaluation will help determine the degree to which
ART programs are functioning to minimize emergence of HIVDR emergence.
This activity will include the following:
•develop a list of EWIs that can be/should be regularly collected at all sites
•determine methods of data abstraction of EWI from different current systems
•identify sites for collecting EWI
Activity Narrative: •strengthen the ART information management systems by integrating EWI into routine ART monitoring and
reporting
•monitor whether ART programs are functioning to optimize prevention of HIV drug resistance
•identify and implement mechanisms to provide support supervision to improve EWI and ART delivery
The HIVDR WG will work with USG partners and the MOH to determine which of the listed EWI can be
captured from current ART medical records systems or ART cards. WHO recommends that countries collect
EWI that are readily available and that are most useful for program assessment. Countries need not collect
all indicators. The following are the primary indicators suggested for use in Uganda:
1) Prescribing Practices: the proportion of individuals starting ART during a selected quarter who are
prescribed a standard regimen, or a regimen considered appropriate according to national guidelines and
the HIV DR WG. The recommended target is 100%.
2) Percentage of patients Lost to Follow-up: the proportion of ART clients lost to follow up during the first 12
months following initiation of ART, not including those who are dead, transferred out or stopped ART. The
recommended target is <20%
3) Patient retention on first-line ART: the proportion of clients initiating first-line ART who are still on first-
line ART after 12 months. The recommended target is >70%
4) ART appointment-keeping: the proportion of clients who attended all scheduled appointments during a
year, excluding those who are lost to follow-up, dead, transferred out, or stopped ART. The recommended
target is 80%
5) Drug supply continuity: the number of quarters in the last year in which there were ARV drug stock-outs
for any of the standard ART regimens supplied by the site. The target is zero.
Although WHO recommends collecting information on pill count/adherence, this indicator could not be
assessed during the pilot study due to weaknesses in routine ART adherence assessment at most sites. In
addition, the suggested use of adherence for each individual drug was rarely collected, and will be left out
of future EWI evaluations. The recommended indicator for "On-time Drug Pick up", meaning the proportion
of persons who pick up all prescribed drugs within 3 scheduled days, could not be assessed because some
clinics provide more drugs to cover for delayed pick-up times. Therefore, this indicator will also be excluded.
.
The country team, particularly the SI working group, will work with partners, the MOH, and the HIV DR WG
to develop systems for routine integration of these EWI into data collection systems, and for partners and
other clinical sites to have the capacity to extract and evaluate this information routinely. This will also
require coordination not only with partners, but also with the SI TWG, the HIV DR WG and the MOH
Resource Center that supports the national HMIS system. We will perform training in the collection,
extraction, and programmatic utilization of EWIs. Specific evaluation of EWIs will be expanded to 80 sites in
FY2009, covering all regions, in order to strengthen the ART information management systems, to ensure
that EWI are integrated into routine ART reporting systems and to monitor whether ART programs are
functioning to optimize prevention of HIV drug resistance. Through training and consultations, we will
provide support supervision to improve on the indicators for better ART delivery.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.17:
