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: 2007 2008 2009
In December 2007, Makerere University School of Public Health (MUSPH) and the Centers for Disease
Control and Prevention (CDC) renewed their commitment to develop human resource capacity for
management of HIV/AIDS programs in Uganda, and continue to collaborate with Rakai Health Sciences
Program (RHSP) to deliver comprehensive community based HIV/AIDS prevenetion, care and treatment
services to over 5000 HIV infected persons and their family members in Rakai and Lyantonde districts. A
few of the patients served come from districts neighboring Rakai, like Masaka and Mbarara). This is a five
year grant that carries forward lessons learnt in phase1. The grant has two major programming
components.
1) The SPH-CDC HIV/AIDS Fellowship Program is a capacity building and training program implemented by
Makerere School of Public Health to strengthen the leadership and management of HIV/AIDS programs in
Uganda. The Program aims at building competencies of professionals and health care workers in HIV/AIDS
program leadership, management, and comprehensive HIV prevention, care and treatment through hands-
on apprenticeships, technical placements, and offsite training. The overall aim of the Program is to build
capacity for high quality HIV/AIDS prevention, care, and treatment and support services in Uganda. MUSPH
also recently received additional funds from CDC to to establish an internet based distance learning
program in colloboration with Johns Hopkins University. This program targets staff at various PEPFAR
supported partner organisations.
2) The comprehensive community based HIV prevention, care and treatment program is implemented by
RHSP, a non-government not for profit organization, located in rural Rakai district, South Western Uganda.
RHSP is a stakeholder in provision of HIV prevention, care and treatment to HIV positive clients in Rakai
and Lyantonde and to a small extent, the neighboring districts like Masaka and Mbarara. Since June 2004,
with support from PEPFAR, RHSP has expanded coverage and access to comprehensive HIV/AIDS
prevention, care and treatment to the population in and around Rakai District. Activities conducted include
an innovative home based and community-based VCT program, provision of basic care, ART, PMTCT, TB
care, health education, mitigation of HIV through prevention of domestic violence and medical male
circumcision (MMC) for HIV prevention.
The PMTCT program currently operates 17 mobile clinics in Rakai and Lyantonde districts. These mobile
clinics are located at already existing government centers and are run by a team of medical officers, clinical
officers, nurses and counselors on a rotational bimonthly basis.
During the FY 2008, the program has continued to implement the new WHO PMTCT guidelines, where
- All pregnant women eligible for ART are given AZT+3TC+NVP as the first line regimen.
- Women for whom ART is not yet indicated, AZT is provided at 28 weeks of pregnancy plus single dose
NVP and 3TC at onset of labour, with a 7-day tail of AZT plus 3TC in order to reduce the risk of NVP
resistance;
- Alternatively, prophylactic AZT from 28 weeks plus single dose NVP for woman or single dose NVP and
AZT+3TC during labour and 7 days postpartum for woman, or single dose NVP to women and infant
- The program has adopted the modified infant ARV prophylaxis recommended by a randomized clinical trial
conducted in Malawi, to provide where infants born to HIV positive mothers are offered single dose NVP
soon after birth plus AZT for 7 days, then the extended prophylaxis with nevirapine and AZT (zidovudine,
Retrovir), after completion of the 7 days of AZT for fourteen weeks of life.
- Approximately, 100 HIV positive persons become pregnant in Rakai each year. In FY 2008, a total of 26
mothers were enrolled into the PMTCT program and 20 babies were delivered live for the PMTCT mothers
during the first quarter (January-March 2008) while in the second quarter, 35 mothers and 12 babies
received PMTCT services from the program.
- Health education for the pregnant mothers: All HIV positive mothers receive targeted education to address
issues like antenatal care attendance, delivery under the care of a trained mid wife, contraception and infant
feeding.
- Infant feeding: Following results that revealed a higher mortality among formula-fed infants as compared to
the breastfed infants born to HIV-positive mothers, we ceased provision of infant formula. We currently
recommend exclusive breast feeding as the safest infant feeding option for these babies.
HIV counseling will be provided for pregnant women residing in Rakai, Lyantonde and the neighboring
districts of Masaka and Mbarara. These will include mothers participating in the Rakai cohort studies as well
as HIV positive women enrolled in the HIV clinics.
- PMTCT counseling services shall be provided to all the HIV positive women identified through the above
sources. ARV prophylaxis, infant feeding counseling shall be provided for the HIV-positive women identified.
These women shall be encouraged to attend regular antenatal care clinics at their nearest health centers.
- On-going health education to all pregnant HIV positive mothers shall be given during pregnancy and the
post partum period, emphasizing the importance of delivery in a health center, post-partum hygiene, infant
feeding and adherence to ARV prophylaxis for the mother and baby.
- Reproductive health services will particularly be provided to these women.
ARV prophylaxis - The program shall provide counseling and testing for pregnant mothers .This will help
identify HIV positive mothers so that they are provided with the available PMTCT care.
- RHSP shall provide PMTCT services via 17 clinics spread out in communities in Rakai and Lyantonde
districts. ARV prophylaxis shall be provided to all HIV positive pregnant women registered with the program
clinics according to WHO guidelines i.e.
- All pregnant women eligible for ART shall be given AZT+3TC+NVP as the first line regimen.
- For Women for whom ART is not yet indicated, AZT will be provided from 28 weeks of pregnancy plus
single dose NVP and 3TC at onset of labour, with a 7-day tail of AZT plus 3TC in order to reduce the risk of
NVP resistance;
- Alternatively, prophylactic AZT from 28 weeks plus single dose NVP for woman and single dose NVP and
7 days of AZT for infant or single dose NVP and AZT+3TC during labour and 7 days postpartum for woman,
and single dose NVP for infant; or single dose NVP to women and infant
- The program will continue to offer the modified infant ARV prophylaxis to infants born to HIV positive
mothers where the infant is offered single dose NVP soon after birth plus AZT for 7 days, then the extended
prophylaxis with nevirapine and AZT (zidovudine, Retrovir), after completion of the 7 days of AZT for
Activity Narrative: fourteen weeks of life.
Training - In this budget period, two permanent district health center staff in each of the 17 clinics at which
we conduct our outreaches will receive training and refresher courses in referral and screening of HIV+
patients, HIV care and PMTCT care services.
- These health units will be provided with materials and services such as PMTCT drugs if needed,
Information Education and Communication (IEC) materials, and access to consultation to enable them
actively participate in provision of quality PMTCT services. We shall provide structured continuing medical
education sessions (CME) for various district health staff participating in PMTCT.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13231
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13231 4022.08 HHS/Centers for Makerere 6421 5738.08 Developing $40,000
Disease Control & University School National
Prevention of Public Health Capacity for
Management of
HIV /AIDS
Programs and
Support for the
Delivery of HIV
Prevention,
Care and
Treatment
Services in
Rakai District
8327 4022.07 HHS/Centers for Makerere 5738 5738.07 Developing $36,670
Disease Control & University Institute National
4022 4022.06 HHS/Centers for Makerere 3177 1084.06 $35,250
Disease Control & University Institute
Prevention of Public Health
Emphasis Areas
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Safe Motherhood
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $24,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
Makerere University School of Public Health (MUSPH) is located within the Mulago National Teaching and
Referral Hospital in Uganda. The mission of MUSPH is to improve the attainment of better health for people
of Uganda through public health training, research and community service. In December 2007, Makerere
University School of Public Health (MUSPH) and the Centers for Disease Control and Prevention (CDC)
renewed their commitment to develop human resource capacity for management of HIV/AIDS programs in
Uganda, and continue to collaborate with Rakai Health Sciences Project (RHSP) to deliver
comprehensive community based HIV/AIDS prevenetion, care and treatment services to over 5000 HIV
infected persons and their family members in Rakai and surrounding districts. This is a five year grants
that carries forward lessons learnt in phase1. The grant has three major programming components. 1) The
comprehensive community based HIV prevention, care and treatment implemented by RHSP. 2) The SPH-
CDC HIV/AIDS Fellowship Program is a capacity building and training program implemented by Makerere
School of Public Health to strengthen the leadership and management of HIV/AIDS programs in Uganda.
The Program aims at building competencies of professionals and health care workers in HIV/AIDS program
leadership, management, and comprehensive HIV prevention, care and treatment through hands-on
apprenticeships, technical placements, and offsite training. 3) MUSPH also recently received additional
funds from CDC to to establish an internet based distance learning program to support the training of
PEPFAR partners in collaboration with Johns Hopkin University Center for Clinical Global Health Education
(CCGHE).
The comprehensive community based HIV prevention, care and treatment program is implemented by
and Lyantonde and to a smaller extent, the neighboring districts like Masaka and Mbarara. Since June
2004, with support from PEPFAR, RHSP has expanded coverage and access to comprehensive HIV/AIDS
circumcision (MMC) for HIV prevention. The community-based VCT program is nested in the Program's
existing annual research activities, where persons residing in the study areas are offered counseling and
testing in their respective communities. HIV results are returned to these clients through program
counselors who reside in these communities. VCT is also offered at the HIV care clinics and in the homes of
HIV positive index persons. All persons who test HIV positive and accept to learn their HIV status are
referred to the program HIV care clinic nearest to their community or nearest to their home. The program
currently operates 17 mobile clinics in Rakai and Lyantonde districts. These mobile clinics are located at
already existing government centers and are run by a team of medical officers, clinical officers, nurses and
counselors on a rotational bimonthly basis. The majority of patients currently enrolled on the HIV care
program are adults (60% female, 40% male) and only about 5% are children 0-14 years old.
The RHSP medical male circumcision program: Three trials of male medical circumcision (MMC), including
one conducted by the Rakai Health Sciences Program (RHSP) in Rakai District, Uganda, have shown that
the procedure reduces male HIV acquisition by 50-60% and has the potential to dramatically curtail the HIV
epidemic in areas of Africa where MMC is uncommon and the epidemic most severe. Additional benefits of
MC in HIV-negative males include significant reductions in male genital ulcer disease (GUD) and HSV-2
acquisition and in vaginal sexually transmitted infections and genital ulcer disease in female partners.
Population-level effects on HIV incidence will be achieved if MMC is provided to and is accepted by men
(and their partners), and if there is no increase in sexual risk behaviors (i.e., risk compensation). The RHSP
has a state-of-the-art outpatient surgical facility and trained highly experienced surgical teams (doctors,
clinical officers, and operating room staff) which can accommodate more than 3,000 surgeries a year. As
part of the MMC Service, we provide extensive HIV prevention counseling pre- and post-surgery; offer free
condoms; provide information to men, and whenever possible to their women partners, regarding wound
healing, wound care and the need to abstain from sex until healing is completed; and offer free individual
and couples' VCT. The Rakai MMC Program also conducts community-level health education for both men
and women regarding HIV Prevention (ABC) and MC. The information is provided through town meetings,
sports events, drama groups and videos. Women need to be informed that MC does not guarantee that the
male is HIV-negative, that abstention from sex following the procedure is of great importance regardless of
the male partner's HIV status, and that condom use is crucial regardless of MC status if the partner is HIV-
positive or of unknown serostatus.
Through PEPFAR, HIV-infected individuals indentified through MMC service are offered a free Basic Care
Package, including cotrimoxazole, bed nets, clean water containers and hypochlorite tablets. Once they
reach eligibility for HAART (CD4 count <250 cells/ml or WHO clinical stage 4), they are offered HAART and
clinical monitoring via RHSP mobile and fixed clinics.
In order to facilitate safe MMC, RHSP is offering training to different cadres of medical personnel including
surgeons, clinicians, counselors and operating room assistants. The Rakai center has been selected by
WHO to serve as a regional MC training center.
Community based health education is being provided in an effort to continuously inform communities about
HIV/AIDS and STD prevention. Over 4700 individuals attended the general community health meetings,
with an almost equal distribution by gender i.e. ~ 52% females. Two community health mobilisers (CHMs)
meetings and 3 Community advisory board (CAB) meetings have been held so far (2 of which were
quarterly meetings and 1 an executive meeting). During these meetings the role of CAB in community
based ART program as well as the role of abstinence and faithfulness (AB) were discussed.
Over 182 clinics on site health education sessions have so far been conducted. Each clinic day is starts with
a one hour health education/ question and answer session to address general patient concerns as well as
general topics like HIV/STD prevention, including ABC, positive living, drug adherence, sanitation/hygiene,
family planning, nutrition, and disclosure. Other harmful behaviors like alcohol abuse, smoking and drug use
are discussed on a rotational basis. Each session is attended by 60-80 patients.
Rakai HSP has successfully reviewed and approved message to be included in the drama scripts. The
drama messages address AB among other things. So far 9 drama sessions have been conducted attracting
a total attendance of 1245 people (704 females and 541 males).
Under the circumcision service program, 25 community meetings have taken place with an attendance of
Activity Narrative: 1620 people (854 females and 766 men). Six sensitization meetings have so far been conducted with 226
men and women.
In 2009, community based health education and AB promotion will be maintained in an effort to
continuously inform communities about HIV/AIDS and STD prevention. Through the VCT program HIV
prevention counseling including AB messages will be provided. The program will continue to integrate
prevention counseling into the care and treatment programs. Couples testing will be encouraged thus
promoting mutual disclosure of results and strengthening the B messages. ‘A' messages will be encouraged
for single adolescents in and out of schools. Efforts will be made to integrate other prevention interventions
at the following levels; 1) prevention counseling and couples counseling and testing in the VCT program; 2)
prevention with positives counseling and support for all patients in the HIV/AIDS clinics and PMTCT
program; 3) integration of prevention counseling in the MMC program; 4) Post-exposure prophylaxis for
health care providers and post- sexual exposure (rape and defilement). Other prevention activities will
include prevention counseling, condom education and distribution, STI diagnosis and treatment. The
Program will continue to educate communities about the entire spectrum of prevention interventions;
abstinence, faithfulness and other prevention including MMC, as appropriate. We will also continue to
implement gender based violence (GBV) activities. The education activities will be conducted in Rakai and
neighboring districts through the following fora;
• Community advisory board meetings will be held quarterly. The CAB, who are community representatives,
will continue to advise the program on best ways of packaging the AB messages in an appropriate
community sensitive manner, and on how to reach potential program beneficial lies. The CAB will also be
part of the team that will promote AB and other prevention in their communities.
• CHM meetings will be held annually. The CHMs reside in communities within the program operational
areas, they, like the CAB members will play advisory as well as dissemination roles in the promotion of AB
and other prevention in the communities.
• Health education sessions will be used to actively promote AB and other prevention. The program has a
well trained, qualified, and experience team of health educators which works in collaboration with the district
health education team. Education sessions will be held in phases including sensitization meetings that will
target community opinion leaders, village/town meetings to target whole communities, HIV satellite clinics
sessions to target people enrolled in ART care programs, at circumcision centers to target people enrolling
into the circumcision program. Attempts will also be made to reach out of school adolescents.
• Drama shows will continue to be used in promoting AB and other prevention. We have two experienced
drama groups that do the shows. Drama scripts will be modified to add more messages to promote AB and
other prevention.
Additional information will be given during the education sessions which will include educating communities
about the locations of satellite clinics within their communities, the kind of services they should expect to
receive at the facilities, the clinic days, and also discuss a range of other issues including PMTCT,
reproductive health, pediatric HIV care, feeding for infants living with HIV, adherence, stigma, community
engagement/role into successful HIV care provision and access, and challenges/ opportunities especially
during the discussion component of the meetings. Similar education avenues will be used to educate
communities about availability of male circumcision services.
Continuing Activity: 13232
13232 4019.08 HHS/Centers for Makerere 6421 5738.08 Developing $44,823
8324 4019.07 HHS/Centers for Makerere 5738 5738.07 Developing $24,823
4019 4019.06 HHS/Centers for Makerere 3177 1084.06 $23,860
Gender
* Addressing male norms and behaviors
* Reducing violence and coercion
Estimated amount of funding that is planned for Human Capacity Development $34,000
Table 3.3.02:
ACTIVITY UNCHANGED FROM FY 2008
Activity Narrative: a total attendance of 1245 people (704 females and 541 males).
1620 people (854 females and 766 men). Six sensitization meetings have so far been conducted with 226
Community based health education and AB promotion will be maintained in an effort to continuously inform
communities about HIV/AIDS and STD prevention. Through the VCT program HIV prevention counseling
including AB messages will be provided. The program will continue to integrate prevention counseling into
the care and treatment programs. Couples testing will be encouraged thus promoting mutual disclosure of
results and strengthening the B messages.. ‘A' messages will be encouraged for single adolescents in and
out of schools. Efforts will be made to integrate other prevention interventions at the following levels 1)
prevention counseling and couples counseling and testing in the VCT program, 2) prevention with positives
counseling and support for all patients in the HIV/AIDS clinics and PMTCT program, 3) integration of
prevention counseling in the MMC program, 4) Post-exposure prophylaxis for health care providers and
post- sexual exposure (rape and defilement). Other prevention activities will include prevention counseling,
condom education and distribution, STI diagnosis and treatment. The Program will continue to educate
communities about the entire spectrum of prevention interventions; abstinence, faithfulness and other
prevention including MMC, as appropriate. We will also continue to implement gender based violence
(GBV) activities. The education activities will be conducted in Rakai and neighboring districts through the
following fora;
- Community advisory board meetings will be held quarterly. The CAB, who are community representatives,
- CHM meetings will be held annually. The CHMs reside in communities within the program operational
- Health education sessions will be used to actively promote AB and other prevention. The program has a
- Drama shows will continue to be used in promoting AB and other prevention. We have two experienced
Continuing Activity: 13233
13233 12431.08 HHS/Centers for Makerere 6421 5738.08 Developing $20,000
12431 12431.07 HHS/Centers for Makerere 5738 5738.07 Developing $54,000
Estimated amount of funding that is planned for Human Capacity Development $10,000
Table 3.3.03:
that carries forward lessons learnt in Phase 1. The grant has three major programming components. 1) The
(CCGHE). The comprehensive community based HIV prevention, care and treatment program is
implemented by RHSP, a non-government not for profit organization, located in rural Rakai district, South
Western Uganda. RHSP is a stakeholder in provision of HIV prevention, care and treatment to HIV positive
clients in Rakai and Lyantonde and to a smaller extent, the neighboring districts like Masaka and Mbarara.
Since June 2004, with support from PEPFAR, RHSP has expanded coverage and access to comprehensive
HIV/AIDS prevention, care and treatment to the population in and around Rakai District. Activities
conducted include an innovative home based and community-based VCT program, provision of basic care,
ART, PMTCT, TB care, health education, mitigation of HIV through prevention of domestic violence and
medical male circumcision (MMC) for HIV prevention. The community-based VCT program is nested in the
Program's existing annual research activities, where persons residing in the study areas are offered
counseling and testing in their respective communities. HIV results are returned to these clients through
program counselors who reside in these communities. VCT is also offered at the HIV care clinics and in the
homes of HIV positive index persons. All persons who test HIV positive and accept to learn their HIV status
are referred to the program HIV care clinic nearest to their community or nearest to their home. The
program currently operates 17 mobile clinics in Rakai and Lyantonde districts. These mobile clinics are
located at already existing government centers and are run by a team of medical officers, clinical officers,
nurses and counselors on a rotational bimonthly basis. The majority of patients currently enrolled on the
HIV care program are adults (60% female, 40% male) and only about 5% are children 0-14 years old. The
RHSP laboratory: RHSP has an established state-of-the-art laboratory infrastructure located at Kalisizo
center that supports the evaluation and monitoring of patients on the program. The range of tests carried
out include: HIV testing by 2 ELISA tests and western blot if ELISA is discordant, microbiology tests like
urinalysis, Ziehl Nelsen tests for TB screening, blood cultures etc, Serology like serum CRAG, Chemistry
tests like liver and renal function test and hematology, among others.
positive or of unknown serostatus. Through PEPFAR, HIV-infected individuals indentified through MMC
service are offered a free Basic Care Package, including cotrimoxazole, bed nets, clean water containers
and hypochlorite tablets. Once they reach eligibility for HAART (CD4 count <250 cells/ml or WHO clinical
stage 4), they are offered HAART and clinical monitoring via RHSP mobile and fixed clinics. In order to
facilitate safe MMC, RHSP is offering training to different cadres of medical personnel including surgeons,
clinicians, counselors and operating room assistants. The Rakai center has been selected by WHO to serve
as a regional MC training center.
1.Provision of circumcision to 2700 men. Currently, preparations have been made and the provision of
circumcision service has been initiated. We have so far provided circumcision service and post operative
care and follow up for over 1500 men. As part of the preparations RHSP conducted the following activities;
Held internal planning meetings to lay down a detailed work plan; Held meetings with stakeholders including
Community Advisory Board members (CAB), community opinion leaders, and Rakai program community
mobilizers to discuss means and ways of mobilizing communities for this service; Recruited personnel as
outlined in the budget and work plan, who are conducting the activities; Drafted forms that are used to
collect service information/records, and drew plans on how records will be managed; All recruited staff have
been fully trained and certified to perform the various activities. These include Medical officers, clinicians,
nurses, counselors, health educators, follow up team members, theatre personnel, data, technical and
administrative staff; Necessary supplies procured (including theatre supplies); Secured space for overnight
stay for the clients who come from far and wish to spend a night. Community mobilization, sensitization and
health education about the MMC activities were started and are ongoing. Community mobilization
Activity Narrative: messages have already been developed and are in use. About 2000 men have already been sensitized and
mobilized for this activity.
The demand for MMC in Rakai and neighboring districts is enormous yet our capacity to handle this
demand is limited, more so for people living long distances from the Rakai center. Plans are being made to
address this challenge by increasing the number of operating rooms at the central facility in order to be able
to offer more surgeries per day. The programme plans to pilot test mobile circumcision services so as to
take the service near to the people. The programme plans to work hand in hand and create linkages with
trainees who will graduate from the Rakai MMC training center to ensure that they put what they learn in
practice when they go back to their units. These linkages will require close supervision and monitoring and
therefore need for an additional facilitation.
2.Training of Health personnel to perform safe surgery - Preparations for this activity are still on going. The
following have already been accomplished;
Contacted district Medical officers and the district medical team to help us identify priority units and staff
whom we need to consider for training first. Units which already have the capacity to offer circumcision but
need training in order to be able to offer a complete circumcision package as recommended by WHO have
been identified; Identified 50% of the potential trainees who will be invited for the training, the identification
process is still ongoing; Identified 7 trainers and sent them for a trainer of trainers course which they
successfully complete and were certified by WHO as trainers; Developed a training curriculum/syllabus for
the training; Identified accommodation for the trainees; Space for training and training aids are available;
Closely monitor and supervise the trainees. This exercise will go a long way in decentralizing circumcision
services and ensuring sustainability of the service. This exercise will require additional transport facilitation
since trainees will come from all parts of the country.
Increase the number of surgeries to be offered in a year from 2700 to 3500 and to pilot test mobile MMC
services targeting areas that are far from the Rakai center and far from health level 4 centers. The RHSP
will continue to provide circumcision services to ~3500 men aged 13-49 residing in Rakai and neighboring
districts, in FY 2009. The services will be offered within the Rakai Health Sciences Center (RHSC) which
contains three fully equipped operating theatres, a recovery room, sluice, autoclaves and sterile storage,
and a dormitory for overnight stay for men who reside far from the facility; Men will be offered free VCT prior
to surgery, but this will not be mandatory and HIV positive men will be referred to the Rakai Suubi clinic for
HIV care. The VCT component of MMC will be supported through the CT budget; Circumcised clients will
remain in the RHSP dormitory overnight and will be discharged after examination for short-term
complications. Arrangements will be made for patients to contact RHSP in case of complications after
discharge. Furthermore, men will be asked to return 1 week and 4 weeks post-surgery to certify wound
healing. Patients will be instructed in wound care and be told to abstain from sexual intercourse until full
wound healing is certified; Records will continue to be maintained of any adverse events related to surgery
and compliance with instructions on abstinence until complete healing is achieved; After resumption of
intercourse, men and their partners will be advised to practice safe sex (i.e., abstinence, monogamy with an
uninfected partner, or use of condoms); - Provide extensive HIV prevention counseling pre- and post-
surgery; offer free condoms; provide information to men, and whenever possible to their women partners,
regarding wound healing, wound care and the need to abstain from sex until healing is completed; and offer
free individual and couples' VCT; Conduct community-level health education for both men and women
regarding HIV Prevention (ABC) and MC and provide this information through town meetings, sports events,
drama groups and videos; Involve women in the MMC program, they need to be informed that MMC does
not guarantee that the male is HIV-negative, that abstention from sex following the procedure is of great
importance regardless of the male partner's HIV status, and that condom use is crucial regardless of MC
status if the partner is HIV-positive or of unknown serostatus; HIV-infected individuals identified through
MMC service will be referred for free Basic Care Package, including cotrimoxazole, bed nets, clean water
containers and hypochlorite tablets. Once they reach eligibility for HAART (CD4 count <250 cells/ml or
WHO clinical stage 4), they will be offered HAART and clinical monitoring via RHSP clinics. This will be
supported by the adult care and ART budget/component of the RHSP; Propose to pilot test mobile MMC
services to areas that are a long distance from the Rakai center and far from health center IV and therefore
have no easy access to the MMC services.
2. Training - The RHSP has experienced surgeons and nursing staff to provide training to health personnel
and will train an additional 45 physicians and/or clinical officers, and approximately ~ 50 theatre nurses and
counselors in FY09. Priority will be given to trainees from Level 4 health centers in Uganda, but training
will also be provided to appropriate government and private health professionals from neighboring districts.
Trainees will first study the WHO manual and observe surgeries conducted by experienced practitioners.
They will then conduct a minimum of 24 supervised surgeries until certified as competent. Service records
will be maintained on the number of surgeries done, the time required to complete each procedure, and on
any operative or post-operative complications. Theatre nurses will be trained in theatre procedures, asepsis
and post-operative care, whereas counselors will be trained in MMC counseling. Each health professional
trained by the RHSP will be observed performing or assisting circumcisions in the first 3 months after their
initial training, in order to assess their proficiency post-training. The follow up may occur in their place of
work, or they may be invited back to the RHSC, depending on logistics. Their surgical records on the MC
services they provided will be reviewed.
3. Needs Assessment - RHSP will conduct a needs assessment in an additional five Level 4 health facilities
which are equipped with operating theatres, in Rakai and neighboring Districts. This will determine the
needs for facility improvements, equipment and supply needs in the district. The information will be provided
to the MOH for use in planning program expansion. Some of the trainees proposed above will be initially
from these facilities.
Estimated amount of funding that is planned for Human Capacity Development $340,000
Program Budget Code: 08 - HBHC Care: Adult Care and Support
Total Planned Funding for Program Budget Code: $23,191,954
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
With PEPFAR support, Uganda is making significant progress towards providing care and support, and antiretroviral therapy
(ART) to people living with HIV/AIDS (PHA). In FY08, PEPFAR funded care and support for 340,000 people and provided over
130,000 with ART (90% of all people receiving ART nationally). However, the number of people needing ART is approximately
350,000 (UNAIDS estimate), so only about 40% of those in need of ART are receiving it. Challenges for providing greater
coverage of services include human resources, counseling and testing, measuring care and treatment outcomes, lab
infrastructure, and the logistics system.
Care and treatment services
Care and support is broadly defined to include all activities that enhance the quality of life of HIV-infected persons, from diagnosis
through end-of-life. Services vary in scope, coverage and quality, and are delivered in a variety of settings including health
facilities, communities and homes. Community and home-based models have gained prominence due to their cost-effectiveness
and the fact that some care does not need to be provided in facilities. Few organizations can offer the full range of services,
however, so coordination and establishment of referral networks to co-manage clients are essential elements of service delivery.
Generally, services are most comprehensive and accessible in urban areas, making it necessary to implement strategies that
bring services to rural areas where more people live.
The FY08 Program
In FY08 there was a significant increase in number of PHA in the country receiving the Basic Care Package (BCP) with over 80%
of PHAs routinely receiving cotrimoxazole. As noted, the number receiving ART increased. Adherence to ART has remained high
(95%) although retention on ART remains a challenge. The national treatment policy was revised in 2008, changing the eligibility
cut-off for ART initiation from CD4<200 cells/mm3 to <250. All TB/HIV co-infected persons and HIV infected pregnant women with
CD4<350 will also be eligible for ART. Moving to the WHO-recommended level of <350 increases the estimated number of adults
requiring ART from 250,000 to 350,000, the new UNAIDS/WHO estimate.
A pilot survey at 40 treatment sites was conducted at the end of 2007 by the national HIV Drug Resistance Working Group. Half of
the sites experienced drug stock outs in the previous quarter, and weak data collection prevented measuring adherence and
delays in drug pickup. (None of the drug stock outs occurred in PEPFAR-supported sites, and stock outs at other sites were
mostly covered by USG-provided buffer stocks.) Another survey at a larger number of sites, plus surveys of treatment-acquired
resistance, are planned. These data are critical to inform the appropriate use of ARV regimens in the context of emerging drug
resistance.
FY09 strategies and activities
A review of national needs and the existing response identified six key areas that require attention to achieve widespread,
sustainable and high quality care and treatment. These are:
(1) expand pain management in care and treatment;
(2) scale up nutrition interventions and livelihood initiatives;
(3) integrate prevention, care and treatment services and link them to reproductive health and cervical cancer screening;
(4) use innovative strategies to provide alternative sources health care workers, including task shifting and the increased
involvement of PHAs and institutions of higher learning;
(5) expand distribution of the basic care package (BCP) and prevention with positives activities;
(6) identify and provide early treatment for HIV-positive pregnant women with follow-up of mother-infant pairs during post-natal
care and immunization visits.
An additional strategy will be to decentralize the provision of services to more rural areas through Health Center IIIs and
community-based care.
Care and Treatment
In FY09, the USG will have a special focus on clinical care at all supported facilities to improve: (1) routine screening of all HIV-
positive persons to determine ART eligibility; (2) pain management and symptom control through regular screening and
assessment of pain, and treatment or referral; (3) treatment and prevention of OIs including STIs and TB; (4) routine clinical and
immunological monitoring of those on ART; 5) support for drug adherence; (6) linkages to the Presidential Malaria Initiative for
supply of insecticide-treated bed nets and diagnosis and management of malaria. Ongoing capacity building for ART monitoring
will be expanded beyond adult care to include aspects of pediatric ART, PMTCT, ARV drug resistance surveillance and Early
Warning Indicators.
Food and Nutrition
In FY09, the USG will integrate comprehensive food and nutrition interventions within care and treatment services. These include:
(1) assessments to determine nutritional status, food access and availability; (2) nutrition counseling, prevention of food and
waterborne diseases, and infant and young child nutrition feeding options; (3) targeted food and nutrition support including food
rations for HIV/AIDS affected households, food supplements for high risk groups and those with mild-to-moderate malnutrition,
supplementary and therapeutic foods for moderately and severely malnourished PHAs, micronutrient supplementation and
replacement feeding for infants. 40,000 PHAs on care and treatment will receive nutritional assessment and education of whom
an estimated 10,000 malnourished individuals will receive therapeutic foods. 800 staff will be trained to provide food and nutrition
interventions at 77 service outlets. Those graduating from therapeutic and supplementary food support will be linked to
sustainable livelihood initiatives through social support activities.
Integration of services
The USG will strengthen the scope of non-ART services at all supported sites and establish coordinated linkages and delivery of
these services. The non-ART services include: (1) provider-initiated HCT; (2) HIV primary care and distribution of the BCP; (3) TB
diagnosis and management; (4) family planning and reproductive health (RH) services for HIV-positive women; (5) nutritional
assessment and counseling; (6) prevention-with-positives (PWP). RH services will include screening for cervical cancer. The USG
has identified cervical cancer prevention among HIV-positive women as an area of special focus for FY09. Three sites will pilot the
"see and treat" approach to cervical cancer prevention. They will conduct training, perform histopathology and quality assurance
for visual inspection with acetic acid screening, and provide advanced cervical cancer treatment.
In response to the shortage of health care workers, and in an attempt to build a sustainable workforce, USG will expand its
support of pre-service training. A program is proposed to place health care trainees in internships and develop structured
approaches to assessing the quality of care provided once trainees are in the workplace. Innovative strategies to increase the
availability of human resources for HIV/AIDS service delivery will be implemented. These strategies include: (1) improved
supportive supervision; (2) "task-shifting" in the health sector with special emphasis on non-traditional health workers such as
volunteers and PHAs (as "expert clients"). This will require establishing systems for training, certification and policy change by the
GOU and professional associations to permit volunteers and PHAs to provide care; (3) direct support to the Health Service
Commission, professional medical councils, MOH human resources division and the District Health Officers to recruit, train and
retain health workers.
Basic Care Package and Prevention with Positives (PwP)
The Basic Care Package (BCP) is a minimum set of evidence-based care interventions for HIV infected persons. The BCP
includes cotrimoxazole for OI prophylaxis, insecticide treated bed nets (ITN), a safe water vessel, water purification solution,
information on PWP written in local languages, and condoms as appropriate. In FY09, there will be a special focus on providing
the BCP to HIV-positive pregnant women attending antenatal-care and PMTCT programs. Through increased support to National
Medical Stores (NMS) and Joint Medical Stores (JMS), PEPFAR will ensure that the BCP is available to all patients accessing
care and treatment services at MOH sites. Through support to social marketing the BCP will be made available to a wider clientele
including the private sector.
The PwP approaches involve (1) provider-initiated family-based HCT, (2) supported disclosure of HIV status, and (3) counseling
on mother-to-child transmission, family planning services, and STI screening and management. In collaboration with MOH, USG
partners will continue to train care and treatment providers to provide HCT and manage referrals to community-based care and
PHA networks. A national behavior change communication campaign to increase PwP will continue to increase awareness of the
need for and availability of PWP programs.
Pregnant Women and Mother-Infant Pairs
Improved care and treatment of HIV-positive pregnant women and post-natal follow-up of mother-infant pairs is an FY09 focus
area. All USG supported sites offering ART and/or antenatal services will provide PMTCT and/or referrals to ensure mother-infant
pairs have post-delivery follow-up in an HIV/AIDS clinic. To reduce loss-to-follow-up, USG will support partners to implement a
family-centered approach to providing care for mothers, infants, and household members. This will also foster male involvement.
Through these activities, over 15,000 HIV-exposed infants will access early infant diagnosis services. All identified HIV positive
infants will be started on ART irrespective of CD4 count as per the revised MoH guidelines.
Linkages, referral mechanisms and systems
A key focus of this year is to strengthen referral mechanisms and linkages between in-patient, clinic and home-based care, and
with OVC care and support services. As hospitals and Health Center (HC) IVs reach capacity, clinically stable patients will be
referred to lower levels (e.g., HC IIIs and community-based care). Network Support Agents will play an increasing role in ensuring
that referrals and linkage between health facilities and the community actually happen. They will track patients, provide adherence
counseling, provide at-home services, and support caregivers. This approach will be scaled up to cover over 41 out of 82 districts.
With the rapid scale-up of care and treatment services in an environment of chronic shortages in human resources, USG will
support programs to build capacity of PHAs to improve referrals and linkages between facilities and communities, provide
adherence counseling and support, increase ART literacy, identify HIV-infected children in the community and link them to
services, and support efforts to improve PWP initiatives. All PHAs will be linked to PMTCT, food and nutrition interventions,
TB/HIV, family planning and family-based care. PHAs will be trained as caregivers and a structured support mechanism
established to mentor them. Activities aimed at ensuring personal, food and environmental hygiene will be included. BCP kits will
also be distributed through PHA groups and networks.
Through increased support to programs that mobilize and build capacity of PHA groups and networks, the USG will ensure that
PHAs are linked to involved in the following social support: (1) food security interventions, income generating activities and
sustainable livelihood strategies; (2) community mobilization and promotion of awareness of HIV/AIDS prevention, HIV counseling
and testing, and care and treatment; (3) stigma reduction; (4) support for caregivers. Significant aspects of this program will be
achieved by leveraging non-PEPFAR resources.
Linkages between care and treatment and the laboratory system will be strengthened in FY09. This is necessary in order to
comply with guidelines for CD4 cell assessment of HIV infected individuals every 6 months, for viral load measurements, and for
early infant diagnosis. The capacity of regional referral laboratories and designated district laboratories in both the public and
private sector will be built to act as hubs for providing diagnostics. Support for establishing referral networks between lower health
center laboratories and the hubs will be scaled up to cover the whole country. Priority will be given to HIV-exposed infants,
patients under care but not yet enrolled on ART, TB/HIV co-infected patients, and HIV-positive pregnant women. This will
significantly increase number of TB/HIV co-infected patients and HIV-positive pregnant women on ART.
Gender issues
Analysis of USG supported activities shows that more than 65% of clients accessing HIV/AIDS services are women. This raises
two issues: 1) the need to increase awareness of HIV testing and care among men, and 2) the challenge of disclosure by women
to male partners and families. The failure to disclose directly affects adherence to treatment, PMTCT initiatives, family planning
and significantly increases the opportunity cost of HIV/AIDS care.
In addition, most caregivers are women. Caregivers often deal with high rates of burnout due to lack of professional supervision
and support, the time burden, and emotional stress. USG supported programs will work to improve personal and organizational
support for caregivers. There will be increased targeting of men to improve their roles in care giving, to encouraged men to seek
HCT and care, and to provide support to female caregivers.
Monitoring and Reporting
PEPFAR will monitor and enhance the quality of facility-based HIV care and treatment through the activities of HIVQUAL and HCI.
The two partners will work with other PEPFAR and non-PEPFAR partners in improving data recording, analysis and utilization.
Data will be used to analyze treatment outcomes among a cohort of patients on ART at 6 and 12 months. To improve quality of
care and treatment services, partners will: (1) institutionalize quality of care approaches (2) integrate supportive supervision for all
health workers; (3) develop and implement performance indicators; and (4) set up quality improvement teams at health facilities
and sub-districts.
Table 3.3.08:
CDC HIV/AIDS Fellowship Program is an capacity building and training program implemented by Makerere
The community-based VCT program is nested in the Program's existing annual research activities, where
persons residing in the study areas are offered counseling and testing in their respective communities. HIV
results are returned to these clients through program counselors who reside in these communities. VCT is
also offered at the HIV care clinics and in the homes of HIV positive index persons. Through the medical
male circumcision service, clients seeking male circumcision service are also offered counseling and
testing. All persons who test HIV positive and accept to learn their HIV status are referred to the program
HIV care clinic nearest to their community or nearest to their home. The program currently operates 17
mobile clinics in Rakai and Lyantonde districts. These mobile clinics are located at already existing
government centers and are run by a team of medical officers, clinical officers, nurses and counselors on a
rotational bimonthly basis.
Services offered include: health education, On-going HIV counseling, PMTCT, treatment and prophylaxis for
opportunistic infections, provision of antiretroviral therapy, prevention for positives, laboratory screening and
monitoring of various infections, reproductive health services, provision of basic care packages containing
safe water vessel with hypochlorite solution for treatment of water, insecticide-treated bednets, and
condoms. All HIV positive patients receive cotrimoxazole prophylaxis (if not contraindicated).
The majority of patients currently enrolled on the HIV care program are adults (60% female, 40% male) and
only about 5% are children 0-14 years old.
The RHSP laboratory: RHSP has an established state-of-the-art laboratory infrastructure located at Kalisizo
center that supports the evaluation and monitoring of patients on the program. All samples except those
collected for rapid field testing like hemoglobin, binax and serum lactate, are transported back to the central
Kalisizo laboratory for testing. The range of tests carried out include: HIV testing by 2 ELISA tests and
western blot if ELISA is discordant, microbiology tests like urinalysis, Ziehl Nelsen tests for TB screening,
blood cultures etc, Serology like serum CRAG, Chemistry tests like liver and renal function test and
hematology, among others. As an accredited TB center, the program is making efforts to streamline TB
diagnostics. In addition to laboratory testing, there is an X-ray facility to support diagnosis. Resistance
testing for TB is outsourced at another laboratory. The RHSP program has refurbished some government
facilities to increase clinic space for provision of clinical services.
The RHSP medical male circumcision program: Three trials of male circumcision (MC), including one
conducted by the Rakai Health Sciences Program (RHSP) in Rakai District, Uganda, have shown that the
procedure reduces male HIV acquisition by 50-60% and has the potential to dramatically curtail the HIV
epidemic in areas of Africa where MC is uncommon and the epidemic most severe. Additional benefits of
Population-level effects on HIV incidence will be achieved if MC is provided to and is accepted by men (and
their partners), and if there is no increase in sexual risk behaviors (i.e., risk compensation). The RHSP has
a state-of-the-art outpatient surgical facility and trained highly experienced surgical teams (doctors, clinical
officers, and operating room staff) which can accommodate more than 3,000 surgeries a year. Men
requesting MC are consented for surgery, which is performed under local anesthesia using either the sleeve
or dorsal slit procedures. After observation in a recovery room, discharged men are followed at 1-2 and 7-9
days and 4-6 weeks to monitor healing and potential surgical complications. Men and their partners are
instructed on wound care and on avoidance of intercourse until wound healing is complete. As part of the
MC Service, we provide extensive HIV prevention counseling pre- and post-surgery; offer free condoms;
provide information to men, and whenever possible to their women partners, regarding wound healing,
wound care and the need to abstain from sex until healing is completed; and offer free individual and
couples' VCT. The Rakai MMC Program also conducts community-level health education for both men and
women regarding HIV Prevention (ABC) and MC. The information is provided through town meetings,
Activity Narrative: Package, including cotrimoxazole, bed nets, clean water containers and hypochlorite tablets. Once they
WHO to serve as an East African regional MC training center.
Progress to date:
Basic care:
In this financial year (FY 2008), we proposed to provide basic HIV care to 5000 HIV positive clients. In this
program, HIV basic care comprises of continuous health education which is given on every clinic day before
the clinical sessions begin. These sessions cover a wide range of health issues including PMTCT,
feeding/nutritional issues, family planning, drug adherence, couple counseling, and disclosure among other
topics. Treatment of opportunistic infections, on-going HIV counseling, provision of HIV basic care package
for prevention of diarrheal diseases and malaria.
Education on prevention of domestic violence is also provided through the "Safe Homes and Respect for
Everyone" (SHARE) program.
In the first 6 months of this financial year, the program had enrolled 4501 HIV positive clients and 4111 were
under regular care.
Clients in regular care receive the basic care package and we are currently pilot testing an evaluation of the
utilization of these basic care packages provided to HIV-positive clients through impromptu (unannounced)
home checks.
Laboratory monitoring: The program laboratory has the capacity to carry out various screening and
monitoring tests. These include: CD4 testing, viral load chemistry tests, hematology, serology, and
microbiology. Each patient enrolled for care have CD4 count testing at least 6 monthly to assess eligibility
for antiretroviral therapy or monitor immunological improvement while on ART. All patients on ART have 6
monthly viral loads to assess virologic failure.
In this financial year, Number of tests performed include: HIV testing: 7524 Elisa tests, 499 Western blot
tests, 2510 PCR tests (of these, 1700 were from the HIV clinic and 57 were for infant diagnosis, others from
other Rakai studies), 4076 CD4 counts, of which 2806 were for the HIV clinic and 457 for other health
centers in the district (Lyantonde and Kitovu hospital). 5370 RPR and 401 TPPA tests for syphilis diagnosis,
310 Elisa for HSV-2 diagnosis, 20 serum CRAG and epatitis-B tests.
Laboratory support to other health units: The program currently provides CD4 count testing for HIV positive
patients of Lyantonde hospital.
ART: In the first 6 months of FY 2008, we initiated 305 clients onto ART, making the total cumulative
number of patients on ART as of
to 1594.
In FY 2009, emphasis to be put on:
•Screening for Sexually transmitted infections like syphilis.
•Provision of health education at the HIV clinics and at the community level via community meetings.
•Preventive services like the basic care package, provision of condoms at both
•Treatment and prophylaxis of opportunistic infections like Tuberculosis, cryptococcal meningitis, PJP
•Prevention of gender-based violence.
•Training of HIV care providers based at the program and those providing care at district health centers.
•On-going support and counseling at the clinics and through the resident counselors.
•Appropriate laboratory monitoring through the central laboratory based at the Kalisizo station.
•Family involvement/ testing
Geographical coverage
These services are provided to Rakai and Lyantonde district and a few residents of the neighboring districts
of Masaka and Mbarara, via 17 outreach/mobile clinics which operate on a bimonthly basis.
The program targets all persons residing in these districts. Via community meetings, the population is
encouraged to visit the clinics for HIV testing and those who turn out HIV positive are retained for HIVcare.
All clinics are located at already existing government health centers. This in part has reduced the stigma
among our clients because the health center serves both HIV positive and negative persons.
Other non-PEPFAR support:
Most of the routine viral load testing is supported by NIH-ICER.
Continuing Activity: 13234
13234 4023.08 HHS/Centers for Makerere 6421 5738.08 Developing $250,000
8328 4023.07 HHS/Centers for Makerere 5738 5738.07 Developing $229,565
4023 4023.06 HHS/Centers for Makerere 3177 1084.06 $136,000
* Increasing gender equity in HIV/AIDS programs
Estimated amount of funding that is planned for Water $20,000
infected persons and their family members in Rakai and surrounding districts. This is a five year grant that
carries forward lessons learnt in phase1. The grant has three major programming components. 1) The
The program aims at building competencies of professionals and health care workers in HIV/AIDS program
and Lyantonde and to a small extent, the neighboring districts of Masaka and Mbarara. Since June 2004,
an innovative home based and community-based Voluntary Counseling (VCT) program, provision of basic
palliative HIV care, antiretroviral therapy (ART), Prevention of Mother to Child Transmissionm (PMTCT),
tuberculosis (TB) care, health education, mitigation of HIV through prevention of domestic violence and
counseling and testing in their respective communities. HIV test results are returned to these clients through
program resident community counselors. VCT is also offered at the HIV care clinics and in the homes of
HIV positive index persons to household memebrs. Through the medical male circumcision service, clients
seeking male circumcision service are also offered VCT. All persons who test HIV positive and accept to
learn their HIV status are referred to the program HIV care clinic nearest to their community or nearest to
their home. The program currently operates 17 outreach clinics in Rakai and Lyantonde districts. These
officers, nurses and counselors on a rotational bimonthly basis. Services offered include: health education,
on-going HIV counseling, PMTCT, treatment and prophylaxis for opportunistic infections, ART, HIV
prevention for positives interventions, laboratory screening and monitoring of various infections,
reproductive health services, provision of basic care packages containing safe water vessel with
hypochlorite solution for treatment of water, insecticide-treated bednets, and condoms. All HIV positive
patients receive cotrimoxazole prophylaxis (if not contraindicated). The majority of patients currently
enrolled on the HIV care program are adults (60% female, 40% male) and only about 5% are children 0-14
years old.
Kalisizo laboratory for testing. The range of tests carried out include: HIV testing by ELISA tests and
positive or of unknown serostatus. Through PEPFAR support, HIV-infected individuals indentified through
Activity Narrative: MMC service are offered a free Basic Care Package, including cotrimoxazole, bed nets, clean water
WHO clinical stage 4), they are offered HAART and clinical monitoring via RHSP mobile and fixed clinics. In
order to facilitate safe MMC, RHSP is offering training to different cadres of medical personnel including
Basic HIV care: In this financial year (FY 2008), RHSP proposed to provide basic HIV care to 5000 HIV
positive clients. In this program, HIV basic care comprises of continuous health education offered on every
clinic day before the clinical sessions begin. These sessions cover a wide range of health issues including
PMTCT, nutritional education, family planning, drug adherence, couple VCT, and disclosure among other
for prevention of diarrheal diseases and malaria. Education on prevention of domestic violence is also
provided through the "Safe Homes and Respect for Everyone" (SHARE) program. In the first 6 months of
this financial year, the program had enrolled 4501 HIV positive clients and 4111 were under regular care.
home checks. The program laboratory has the capacity to carry out various screening and monitoring tests.
These include: CD4 testing, viral load chemistry tests, hematology, serology, and microbiology. Each
patient enrolled for care have CD4 count testing at least 6 monthly to assess eligibility for antiretroviral
therapy or monitor immunological improvement while on ART. All patients on ART have 6 monthly viral
loads to assess virologic failure. In this financial year, Number of tests performed include; HIV testing: 7524
Elisa tests, 499 Western blot tests, 2510 PCR tests (of these, 1700 were from the HIV clinic and 57 were for
infant diagnosis, others from other Rakai studies), 4076 CD4 counts, of which 2806 were for the HIV clinic
and 457 for other health centers in the district (Lyantonde and Kitovu hospital). 5370 RPR and 401 TPHA
tests for syphilis diagnosis, 310 Elisa for HSV-2 diagnosis, 20 serum CRAG and hepatitis-B tests.
Laboratory support is also provided to other health units: The program currently provides CD4 count testing
for HIV positive patients of Lyantonde hospital. ART: In the first 6 months of FY 2008, we initiated 305
clients onto ART, making the total cumulative number of patients on ART as of June 2008 to 1594.
In 2009, emphasis to be put on:
- Screening for Sexually transmitted infections like syphilis.
- Provision of health education at the HIV clinics and at the community level via community meetings.
- Preventive services like the basic care package, provision of condoms at both
- Treatment and prophylaxis of opportunistic infections like Tuberculosis, cryptococcal meningitis,
Pnemocytis pneumonia
- Prevention of gender-based violence.
- Training of HIV care providers based at the program and those providing care at district health centers.
- On-going support and counseling at the clinics and through the resident counselors.
- Appropriate laboratory care and treatment monitoring through the central laboratory based at the Kalisizo
station.
- Family involvement in HIV testing
of Masaka and Mbarara, via 17 outreach/mobile clinics which operate on a bimonthly basis. The program
targets all persons residing in these districts. Via community meetings, the population is encouraged to visit
the clinics for HIV testing and those who turn out HIV positive are retained for HIV care. All clinics are
located at already existing government health centers. This in part has reduced the stigma among our
clients because the health center serves both HIV positive and negative persons.
Other non-PEPFAR support - Most of the routine viral load testing is supported by NIH-ICER.
Continuing Activity: 13238
13238 4021.08 HHS/Centers for Makerere 6421 5738.08 Developing $469,023
8326 4021.07 HHS/Centers for Makerere 5738 5738.07 Developing $469,023
4021 4021.06 HHS/Centers for Makerere 3177 1084.06 $386,705
Estimated amount of funding that is planned for Human Capacity Development $279,000
Program Budget Code: 10 - PDCS Care: Pediatric Care and Support
Total Planned Funding for Program Budget Code: $5,564,403
Of the estimated 940,000 people living with HIV/AIDS (PHA) in Uganda, about 130,000 are children below the age of 14 years
(UNAIDS 2008). Infant mortality among children born to HIV-infected and uninfected mothers is estimated at 209 and 98 per
1,000 births respectively (Rakai Program Cohort, 2000). Without access to ART, 50% of HIV infected infants will die before their
second birthday and 75% will die before their fifth birthday (UNAIDS, 2005). UNAIDS does not provide estimated national need for
children requiring ART, but if one assumes 15% of the estimated total of 350,000 persons, this would be 52,500 children and
infants in need of treatment.
The primary mode of transmission of HIV in children is mother-to-child-transmission (MTCT) accounting for over 95% of HIV
infections in children under 12 years, and 18% (25,000) of 135,000 new HIV infections annually. Factors contributing to high
MTCT rates and large numbers of HIV-positive children include: 1) high fertility rate of 6.7 children per woman; 2) the 6.5% HIV
prevalence among pregnant women; 3) limited access to PMTCT interventions; 4) use of less effective antiretroviral therapy
(ART) regimens for PMTCT; and 5) lack of safe and affordable infant feeding options resulting in HIV transmission through breast
Policy and guidelines
The National Pediatric ART Committee, established in 2006, developed a pediatric HIV Ten-Point Management Plan:
1. Early diagnosis of HIV infection
2. Growth and development monitoring
3. Routine childhood immunizations and deworming for helminthes
4. Nutrition education and supplementation
5. Aggressive treatment of acute infections
6. Prophylaxis and treatment of opportunistic infections
7. Psychosocial support and palliative care
8. Adolescent care and support
9. Mother and family care
10. Antiretroviral therapy when available and indicated
In the absence of affordable and safe infant feeding options, exclusive breast feeding up to 6 months of age with rapid weaning is
recommended for all HIV-exposed infants. Cotrimoxazole prophylaxis should be initiated at 4-6 weeks of age or first encounter
with health system and continued until HIV infection can be reliably excluded. For breast-feeding exposed infants, virologic HIV
testing using DNA-PCR at 4-6 weeks is recommended. Infants negative by DNA-PCR should have an HIV antibody test 3 months
after cessation of breast feeding and if positive, referred into care. Non breast-feeding infants found negative at 6 weeks by DNA
PCR should have a confirmatory antibody test at 9-12 months. Indications for ART initiation vary with age. The revised National
ART Guidelines (June 2008) broadened the ART eligibility criteria to include all infants under 12 months of age with a confirmed
diagnosis of HIV irrespective of CD4 count or percentage.
FY08 accomplishments
The Uganda National Strategic Plan for HIV/AIDS 2006/7-2011/12 recognized children as an underserved population and
advocated for improved support. Through PEPFAR, many partners have supported capacity building for pediatric care and
treatment by training health providers, particularly in communication with children, child survival strategies, Early Infant Diagnosis
(EID), and administration of complex ARV regimens. MOH has adapted the Integrated Management of Childhood Illnesses (IMCI)
complementary HIV course for training primary-level health workers in pediatric HIV. MOH and partners have established regional
mentors for pediatric HIV care and treatment.
The number of accredited ART sites with capacity to provide pediatric care and treatment increased from 30 in 2006 to 209 in
2008. In FY08, 11,686 children were on ART supported by PEPFAR, with a male to female ratio of 1:1. This is an increase of
2,859 children since 2007. All children in care were indirectly supported through USG inputs in national training, laboratory
diagnostics, logistics systems, quality assurance and policy. However, only 9% of all persons on PEPFAR supported ART are
children, a decline from 11%. This relative change in children treated can be partially attributed to the increase in the family-
centered approach to care, which has identified proportionally more adults. As of June 2008, MOH reported a total of 12,577
children on ART nationally, meaning that PEPFAR supports 95% of all children on treatment. The number of children needing
ART will increase with the recently revised national guidelines that recommend ART for all confirmed HIV-positive infants under
12 months. Based on the new guidelines, an additional 25,000 infants may require ART in the absence of better PMTCT
interventions.
There has been progress in identifying HIV infected children. In October 2006, MOH in collaboration with partners initiated EID,
which uses DNA-PCR to diagnose infant HIV infection. The EID program is linked to 214 health facilities and has conducted more
than 13,500 tests using Dried Blood Spot specimens processed at 7 reference laboratories countrywide. Each district has at least
one health facility able to refer or test specimens using HIV DNA-PCR. The program targets HIV exposed infants with mothers
diagnosed during antenatal care or newly identified at post-natal and immunization visits. In addition, several health facilities are
implementing Provider Initiated HIV Counseling and Testing (PICT) in pediatric in- and out-patient wards with support from Baylor-
Uganda, RTI, and MJAP programs.
Through the Clinton Foundation HIV/AIDS Initiative (CHAI), commodities supporting pediatric HIV diagnosis, care and treatment
have been available nationally since 2006/7, greatly improving access to pediatric care. Commodities include pediatric ARVs drug
formulations, laboratory reagents for HIV diagnosis in children, nutritional supplements, and cotrimoxazole. Staffing support and
training were also provided to some sites. When the pediatric component of CHAI ends in 2010, it is expected that these activities
will be rolled into the existing national program supported by PEPFAR and MOH-Global Fund. The USG team and the MOH will
plan for this transition; otherwise it is possible that services, particularly the EID program initiated with CHAI support and
procurement of costly pediatric ARV formulations, will be disrupted
Two annual national pediatric advocacy meetings were held bringing together all stakeholders. The aim of these meetings was to
harmonize practices and improve coordination among providers. Family based care was piloted and adopted by several partners,
thereby improving pediatric access. Counseling guidelines were revised to address HIV testing issues in children. The National
HIV Care Quality Improvement (QI) program was rolled out to 220 ART sites with support from HIVQUAL and HCI. Specific
pediatric indicators are being used at sites located in Northern Uganda with support from UNICEF. The plan is to scale-up
evaluation of pediatric care to all ART sites.
Challenges
1. Limited access to pediatric care: Although the number of children on ART doubled in the previous year, they comprise only 9%
of the all persons on treatment, still below the MOH target of 15%. The MOH estimates that 27% of eligible children are on ART.
Pediatric care is especially limited in rural areas. Major factors contributing to the limited access are:
a) Inadequate community education and mobilization for pediatric care services. Many parents and guardians are still reluctant to
establish the HIV status of their children, even when children have a history of exposure. Adults in care are often unwilling to bring
in children for HIV testing or may even deny them care and treatment after being diagnosed positive.
b) Human resource gaps: Shortage of health workers with skills in pediatric care remains a major challenge. Children require
more physician time and therefore suffer most from understaffing. Because of these staffing shortages, fewer ART sites provide
pediatric HIV/AIDS care compared to adult treatment. Although task-shifting has alleviated some human resource problems at
ART sites, the technical expertise and time required for pediatric care prevents task shifting from fully addressing the shortage in
pediatric health care staff.
c) Inadequate commodity supplies: Pediatric ARV regimens are more costly and complex than adult regimens. The challenge of
procuring pediatric ARV formulations will increase when the Clinton Foundation donation ceases in 2010. In addition, pediatric TB
drug formulations are unavailable in Uganda. Although Uganda eventually plans to relieve the ARV drug supply problems by
producing its own generic drugs in partnership with Cipla and Quality Chemicals, a plant for the production of pediatric
formulations has not yet been built.
d) Limited coverage of EID: Although the EID program has improved the capacity for HIV diagnosis in infants under 18 months,
the number of facilities linked to the service is limited. It is estimated that only 13% of the estimated 91,000 HIV exposed infants
were tested through this program in 2007. In addition, the system for sample collection, transport to the reference laboratory,
sample processing and return of results (turn-around time) needs to be reviewed to improve efficiency.
2. Data gaps: The demand for pediatric care is not really known as there are no clear data on numbers of infected children,
number in active care nationally, and number eligible for ART. The AIDS Indicator Survey planned for early 2009 will hopefully
address this gap. Improved reporting, national program monitoring and evaluation are needed.
3. Continued MTCT: The national PMTCT program is less than optimal. There are also weak linkages between the PMTCT
program and pediatric care leading to ‘loss to follow-up' of HIV exposed infants, missed opportunities for HIV diagnosis and for
timely initiation of treatment.
4. Adolescent sexuality: Sexuality and reproductive health needs of HIV infected adolescents are a challenge. In addition to the
unmet medical needs, adolescents with HIV are a particularly vulnerable group with a wide range of psychosocial needs. Lack of
child and adolescent-friendly services including reproductive health and family centered care compound the problem.
5. Adherence to ART: Adherence is a greater challenge in children partly due to the requirement for dose adjustments as weight
increases, lack of stable caregivers particularly if orphaned, lack of disclosure of HIV status, and adolescent hormonal changes.
This may have implications for earlier drug resistance in children if not addressed.
6. Linkages: Linkage between pediatric care and OVC programs is still weak and yet the majority of HIV-infected children are
orphaned and vulnerable. Follow-up and community support of HIV-infected children is either non-existent or inadequate, and
needs strengthening to reduce loss to follow-up and attrition.
7. Nutrition: Alternative safe infant feeding options are lacking, increasing the risk of transmission through breast feeding. The
majority of HIV infected children are malnourished; for example, up to 30% of children in the nutrition unit at Mulago National
Referral Hospital are HIV infected.
FY09 Focus Areas
In FY09, USG will continue to leverage other donor resources including the Global Fund, the Clinton Foundation, UNICEF, and
others to increase the number of children receiving HIV care and ART. In FY09, 12,735 children 0-14 years old will receive
antiretroviral treatment from USG-supported sites.
1. Continue capacity building for pediatric health care staff through training, mentorship and supervision. Emphasis will be put on
building capacity of community care groups such as PHA networks, religious leaders and volunteers to assist with pediatric care.
The existing prevention with positives (PWP) interventions will be strengthened to enhance disclosure at the family level and
support parents and guardians to test children for HIV. Approaches such as Provider Initiated HIV Counseling and Testing (PICT)
and ‘Know Your Child's Status' campaigns will be encouraged within existing HIV clinics and home-based HCT programs. USG
will support the expansion of the pediatric mentoring program using regional pediatricians and experts.
2. Scale-up of Early Infant HIV Diagnosis (EID). This will involve review and possible modification of the current communication
system between testing centers and care units to ensure timely delivery of results. Better communication will also minimize
attrition of eligible children.
3. Referral and linkages: The USG will continue to strengthen linkages among OVC, PMTCT, EID, and pediatric HIV care and
treatment services. All HIV exposed and infected children are vulnerable and/or orphaned and therefore need to be linked to ART
care and OVC services.
4. Address adolescent sexuality issues: USG will support the extension of PWP programs to HIV-infected youth to encourage
them to understand the implications of being HIV positive, need for ART adherence, individual responsibility in HIV prevention,
use of condoms and family planning services. Focus will be put on integrating confidential care within broad-based youth
programs to minimize stigma.
5. Provide nutritional counseling and supplementation to eligible children and their families. The USG will establish and strengthen
linkages with the NuLife program to provide therapeutic and supplemental food to nutritionally compromised children. Routine
PICT is required to diagnose infection among malnourished children. HIV diagnosis care and treatment will be integrated into
routine care for children in nutrition units and linkages between the two units strengthened. Micronutrient supplementation with
multivitamins will be introduced as part of routine pediatric HIV care and support.
6. Guidelines for pediatric care recommend initiating cotrimoxazole prophylaxis from 6 weeks after birth until HIV infection is
excluded after weaning. Other components of the BCP such as insecticide treated bednets, safe water systems, treatment for
malaria and other OIs delay the progression to AIDS. The USG will continue to supply the BCP to mother-child pairs. To ensure
continued availability of pediatric care commodities, the USG will work closely with the MOH, UN and other partners in the Global
Fund development process to plan for gaps resulting from the end of Clinton Foundation support.
Table 3.3.10:
RHSP provides a range of HIV care and treatment services for children ages 0-14 including; early infant
diagnosis using DNA-PCR, psychosocial support, VCT, nutritional counseling and education, diagnosis and
treatment of opportunistic infections, laboratory monitoring, preventive services, health education, provision
of antiretroviral therapy and family counseling and testing. To date, a total of 66 HIV positive children under
the age of 2 years have been screened for ART eligibility. Of these, 17 are currently receiving antiretroviral
treatment. Following the new WHO guidelines for infant initiation of ART, all HIV positive infants under the
age of 2 years are being initiated on ART irrespective of CD4 cell percentage. Over 196 HIV positive
children aged 2-14 years have been screened for ART eligibility and 55 of these are currently on treatment.
Families of HIV positive children have been provided with VCT, so as to mobilize family support for these
children and ensure treatment adherence. All the HIV-positive children active in care have received the HIV
basic care package, comprising of a safe water vessel and sodium hypochlorite solution for water
disinfection to reduce incidence of diarrheal diseases and insecticide-impregnated bed nets, for prevention
of malaria. Cotrimoxazole prophylaxis is provided to all HIV infected children and to babies born to HIV
positive mothers, until HIV infection is excluded (ruled out). Laboratory screening and monitoring: All
children that are not yet eligible for ART will have CD4% re-assessment performed every 3 months while
those on ART have semi-annual CD4 and viral load reassessment. Other laboratory testing done include:
hematology (complete blood counts), chemistry, (liver and renal function tests), and serology.
These services are provided to HIV positive children residing in Rakai and Lyantonde districts.
FY 2009 and 2010 ACTIVITIES: Emphasis areas to be addressed include:
- Expansion of the early infant diagnosis program for HIV diagnosis among infants
- Diagnosis and treatment of opportunistic infections
- Provision of daily cotrimoxazole for prophylaxis
- Mobilization of family support for the children in care
- Laboratory monitoring
- Provision of antiretroviral therapy for eligible children (including infants below 12months of age who are
confirmed HIV positive irrespective of CD4 count)
- Nutritional counseling and education
- HIV preventive education and services
* Malaria (PMI)
* TB
Estimated amount of funding that is planned for Human Capacity Development $12,500
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $9,377,597
Detection and treatment of cases of tuberculosis (TB) continues to be a high priority. In Uganda, the annual incidence rate of
smear positive TB cases is 154/100,000, with a prevalence of all cases of 561/100,000 and a TB mortality rate of 84
deaths /100,000 (2008 WHO Global TB Control report). The TB case detection rate of 50.2% remains below the WHO/IUATLD
(International Union against TB and Lung Diseases) target of 70%. TB treatment success rate is estimated to be 73%, which is
also below the WHO/IUATLD target of 85%. TB treatment outcomes remain poorly documented, with only 13% of treated
pulmonary TB patients having a record of sputum smear conversion. Overall, too many newly diagnosed TB patients die during
drug treatment, while others default or are lost to follow up. On the other hand, efforts to establish linkages between TB and
HIV/AIDS care and treatment programs are improving. In Uganda, as in most of sub-Saharan Africa, TB remains the leading but
most preventable cause of morbidity and mortality among People Living with HIV/AIDS (PHA).
The Ugandan TB/HIV policy guidelines and the TB/HIV communication strategy were launched in 2006. Significant progress has
been made in improving the collaboration between HIV and TB activities at the national level. An integrated management
approach employs a decentralized service delivery and referral system. However, limited coordination and support of TB/HIV
activities at the district level hampers effective collaboration. Resulting problems include: poor dissemination of TB/HIV policy
guidelines to districts and facilities; under-reporting of TB/HIV indicators; frequent stock-outs; and limited application of basic TB
infection control practices. Significant challenges exist in the reporting of indicators by partners; the same clients are often
reported by both TB service providers and by referring HIV care and treatment partners. Other significant constraints include the
lack of guidelines to address Multidrug-Resistant TB (MDR-TB), Extensively Drug Resistant TB, (XDR-TB), and childhood TB.
PEPFAR/USG will work with the National TB and Leprosy Program (NTLP) towards addressing these limitations.
FY08 achievements
In FY08, PEPFAR/ USG supported the integration of TB/HIV activities at the facility level in 524 sites. The key TB/HIV integration
activities included TB screening and TB treatment of HIV infected clients; HIV counseling, and testing (HCT); and provision of HIV
prevention, care and treatment to TB patients. In FY08, USG-supported sites provided TB treatment to 12,770 HIV positive TB
patients, less than the target of 20,740. The number of registered TB patients who underwent HIV counseling and testing, and
received their results was 17,783. This is considerably less than the FY08 target of 53,432 TB patients to be counseled and tested
for HIV. However, the target was overly ambitious, and is higher than the total number of reported TB cases nationally. Since the
entry point of significant proportion of TB cases in USG supported sites is through HIV care and treatment, where counseling and
testing already took place, these people do not require HCT again. A more realistic target for FY09 will be based on the actual
number of total TB cases being reported by MOH.
The USG/PEPFAR-Uganda team recognizes that integration of TB and HIV activities provides a vital contribution to achieving
PEPFAR HIV treatment and prevention targets, and to improving Uganda's TB indicators. In addition, TB surveillance, monitoring
and evaluation need strengthening. With this in mind, USG will continue to target the following key areas:
1. Support the National TB/HIV Coordination Committee (NCC) and district-level TB/HIV activities to integrate services across all
81 districts. This will occur through support of the Tuberculosis Control Assistance Program (TB-CAP) and other PEPFAR
partners within the TB/HIV portfolio, through the TB/HIV NCC and the Uganda Stop-TB Partnership. Integration requires the rapid
scale-up of routine HCT services for suspected and confirmed TB patients, and linking those who are co-infected to HIV/AIDS
care and treatment services. These activities will be supported by the 20 TB/ HIV implementing partners. Partners providing HIV
care and treatment will enhance TB/HIV integration through routine TB screening of HIV-positive clients, and providing treatment
to those with active TB.
2. Support implementation of the "Three I's of HIV/TB" by:
(a) Strengthening routine Intensified TB Case Finding (ICF) among HIV-infected clients in HIV prevention, care and treatment
settings.
(b) Implementing simple, low-tech TB Infection Control (IC) measures in health facilities to prevent TB transmission among PHA
and health care workers. This includes workplace controls such as triaging of patients, health education of patients and health
workers, and separation of TB infected patients.
(c) Developing policies and guidelines for Isoniazid Preventive Therapy (IPT). Existing IPT pilot programs implemented by the
AIDS Information Center (AIC), MJAP and HBAC will be evaluated to generate a local evidence base to inform TB/HIV policy
guidelines and the MOH.
3. Increase the availability and quality of TB and HIV diagnostic services by strengthening laboratory systems at facility, regional
and national referral levels with an emphasis on laboratory infrastructure, human resources, commodities, supportive supervision,
quality assurance, timely diagnosis of sputum smear negative cases and infection control.
4. Support surveillance of drug resistant TB, and linkages of persons with resistant TB to appropriate treatment services. The TB
Drug Resistance Surveillance is a Strategic Information activity; a detailed description is among the SI activity narratives.
5. Strengthen monitoring and evaluation of HCT among TB patients, and improve linkages and referral to HIV care and treatment.
Reporting has previously been a weak area. The national ART card is being revised to include TB indicators. TB registers
currently include information on HIV, but training, supervision and improved reporting of these data are required.
Other donor support and leveraging
At the national level, PEPFAR funding complements other sources of TB funding that comes from WHO, the Global Fund for
AIDS, TB and Malaria (GFATM), the German Leprosy and TB Relief Association, and the Foundation for Innovative Diagnostics
(FIND). At the district level, PEPFAR funding is leveraging non-PEPFAR USAID funding for expansion of Community-Based (CB)-
DOTS in 12 districts under TB-CAP, and nine districts through NUMAT. These non-PEPFAR funds provide district level support of
CB-DOTS supervisors to oversee linkages between community- and facility-based care, and between TB and HIV activities.
Support of national, district and facility-level TB/HIV integration
USG support for integration of TB/HIV activities has been in three primary areas: a) enhancing the working relationships between
NTLP and the AIDS Control Program (ACP); b) assisting the National Coordination Committee to develop National Program
implementation plans; and c) providing supervisory and technical support at district and facility levels. At the district level, USG
continues to help establish and support district level TB/HIV coordination, and to ensure that integration activities are incorporated
into district health plans. In over 80 health care facilities, USG will continue to provide supportive supervision, quality assurance
and assistance in developing Infection Control Committees to ensure that infection control procedures are in place to reduce TB
transmission. In order to strengthen monitoring, evaluation, drugs and supplies for TB/HIV, USG will emphasize the support of
health facilities to use national recording and reporting procedures, and logistics management information systems.
PHAs and referrals
Coordination mechanisms have been set up at the district level to facilitate experienced TB/HIV co-infected patients to serve as
peers in their communities. Through programs that build capacity of PHA groups and networks, USG will continue to support
linkages and referrals between facility-and community-based TB care. PHAs are trained to act as network support agents, to link
health facilities with communities, provide adherence counseling and support, and facilitate referrals between TB and HIV care
and treatment services. This is an ongoing activity.
Scale up of the "Three I's of HIV/TB"
In FY09, USG will facilitate the scale up of the three I's: Intensified case finding (ICF) among PHA, TB infection control (IC) in HIV
settings, and Isoniazid preventive therapy (IPT). A workshop for all USG TB/HIV Implementing partners to provide guidance for
ICF, IC and TB/HIV recording and reporting will be conducted. USG Implementing Partners will work with the health facilities and
districts to develop and implement TB infection control in HIV care and treatment settings. USG will continue to provide technical
support to NTLP and ACP to develop guidelines for TB infection control and to explore innovative ways of reducing barriers to the
provision of IPT for HIV-infected patients with latent TB. At present, the MOH does not recommend implementation of IPT at
facilities if there are manpower shortages, incomplete case detection rates, and lack of quality assurance for laboratory diagnosis
of TB. However, AIC and MJAP have the capacity to provide IPT. AIC has already started, and MJAP is developing a
programmatic approach to doing so.
HIV Counseling and Testing and TB Screening and Treatment
In FY09, the USG will continue to support expansion of integrated TB/HIV programs at regional referral hospitals and district
health facilities. The goals are to provide HIV counseling and testing to 80% (estimated 34,061) TB patients, and to enhance
routine TB screening among all HIV positive clients on care and treatment in USG supported sites. In FY09, USG targets are to
provide TB treatment for 100% (estimated 16,189) HIV-positive TB patients at USG supported sites. USG/PEPFAR partners will
continue to train and support health care workers to accurately perform routine TB diagnostics and conduct HIV rapid testing
among both suspected and laboratory-confirmed TB patients. At rural health centers, nursing assistants are being trained as
microscopists, and nurses receive training in rapid HIV-testing. National programs will be assisted to develop guidelines for
screening, diagnosis and treatment of TB in HIV-infected children. Pediatric HIV programs will be supported to provide TB
screening, and linkages and referrals to treatment. With USG support, the modified TB registers will be used to capture data on
HCT, and the provision of cotrimoxazole and ARVs to co-infected patients.
Linkages with HIV Prevention, Care and Treatment
In FY09, USG will increase focus on ensuring that TB/HIV co-infected patients are regularly screened for ART eligibility.
Coordination between CB-DOTS and ART programs will ensure that TB/HIV co-infected patients who are eligible receive ART, as
well as support for adherence to both TB and HIV treatment. Provision of palliative care to co-infected patients will also be
enhanced. A minimum package of Prevention with Positives (PWP) will be implemented in TB treatment settings. Health care
providers in TB settings will be trained to provide components of the minimum package, including information on PWP, partner
based counseling and testing, supported disclosure, safe sex counseling, and information on PMTCT and STI management.
Expanded provision of the Basic Care Package, which includes bed nets, cotrimoxazole, condoms and a water vessel, will take
place.
Laboratory and diagnostic support
USG will strengthen and support the Central Public Health Laboratory (CPHL) and the National TB Reference Laboratory (NTRL)
to roll out a training package on TB sputum smear microscopy for laboratory technicians. Progress has been made in customizing
the generic WHO/CDC/IUATLD sputum microscopy training package for use in Uganda, and roll out of this training to all TB
laboratories is ongoing. Support to NTRL to conduct National External Quality Assurance of TB microscopy and diagnosis in all
nine regions of the country will continue. USG will continue supporting NTRL to develop its capacity for drug sensitivity testing and
for conducting surveillance of drug-resistant TB. Surveillance will be enhanced through a specimen referral system for transport of
sputum from previously treated TB patients, from peripheral diagnostic labs to the NTRL for TB culture and drug sensitivity testing.
Funding for this activity has just become available. The sputum referral system has been developed and the logistics of shipping
sputum specimens clarified. A shipping coordinator will soon be recruited. An increase in the number of TB culture facilities to
include an additional two regional labs did not occur last year, but is planned for this year through USG support to NTRL. The
NTRL now has the capacity to do rapid MDR-TB screening tests using mycobacterium growth indicator tubes (MGIT), a rapid
detection method for the isolation of mycobacteria from clinical specimens. Second-line drug susceptibility testing will be
introduced. The USG is assisting NTLP to conduct a national TB drug resistance survey; the protocols has been finalized and
submitted for IRB clearance. Results from this will provide data to inform development of national policy guidelines for
management and prevention of MDR-TB.
Table 3.3.12:
care, health education, mitigation of HIV through prevention of domestic violence and Medical Male
Circumcision (MMC) for HIV prevention.
condoms. All HIV positive patients receive cotrimoxazole prophylaxis (if not contraindicated). The majority of
patients currently enrolled on the HIV care program are adults (60% female, 40% male) and only about 5%
are children 0-14 years old.
RHSP has an established state-of-the-art laboratory infrastructure located at Kalisizo center that supports
the evaluation and monitoring of patients on the program. All samples except those collected for rapid field
testing like hemoglobin, binax and serum lactate, are transported back to the central Kalisizo laboratory for
testing. The range of tests carried out include: HIV testing by 2 ELISA tests and western blot if ELISA is
discordant, microbiology tests like urinalysis, Ziehl Nelsen tests for TB screening, blood cultures etc,
Serology like serum CRAG, Chemistry tests like liver and renal function test and hematology, among others.
As an accredited TB center, the program is making efforts to streamline TB diagnostics. In addition to
laboratory testing, there is an X-ray facility to support diagnosis. Resistance testing for TB is outsourced at
another laboratory. The RHSP program has refurbished some government facilities to increase clinic space
for provision of clinical services.
positive or of unknown sero-status.
Through PEPFAR, HIV-infected individuals identified through MMC service are offered a free Basic Care
•To date, all patients seen in the 17 clinics have routine clinical evaluation for Tuberculosis and those
suspected to have TB are further investigated through laboratory and radiological examination.
•In the first two quarters of FY 2008, a total of 258 clients with clinical symptoms suggestive of TB were
received sputum screening. 34 of these were sputum positive and were initiated on anti-TB treatment. An
additional 8 patients with negative sputum results were initiated on TB treatment basing on radiologic
findings.
•Efforts to improve diagnosis of Multi-drug resistant TB have been put in place. All sputum samples of
suspected MDR TB patients are sent to Joint Clinical Research (JCRC) laboratory.
•Plans are underway to start culturing sputum negative samples to completely rule out active TB among
sputum-negative patients with suspected TB.
•Currently piloting the provision of Isoniazid prophylaxis to HIV positive patients.
TB screening - continue to provide routine clinical assessment of all patients for TB. This service shall be
provided for patients attending the program HIV clinics as well as the general STI clinic; and provide
laboratory (Gram stain, Ziehl Nelsen testing) and radiological (x-ray) investigations.
TB drugs - Rakai program was accredited by the Rakai district as a TB treatment center. All Uganda
Ministry of Health TB drugs are provided free of cost through the district health office.
Monitoring- RHSP works with the district TB team to follow-up patients on TB therapy. The district has an
established TB treatment follow-up system, with TB DOTS community volunteers. Strengthen the available
TB treatment and follow-up services by referral of the TB patients to the community volunteers for
supervised DOTS. Additionally, out TB focal clinician will continue to liaise with the district TB team and the
community volunteers.
•The program will work with the district TB program to improve monitoring of patients initiated on TB
treatment. A program home visitor, a key person on the TB/HIV program, will occasionally carry out
unannounced home visits to these patients, to ensure adherence to treatment
•Laboratory monitoring will be provided for all patients on TB treatment. We shall specifically monitor the
liver function tests every 6 months and whenever clinically indicated.
INH prophylaxis - PPD testing will be provided for patients under our care and those eligible for INH
prophylaxis will be provided with this service.
Support to the district TB program - RHSP will support diagnosis of TB at 17 health units, with diagnosis
reagents and support to the Rakai district x-ray facility through quarterly provision of supplies like x-ray
films, and developer chemicals.
These activities will be conducted in the Rakai and Lyantonde districts. Persons targeted in this program are
HIV positive persons attending our 17 clinics as well as their family members.
Emphasis areas addressed are TB Screening and diagnosis, treatment, monitoring and prevention.
All the above activities directly support the PEPFAR TB/HIV program area.
Continuing Activity: 13235
13235 4018.08 HHS/Centers for Makerere 6421 5738.08 Developing $15,000
8323 4018.07 HHS/Centers for Makerere 5738 5738.07 Developing $14,450
4018 4018.06 HHS/Centers for Makerere 3177 1084.06 $14,450
Estimated amount of funding that is planned for Human Capacity Development $8,500
prevention, care and treatment to the population in and around Rakai District. Aactivities conducted include
clinical monitoring via RHSP mobile and fixed clinics. In order to facilitate safe MMC, RHSP is offering
training to different cadres of medical personnel including surgeons, clinicians, counselors and operating
room assistants. The Rakai center has been selected by WHO to serve as a regional MC training center.
The program has provided counseling and testing to a total of about 7000 clients through the HIV care
clinics, the male circumcision service and the Rakai community cohort study (RCCS). Through these
programs, persons wishing to have HIV testing have been educated, counseled and been tested at the
Rakai program laboratory. Of these, about 2800 are new testers. Provision of counseling and testing
services though three different avenues has increased the population access to CT services.
Men and women who wish to have couple counseling or assisted disclosure are offered the service through
counselors resident in the communities, as well as through mobile counselors attached to the mobile ART
clinics and to circumcision mobile hubs. We have established discordant couple clubs for discordant
Activity Narrative: couples through which clients share experiences, support, and encourage each other and are educated on
how to avoid transmitting or acquiring HIV from their partners.
RHSP counselors have been trained and certified in pediatric and child counseling. In FY2008 we have
provided counseling and testing to 292 children of whom 82 were HIV positive. The children are mainly
identified through the HIV clinics.
The Rakai Health Sciences Program will continue to;
- Provide CT through the HIV clinics and the Rakai annual home based surveys. The CT budget will support
pre and post test HIV counseling in this program area.
- Actively trace HIV positive clients who delay to seek receipt of their test results with support of community-
based counselors and a team of mobile counselors for clients who are in areas that are not covered by the
community resident counselors.
- Support discordant couple clubs that were established in FY 2008 and form new clubs to cover the
underserved areas. Through these clubs, couples living in discordant relationships will receive enhanced
counseling and education on how to prevent HIV transmission and acquisition. Emphasis will be put on
abstinence, being faithful to one partner and consistent use of condoms. We will also address other
reproductive health issues including family planning in these clubs to assist the discordant couples in
making informed choices
- Offer CT and follow up counseling for exposed children. Children will be recruited and followed up through
the HIV clinics and other testing centers.
The CT services will be provided mainly to residents of Rakai and Lyantonde districts and to a smaller
extent to residents of communities in neighboring districts like Masaka which border with Rakai.
Continuing Activity: 13236
13236 4024.08 HHS/Centers for Makerere 6421 5738.08 Developing $521,850
8329 4024.07 HHS/Centers for Makerere 5738 5738.07 Developing $521,850
4024 4024.06 HHS/Centers for Makerere 3177 1084.06 $119,400
Estimated amount of funding that is planned for Human Capacity Development $132,600
Table 3.3.14:
and Lyantonde and to a small extent, the neighboring districts namely Masaka and Mbarara. Since June
prevention, care and treatment to the population in and around Rakai District. Activities conducted include;
an innovative home based and community-based voluntary Counseling and Testing (VCT) program,
provision of palliative basic HIV care, antiretroviral therapy (ART), Prevention of Mother to Child
Transmission (PMTCT), tuberculosis (TB) care, health education, mitigation of HIV through prevention of
domestic violence and medical male circumcision (MMC) for HIV prevention. The community-based VCT
program is nested within the program's existing annual research activities, whereby persons residing in the
study areas are offered counseling and testing in their respective communities. The HIV test results are
returned to the clients through program counselors residing within the communities. VCT is also offered at
the HIV care clinics and in the homes of HIV positive index persons. Through the medical male
circumcision service, clients seeking male circumcision service are also offered counseling and testing. All
persons who test HIV positive and accept to learn their HIV status are referred to the program HIV care
clinic nearest to their community or nearest to their home. The program currently operates seventeen (17)
outreach clinics in Rakai and Lyantonde districts. These outreach clinics are located at already existing
rotational bimonthly basis. Services offered include: health education, on-going HIV counseling, PMTCT,
treatment and prophylaxis for opportunistic infections, provision of antiretroviral therapy, prevention for
positives, laboratory screening and monitoring of various infections, reproductive health services, provision
of basic care packages containing safe water vessel with hypochlorite solution for treatment of water,
insecticide-treated bednets, and condoms. All HIV positive patients receive cotrimoxazole prophylaxis (if not
contraindicated). The majority of patients currently enrolled on the HIV care program are adults (60%
female, 40% male) and only about 5% are children 0-14 years old.
Kalisizo laboratory for testing. The range of tests carried out include: HIV testing by ELISA and western blot
if ELISA is discordant, microbiology tests like urinalysis, Ziehl Nelsen tests for TB screening, blood cultures
etc, serology like serum CRAG, chemistry tests like liver and renal function tests and hematology, among
others. As an accredited TB treatment center, the program is making efforts to streamline TB diagnostics. In
addition to laboratory testing, there is an X-ray facility to support TB diagnosis. Resistance testing for TB is
outsourced at a reference laboratory. The RHSP program has refurbished some government facilities to
increase clinic space for provision of clinical services.
provide information to men, and whenever possible to their female partners, regarding wound healing,
male is HIV-negative, that abstinence from sex following the procedure is of great importance regardless of
Activity Narrative: MMC service are offered a free Basic Care Package, including cotrimoxazole, insecticide treated mosquito
bed nets, clean water containers and hypochlorite tablets. Once they reach eligibility for HAART (CD4 count
<250 cells/ml or WHO clinical stage 4), they are offered HAART and clinical monitoring via RHSP mobile
and fixed clinics. In order to facilitate safe MMC, RHSP is offering training to different cadres of medical
personnel including surgeons, clinicians, counselors and operating room assistants. The Rakai center has
been selected by WHO to serve as an East African regional MC training center.
Progress to-date
The program purchases antiretroviral (ARV) drugs on a quarterly basis through Medical Access, Uganda
Limited (MAUL). The program maintains a 3-months buffer stock to prevent stock-outs that may arise from
unpredicted lead times of various drug manufacturers. The ARVs are temporarily stored in a central logistics
store in Entebbe before being dispatched to the central pharmacy in the Kalisizo field station. At the
pharmacy, these drugs are arranged and stored in shelves, from which smaller quantities are drawn when
needed. The drugs are tracked in log books to ensure proper use and keeping track of expiry dates and
balances at hand. RHSP is in the process of establishing an electronic drug tracking system which will
make drug management and tracking in the pharmacy easier. The ARV drugs that are currently used at the
program include first and second line ARV drugs as recommended by the national Treatment guidelines.
The first line regimens include zidovudine, lamivudine, nevirapine, efavirenz, tenofovir while second line
drugs include Truvada (emtricitabine + tenofovir), Aluvia, didanosine, and abacavir. Stavudine is slowly
being withdrawn as a first line drug, following Ministry of Health recommendations. The majority of ARVs
are FDA approved generics. The shift to generic drugs has greatly lowered the cost of ART per patient. With
the current drug costs, the monthly cost of treatment for a patient on first line regimen is about $20 as
compared to $ 60 for a second line regimen. Overall, annual ARV cost per person on first line drugs is about
$ 250 and about $ 750 for patients on second line regimen. Training of logisticians and pharmacy managers
in drug forecasting and logistics chain management is conducted at least quarterly by the Infectious
diseases Institute and MAUL. The program has successfully maintained a regular ARV drug supply to
patients with no stock outs since the start of the program.
In 2009, ARV drug purchase and supply will continue as above. ARV drugs shall be provided to all HIV
positive clients with a CD4 count of 250 or below or a WHO stage of IV. These drugs shall be provided to
clients registered at the 17 mobile clinics operated by the program and selected MOH facilities within Rakai
and Lyantonde districts (the MOH facilities will be selected in consultation with the District Health Team).
Medical Access (Uganda) shall remain the key provider of our program's ARV drugs. Purchase of drugs will
be done on a quarterly basis. We shall purchase first and second line ARV drugs. (First line regimen:
Zidovudine, Lamivudine, Nevirapine, Efavirenz, Tenofovir and second line drugs: (Truvada (emtricitabine +
tenofovir), Aluvia, didanosine, abacavir).We shall alter the ARV drug lists as new guidelines come up. We
plan to provide ARV treatment to about 2,500 HIV positive persons, with about 150 getting onto second line
regimen. The estimated cost of ARV drugs for this year is $ 740,000 (the rest of the budget will support
personnel costs for pharmacy staff and distribution of drugs). Training will continue in order to build capacity
for the logisticians, pharmacy technicians, and assistants in planning and management of ARV drugs.
Continuing Activity: 13237
13237 4020.08 HHS/Centers for Makerere 6421 5738.08 Developing $887,805
8325 4020.07 HHS/Centers for Makerere 5738 5738.07 Developing $887,805
4020 4020.06 HHS/Centers for Makerere 3177 1084.06 $637,805
Estimated amount of funding that is planned for Human Capacity Development $147,805
Program Budget Code: 16 - HLAB Laboratory Infrastructure
Total Planned Funding for Program Budget Code: $18,214,229
The goal of this program area is to establish quality-assured, tiered lab services as described in the Uganda National Minimum
Health Care Package (UNMHCP). The USG will work towards this goal through improvement of systems management, lab
infrastructure, staffing needs, lab and logistics management, quality assurance and informatics. The approach will be in line with
the "WHO 2008 Maputo Declaration on Strengthening of Laboratory Systems in Africa."
National Laboratory Structure
Lab services are available at Health Center (HC) levels III and IV, district and regional hospitals, and national reference labs. The
latter include the Central Public Health Laboratory (CPHL), the National Tuberculosis Reference Laboratory (NTRL) and the
Uganda Virus Research Institute (UVRI). CPHL acts as the lab support center for rolling-out training, quality assurance (QA) and
logistics, in addition to undertaking its more traditional roles in public health. Below the national level, there are lab services at 11
Regional Referral Hospitals. Each district or group of districts has 1 referral hospital, 4-5 HC IVs and 5-10 HC IIIs. There are also
labs in the private sector.
There are numerous challenges to improving and maintaining quality lab services:
1. Organization and Management: There is no Division of Laboratory Services within the MOH, and no other single coordinating
body for lab services. As a result, management, coordination and supervisory responsibilities are not clearly defined. Public health
and clinical services fall under different departments within the MOH. Because there is no other effective unit, CPHL carries out
work related to both departments, particularly the supervision of lower-level labs.
2. Infrastructure: Most health-facility labs are old and need renovation if they are to meet recommended standards. Many lower-
level facilities were upgraded to HC III and IV levels without improvement in infrastructure, and in 60% of cases, without labs.
There is a widespread lack of reliable utilities and mechanisms for waste disposal and infection control at all levels.
3. Human Resources: The inability to recruit and retain qualified staff is the most serious constraint to improving lab services.
Technician training schools graduate significant numbers of students each year, but their knowledge and practical skills are weak.
It is difficult to deploy and retain staff in public sector labs. Dissatisfaction among lab workers is high due to low pay, lack of
respect, poor working conditions and few career opportunities. Many labs do not meet the recommended staffing norms and
resort to employing unqualified staff who are not recognized by the Allied Health Practitioners' Council (AHPC).
4. Equipment and Supplies: Lab commodities are procured through the National Medical Stores (NMS). Generally inventory and
procurement systems are too weak to ensure an uninterrupted supply. Most facilities experience regular stock-outs of essential
commodities, limiting their ability to carry out basic tests. In addition, many labs lack essential equipment such as microscopes
and sterilizers. Some equipment, especially when donated, does not meet required standards. Equipment in some facilities either
lacks skilled operators or is not adequately maintained. This often occurs because maintenance agreements and training are not
included in procurement contracts.
5. Quality Assurance: Weak infrastructure and human resources in equipment and supplies management, and in other lab-related
activities, compromise the quality of lab services and lead to a loss of trust in those services by both clinicians and patients.
Guidelines and standard operating procedures (SOPs) are not fully disseminated or implemented country-wide; not all labs
receive regular supervision due to the limited capacity at the CPHL and District Health Offices (DHO). There is no coordinated
system for QA across facilities; follow-up and corrective action of under-performing labs is weak. Record keeping in labs is poor
and little attempt is made to standardize or collate data from labs at the district or central levels.
6. Informatics: Currently, information and data are managed manually, and are not used effectively at any health-facility level for
reporting and planning. Transmission of information between different levels and sectors is not effective. The use of computerized
systems is limited due to funding constraints and the scarcity of skilled staff.
7. Regulatory Framework: The existing regulatory system is weak. AHPC, for example, is mandated to register all lab practitioners
and labs, but is understaffed and under-funded. Consequently, many labs and their staff operate without proper registration.
8. M&E: The existing system for M&E within the lab sector is weak and unable to measure the system's performance or its
support for the delivery of the UNMHCP.
9. Financing: Health lab services are grossly under-funded. There is no dedicated budget line for lab services, either centrally or
within districts; the small amount that is allocated from Primary Health Care funds is often misdirected. PEPFAR remains the
major source of funding for the lab sector.
Accomplishments and FY09 Goals
Against these challenges, the USG has made progress in addressing service delivery at all health facility levels, and improving
overall systems management at the central and district levels.
1. Organization and Management: USG is supporting MOH to develop an effective lab management structure that can provide
advocacy, stewardship and coordination of services. Working with the National Laboratory Technical Committee, USG drafted the
Uganda National Health Laboratory Services Policy and a 5-year Implementation Plan. Funding for a senior Technical Advisor to
MOH was set aside in FY08; his duties will include completion of the Policy and Implementation Plan, advocating for and
facilitating the re-establishment of a Division of Laboratory Services, liaising with the PEPFAR Laboratory TWG and implementing
partners (IP), and integrating IP lab strengthening activities into the National Plan. To promote ownership and sustainability of
activities within the districts, IPs are encouraged to support the DHO with funding and technical assistance.
2. Infrastructure: During FY08, 14 HC IV labs, 2 regional blood bank labs, and the NTRL training lab were renovated. Six of the 11
regional hospitals now have access to high-quality labs; in FY09, 2 more will be renovated. Using FY08 funds in the coming year,
USG will renovate 20 HC IV labs, 3 regional blood-bank labs, complete the renovations to the NTRL clinical labs and build a new
CPHL. The latter will be built adjacent to MOH headquarters to facilitate the transition of CPHL staff into an MOH Division of
Laboratory Services.
3. Human Resources: USG provides direct support to training schools. This will be expanded in FY09 to include curriculum
review, bursaries for field attachments, and training grants for tutors. USG is sponsoring over 100 technicians and microscopists
already working in labs to return to school for 2 years of refresher training. Through the Training Coordination Unit (TCU) at
CPHL, the range of courses includes basic diagnostics, equipment maintenance, and lab management. Country-wide training in
performing HIV rapid tests is on-going and follow-up of trainees to determine performance is underway; to date, 1,264 health care
staff have been trained in HIV rapid testing. By the end of FY09, CPHL will have trained 3,500 staff nationwide to provide HCT.
Training in specimen collection for the Early Infant Diagnosis (EID) Program was combined with training in the collection of dried
blood spots for HIV rapid testing; staff at 150 sites have been trained in both. The OGAC-Becton Dickinson (BD) partnership
supported training of technicians from 64 sites in External Quality Assurance (EQA) for measurement of CD4+ cell counts during 2
workshops; 4 more workshops will be completed this year. BD has also provided technical assistance to NTRL in conducting
training in the TB specimen referral system, and in providing two regional trainings using the WHO/CDC/IUATLD AFB Direct
Smear Microscopy training package. These activities will continue in FY09. The CPHL TCU is responsible for overseeing all
training activities as well as directly initiating some of them, particularly in lab and logistics management. In collaboration with
CDC-GAP, the first of 3 workshops piloting the ‘Job-Task-Based' approach to training was held in FY08. Additional training in
logistics management will be held in FY09 in collaboration with NMS and SCMS for all labs in the country enrolled in the NMS lab
credit line.
4. Equipment and Supplies: The procurement of lab equipment is unregulated. Equipment is purchased according to prevailing
market prices, usually without associated training or service agreements. Moreover, the lab equipment market is dynamic and
new models replace ‘obsolete' models every few years, presenting particular problems for service and maintenance. As part of
infrastructure improvement, USG continues to support the procurement, training and servicing of equipment appropriate to each
health-facility level, with a focus on HC III labs; 80 labs have received lab equipment to date. A credit line was established in 2005
to procure and distribute lab commodities through NMS and the FBO Joint Medical Stores (JMS). Over 40% of the current needs
of more than 1,000 facilities are being met; for HIV rapid tests and accessories, funded separately under the PEPFAR CT,
PMTCT and integrated TB/HIV program areas, nearly 100% of needs are met. Despite this, stock-outs of HIV rapid test kits
continued in FY08. NMS distributes HIV rapid test kits, HIV DNA PCR kits for infant diagnosis, and CD4+ cell count kits for
PMTCT donated by the Clinton Foundation. Funding for the latter will continue through 2010. Through expanded efforts in FY08,
specimens from 150 health facilities were tested for EID and this will be further expanded in FY09 to 300 facilities covering all
regions of the country. NMS will widen its reagent and commodities portfolio to include reagents for CD4+ counting, hematology
and serum chemistries. However, TA from SCMS to NMS is needed to establish regional NMS storage depots, and to monitor the
supply chain to verify distribution of commodities to district and sub-district facilities.
5. Quality Assurance: MOH has assigned District Laboratory Focal Persons (DLFP) and Regional Laboratory Coordinators (RLC)
to oversee lab services at the district and regional levels, respectively. CPHL and the appropriate MOH departments, working with
quality-of-care initiatives and EQA programs for HIV, TB and malaria, are taking a more central role in conducting and
coordinating national QA initiatives through zonal supervisors. This activity does not yet cover the whole country, however. A
common, field-tested assessment tool is in use to evaluate lab service provision, commodities management, and QA of diagnostic
testing; SOPs for all phases and levels of lab testing have been distributed. Supervision of district personnel is conducted
regularly and each of 1,002 GOU and NGO labs are visited quarterly. EQA for CD4+ counting has been extended to 64 labs, and
EQA for hematology and serum chemistries will be introduced in FY09. During regular lab assessment visits across the country,
capacity for CD4+ counting, hematology and serum chemistries is noted and the geographical coordinates of those labs with
capacity and that are enrolled in EQA programs is recorded using GPS. Mapping of these facilities has been done using GIS to
enable facilities to network and maximize the use of limited resources for monitoring ART eligibility and treatment response.
Proficiency testing of diagnostics for HIV-related opportunistic infections will be scaled up to cover 400 of the 1,002 government
and NGO labs nationwide. A data collection system was established at CPHL in 2006, and MOH now collects and enters monthly
data on numbers of tests performed and results, including QA testing at facilities across the country. This system needs to be
expanded and integrated into HMIS, and shared with the MOH Epidemiologic Surveillance Division that is responsible for disease
control activities.
6. Informatics: The paucity of real-time information from the lab sector is a major constraint to the improvement of lab services in
Uganda. Management is critically dependent on the ability to efficiently collect and analyze data from all parts of the country. Data
handling capacity at CPHL has been improved by the addition of more staff to analyze data, forecast needs and plan activities. A
feasibility assessment of the use of mobile telephones for data information sharing was started in FY08 and will be continued in
FY09. To support the expansion in informatics, USG will further strengthen capacity at CPHL to allow analysts and planners at
both the central and district levels access to lab databases.
7. M&E: USG will continue to support the strengthening of M&E in the lab sector by implementing the national Performance
Monitoring and Management Program. Data on indicators beyond those required by PEPFAR will be collected to better inform
planning. CPHL will need TA to manage the data files it is building on infrastructure improvements, technical capacity, technician
training and lab management, and which are based on QA activities across the country.
8. Financing: Much of the funding in the PEPFAR lab infrastructure program area that is intended to benefit the lab capacity of the
entire country stays within central government entities and is not distributed further. Given central government bureaucratic
obstacles, the funding channel via MOH has proved to be an inefficient way to support the implementation of PEPFAR goals.
Some funding has to remain at the central level, but an alternative approach is to directly fund DHOs through existing or new IPs.
This would promote ownership and sustainability at the district level; DHOs, being more directly accountable to the people who
are the intended beneficiaries are likely to be more responsive. Funds could be released to Districts on a competitive basis;
continued support would be dependent on performance based on an approved District Health Plan. The IPs could ensure that
their own activities, including infrastructure and networks, are fully integrated into district plans. IPs could play an important role
both as a conduit for funding and in providing TA and oversight on behalf of the PEPFAR TWGs. Once such a model is
established, it may be possible to interest other donors and/or the Ugandan Government to support the approach more widely.
The lab sector of PEPFAR-Uganda will pilot this approach in FY09.
Table 3.3.16:
University School of Public Health and the Centers for Disease Control and Prevention (CDC) renewed
their commitment to develop human resource capacity for management of HIV/AIDS programs in Uganda,
and continue to collaborate with Rakai Health Sciences Project (RHSP) to deliver comprehensive
community based HIV/AIDS prevenetion, care and treatment services to over 5000 HIV infected persons
and their family members in Rakai and surrounding districts. This is a five year grants that carries forward
lessons learnt in phase1. The grant has three major programming components. 1) The comprehensive
community based HIV prevention, care and treatment implemented by RHSP. 2) The SPH-CDC HIV/AIDS
Fellowship Program is an capacity building and training program implemented by Makerere School of Public
Health to strengthen the leadership and management of HIV/AIDS programs in Uganda. The Program aims
at building competencies of professionals and health care workers in HIV/AIDS program leadership,
management, and comprehensive HIV prevention, care and treatment through hands-on apprenticeships,
technical placements, and offsite training. 3) MUSPH also recently received additional funds from CDC to to
establish an internet based distance learning program to support the training of PEPFAR partners in
collaboration with Johns Hopkin University Center for Clinical Global Health Education (CCGHE).
rotational bimonthly basis.This is part of the integration efforts into the existing health sysytem.
condoms. All HIV positive patients receive cotrimoxazole prophylaxis.
and couples' VCT.
western blot if ELISA is discordant (this algorithm has been validated in our setting and has proven to be
superior to rapid tests), microbiology tests like urinalysis, Ziehl Nelsen tests for TB screening, blood cultures
etc, Serology like serum CRAG, Chemistry tests like liver and renal function test and hematology, among
others. As an accredited TB center, the program is making efforts to streamline TB diagnostics in Rakai. In
addition to laboratory testing, there is an X-ray facility to support diagnosis. Resistance testing for TB is
outsourced at another laboratory. The RHSP program has refurbished some government facilities to
In FY 2008, RHSP proposed to purchase a chemistry analyzer and this is now fully running. This has made
possible patient evaluation of liver and renal function tests.
The laboratory has in this financial year provided several diagnostic and monitoring tests to both HIV
positive and negative clients.
Between April 1st 2008 and 25th August 2008, the following tests had been done in the program laboratory:
HIV testing: 7524 Elisa tests, 499 Western blot tests, 2510 PCR tests (of these, 1700 were from the HIV
clinic and 57 were for infant diagnosis, others from other Rakai studies), 4076 CD4 counts, of which 2806
were for the HIV clinic and 457 for other health centers in the district (Lyantonde and Kitovu hospital). 5370
RPR and 401 TPHA tests for syphilis diagnosis, 310 Elisa for HSV-2 diagnosis, 20 serum CRAG and
Hepatitis-B tests.
Activity Narrative: The Kalisizo laboratory supports testing of all samples collected from the 17 mobile HIV clinics run in Rakai
and Lyantonde districts, community HIV testing and laboratory testing for some patients in Lyantonde
hospital.
The program shall continue to utilize the central laboratory based at Kalisizo for all laboratory testing. The
various laboratory sections to be utilized include: general section for serology like HIV testing, serum CRAG
tests, malaria testing, toxoplasmosis titres, chemistry testing, CD4 counts (using a facs caliber), Hematology
section for Complete blood counts and ESR, Microbiology section for urinalysis, blood culture, Gram stain,
ZN for identification of Acid fast bacilli (AFBs).Viral load testing shall also be done on all patients receiving
antiretroviral therapy at 6 monthly intervals. The program will continue to support laboratory (CD4) testing
and training for health units providing ART that lack adequate laboratory support.. We will continue to hold
meetings with the DHO (district health officer) to identify health units that will need laboratory improvements
through training. These activities will be coordinated with CPHL/MOH
Early Infant diagnosis: The program is currently liaising with the MOH EID coordination office to provide HIV
DNA testing to babies born to HIV positive mothers. In FY 2009, in consultation with the MOH EID
coordination office, we propose to put in place laboratory capacity to perform Early infant diagnosis (EID). In
the past, the program has had to out source EID to another laboratory, but the time to result receipt is quite
long (2 months). By equipping our laboratory with this capacity (instrumentation, man power, consumables
etc) shall diagnose HIV in infants as early as possible. This will enable RHSP and other providers in the
district to provide antiretroviral therapy and other preventive measures early enough. With this facility in
place,the program hopes to assist other centers in need of EID, with testing of their infant blood samples
and overall shall achieve early detection of infant HIV in Rakai, Lyantonde and neighboring districts of
Masaka and Mbarara.
Training of laboratory staff: With the introduction of new laboratory equipment, shall provide training to staff
to ensure proper usage. There will be quarterly retraining of all laboratory staff in the management, care and
operation of various laboratory equipment.
Quality control: The program shall strengthen laboratory quality control by having a full time laboratory staff
dedicated to internal laboratory quality control monitoring of the various activities.
Technical assistance and Quality assurance: The program has a rigorous internal quality control program as
well as participation and satisfactory status in external proficiency survey (VQA and CAP).
Continuing Activity: 13239
13239 4026.08 HHS/Centers for Makerere 6421 5738.08 Developing $500,000
8330 4026.07 HHS/Centers for Makerere 5738 5738.07 Developing $486,000
4026 4026.06 HHS/Centers for Makerere 3177 1084.06 $182,400
Estimated amount of funding that is planned for Human Capacity Development $30,000
This PHE activity 'Evaluating Two Types of Male Circumcision Procedures' was approved for inclusion in
the COP. The PHE tracking ID associated with this activity is 'UG.08.0166'.
This is not a new activity but a continuation of Activity ID 10102.08, which is not brought in the list of
continuing activities when I click on the "Modify Continued Activity Information' tab below.
New/Continuing Activity: New Activity
Continuing Activity:
Estimated amount of funding that is planned for Public Health Evaluation $250,000
Table 3.3.17:
Referral Hospital in Kampala. The mission of MUSPH is to improve the attainment of better health for
people of Uganda through public health training, research and community service. In December 2007,
Makerere University School of Public Health (MUSPH) and the Centers for Disease Control and Prevention
(CDC) renewed their commitment to develop human resource capacity for management of HIV/AIDS
programs in Uganda, and continue to collaborate with Rakai Health Sciences Project (RHSP) to deliver
(CCGHE). MUSPH also receives funding for a Public Health Evaluation (PHE) "Crane Survey" Surveillance
of HIV and STI infections and associated risk factors among most-at-risk populations in Kampala, Uganda.
In Uganda, HIV surveillance and prevention activities focus almost entirely on the general population. Little
is known about the risk of HIV infection among most-at-risk populations (MARPs), as well as their
prevention, care and treatment needs. Similarly, little bio-behavioral surveillance is conducted among
MARPs. This public health evaluation (PHE) employs MARP surveillance methods for high-risk groups
including men having sex with men, female partners of MSM, female sex workers, non-paying partners and
paying clients of sex workers, university students, and transport workers in Kampala, Uganda. The project
goal is to inform Uganda's public health system about groups at high risk for HIV infection and to eventually
facilitate and evaluate prevention activities and related services. The project objectives include a)
identification and recognition of selected high risk groups, b) monitoring trends in prevalence of HIV and
other selected sexually transmitted infections (STIs), and c) identifying and describing risk factors
associated with HIV infection. This PEPFAR-funded surveillance system will be conducted in collaboration
with the Ugandan MOH and the Centers for Disease Control and Prevention. These surveys will be
conducted every other year with different MARP groups sampled on alternate years. The target sample
size is approximately 600 per MARP group, totaling 3600; the estimated sampling period is 3 months per
group beginning in May 2008. Future MARP groups may include street youth, people in concurrent sexual
partnerships, women having sex with women, and fishing communities. MARP groups are sampled nearly
concurrently using the same infrastructure. Respondent-driven sampling are employed; quantitative data
are collected through audio-computer-assisted self interviews; qualitative data are collected through
individual semi-structured interviews. Specimen collection includes blood and urine, as well as rectal and
vaginal swabs. HIV voluntary counseling and testing are provided, as well as testing and treatment for
selected STIs. Findings will be disseminated to develop or improve control activities and services.
During FY 2008, the Crane Survey accomplished all logistical measures for survey setup. The investigators
conducted planning meetings with MUSPH, MOH, CDC, and other key stakeholders. All IT and lab systems
were developed and implemented, including innovative software WinMARP a results.exe program,
designed by CDC-Uganda software design team. Furthermore all questionnaire instruments were placed
into ACASI (Audio Computer Assisted Self Interview) format using the QDS (Questionnaire Design Studio)
format so that recruits could self-administer the behavioral questionnaires. These softwares ensure
anonymity, confidentiality, scheduling, patient flow, and results delivery to all recruits. Over the months prior
to initiating the survey, the Crane Survey team pretested and refined all research instruments, methods,
and clinic flow.
In January and February 2008, 10 Nurse Counselors, 4 Coupon Managers, 2 Data Managers, 4 Medical
Laboratory Technicians, 1 Administrative Assistant, and 3 Janitors were selected after a competitive
interview process at the MUSPH to comprise the Crane Survey staff. All hired contracted staff received
initial and continued training and capacity building of respondent driven sampling (RDS) methodology to 19
individual members. The initial training was for a 2-week period in February 2008 during which sampling
concepts were taught, HIV VCT for MARPs reviewed, network, software and data systems implemented,
and training on specimen collection and testing provided to appropriate staff members.
The surveillance system formally began data collection activities on May 19 2008. Since the beginning of
the survey, 30 seeds have been trained to initiate peer and partner recruitment for initial waves for five
MARP groups. As of August 23 2008, 1,075 recruits have redeemed their coupons in order to be
screened, of whom 823 were eligible for survey participation. 212 recruits tested positive for HIV antibodies
and were referred to or will be referred to HIV care centers in greater Kampala. 133 recruits have tested
positive for STIs and have been offered (or will be offered) appropriate treatment onsite. 20 recruits have
been interviewed for in-depth individual qualitative interviews.
As of 23 August 2008, there are 2,777 MARP survey participants remaining to be enrolled and is expected
to take a time period through early 2009. The sixth (and final) group for this cycle will be introduced in mid-
September 2008. There are 55 qualitative interviews remaining. As the MARP surveillance system has
been proposed as an ongoing surveillance activity, the infrastructure now exists to sample other MARP
groups not previously included in the first cycle.
In FY 2009, the Crane Survey will conduct formative research for other identified urban Kampala MARP
groups based on literature and data in order to include them in the surveillance system. The surveillance
system will continue to sample current FY 2008 MARP groups if target sample not yet attained.
Once appropriate MARP groups have been identified by formative research, a minimum of four new groups
will be introduced into the surveillance system, with the same expectation that they would be sampled every
other year throughout the surveillance system. This would introduce an additional 2,400 recruits.
Activity Narrative: The Crane Survey staff will continue to receive ongoing refresher courses in RDS methodology and
sampling, HIV counseling and testing for MARP groups, data management, and laboratory testing. All
recruits will participate in specimen collection and testing, behavioral data collection using ACASI or CAPI
technology, and peer recruitment. Furthermore, FY 2009 Crane Survey activities will require submission for
ethics continuations for both the main and formative protocols (from CDC-Atlanta, UVRI, and UNCST). As
the surveillance system will have collected complete data sets, standard data cleaning will be required and
data analysis may then be conducted. These results will be disseminated via Local Stakeholders meeting,
national and international conferences, and peer-reviewed scientific publications. There will be an ongoing
collaboration with existing HIV treatment centers in greater Kampala in addition to other MARP-specific
programs (e.g. MARPI project at the STD Clinic at Mulago Hospital).
Continuing Activity: 13240
13240 10102.08 HHS/Centers for Makerere 6421 5738.08 Developing $473,300
10102 10102.07 HHS/Centers for Makerere 5738 5738.07 Developing $386,672
Estimated amount of funding that is planned for Human Capacity Development $142,000
This PHE activity 'Assessing the Relationship between Intimate Partner Violence and HIV Status Disclosure
in Rakai District, Uganda' was approved for inclusion in the COP. The PHE tracking ID associated with
activiy is 'UG.07.0157'.
Continuing Activity: 17111
17111 17111.08 HHS/Centers for Makerere 6421 5738.08 Developing $50,000
Estimated amount of funding that is planned for Public Health Evaluation $0
that carries forward lessons learnt in Phase 1. The grant has three major programming components.
1) The comprehensive community based HIV prevention, care and treatment implemented by RHSP. The
focus is this program is to provide comprehensive HIV/AIDS prevention, care and treatment to over 5000
HIV positive clients in Rakai and neighbouring districts. RHSP also has a program for prevention of Gender
Based Violence (GBV) and Medical Male Circumcicion (MMC). Details of the activities under RHSP are
described in other separate narratives.
2) The SPH-CDC HIV/AIDS Fellowship Program is a capacity building and training program implemented by
on apprenticeships, technical placements, and offsite training. The overall aim of the program is to build
capacity for high quality HIV/AIDS prevention, care, and treatment and support services in Uganda.
3) MUSPH also recently received additional funds from CDC to to establish an internet based distance
learning program to support the training of PEPFAR partners in collaboration with Johns Hopkin University
Center for Clinical Global Health Education (CCGHE). This is a public-private partnership that has the
following goals:
-Establish a Project Coordinating Center in Kampala, that will train and employ Ugandan nationals to lead
and sustain this initiative over the long term.
-Establish free connectivity for Ugandan PEPFAR partners to a new national high-band internet network
supported by RENU, UTL and a large multinational business consortium that will link the Ugandan network
to a submarine cable landing site in Mombasa, Kenya.
-Develop a web-based portal for this initiative, located in Uganda, to support multiple distance learning
tools/functionality for the PEPFAR program
-Develop initial priority distance learning programs, defined by key PEPFAR partners
-Initiate an ongoing program evaluation to document the impact of this initiative
-Initiate discussions with local and international business interests, in order to develop a long-term
sustainable business plan for this initiative.
Progress of the SPH-CDC Fellowship Program: The SPH-CDC Fellowship program currently has four major
training activities: 1) the two-year (long-term) fellowship which has been implemented for the last six-seven
years, 2) short courses, 3) the recently launched six month (medium-term) fellowship, and 4) the technical
placements which will begin in the third quarter of FY 2008. The medium-term fellowships target mid-level
managers and coordinators of programs who may not be able to spend 2 years undertaking the long-term
Fellowship. Medium-term Fellowships will be offered for a 6-months period, during which participants
undergo a one-month training and implement a project related to the training received. A number of
achievements have been registered. In the previous grant, 45 long-term fellows were trained and the
majority are currently in senior management positions within the country, with four working in other
countries within Africa and one in Nepal. Over 1,000 individuals received short courses in management.
Since the start of the new grant in December 2007 several activities have been conducted including
selection, enrolment, and training of long-term Fellows, the mentorship workshop held May 30, 2008, offsite
training courses and placement of long-term Fellows in different host institutions. A total of eleven (11)
Fellows were recruited for the long-term Fellowship for the period April 2008 - March 2010. Fellows
reported for their orientation and training on April 8, 2008 and undertook short courses in monitoring and
evaluation, behavior change communication for HIV/AIDS, healthy plan-it, and design and implementation
of HIV/AIDS programs up to May 16, 2008. All Fellows reported to their host institutions on May 19, 2008
and will stay with these institutions until November 3, 2008 when they will report back for additional short
courses. A total of eleven host institutions were selected for the long-term Fellowship during this period.
Each Fellow has been assigned a host and academic mentor for purposes of professional and academic
growth. Four offsite training courses were run for four institutions during this period (KADDE-NET, CRS,
Reproductive Health Uganda, and Pallisa Youth Development Association). The four courses attracted a
total of 92 participants. The courses conducted included Design and Implementation of HIV/AIDS Programs,
Advocacy and Resource Mobilization, and Scientific Writing. Curriculum development for medium-term
fellowships is ongoing; a new curriculum for the continuous quality improvement (CQI) course was
developed and the course started running on August 4, 2008, with 24 fellows drawn from 12 institutions (two
fellows from each institution). The fellows from each institution are given funding and technical support to
implement a project to enhance learning and also improve on the systems within their organization. We are
in the process of developing other curricula for other courses including monitoring and evaluation (M&E),
strategic leadership and management, finance for non-financial managers, scientific writing, among others.
In FY 2008 671 individuals will be supported; 600 individuals will receive training through short courses, 48
through medium-term fellowships and 12 through technical placements, in addition to the 11 long-term
Fellows.
Progress of the CCGHE initiative: This is a new program, started in FY 2008. Capacity building for PEPFAR
is the primary goal of this distance learning initiative. An initial needs assessment has been conducted,
informed by discussions with key PEPFAR partners and sponsors in Uganda.
FY 2009 plans for CCGHE initiative: In the next year (FY 2009), the initial phase of this initiative plans to
assist the IT departments of 19 PEPFAR partner and sponsor institutions in Kampala, Entebbe and Rakai in
for connectivity to the new high band internet network. Based on the initial needs assessment, the following
Activity Narrative: specific PEPFAR capacity building activities will be prioritized for the next year:
•Establish Web-based (audio and video) conferencing between PEPFAR partners
•Establish Telemedicine links between PEPFAR partners
•Initiate web-casting and digital archiving of key PEPFAR educational programs in Uganda
•Establish a Learning Management System for creating on-line training courses for PEPFAR in Uganda
•Establish a digital library for production and sharing of key PEPFAR educational resources
•Initiative PEPFAR Uganda HIV Clinical Grand Rounds, which would be supported by video conferencing
between Kampala and Entebbe (and possibly Rakai) with web streaming and DVDs provided to other
PEPFAR partners in Uganda.
•Develop a telemedicine Consult Service with video conferencing between Kampala and Entebbe (and
possibly Rakai) with audio and/or text portal-based chat links to other PEPFAR institutions.
•Creation and distribute and on-line and DVD video training program for male circumcision.
•Create a digital interactive laboratory training course in rapid HIV testing for PEPFAR partners.
•Create a distance learning course for Pediatric HIV Care.
•Creation of Distance Learning Course for MEPP Data Management.
FY 2009 plans for SPH-CDC Fellowship: In FY 2009, MUSPH fellowship program will support a total of 600
individuals. We will support 22 long-term fellows (11 fellows continuing and 11 new fellows admitted in FY
2009). Two medium term-fellowships will be conducted, each with 24 fellows; a total of 48 medium-term
fellows from 24 institutions in the year. In addition to these, short courses will be provided for 518 individuals
and technical placements for 12 individuals. Through the medium-term fellowships the program will support
the individuals and institutions to improve on identified systemic gaps within their organizations. In addition
to the M&E and CQI courses that have been developed in FY 2008, more courses will be evaluated through
a formal needs assessment involving key stakeholders. Within the medium-term fellowships, the short
courses at MUSPH will be delivered in three modules, in a staggered manner, for a period of 4 weeks; two
weeks at the beginning of the course, one week in the middle of the course and another week at the end of
the course. Technical placements involve attachment of an individual working with an HIV/AIDS
organization at another institution to learn and enable transfer of best practices. Short courses will be
provided to institutions, tailored to their needs. Through the Fellows apprenticeship attachments 46
organizations involved in HIV/AIDS service provision, information dissemination as well as policy
development and implementation will be supported (22 through long-term and 24 through medium-term
fellowships). More institutions will be reached through the short courses. These will include public and
private organizations (CBOs, FBOs, NGOs etc). The institutions will cut across several districts within the
country; deliberate efforts will be made to reach the rural districts. Varied emphasis areas, beneficiaries and
stakeholders associated with organizations that will be hosting the fellows and receiving short courses will
therefore be reached indirectly. The indirect targets may include people affected by HIV/AIDS as well as
special populations such military and refugees.
Continuing Activity: 13241
13241 4017.08 HHS/Centers for Makerere 6421 5738.08 Developing $1,566,587
8322 4017.07 HHS/Centers for Makerere 5738 5738.07 Developing $850,000
4017 4017.06 HHS/Centers for Makerere 3177 1084.06 $700,000
Estimated amount of funding that is planned for Human Capacity Development $935,674
Table 3.3.18:
