Protecting Families Against HIV/AIDS (PREFA) is a Non-Governmental Organization that has been actively

promoting comprehensive PMTCT activities in Uganda since 2004. With initial PEPFAR funds, PREFA was

only able to operate PMTCT in 4 districts namely; Kampala, Wakiso, Kayunga and Tororo. In late 2007,

PEPFAR funds were modestly increased, and the Ministry of Health (MOH) in collaboration with key

PMTCT stakeholders mandated PREFA to expand to 22 additional districts. The expansion of PREFA's

services would address the low PMTCT coverage in Uganda; with a specific focus on implementing PMTCT

in eastern and central districts of the country (Eastern region-17; Central region-9).

The organization successfully allocated conditional grants to support the 22 new districts; enabling the

project to offer PMTCT services up to all new Health Center IIIs (HCIIIs) in their coverage areas.

Consequently, PREFA developed a new plan to implement PMTCT services. PREFA utilized a district wide

approach, where the District health officers (DHOs) developed their own PMTCT plans. A MOH technical

panel assisted the DHOs in prioritizing their PMTCT activities according to district coverage and uptake

needs. With PEPFAR funds, PREFA currently supports 26 districts for PMTCT service provision and

technical assistance, namely: Amuria, Budaka, Bududa, Bukedea, Bukwo, Busia, Butaleja, Kaberamaido,

Kalangala, Kampala, Kapchorwa, Katakwi, Kiboga, Kumi, Luweero, Manafwa, Mbale, Mityana, Mubende,

Nakaseke, Nakasongola, Pallisa, Sironko, Soroti, Tororo and Wakiso and 2 sub-partners Tororo District

Hospital (TDH) and Islamic Medical Association of Uganda (IMAU).

In FY 2008, PREFA and their sub-partners are expected to support PMTCT implementation to

approximately 70% of their target population, including 303 health care outlets: 31 hospitals, 48 health

centers (HC) IVs, and 224 HC IIIs, out of a potential 400 outlets within the 26 districts. The program is

expected to provide HIV counseling and testing [HCT] to 274,697 pregnant women (out of an expected

413,078 pregnant women), and identify 20,504 (out of 29,292) HIV+ women. All identified HIV positive

pregnant women will receive ARV prophylaxis (12,303 combined ARVs, 2,050 on HAART at 10% eligibility,

and 6,151 to receive NVP only). A total of 16,403 HIV positive women (80%) will be expected to give birth at

health facilities, and all of their newborns will receive ARV prophylaxis.

The DHOs, with technical support from MOH and PREFA, have finished preparing the Maternal/Child

Health (MCH) units for PMTCT implementation and are working hard to meet their annual target. The new

program is in major transition, since it provides PMTCT services within a large 26 district coverage area.

The FY2008 semi-annual MEEPP report (October 2007-March 2008), most of the new districts had not

started implementing PMTCT, thus only 30,442 women had received antenatal care (ANC)/PMTCT services

via 25 health care outlets in PREFA's original 4 districts. Of the 30,442 women seen, 2,485 were identified

to be HIV positive and 2,210 of them received ARV prophylaxis. Results from the new districts will be

included in the FY2008 Annual report.

Furthermore, PREFA is supporting the MOH to hire two new staff members, in order to strengthen the

logistics and community services departments of the National PMTCT program. The extra staff support will

assist MOH with the monitoring and supervision of PMTCT activities nation-wide.

In FY 2009, PREFA and its sub-partners will further strengthen and expand intra-district support of

comprehensive PMTCT services including: providing routine HCT to 302,167 pregnant women (projected at

10% increment and at 7% HIV prevalence), in the on-going 26 districts (Eastern region-17; Central region-9)

and an additional new 7 West-Nile districts (Adjumani, Moyo, Yumbe, Koboko, Nyadri, Arua, and Nebbi),

through 419 outlets (31 hospitals, 48HCIVs, 311HCIIIs, and outreaches to 29HCIIs). PREFA has estimated

to reach 21,152 HIV+ pregnant women with PMTCT services. Providing comprehensive PMTCT services

will follow the four pillar approach: primary prevention; family planning; provision of ARV prophylaxis; and

care and support.

PREFA's core targets in FY 2009, (not including TDH and IMAU) will be 276,167 pregnant women, and their

families. The PREFA supported districts will continue intra-district scale up with outreaches to some HC-IIs.

Clients will receive a comprehensive PMTCT package including opt-out routine HCT and hemoglobin (Hb)

estimation at all MCH units. An estimated 20,242 HIV+ pregnant women will receive a basic care package

(BCP), their blood samples be referred for CD4 testing after WHO clinical assessment. ARV prophylaxis

and treatment for HIV+ mothers and their babies will be provided according to national revised PMTCT

policy including: approximately 4,048 (20%) women who present for ANC and are eligible for ART

(CD4<350) will receive HAART; 14,170 (70%) will receive combined ARV prophylaxis and those who

present late estimated at 10% (2,024), will receive SD-NVP. Given the availability of pre-packaged take

home NVP syrup for infants, majority of infants (> 20,000) born to HIV positive women will receive NVP or

AZT syrup as recommended in the policy guidelines. Midwives in MCH units will receive training in

PMTCT/RH issues under the comprehensive IMAI/IMPAC course. The acquired skills from the training will

enable them to provide appropriate ARV prophylaxis or actively manage clients with the nearest ART clinic,

provide infant feeding counseling and conduct early infant diagnosis. All ART clinics will prioritize HIV+

pregnant women for screening and ART provision. In addition, HIV+ mothers will receive quality obstetric

care (focused antenatal, maternity, and post-natal care).

In order to strengthen links between existing ART implementing partners (IPs) and PMTCT sites, PREFA

will facilitate the development of district work groups; will include members from both programs. These

district work groups will assist in developing a district wide system, to better manage all referred HIV+

positive women and their babies. Family planning (FP) will be provider-initiated for all adults presenting at

all health facilities up to HC-II. FP will be strengthened in ANC and postnatal services, through districts

providing personnel close supervision, and emphasizing HIV+ women attending postnatal clinics. . All

mothers of babies accessing postnatal and young child clinics will be counseled to test for HIV (if not done

and documented before delivery), to know their status and assess if their babies are exposed to HIV. Early

infant HIV testing with appropriate counseling will be integrated according to policy guidelines. Blood

specimens (DBS) will be taken from all HIV exposed infants and tested using DNA-PCR at the nearest

diagnostic centers. All tested infants will be linked to care and support services including infant feeding

services.

To ensure quality PMTCT services, PREFA will assist district health teams to strengthen their reproductive

Activity Narrative: health systems (RHS) through collaboration with relevant stakeholders in each district. The RHS

collaborative activities will include: strengthening human resource capacity by training more service

providers in PMTCT, infant feeding counseling, PMTCT policy updates for 260 health workers (10 per

district), and training/mentoring 130 counselor supervisors (5 per district) in all 26 districts. All trainees will

receive post-training follow-up after 3 months. Furthermore, PREFA will support districts by hiring 130

additional staff members (5 per district, with a plan to eventually add them to the district pay role), in

specialty areas where qualified staff are vital to a comprehensive PMTCT program. Districts' critical staffing

needs are in pediatric care and counseling, Early Infant Diagnosis (EID) with linkage to pediatric care, FP,

community awareness and mobilization. District health teams will support improvement of facilities to

accommodate such additional services as routine HCT. PREFA will also provide technical support for

implementation of PMTCT activities, procurement of limited essential maternity equipment, as well as funds

for activities agreed upon at district level. The organization will support mechanisms for enhancing PMTCT

service delivery through private and government health units (public-private partnership) collaboration,

including sensitization of traditional birth attendants (TBAs), private midwives, and other relevant

professional associations in PMTCT, to enable them identify and refer HIV+ women to deliver in health

facilities. PREFA will facilitate the Districts improvement of monitoring and evaluation capacity through

training in data management processes. The organization will provide computers (as needed), other forms

of data processing and storage, data quality assessment; ensuring timely reporting from health facilities to

district health offices, MOH and PREFA. District health teams will conduct regular monthly supervision of

health facilities, MOH will host quarterly supervision visits through regional supervisors. Quality assurance

for HIV tests will be conducted in collaboration with the MOH central laboratory.

PMTCT service provision will be further strengthened through performance monitoring, and link referrals

within and between facilities located in communities around the country. Districts will strengthen their

community PMTCT activities by utilizing existing workforce structures, including: health workers, PHA,

community post test clubs, Community Based Organizations (CBOs), and community resource persons

(VHTs, CCAs and TBAs). A total of 6,240 PMTCT mobilizers (240 per district) will receive relevant training

in PMTCT enabling them to mobilize, sensitize, counsel, refer and set up follow-up visits appropriately for

clients and their families. During the FY 2009 intra-district scale up of the PMTCT services, PREFA plans to

support and target at least 1000 moderate to severely malnourished HIV+ positive pregnant women with

nutrition supplements. PREFA will also liaise with the MOH and other stakeholders to print and disseminate

updated training materials, policy guidelines, related registers, and appropriate community PMTCT IEC

materials. Furthermore, PREFA will scale up to other districts, the Family Care Consortium approach

(FCCA) for families. Over the years, the FCCA has successfully improved access and uptake of quality

comprehensive HIV/AIDS services, including PMTCT, pediatric and adult ART in lower health facilities in

Kampala.

In addition to the activities above, sub-partner TDH will support provision of PMTCT services to 21,000

women in ANC and 4,300 of their male partners; provide ARV prophylaxis to 600 HIV+ pregnant women

and EID for HIV exposed children at 9 more health facilities. Health teams will conduct home visits to 600

HIV+ pregnant/nursing mothers (2 visits each), conduct 600 home based HCT to increase access to HIV

services by family members, provide the Basic Care Package (BCP), and refer clients and family members

for further care/treatment to TASO - Tororo and TDH ART clinics. Funding will also support training 45

health workers in pediatric care, rapid HCT, procuring test kits, lab equipment, reagents and supplies,

therapeutic feeding of 480 infants, and nutrition classes for all enrolled HIV+ mothers. Approximately 480

HIV+ pregnant women and breastfeeding mothers will be supported with nutrition supplements. The

program will also facilitate community support teams to mobilize the community for PMTCT and monitor its

contribution to service delivery. Community sensitization will continue through monthly radio talk shows,

drama by HIV/AIDS support groups, and community video shows. During FY 2009, most of the TDH

activities will be merged into those of Tororo district; TDH will be phased out as a sub-partner organization.

At the next planning phase, the district health team will meet with TDH to discuss the phase-out strategy.

Similarly, in FY 2009, IMAU, another sub-partner, will continue to provide comprehensive PMTCT services

at Saidina Abubakar Islamic Hospital (SAIH) and in collaboration with the DHO Wakiso district, support

provision of PMTCT services at 10 HCIIIs: Namulonge, Manze, Kalibbala, Bulondo, Tikkalu, Kira, Kakiri,

Wakiso Epicentre, Nsangi and Kiziba. IMAU is planning to add on other 5 health centre IIIs in the FY 2009,

these include: Nabweru, Mende, Kasozi, Namalire and Gombe (please note that these facilities are subject

to final confirmation from IMAU and Wakiso district). SAIH will provide PMTCT services to 5,000 pregnant

women and 1,200 of their male partners. The program will also offer treatment options of combined ARV

drugs for PMTCT to 310 HIV+ mothers and their infants, CD4 tests for all HIV+ women, and ART to eligible

women and their partners. PCR tests will be done for 180 HIV-exposed infants. IMAU will also conduct

community education and mobilization through religious leaders, local council leaders, and PHAs, who will

target 30,000 adult men and women, using health fairs, outreaches, sermons, group talks, mini lectures and

home visits. The project will support the community educators to conduct home visits and referral of 4,500

pregnant women and their families. This project will also support IMAU's faith based network model for

improving HIV/ AIDS services, which has a health facility component and a community component with

linkages between the two. The funding will also support purchase of HIV test kits, PMTCT ARVs,

equipment, logistics and supplies, and training of 30 service providers in PMTCT counseling.

Overall, PREFA contributes greatly to PEPFAR due to its vision of improving access and uptake of high

quality HIV/AIDS services, and the utilization of the family approach to provide comprehensive PMTCT

services. In FY 2009, this program will reach an estimated 302,167 pregnant women (out of an expected

413,078 pregnancies). HCT service and ARV prophylaxis will be provided to an estimated 21,152 HIV+

women (out of an expected 29,292 HIV+ women) and their infants, as well as appropriate referral for

treatment, care and support services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13310

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13310 4047.08 HHS/Centers for Protecting 6438 679.08 Promoting $5,000,000

Disease Control & Families Against Extensive

Prevention AIDS Implementation

of Quality

Prevention of

Mother to Child

Transmission

(PMTCT)

8356 4047.07 HHS/Centers for Protecting 4813 679.07 $4,847,705

Disease Control & Families Against

Prevention AIDS

4047 4047.06 HHS/Centers for Protecting 3186 679.06 $1,130,076

Disease Control & Families Against

Prevention AIDS

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $15,000

Economic Strengthening

Education

Water

Table 3.3.01:

This PHE activity 'Interactions between HIV and malaria in African Children: Tororo Child Cohort (TCC)

Study"' was approved for inclusion in the COP. The PHE tracking ID associated with this activity is

"UG.07.0162.'

New/Continuing Activity: Continuing Activity

Continuing Activity: 13311

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13311 10083.08 HHS/Centers for Protecting 6438 679.08 Promoting $145,000

Disease Control & Families Against Extensive

Prevention AIDS Implementation

of Quality

Prevention of

Mother to Child

Transmission

(PMTCT)

10083 10083.07 HHS/Centers for Protecting 4813 679.07 $145,000

Disease Control & Families Against

Prevention AIDS

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Estimated amount of funding that is planned for Public Health Evaluation $367,000

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.17: