The US Centers for Disease Control and Prevention [CDC] in Uganda will implement the following activities:

Program and incidence based surveillance: The goals of this activity are to pilot and expand a new way of ante-natal clinic based surveillance by tapping into the PMTCT program. It aims at making use of both reported, aggregated, clinic based PMTCT data (HIV prevalence) as well as using remnant HIV-positive bloods from PMTCT clinics for HIV incidence surveillance. This activity will commence in the capital at select PMTCT clinics before expanding up-country with the aim of covering all current ANC sentinel surveillance sites. At select sites routine electronic data capture systems will be established, and hence better inform both the PMTCT and the HIV surveillance system. This activity's cost efficiency is largely a function of the cost of lab consumables for HIV incidence testing. Data will be used to inform about Uganda's HIV epidemic as well as the PMTCT program.

ACASI: Following deliberations and discussions with interested parties and stakeholders the goals and objectives have broadened to address the following: Demonstrate the feasibility of audio-computer-based self interviewing (ACASI) in household-based survey settings, the feasibility of eliciting information on socially sensitive behaviors (through ACASI), the addition of measuring chronic disease related markers (partially through ACASI), and exploring the potential of a district based continuous surveillance system that informs both the district and national level. The elicited information has great potential to contribute to health systems strengthening through planned co-ownership of this activity. The coverage is aimed at just 1 or 2 districts to demonstrate feasibility and advocate for a future standing national system. It also has a clear potential to inform the Government about chronic diseases that affect both HIV infected and uninfected citizens. Cost efficiency will mainly be a function as to what degree such a surveillance system can replace very expensive ad-hoc population-based surveys (DHS, AIS, SPA, others); other cost efficiency measures may be realized through utilizing district based infrastructure and staff. A protocol that is now part of a larger AIDS Indicator Protocol (nested sub-study) may be revised and re-submitted for review as a stand-alone protocol and will include measures to inform about the costs of such a surveillance system.

Last 1000 infections (protocol title: VCT based surveillance of HIV acquisition): This enterprise aims at establishing a dual use activity: To improve the routine voluntary and counseling (VCT) process and to inform about Uganda's HIV epidemic. The objectives are to establish an audio-computer-based self interviewing (ACASI) mechanism that largely replaces the face-to-face interviews with clients, to process the ACASI data in real time and thus make it available for the post-test counseling process. Additional HIV incidence testing on HIV-infected clients' remnant blood will enable us to evaluate factors associated with HIV acquisition which in turn should further improve the counseling process. This activity is currently limited to Kampala and the surrounding Wakiso District; the target population comprises routine VCT clients. The introduction of this relatively novel information technology has the potential of being expanded to other routine health services within the same provider, potentially lessening the work load of staff. An approved protocol will evaluate the ACASI data and regular feedback with the counselors will inform about the utility of this novel form of client interviewing.

MARPS study: Also dubbed "Crane Survey", its goal is to establish a standing and flexible bio-behavioral surveillance system that is capable to repeat survey established HIV high risk groups as well as conduct ad-hoc surveys among groups suspected to be of high risk for HIV or groups that stakeholders in Uganda expressed a need to learn more about. Its other goal is to introduce and promote the novel use of information technology, including ACASI, fingerprint scanning and the use of other electronic media to interact with survey participants. Its objectives are to measure HIV prevalence, STI prevalences, as well as demographic and behavioral risk factors in defined most-at-risk populations. Its geographic coverage currently is limited to greater Kampala; a protocol amendment under review proposes to repeat select surveys up-country. The Crane Survey's procedures contribute to health system strengthening through pre- and on the job training in counseling persons on high risk behaviors, and expanding the capacity of the MOH's STD laboratory to perform non-routine tests for select sexually transmitted infections. As this surveillance activity will become a standing system, it is expected to also become more cost-effective as start-up costs would no longer be required.

Appropriate Technologies: The CDC Informatics Unit (IU) in Uganda provides technical assistance for the development and implementation of strategic information systems to PEPFAR funded partners. Our emphasis on these electronic systems is to align the systems to the existing national Health Sector Strategic Plan as we develop appropriate EMR.

VCT-based surveillance of HIV acquisition: (aka "Last 1000 Infections"): This activity aims at demonstrating and using VCT as a surveillance data source: With the use of audio-computer assisted self interviewing (ACASI) technology, VCT clients will undergo a more detailed routine client interview. In addition VCT clients who test HIV-positive will have their left-over blood sample undergo additional testing to identify whether they were recently infected or are long-term infected. Both ACASI and lab data will then be used to describe HIV acquisition, transmission, and at risk behaviors. ACASI data will be made available to counselors to improve on the counseling process as well. The protocol is approved and preparations are in place to start this project in the coming months. A delay occurred as the initially chosen VCT provider could not provide an adequate physical environment on its premises and a new VCT provider had to be found. Currently we are making final preparations on the data instruments and overall design. We anticipate a start within FY2010, depending on the time it takes to identify for the right funding mechanism currently the main reason why this project has not yet started at time of writing. Training for 3-4 staff will include protocol adherence and project-specific data management. We anticipate that the implementation of the ACASI technology will have a show-casing effect for many visitors from other organizations and promote the spread of this technology that is still new for Uganda. The introduction of IT use for routine HIV-related services also has the potential to expand to other areas such as using IT to deliver routine (standardized) information to clients or to replace paper-based data collection at health facilities.

"Evaluating use of ACASI": This was supposed to be a nested sub-study within the planned UAMIS (Uganda AIDS/Malaria Indicator Survey). The intent was to pilot the feasibility and utility of using audio-computer assisted self interviewing (ACASI) technology within a household, population-based survey. However, after postponing UAMIS twice since 2008, this survey was meanwhile cancelled and is expected to be replaced with an AIDS Indicator Survey (AIS) only. Investigators may propose to extract the sub-study from the original UAMIS protocol and submit an independent protocol to the local and CDC IRB. Investigators also propose to make better use of the monies and in addition to the original objective - widen the scope of the substudy to 1) evaluate the feasibility of asking highly sensitive behavioral questions in a household setting and 2) to add chronic disease biomarkers. Thus the overall goal is now to demonstrate the feasibility of a different type pop-based survey that makes better use of IT in data collection, uses a refined data instrument and informs the Ministry and stakeholders on the distribution of chronic disease in the country. The sample size will be small (500-1000) as this is a demonstration project only, the survey participants' data are not intended to be nationally representative. We plan to implement this project in FY 2010, during or after the main survey has been completed. Training will include biological measurements, IT-related data management and protocol adherence. Investigators expect that local stakeholder in this activity, especially the Ministry of Health, will recognize the potential of this novel interview technology and gradually apply it in other data collection activities as well. The added biomarkers related mostly to non-infectious, chronic disease will demonstrate the added value that HIV-focused surveys can provide to other pressing health information needs.

Program & Incidence-based HIV surveillance: Preparations are ongoing with the MoH to pilot and later expand HIV incidence surveillance in a PMTCT setting with the ultimate goal of replacing conventional ANC based HIV surveillance that conduct unlinked anonymous HIV testing on left-over blood without consent. Training for 4-6 staff will encompass protocol adherence and possibly IT-related data management. The protocol is meanwhile approved; identifying the right funding mechanism led to further delays in this activity which is now expected start its field activities in FY2010. Once shown to be feasible and successful, this pilot is expected to expand, be incorporated into the MoH's routine HIV surveillance system and discontinue conventional ANC surveillance.

MARPS study: This is an ongoing surveillance activity (dubbed "Crane Survey"). The survey's 1st phase was successfully completed in 2009 (sampling female sex workers and their male partners, men having sex with men, university students, and motorcycle taxi drivers). Current activities include data cleaning and analysis as well as preparing for the next phase that will survey school students, drug users and high risk heterosexuals. Field activities are currently paused due to ongoing IRB review of the protocol amendment, unexpected cost increases, and the necessity of finding a new survey office in downtown Kampala. This 2nd phase of field activities will commence in the 1st half of 2009. We anticipate training for approximately 15 staff on protocol adherence, IT training (ACASI), possible also on VCT. This collaborative activity between CDC, MOH, and Makerere University (School of Public Health, SPH) mostly involves SPH staff, thereby greatly expanding SPH's technical capacity and skills.

Appropriate Technologies: The CDC Informatics Unit (IU) in Uganda provides technical assistance for the development and implementation of strategic information systems to PEPFAR funded partners. We have identified within IU the need to further strengthen the usage of appropriate technologies at the national, district and health facility levels. Our emphasis on these electronic systems is to align the systems to the existing national Health Sector Strategic Plan as we develop appropriate EMR.

In FY 2010, the Informatics Unit, through contracts where necessary, will evaluate the performance of manual and electronic systems, develop new and upgrade electronic systems using appropriate technologies, train 30 key personnel in Strategic Information and install and support electronic systems at different administrative levels in support to the GOU through 21 implementing partners.