Overview narrative

Uganda has made significant progress towards providing HIV prevention, treatment, care and support. An estimated 135,000 new HIV infections occur in Uganda each year and about 80% of these are adults. With the scale up of HIV counseling, the number of Persons Living with HIV/AIDS (PHAs) who know their HIV status and therefore opt to access HIV care is increasing.

There are several challenges encountered in the delivery of HIV services. These include high demand for services, weak health infrastructure (human resource, monitoring and evaluation, laboratory systems, logistics management systems) and poor coordination and linkages among providers, with resultant duplication in reporting, and inequitable access to services.

Although the number of persons in active HIV care is unavailable nationally, by June 2009, 193,746 (60% of eligible) HIV positive clients were receiving ART with adults comprising 91.5 % of recipients at 350 service outlets are countrywide. However, the number of people in need of ART is approximately 358,000 (UNAIDS) implying an unmet need of more than 50%. Of the estimated 42,140 children in urgent need of antiretroviral treatment, only 39% are receiving it as compared to 63% of eligible adults. Access to PMTCT services is estimated at 48% among pregnant women, and only 21% of the pregnant women eligible for HAART received treatment in the year ending June 2009. It is estimated that only 17% of infants were able to access Early Infant Diagnosis in the pat year and yet the national guidelines recommend antiretroviral treatment of all infants below 12 months. In relation to TB and HIV, over 39% of all incident TB cases are HIV positive. According to the Uganda National TB Program report, the treatment success rate is 74% against a target of 85%, and the TB Case Detection Rate is 57% versus the target of 70%.

The purpose of this mechanism is to support the provision of comprehensive, community-based HIV/AIDS services in Uganda. The mechanism will combine a facility- and community-based strategy to deliver HIV/AIDS services, in order to maximally reach entire communities while engaging them adequately to promote substantial community ownership of the program.

The main activities of this mechanism include:

1. Continued provision of comprehensive HIV care to an existing pool of 3,800 clients and 1700 on ART at Mbuya, Kinawataka and Banda in Kampala district and 350 clients in care and 30 on ART at Kasaala clinic, Luweero district; and expansion of the coverage of these HIV/AIDS services.

2. Training, mentorship, and capacity building of selected Ugandan HIV/AIDS care, support and treatment organizations, particularly non-governmental, community-based, and faith-based organizations in comprehensive, community-based HIV/AIDS service delivery.

3. Establishing a functional monitoring and evaluation system of community interventions in coordination and in line with the national HMIS and monitoring and evaluation systems

While maintaining facility-based services, this mechanism will focus on establishing a successful and sustainable community program with a high degree of community ownership. This program will be implemented by interacting with communities in such a way as to build them up, include them in each step of the program, and stimulate their own problem-solving and leadership. Such a community program may include, but not necessarily be limited to the following community strategies: direct health service delivery in communities or in homes, use of cultural interpreters or community ombudsmen to ensure culturally appropriate interventions, income generation, economic strengthening and/or microfinance activities, participatory community dialogues and facilitated problem-solving about health issues, community health groups and community health workers sustained by the community, community generation and use of health data, strong linkages between local public health facilities and community health groups and workers, a census-based approach to achieve ongoing access to all segments of the community by community health groups or workers, and support for empowerment of community members, especially women, in both health and non-health areas identified as priorities by the community.

The scope of activities will include all technical areas of PEPFAR including: Prevention of Mother to Child Transmission (PMTCT); Abstinence/Be Faithful; HIV Prevention including Medical Male Circumcision; Adult Care and Support; Pediatric Care and Support; Tuberculosis/HIV; Orphans and Vulnerable Children (OVC); Gender-based Violence (GBV); Prevention with Positives (PWP), HIV Counseling and Testing (HCT);: Antiretroviral Treatment, Laboratory Services; Strategic Information; and Other/Policy Analysis and System Strengthening.

This program will promote community-based HIV/AIDS service delivery systems and activities, while supporting creative community-based HIV/AIDS initiatives particularly in the non-governmental (NGO), Community-based (CBO) and faith-based organization (FBO) settings. The program will also progressively expand the coverage, quality and range of interventions, as well as the population and geographic coverage for capacity building support for implementing partners, and demonstrate these achievements through measurable outcomes.

The mechanism will work closely with district health offices and the Ministry of Health, so that community activities and M&E systems are as much in line with national systems as possible. Also, through coordination with both the Ministry of Health and the US government PEPFAR team, the program will identify other indigenous organizations with whom to work to build capacity in community-based approaches to HIV/AIDS service delivery.

Some of the specific challenges facing provision of adult HIV care and support include high demand for services, weak heath infrastructure, poor coordination between providers of the various components with resultant inefficiencies, limited numbers of skilled providers, poor community linkages with loss-to-follow-up of clients in care, inadequate data management, and difficulties in monitoring the quality of care.

This program will support at least 4 health facilities and their surrounding communities in Luweero and Kampala district to implement a comprehensive adult HIV care and treatment services program including provision of basic care that comprises of OI prophylaxis using daily cotrimoxazole, use of clean water, insecticide treated bed nets, and condoms where appropriate. Apart from the basic care package, the program will provide OI diagnosis and treatment, TB screening and treatment, and routine assessment for ART eligibility. Clients eligible for ART will receive treatment through this program as per national guidelines or be referred to existing clinics. The program will implement strategies to promote adherence to ART and cotrimoxazole to minimize the likelihood of developing drug resistance. The program will also focus on the integration of HIV prevention with HIV care and implement positive prevention initiatives such as partner HIV testing, supported disclosure of HIV status, use of condoms among discordant couples, and STI care. All HIV care and support services will be linked to other HIV prevention services like PMTCT, HCT, ART, Medical Male Circumcision, Blood safety, Injection safety, and OVC care through active linkage by the same provider.

To date, there is an existing pool of over 3,800 clients in care and these 4 facilities and 1,700 of these are on ART. Services will also be scaled up to other facilities and eligible clients.

This program will focus on the following activities in the region of coverage;

1. Provide facility, home and/or community-based basic health care and support to alleviate clinical, psychosocial, physical, and spiritual distress for HIV-infected individuals and their families and caregivers; including Opportunistic Infection (OI) prevention, diagnosis and treatment, provision of the basic care package, nutrition and sustainable livelihoods.

2. Build capacity of other community organization to support the delivery of HIV care and support. Training health care providers to deliver HIV-related services

3. Integrating HIV prevention initiatives within HIV care and treatment. The program will ensure availability of post exposure prophylaxis services for occupational and non-occupational exposure, prevention with positives interventions like partner testing, condom use, contraceptive use

4. Strengthen linkages to ARV, TB, PMTCT, and HCT program activities.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR;

1. Number of health facilities that offer HIV care

2. Number of health care providers trained in facility and/or community HIV care

3. Number of adults and children with advanced HIV infection in care / on ART disaggregated by age and sex, and pregnancy status for women

4. Percent of adults and children with HIV known to be in active care at follow-up

Challenges of the OVC response in Uganda include weak co-ordination mechanisms at both national and local government levels; inadequate OVC management information systems at national and district levels; limited monitoring of quality of care in OVC programs; and high demand for services.

This program will address the needs of the identified Orphans and Vulnerable children as appropriate to age and gender including Care and Support, Education, psychosocial support, Food security, Economic strengthening, Basic health, Child protection and Legal support. The program will develop a census based approach to achieve access to these services to all segments of the vulnerable communities through collaboration with community development officers and related CBOs and CSOs, and use collected data to inform program strategies and activities.

This program will be implemented in the district of Luweero and Mbuya Parish, Kampala with possibility of expansion to other districts, facilities, and communities and build on the already achieved successes of offering the needed OVC services within the existing programs and increasing referral to other OVC providers who are mapped out within the district of operation. The target population will include all the Orphans and Vulnerable children including those affected and infected with HIV, street children, children under extreme labor conditions, and other forms of child abuse: physical, sexual, neglect among others and those in need of legal protection.

The major program goals will be; 1. To improve the lives of orphans and other vulnerable children and families affected by HIV/AIDS, with emphasis on strengthening communities to meet the needs of orphans and other vulnerable children affected by HIV/AIDS. 2. To identify HIV positive children through partnership with other community providers and district structures and ensure early access to clinical care and treatment linked with quality psychosocial care and other essential services. 3. Provide training to caregivers, or equipping communities to train local leaders, members of affected families, and caregivers in meeting specific needs of OVC

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR;

Total number of eligible children (OVC) provided services in 3 or more OVC core program areas beyond psychosocial/spiritual support disaggregated by sex and age Number of OVC care givers trained in comprehensive HIV management Total Number of eligible clients who received food and/or food security disaggregated by age and sex

This program will support at least 4 health facilities and their surrounding communities in Luweero and Kampala district to implement a comprehensive adult HIV care and treatment services program. All Clients in active HIV care will routinely receive prophylaxis for opportunistic infections using daily cotrimoxazole, psychosocial support, screening for TB, and regular assessment for ART eligibility. Clients eligible for ART as per national guidelines will receive treatment through this program or be referred to existing clinics. The program will ensure that these patients continue to be supported with quality care including adherence support to minimize the likelihood of developing ARV drug resistance. All clients on ART will receive regular laboratory monitoring using CD4. Health providers will be trained and mentored to provide the necessary services and their knowledge updated through continuing medical education sessions. Continuous evaluation of programs will be continued with quality improvement teams to be supported in all the implementing sites. Data demand and use at the health facilities will be enhanced with regular cohort analyses to asses the performance of sites. For those on ART, the program will implement strategies to promote adherence to ART

To date, there is an existing pool of over 3,800 clients in care at these four (4) facilities and 1,700 of these are on ART. Services will also be scaled up to other facilities and eligible clients.

Major activities for this program will include:

1. Increasing access to HIV care, treatment, and support at facilities and within communities to HIV-infected persons clients in accordance with National guidelines. The program will expand the number of health care facilities/sites providing basic health care and ART to HIV-infected people and increase the number of patients on ART at supported health care facilities/sites.

2. Training health care providers to deliver HIV-related services. The program will increase the number of health care workers trained to deliver HIV-related clinical services and/or ART provision; increase the numbers of individuals provided with HIV-related basic health care services (including improving the prevention, diagnosis, and clinical management services for HIV/AIDS, sexually transmitted diseases [STDs]) and related opportunistic infections [OI], e.g., TB)

3. Integrating HIV prevention initiatives within HIV care and treatment. The program will ensure availability of post exposure prophylaxis services for occupational and non-occupational exposure, prevention with positives interventions like partner testing, condom use, contraceptive use

4. Supporting the health systems for HIV care and treatment services delivery and strengthening linkages between the various care programs including PMTCT and TB. The program will strengthen the logistics and commodity supplies system through harmonized procurement of HIV testing commodities, laboratory supplies, ARV drugs, and OI drugs with National Medical Stores and/or using existing public and private sector procurement mechanisms. The grantee will increase in the total number of HIV service points with active monitoring and evaluation and quality improvement programs

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR;

1. Number of health facilities that offer HIV care and/or ART

2. Number of adults and children with advanced HIV infection in care / on ART disaggregated by age and sex, and pregnancy status for women

3. Increase the total number of patients currently receiving ART at each health facility/site

4. Percent of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy

Some of the challenges specific to the provision of pediatric care, treatment, and support include limited access to services especially in the rural areas, delays in diagnosis of HIV, limited health provider skills, inadequate commodity supplies for pediatric care and treatment, data gaps on the burden of pediatric HIV nationally, continued mother to child transmission of HIV estimated at 15%, addressing sexual and reproductive health needs of HIV infected adolescents, poor linkages between pediatric care and other programs like PMTCT, OVC, and EID. There is also lack of nutritional support, and inadequate community awareness, mobilization and support.

This program will support health facilities within Luweero district and Mbuya, Kampala district to implement a comprehensive adult HIV care and treatment services program including provision of basic care and support package for all clients, OI prophylaxis, diagnosis and treatment, TB screening and treatment, routine assessment for ART eligibility. To date, there is an existing pool of over 3,800 clients in care and these 4 facilities and 1,700 of these are on ART. Services will also be scaled up to other facilities and eligible clients.

This program will continue to support identification of children and linking them into care from the MCH, OPD and pediatric departments. Integration of these services will be a core focus area for this program with the aim of increasing the number of children in care to about 15 percent of the total in care. The program will endeavor to create child friendly clinics at the health facilities and also address the special adolescent sexual and reproductive health needs through a program focusing on this age group. Providers will receive pediatric HIV counseling skills training to have at least one pediatric counselor at all the supported health facilities. A family centered approach to managing pediatric patients will be implemented to provide support for this particularly vulnerable group, enhance adherence and reduce loss to follow up.

Major activities for this program will include:

1. Increasing access to pediatric HIV care, and support at facilities, and within communities to HIV-infected persons clients in accordance with National guidelines

2. Training health care providers to deliver HIV-related services

3. Supporting the health systems for HIV care and treatment services delivery and strengthening linkages between pediatric care and the various care programs such as PMTCT, ART, OVC, Early Infant Diagnosis

4. Integrating HIV prevention initiatives within HIV care and treatment with a focus on adolescent sexuality issues

5. The program will strengthen the logistics and commodity supplies system through harmonized procurement of HIV commodities

6. Strengthening data management

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR;

1. Number of facilities that offer pediatric HIV care and support

2. Number of health care providers trained in facility and/or community HIV care

3. Number of children with advanced HIV infection in care / on ART disaggregated by age and sex

This program will support 4 health facilities within Luweero and Mbuya, Kampala district to implement a comprehensive adult HIV care and treatment services program including provision of basic care and support package for all clients, OI prophylaxis, diagnosis and treatment, TB screening and treatment, routine assessment for ART eligibility.

The program will provide support to the existing pool of about 200 pediatric patients with antiretroviral treatment (ART) services like CD4 monitoring and out source viral load (VL) services for those that will require VL measurements. Care providers will be trained to support children on ART at all the sites to enhance adherence. The program will disseminate pediatric treatment guidelines to all implementing facilities and provide mentorship and refresher training for staff in pediatric ART in collaboration with other partners. Peer support networks for children on HAART will be supported to reduce stigma and enhance adherence. ARV for pediatric will continue to flow through the MOH and Global fund mechanism.

Major activities for this program will include:

1. Increasing access to pediatric HIV care, and support at facilities, and within communities to HIV-infected persons clients in accordance with National guidelines

2. Training health care providers to deliver HIV-related services

3. Supporting the health systems for HIV care and treatment services delivery and strengthening linkages between pediatric care and the various care programs such as PMTCT, ART, OVC, Early Infant Diagnosis

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR;

1. Number of health facilities that offer pediatric ART

2. Number of children with advanced HIV infection on ART disaggregated by age and sex

3. Percent of children on ART known to be on treatment 12 months after initiation of antiretroviral therapy

The abstinence and Be faithful (AB) program will specifically focus on youth in and out of school less than 14 years of age and clients 15-49 years who test as a couple. Since the majority of the children below 15 as these are largely not yet sexually active, this will comprise the only prevention messaging to them. The school program will include life skills training and will complement the PIASCY program that is implemented through the Ministry of Education and Sports (MOES). Couples will be specifically targeted because majority of new infections in Uganda are occurring among married people in discordant relationships. The specific messaging will aim at reducing concurrent relationships with multiple partners promoting zero grazing. For clients below 15 years of age who are sexually active, further prevention messaging with strategies like condom use will be provided. This will also be the same for couples that are discordant for HIV.

AB prevention activities will be monitored and evaluated through the overall monitoring and evaluation framework of the program through the HIV prevention focal persons at the district health office.

This program will implement HIV prevention activities in support of the Government of Uganda, to scale up a comprehensive and integrated package of HIV interventions and services in the selected areas of Luweero District and Mbuya Parish. The comprehensive prevention package of services will address the major risk factors and contextual factors that drive the epidemic in Uganda following national guidelines for HIV prevention.

The program will focus on but not be limited to the following activities;

1. Expand the capacity of Ugandan communities and organizations to reduce HIV transmission through evidence-based, targeted prevention programs that focus on changing social norms to promote the delay of sexual debut, abstinence, and fidelity with HIV-tested partners, partner reduction, condoms and, medical male circumcision.

2. Support people living with HIV to reduce their risk of HIV transmission through positive prevention or "prevention with positives" interventions, particularly partner testing, and disclosure of HIV status

3. Promotion of gender equity and positive role models, and address negative social norms; gender based violence, stigma, and discrimination will be cross-cutting themes.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR;

Total number of the targeted population reached with individual and /or small group level HIV prevention intervention that are based on evidence and /or meet the minimum standards required

Number of intended target population reached with individual and or /small group level interventions that are based on evidence and or meet a minimum standards

Total number of the targeted population reached with individual and or small group level preventive interventions that are primarily focused on abstinence and /or being faithful, and are based on evidence and /or meet the minimum standards required

Number of the targeted population reached with individual and/or small group level HIV prevention interventions that are based on evidence and/or meet the minimum standards required

Number of Most At Risk Populations (MARP) reached with individual and/or small group level HIV preventive interventions that are based on evidence and/or meet the minimum standards required disaggregated by age

Prevention of Mother to Child Transmission (PMTCT)

This program will implement PMTCT activities in support of the Government of Uganda, to scale up high quality, effective and comprehensive PMTCT services that are fully integrated into the national health system and will mainly focus on the following activities;

1. Provision of accessible, high-quality, comprehensive PMTCT services for HIV-infected women and their families through MCH/HIV integrated care, or establish reliable, active referral networks for PMTCT services.

2. Building the capacity of indigenous HIV/AIDS organizations and technical capacity of health care providers and community health workers to mobilize women and their partners for PMTCT services (rapid HIV counseling and testing in antenatal and maternity settings; combination short-course antiretroviral (ARV) prophylaxis for mother and infant and antiretroviral treatment (ART) for eligible mothers; counseling and support for infant feeding; link with wraparound services, such as nutrition, family planning services for women with HIV, and sustainable livelihood initiative); and strong links to care, treatment and support services.

In the first year, this program is expected to provide HIV testing to all pregnant women attending the antenatal clinics, identify a minimum of 300 HIV-infected pregnant women, provide antiretroviral therapy as per national guidelines, and community follow-up with deliveries supervise by qualified personnel. The program will be closely linked to other services like ART, pediatric care, nutritional support, laboratory infrastructure to ensure quality service delivery.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR;

Number of health facilities providing ANC services that provide both HIV testing and ARVs for PMTCT on site

Number of pregnant women with known HIV status

Number of HIV positive pregnant women who received antiretroviral drugs to reduce risk of mother-to-child transmission

Number of HIV-positive pregnant women assessed for ART eligibility

Number of eligible clients who received food and/or food security

This program will support the procurement of first and second line adult and pediatric ARV drugs for their patient population in accordance with the Uganda national policies and guidelines.

Funds will go towards support for the various stages of the ARV drugs' procurement cycle such as quantification of requirement, the procurement, storage and distribution, quality assurance and tracking of ARVs in close collaboration with HIV treatment providers, MOH Medicines and Supplies Department, MOH- AIDS Control Program, and institutions responsible for logistics and supplies chain management such as National Medical Stores, and Joint Medical Stores.

This program will support 4 health facilities and surrounding communities to implement collaborative TB and HIV activities in the districts of Luweero and Mbuya Parish, Kampala with possibility of expansion to other districts, facilities, and communities. This will be part of a comprehensive HIV care and treatment services program including provision of basic care and support package for all clients, OI prophylaxis, diagnosis and treatment, TB screening and treatment, routine assessment for ART eligibility.

The major areas of focus will be the following;

1. Provision of routine TB screening among HIV clients, TB diagnosis and treatment for clients with active TB, or active linkage of clients to comprehensive HIV/TB care and treatment, in collaboration with specialized TB clinics, which follow national TB-treatment guidelines

2. Improving community support and clinical services for persons living with HIV and TB and their families

3. Promotion of TB/HIV information and literature for communities to improve knowledge on TB and reduce TB/ HIV-related stigma

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR;

Number of HIV-positive patients who were screened for TB in HIV care or treatment settings

Number of HIV-positive patients in HIV care or treatment (pre-ART or ART) who started TB treatment

Number of TB patients who had an HIV test result recorded in the TB register

Number HIV-positive incident TB cases that received treatment for TB and HIV