Uganda has made significant progress towards providing care and support and ART to People Living with HIV/AIDS (PLHA). By March 31, 2009 PEPFAR funded HIV care and support for more than 350,000 people and provided ART to over 150,000 (87% of all ART recipients nationally). However, the number of people in need of ART is approximately 358,000 (UNAIDS), implying an unmet need of more than 50%. In addition, currently, only 9% of all persons on PEPFAR supported ART are children. Based on the new guidelines, an additional 25,000 infants may require ART in the absence of better PMTCT interventions.

Challenges for providing greater coverage of adult care and treatment services include high demand for HIV services, weak infrastructure with limited skilled human resources, weak laboratory support, and multiple uncoordinated logistics supply chain systems. There is limited access pediatric care and treatment with children comprising less than 9% of all clients in care and on treatment nationally. This has been linked to inadequate community education and mobilization for pediatric services, inadequate commodity supplies for pediatric care and treatment, limited coverage of Early Infant Diagnosis (EID) at 17%, continued MTCT estimated at about 15%, challenges of providing sexual and reproductive needs for adolescents, inadequate linkages between PMTCT and ART programs, pediatric and PMTCT programs as well as pediatric and OVC programs. In relation to PMTCT, access to services for pregnant women is estimated at 48% while only 21% of ART eligible pregnant women accessed treatment in the past year ending June 2009. There are inefficiencies in service provision and reporting as a result of poor coordination and linkages.

Mulago Hospital Complex is a national referral and University teaching Hospital with a bed capacity of 1,500. The hospital handles over 300,000 hospitalizations annually and over one million out-patient visits. About 65,000 women attend antenatal care at Mulago Hospital annually of which over 4,000 are HIV-infected (MOH report). The hospital has over 3,000 clinical and non-clinical staff and is host to several training schools for medical students and allied health workers. To date, over 20,000 HIV-infected individuals are in active HIV care, and 11,000 of these are on ART. Mulago Hospital provides TB treatment to over 4,000 patients annually and in the past year; over 200,000 individuals were reached with HIV testing in the various units.

The purpose of this program is to support Mulago Hospital to provide comprehensive HIV/AIDS services to patients within its clinics including Provider Initiated Testing and Counseling (PITC), TB/HIV, HIV basic care and support, PMTCT, OVC, and antiretroviral therapy (ART) for adults (including pregnant women) and children at Mulago Hospital. Currently, there are several specialized HIV clinics providing services such as Mulago ISS, Mulago Communicable Disease Clinic, Mulago TB/HIV clinic, Mulago Infectious Disease Clinics. There are two Mother and Child clinics (Upper and Lower Mulago). In addition, Butabika hospital is an extension of the referral services handling mental health but also providing general services.

The objectives of this program are to support:

1. Comprehensive care and treatment including: increase of coverage, scope of HIV/AIDS services for PHAs and their families; pediatric care and treatment services; strengthen linkages with PMTCT activities and OVC services; in the clinics to respond to existing gaps and minimize overlaps and duplication of services and reporting.

2. Secondly the program will also support Systems strengthening as follows: strengthen health facilities' capacity to effectively integrate HIV/AIDS services through support to M&E, Laboratory, staff capacity, infrastructure /space; training and routine supportive supervision of healthcare workers; and harmonized procurement of logistics and commodity supplies to enhance the comprehensive HIV/AIDS care, and treatment; support sustainability planning at health facilities' levels. The program will also support the recruitment of additional staff where applicable, using the Government of Uganda public service salary scales. This procedure is to support sustainability of this program and avoid parallel service systems, with eventual absorption of such staff onto the government pay role.

3. The third objective is to strengthen monitoring and evaluation through support of health facilities to utilize the Ministry of Health Management Information System (HMIS), and other MOH/ACP registers to produce timely reports, ensure these reports are channeled along the Government of Uganda information flow system and use HIV/AIDS service data for ongoing improvement of program performance.

This program will support Mulago Hospital Complex to implement a comprehensive adult HIV care and treatment services program including provision of basic care and support package for all clients, opportunistic Infection (OI) prophylaxis, 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 treatment guidelines or be referred to existing clinics within their communities. The program will implement strategies to promote adherence to ART to minimize the risk of developing ARV drug resistance. The program will establish quality improvement initiatives for adult HIV care and support in line with Ministry of Health guidelines. Linkages will be strengthened between HIV care and support, pediatric care and support, ART, PMTCT, HCT, and wraparound services such as nutritional support.

Adult care and treatment services within Mulago Hospital will be provided to an existing pool of 20,000 clients in active care 10,000 of whom are currently on ART. Services will also be scaled up to other facilities and eligible clients as they are identified through the HCT program.

For pediatric care and support, this program will work closely with Baylor- Uganda to identify HIVinfected children in the Mulago in patient wards, out-patient clinics, and families of index HIV infected clients that undergo home/ family based testing. These children will be actively linked to the Baylor-Uganda clinic or provided with HIV care and support in the existing clinics using a family model to HIV care. In order to enroll children into care as early as possible, the program will implement Early Infant Diagnosis in collaboration with the Ministry of Health. This will require collection of Dried Blood Spot (DBS) specimens from HIV-exposed infants in the post-natal, immunization clinics and wards implementing Routine HIV testing. The program will endeavor to improve follow-up of the HIV exposed mother-infant pair to ensure results are received and appropriate action taken. All exposed infants will be initiated on cotrimoxazole at 4-6 weeks as per national guidance and this will be continued until HIV infection can be reliably excluded. Children in care will receive OI prevention and care in addition to regular assessment for ART eligibility using both clinical and laboratory methods.

This program will also have a strong capacity building component through training of providers both pre-service and in-service. Trainees to be targeted may come other health facilities in the country, or the region. Continuing medical education will be organized to ensure provider skills are up-dated periodically. Providers will receive pediatric HIV counseling skills training. Children identified as vulnerable will be referred to OVC programs for additional support.

Major activities for this program will include:

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

2. 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. Supporting health systems for HIV care and treatment services delivery and strengthening linkages between the various care programs. 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.

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 support

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

Orphans and Vulnerable Children (OVC) 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 strengthen linkages between facility HIV care and existing OVC providers in the communities around Mulago Hospital. Children identified to be vulnerable in the facilities and home visits will be referred for OVC services while OVC providers will also refer children that need clinical HIV care to this program.

The major program goals will be; 1. 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. 2. 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;

1. Number of OVC care givers trained in comprehensive HIV management 2. Total number of eligible clients who received food and/or food security disaggregated by age and sex

This program will support Mulago Hospital Complex to implement a comprehensive adult HIV care and treatment services program including provision of basic care and support package for all clients, opportunistic Infection (OI) prophylaxis, diagnosis and treatment, TB screening and treatment, and routine assessment for ART eligibility.

Clients eligible for ART will receive treatment through this program at the various established accredited ART clinics as per national treatment guidelines or be referred to existing clinics within their communities. Categories of clients to be prioritized for ART will include pregnant women, patients with advanced HIV infection, and those co-infected with TB.

The program will implement strategies to promote adherence to ART to minimize the risk of developing ARV drug resistance. Laboratory monitoring for clients on treatment using CD4 will be supported in collaboration with other providers and in line with the National laboratory policy and ART guidelines. Clients on treatment will continue to receive prevention and treatment for opportunistic infections as appropriate. The program will endeavor to integrate prevention with treatment. Support for prevention among positives such as partner testing, disclosure of HIV status, condom use, family planning, and community follow-up will be provided as part of the treatment package. Quality improvement initiatives for adult HIV care and support will be implemented in line with Ministry of Health guidelines. The program will ensure regular up-dating of health workers knowledge through re-fresher trainings and continuing medical education sessions. Linkages will be strengthened between HIV care and support, pediatric care and support, ART, PMTCT, HCT, and wraparound services such as nutritional support. Data demand and use at the health facilities will be enhanced with regular cohort analyses to asses the performance of sites.

Adult care and treatment services within Mulago Hospital will be provided to an existing pool of 20,000 clients in active care 10,000 of whom are currently on ART. Services will also be scaled up to other facilities and eligible clients as they are identified through the HCT program.

For pediatric treatment, a specialized pediatric care and treatment clinic exists at Mulago Hospital through support from the Baylor College of Medicine Children's Foundation, Uganda Mulago Center of Excellence. This program will work closely with Baylor Uganda and other existing providers at Mulago Hospital to support the delivery of quality pediatric HIV treatment and other related services. Linkages between PMTCT and pediatric treatment will be strengthened to minimize loss to follow-up of exposed mother-infant pairs through integration of HCT in the MCH clinics and improved referral. Training of health providers in pediatric treatment will be a major activity and this will be pre-service, in service and through continuous medical education. Major support will be through strengthening the systems for delivery of HIV treatment services such as the laboratory infrastructure, the referral systems for patients and laboratory specimens such as CD4, capacity building for health provider skills, logistics systems for management supplies. 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 clinics and trainees facilities and provide mentorship and refresher training for staff in pediatric ART in collaboration with other partners.

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

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

3. Integrating HIV prevention initiatives within HIV care and treatment program. 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. 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.

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

HIV Counseling and Testing (HCT)

The program will work with the Mulago Hospital in-patient wards and out-patient clinics to offer HIV testing using various approaches. This program will build on the existing hospital wide program that has been implementing Provider Initiated HIV Testing (PITC) since 2004. This program will provide PITC in all units including OPD and inpatient wards, Voluntary Counseling and Testing (VCT), Couple testing, Early Infant Diagnosis for all HIV exposed infants, and HIV testing for household members of index clients (through selective home based programs, health visitors, or outreach programs). The hospital handles over 300,000 hospitalizations annually and over one million out-patient visits. About 65,000 women attend antenatal care at Mulago Hospital annually of which over 4,000 are HIV-infected (MOH report).

Clients identified as HIV-infected will be immediately initiated on cotrimoxazole and actively linked to existing HIV care and treatment services. Those found to be HIV negative will be encouraged to remain negative through provision of appropriate prevention messages and condoms. Discordant couples will be linked to psychosocial support groups or discordant couple clubs with the aim of reducing the risk of HIV transmission to the negative partner. The program will establish quality assurance mechanisms for both HIV counseling and testing at all levels of care in line with Ministry of Health guidelines.

This program will focus on the following activities;

1. Expand access to HIV counseling and testing through a variety of collaborative facility and community testing and counseling services

2. Provide couple counseling and testing, and ensure that persons testing HIV positive and discordant couples are provided with support and care, and facilitated disclosure

3. Integrate HIV prevention within HCT and establish clear linkages to ensure adequate referrals and follow-up services

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

1. Number of service outlets providing testing and counseling services

2. Number of individuals who received counseling and testing services for HIV and received their test results: by sex, age, HCT type and test results

3. The number of clients and family members receiving counseling and testing

Abstinence and Be Faithful (AB)

The program will develop HIV prevention interventions that target; staff in the hospital including a large pool of causal laborers and their family members, the students from the various health training institutions attached to Mulago hospital, patients and their caters, and communities around the hospital. The program will leverage resources from HCT and care and treatment technical areas to develop and implement targeted AB prevention interventions. The grantee will develop will support the hospital to integrate comprehensive HIV prevention services and develop targeted behavior change communication messages at the work place and surrounding communities. This activity is linked to prevention activities in the sections for Other Prevention, Male Medical Circumcision and PMTCT.

This program will also reach clients identified as HIV negative in the routine HIV testing and counseling program that is supported though this mechanism. These clients will receive messaging focusing on how to remain negative through abstinence and Be faithful interventions. Trainees in the medical school within Mulago Hospital will also receive HCT and AB messaging.

Other Prevention

This program will support Mulago Hospital health facilities/clinics and medical schools to implement a basic preventive care package for patients. All patients attending the hospital clinics will be offered HIV testing and counseling with their spouses and available family members. Couples identified to be discordant for HIV will be encouraged to use condoms and join discordant couple clubs for continued psychosocial and other support. Apart from partner testing, support will be provided for disclosure of HIV status. Following HIV testing, clients will be provided with effective referral for medical male circumcision (MMC) when appropriate, and supported disclosure of HIV status to spouses and selected family members. Support will be provided to health facilities within Mulago Hospital to provide MMC or condoms using existing nationally approved training materials to ensure that effective prevention programs are instituted for all HIV-infected individuals including discordant couples and a comprehensive prevention program that combine MMC, condom use and Abstinence Be Faithful initiatives.

Prevention of Mother to Child Transmission (PMTCT)

This program will implement PMTCT activities in support of the Government of Uganda and Mulago Hospital and to scale up high quality, effective and comprehensive PMTCT services that are fully integrated into the national health system. About 65,000 women attend antenatal care at Mulago Hospital annually of which over 4,000 are HIV-infected (MOH report).

In collaboration with the existing providers, this program will establish and monitor active and effective linkages between PMTCT, Early Infant Diagnosis, Pediatric HIV/AIDS care and OVC services for comprehensive support to HIV positive pregnant women and their families. The program will also support the Maternal and Child health Clinics at Mulago as an important linkage to antenatal and HIV clinic for continued care of identified mother infant pairs.

The program 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 health providers 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.

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

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

2. Number of pregnant women tested for HIV and received their results

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

4. Number of HIV-positive pregnant women assessed for ART eligibility

5. Number of eligible pregnant and lactating women who received food and/or food security

Laboratory Infrastructure

This program will be implemented in Mulago Hospital, a national referral and University teaching Hospital located in Kampala district. The program will focus on scaling up and strengthening laboratory activities that support HIV services' delivery in accordance with the Uganda national laboratory policies and guidelines. The scope of the laboratory support will address services such as HIV testing for infants, adults and children, diagnosis of opportunistic and other common infections, assessment for antiretroviral therapy eligibility for clients in active HIV care, and monitoring of response to treatment for clients on ART.

The PEPFAR program areas that require specific laboratory support include HIV counseling and testing (HCT), Prevention of Mother To Child Transmission (PMTCT), Biomedical HIV prevention, Adult Care and Support, Pediatric Care and Support, Adult treatment, and Pediatric Treatment.

The program will strengthen linkages between the laboratory and the various services and ensure timely delivery of laboratory results.

Major activities to be supported will focus on but not be limited to;

1. Developing and strengthening laboratory facilities in accordance with MoH laboratory strategic policies and plan to support HIV/AIDS-related activities including the purchase of equipment through competitive procurement

2. Provision of quality assurance, staff training and other technical assistance.

3. Supporting policies based on national and international best practices, training, waste-management systems, advocacy and other activities to promote medical injection safety, including establishing a distribution/supply chain, and the safe and appropriate disposal of injection equipment and other related equipment and supplies.

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

1. Number of testing facilities (laboratories) with capacity to perform clinical laboratory tests (CAPACITY depends on facility level as specified in MOH guidelines)

2. Number of testing facilities (laboratories) that are accredited according to national or international standards

3. Percent of testing facilities (laboratories) that are accredited according to national or international standards

ARV drugs

This program will procure ARV drugs for an existing pool of at least 11,000 clients currently on treatment at the 4 or more facilities in Mulago Hospital. 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.

Tuberculosis/HIV

This program will support Mulago Hospital complex, the national referral and University teaching hospital to implement collaborative TB and HIV activities. 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, and routine assessment for ART eligibility. In addition this program will support TB/HIV integrated activities of the National TB and Leprosy Program (NTLP) and the National TB Reference Laboratory (NTRL).

This program will build on the existing hospital wide routine HIV testing program that is providing TB screening concurrently to clients that are offered HIV testing irrespective of their HIV status. All clients that are offered HIV testing are also screened for TB using a symptom check list. Those suspected to have TB are then subjected to thorough TB investigation using sputum microscopy, chest radiology, ultra sound investigations, or analysis of lymph node or other fluid aspirates. Confirmed TB cases are referred to specialized TB clinic at Mulago that obtains TB medications through the National TB and Leprosy Program. All TB cases are offered HIV testing and those found to be infected initiated on cotrimoxazole, treated for TB and other inter-current opportunistic infections, and evaluated for ART eligibility. ARV drugs maybe initiated during the course of TB treatment in accordance with national treatment guidelines.

Within the five HIV clinics located at Mulago Hospital, all clients will be regularly screened for TB and treated accordingly. TB treatment and follow up using the DOTS strategy will be supported with sub county health workers facilitated to conduct support supervision to TB treatment supporters. The program will implement strategies that increase adherence to ART and TB. The program will ensure regular supplies of medications for TB and opportunistic infections like cotrimoxazole through the national system. Laboratory reagents for TB diagnosis will be procured through the national system. Data management will be strengthened through use of existing MOH data collection tools and provision of regular reports to the national TB program and MOH.

Staff will be trained in TB and diagnosis, and treatment of both conditions. Laboratory capacity for TB diagnosis will be built through training of laboratory technicians in TB sputum microscopy and equipping of laboratories. All supported labs will participate in the National External quality assurance for sputum microscopy. Awareness among patients and communities about TB and HIV integration will be supported through dissemination of IEC materials and health promotion talks. Health workers will be trained in HIV/TB co management. Innovative approaches such as co-location of TB and HIV services will be applied. Staff in supported Health facilities will be supported in data management and analysis using the MOH tools. Support will also be provided to the existing district health systems in provision of support supervision, on job training and logistics for HIV/TB drugs and supplies.

The program will support the Ministry of Health's [MoH] National TB Reference Laboratory [NTRL] to conduct the national external quality assurance for TB microscopy; conduct laboratory staff trainings in diagnosis and treatment of TB using smear microscopy; Support the NTRL with TB sputum referral system and surveillance of drug resistant TB, this activity will include procurement of reagents and supplies for TB culture, need for the MGIT ; ensure that the established mechanisms to provide TB patients with HIV screening are strengthened; institutionalize the "Three Is" of TB, with a major focus on infection control and intensive case finding. The MOH will be supported to strengthen supervision, monitoring and evaluation of TB/HIV activities in particular an M&E officer will be employed to improve the M & E capacity of the NTLP. Gaps in coordination of TB/HIV partners by the MOH will be facilitated through this program. The MOH will be supported in development and dissemination of National TB/HIV policies and guidelines.

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;

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

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

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

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