Uganda has made significant progress towards providing care and support and ART to People Living with HIV/AIDS (PLHA). Of the estimated 1,200,000 people living with HIV/AIDS (PHA) in Uganda, the number of adults in active HIV care nationally is unknown due to gaps in reporting. By March 2009, PEPFAR was supporting over 350,000 Persons living with HIV/AIDS (PHAs) in active HIV care with adults comprising over 90%, with children comprising less than 10%. By June 2009, 193,746 (60% of eligible) HIV positive clients were receiving ART nationally with adults comprising 91.5 % of recipients, with children comprising 8.5 % of recipients. An estimated 42,140 children are in urgent need of antiretroviral treatment. Over 350 service outlets are actively providing ART countrywide. The proportion of HAART eligible HIV-infected pregnant women receiving treatment is still low with only 5,263 (21%) of the estimated eligible 25,000 in the year ending June 2009.

However, the number of people in need of ART is approximately 358,000 (UNAIDS estimate using the CD4<200 cut off), 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.

Of the estimated Ugandans living with HIV/AIDS about 38% (456,000) are aware of their HIV status. In order to improve access to HIV testing, Uganda has embraced various approaches including Voluntary client -initiated counseling and testing (VCT), and Provider Initiated Counseling and Testing (PICT) for example Routine Testing in clinical settings (RCT), and Family based counseling and testing. However, access to HIV counseling and testing is still low.

Challenges for providing greater coverage of adult care and treatment services include: limited human resources, limited access to counseling and testing, incoherent measurement of HIV care and treatment outcomes, weak laboratory infrastructure and several uncoordinated logistics supply chain systems. In addition to challenges affecting adult care and treatment, limited access to pediatric care and treatment is 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 16%, 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. Additional challenges arise from poor coordination resulting in several supply chains, uncoordinated quantification of drugs, and thus gross inefficiencies in service provision and reporting. Thus making programs more comprehensive in scope and coverage is an endeavor to address the above challenges. The program will ensure coordinated and cost efficient comprehensive service provision in support of the national health systems.

The Central districts comprehensive HIV services program will cover public and private not for profit health facilities in the districts of Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende Mpigi, Masaka, Lyantonde, Rakai and Kalangala. These districtshave an estimated total population of 5,959,000 people and with a regional HIV sero-prevalence of 8.5%, about 506,515 are expected to be HIV infected. Curerently about 20% of the population know their HIV status thus about 101,000 people may be seeking care and treatment services in this region. The total number of health services outlets planned to have chronic care units are 261 ranging from district hospitals to HCIIIs. The regional Hospitals found in this region will not be part of the scope of this program, being covered by other programs. The services will include comphrehensive HIV care and treatment to an existing pool of more than 17,000 clients in care and 8,000 on ART.

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 and OVC services; in the clinics to respond to existing gaps and minimize overlaps and duplication of services and reporting. 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; harmonized procurement of logistics and commodity supplies to enhance the comprehensive HIV/AIDS care, and treatment; and support sustainability planning at health facilities' levels. Further more, the program will support the recruitment of additional staff where applicable, using the Government of Uganda public service salary scales. Thus will ensure sustainability of this program and avoid parallel service systems, with eventual absorption of such staff onto the government pay role. 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; aligned with goals and outcomes of CDC/Global AIDS Program and PEPFAR and use HIV/AIDS service data for ongoing improvement of program performance. In all these activities the program will work in close collaboration with other providers to ensure improved coordination and leverage of resources.

This program will support health facilities within Central districts mentioned above, including outreach services to lower level health facilities (HC III) as appropriate; 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.

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 to minimize the likelihood of developing ARV drug resistance. Care and treatment services within these Central districts will be provided to an existing pool of 17000 clients in active care 8000 of whom are currently on ART. Services will also be scaled up to other facilities and eligible clients.

Major activities for this program will include: Increasing access to HIV care, and support at facilities, and within communities to HIV-infected persons clients in accordance with National guidelines; Training health care providers to deliver HIV-related services; 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; Supporting the Central districts' 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: Number of health facilities that offer HIV care; Number of health care providers trained in facility and/or community HIV care; Number of adults and children with advanced HIV infection in care / on ART disaggregated by age and sex, and pregnancy status for women; and Percentage of adults and children with HIV known to be in active care and follow-up

The goal of the National Orphans and other vulnerable children policy is to provide a frame work for the enjoyment of rights and fulfillment of responsibilities of the orphans and other vulnerable children; to ensure that the legal, policy, and institutional frame work for child protection is developed and strengthened at all levels; to establish linkages between public and private not for profit health facilities CSOs and CBOs; to promote sustainable livelihood interventions ,income generation ,Economic strengthening and /or microfinance activities; to develop participatory community dialogues and facilitated problem solving about OVC issues.

The partner 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. They will develop a census based approach to achieve access of 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.

The program will build on the already achieved successes of offering the needed OVC services within the existing programs and the increasing referral to other OVC providers who are mapped out within the districts. They will also endeavor to address the challenges of the OVC response which include weak co-ordination mechanisms at both national and local government levels; Hardly any OVC management of information systems with functional data bases at national and district levels; Limited monitoring of quality of care in OVC programs especially the family centered approach; and inadequate implementation of standard tools to measure quality of care and improvement.

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.

This program will support health facilities within Central Districts 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. Clients eligible for ART will receive treatment through this program as per national guidelines or be referred to existing clinics. The program will ensure that these patients continue to be supported with quality care. This care will include adherence support and regular CD4 monitoring for all patients on ART and those on not yet on HAART. The program will ensure regular up dating of health workers knowledge through re-fresher trainings and 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. Performance based financing programs that are both equitable and encouraging will be encouraged. For those on ART, the program will implement strategies to promote adherence to ART to minimize the likelihood of developing ARV drug resistance.

Care and treatment services within Central districts will be provided to an existing pool of 17,000 clients in active care of which 8000 are currently on ART at their facilities. Services will also be scaled up to other health facilities and eligible clients.

Major activities for this program will include: Increasing access to HIV care, treatment, and support at facilities and within communities to HIV-infected persons clients in accordance with National guidelines; Training health care providers to deliver HIV-related services; 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; 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: Number of health facilities that offer HIV care and/or ART; Number of adults and children with advanced HIV infection in care / on ART disaggregated by age and sex, and pregnancy status for women; Increase the total number of patients currently receiving ART at each health facility/site; percentage of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy.

The partner will work with implementing health facilities to offer PITC in all units including OPD and inpatient wards, Couple testing, Early Infant Diagnosis for all HIV exposed infants, and HCT for household members of index clients (through selective home based programs, health visitors, or outreach programs). In partnership with Uganda Virus Research Institute, establish Quality Assurance mechanisms for both HIV counseling and testing at all levels of care in line with Ministry of Health guidelines. They will conduct effective repeat HIV testing and reporting to minimize wastage of resources and double counting. The partner will also establish and monitor active and effective linkage to care and treatment for all HIV-infected clients identified through PITC activities, and address adherence issues to minimize loss to follow up to less that 10% using case managers, medicine companions, or other effective strategies;

Existing community structures including VHTs, PHA networks, and others, will be utilized to mobilize communities to access HIV/AIDS services and follow-up of HIV-infected individuals to ensure that they receive appropriate care, treatment, and support services.

An estimated 42,140 children are in urgent need of antiretroviral treatment. Without ART, 50% of HIV infected infants will die before their second birthday and 75% before their fifth birthday (UNAIDS, 2005). By June 2009, approximately 16,495 children (39% of eligible) were on ART representing 8.5% of the national total of 193, 746 on ART with a male to female ratio of 1:1.

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 Central Districts 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. 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: Increasing access to pediatric HIV care, and support at facilities, and within communities to HIV-infected persons clients in accordance with National guidelines; Training health care providers to deliver HIV-related services; 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; Integrating HIV prevention initiatives within HIV care and treatment with a focus on adolescent sexuality issues; The program will strengthen the logistics and commodity supplies system through harmonized procurement of HIV commodities; and strengthening data management. Measurable outcomes of the program will be in alignment with PEPFAR goals including: Number of facilities that offer pediatric HIV care and support ; Number of health care providers trained in facility and/or community HIV care and Number of children with advanced HIV infection in care / on ART disaggregated by age and sex

In Uganda, an estimated 42,140 children are in urgent need of antiretroviral treatment. Without ART, 50% of HIV infected infants will die before their second birthday and 75% before their fifth birthday (UNAIDS, 2005). By June 2009, approximately 16,495 children (39% of eligible) were on ART representing 8.5% of the national total of 193, 746 with a male to female ratio of 1:1. 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 Central Districts to implement a comprehensive pediatric 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 350 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: Increasing access to pediatric HIV care, and support at facilities, and within communities to HIV-infected persons clients in accordance with National guidelines; Training health care providers to deliver HIV-related services; 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.

Within the central distict facilities and the surrounding communities, the implementing partner will support health facilities to implement a basic preventive care package for patients and staff; Offer counseling and effective referral for medical male circumcision when appropriate and supported disclosure;Support partner health facilities to provide family based HCT, comprehensive reproductive health services to existing female HIV-infected clients of reproductive age, including use of family planning methods, effective ARV prophylaxis for pregnant or postpartum women and their babies, infant feeding counseling and ongoing support, cervical cancer screening, STI diagnosis and treatment, in a family-centered approach. They will use existing nationally approved training materials to ensure that effective Prevention with Positives programs are instituted for all HIV-infected individuals including discordant couples

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. Some of the 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.

The existing health facilities within the Central districts have some laboratory capacity that will need to be supported with staff or kits for HIV/AIDS diagnosis and monitoring depending on their capacity level. The program will work with other laboratory stakeholders through the district laboratory focal persons to improve laboratory functions at the facilities. The aim will be to have laboratories performing the expected range of diagnostics tests for their level to support service delivery.

The major activities to be supported will focus on but not be limited to; 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; Providing quality assurance, staff training and other technical assistance; 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 PEPFAR performance goals: Number of testing facilities (laboratories) with capacity to perform clinical laboratory tests as specified in MOH guidelines and Number of testing facilities (laboratories) that are accredited according to national or international standards

This program will procure ARV drugs for an existing pool of at least 8000 clients currently on treatment in the estimated 50 health facilities in the Central districts. The program will also support facilities to improve their logistics management capacity to draw down on the National credit line. Activities shall include support to the quantification of ARV drug need, procurement, and storage, dispensing, plus reporting. Working closely with the MOH, the program will help standardize ARV regimens and formulations used at ART sites and harmonize these with the national treatment guidelines.

For TB/HIV integration, the aim of this funding will be to: Provide intensified case finding among clients in HIV care and treatment ensuring at least 100% of them are screened for TB; Institute TB Infection Control in measures; Support provider-initiated counseling and testing in T.B clinics and wards; Enhance cross referral and linkages between HIV and T.B clinics; Strengthen HIV Care and treatment for T.B patients; and promote directly observed treatment (DOT) for T.B HIV co- infected patients.

Activities will include: TB screening of the HIV positive clients in care and treatment at each visit; provider Initiated Counseling and testing will be offered to all TB patients, and those found to be HIV positive will be linked to HIV care and treatment. Health facility staff will be trained in TB Infection control, and facilitated to conduct risk assessment of health facilities, develop TB infection control plans and implement work practice and administrative control measures, and feasible environmental measures such as promoting natural ventilation in waiting and examination rooms. 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 in provision of support supervision, on job training and logistics for HIV/TB drugs and supplies. 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. 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.