Overview narrative

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 June 2009, 193,746 (60% of eligible) HIV positive clients were receiving ART nationally with adults comprising 91.5 % of recipients, and 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. (Performance Report STD/ACP 2008) 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.

As part of the comprehensive HIV prevention package which includes the provision of HIV testing and Counseling, Prevention with Positives interventions, ABC interventions, and other evidence based preventive mechanism like safe Male Medical circumcision will be adopted within the national context. The Program will promote voluntary Medical Male Circumcision in the general population (currently at 25%) with a "catch-up" strategy focusing on older adolescents and sexually active adult males with the goal of reducing incidence by 40% by 2012

Challenges for providing greater coverage of 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. Additional challenges arise from poor coordination of service provision resulting in several partners at health facilities. This has resulted in several supply chains, uncoordinated quantification of drugs, and gross inefficiencies in service provision and reporting.

The objectives of this program include but are not limited to:

1. Supporting the provision of comprehensive HIV care and treatment with increase in coverage and scope of existing HIV/AIDS services for PHAs and their families. Services include HIV Counseling and testing, adult and pediatric basic palliative care and support, PMTCT, ART, TB/HIV. The program will also focus on strengthening linkages between HIV prevention, care, treatment and support services in response to existing gaps and minimize overlaps and duplication of services and reporting.

2. Secondly, the program will support Health Systems Strengthening efforts to promote effective integration of HIV/AIDS services at facilities and surrounding communities. Areas to be supported shall include monitoring and evaluation (M&E), laboratory, infrastructure /space, staff capacity in terms of training and routine supportive supervision, and procurement of logistics and commodity supplies to enhance the delivery of comprehensive HIV/AIDS services. The program will work with the District Health Office to support recruitment of additional staff where applicable, using the Government of Uganda public service salary scales. This will ensure sustainability of this program and avoid parallel service systems, with eventual absorption of such staff onto the government payroll.

3. The third objective is to strengthen program monitoring and evaluation through support of health facilities to utilize the national Health Management Information System (HMIS) to produce timely reports, and 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 the MOH, district health management, and other providers to ensure improved coordination and leveraging of available resources.

This program, Comprehensive Eastern-Scaling up comprehensive HIV/AIDS services in Eastern districts' health facilities and the surrounding catchment areas covers the Eastern Uganda districts of Amuria, Katakwi, Kaberamaido, Soroti, Kumi, Mbale and Tororo. This program will build on progress made so far with over 10,000 patients being supported under PEPFAR in these districts. By March 2009 10,942 HIV-positive clients had been identified and linked to supported health facilities (District hospitals and HC IVs). These patients will continue to be supported with cotrimoxazole prophylaxis basic care kits and other care and support. The program will also support capacity building efforts through training and strengthening logistics systems and the referral system for HIV-positive persons. The program will ensure coordinated and cost efficient comprehensive service provision in support of the national health systems

Working through the District Health Offices (DHO's) the program will support the strengthening of comprehensive HIV/AIDS services in the existing District Hospitals and Health Center IVs and IIIs. This program will work to strengthen existing HIV/AIDS services to make them more comprehensive in scope and coverage care.

Adult Care and support

The program will support districts hospitals and health centers IV and III to implement a basic care and support package for patients. It will assist them to provide comprehensive adult HIV care and treatment services, including outreach services to lower level health facilities (HC III) as appropriate and this will include; the provision of basic care packages to an existing pool of more than 20,000 clients in care. Other support services will include OI diagnosis and treatment including STI diagnosis and management in additional to the traditional care and support that includes OI prevention with prophylaxis, TB screening and treatment, routine assessment for ART eligibility, psychosocial support and prevention with positives interventions

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 cotrimoxazole and use of the basic care package to delay progression to AIDS and the need for ART. Services will also be scaled up to other facilities and eligible clients as appropriate.

Major activities for this program will include:

1. Increasing access to 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 care 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 the KCC 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

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

OVC

The goal of the National Orphans and other vulnerable children policy is to provide a framework for the enjoyment of rights and fulfillment of responsibilities of the orphans and other vulnerable children; to ensure that the legal, policy, and institutional framework for child protection is developed and strengthened at all levels; to establish linkages between public and private not for profit health facilities Civil Society Organizations (CSOs) and Community based Organizations (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.

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.

The program will 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 Eastern Districts.

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 the program 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 and adherence support. 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 the existing pool of 10,000 patients currently receiving HAART in this region continue to be supported with quality care and follow up.

The program will ensure regular CD4 monitoring for all patients on ART and those 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.

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. 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 therap

The program will work with implementing health facilities to offer Provider Initiated HIV Testing and Counselling (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). The HCT program will 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 program will also establish and monitor active and effective linkage to care and treatment for all HIV-infected clients identified through PITC activities.

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. 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, CT type and test results

3. Number of people living with HIV/AIDS (PHAs) reached with a minimum package of prevention with positives (PWP) interventions

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

Pediatric care and support

The Eatern districts currently provide care for about 1300 children below 15 years.This is still below the national target of atleast 15 percent of clients in care being below 15 years.

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%, inadequate sexual and reproductive health services for 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 these districts to implement a comprehensive pediatric HIV care and treatment services program including, timely HIV diagnosis among children, 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:

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;

Number of facilities that offer pediatric HIV care and support

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

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.

Only a few of the health facilities in the Eastern Districts provide pediatric care and treatment. Currently about 1,300 children below 17 years are accessing care but figures of those accessing ART are unavailable.The Eastern comprehensive program will provide support to the existing pool of about 1300 pediatric patients with ART treatment services like CD4 monitoring and Viral Load measurements/DNA PCR. 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. Peer support networks for children on HAART will be supported to reduce stigma and enhance adherence. ARVs for pediatrics will continue to flow through the MOH and Global fund mechanism. Pediatric treatment:

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 to implement a comprehensive pediatric HIV 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 and adherence support.

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

The abstinence and Be faithful program will specifically focus on youth out of school less than 14 years and clients 15-49 who test as a couple. This will comprise the only prevention messaging to children below 15 as these are largely not yet sexually active. This will have the aim of primary prevention of HIV in this population. The focus will be youth out of school and those in casual employment like boda boda cyclers as these are not reached by the school program. Special emphasis will be put on the females as the have higher HIV pravalence compared to their male peers. Couples will be specifically targeted because most new infections are occuring among married people. The specific messaging will aim at reducing concurrent relationships with multiple partners promoting zero grazing. For patients below 15 years who are sexually active further prevention messaging with strategies like condom use will be provided. This will also be the same for discordant couples. AB prevention activities will be monitored and evaluated through the overall monitoring and evaluation frame work of the program through the prevention focal persons at the district health office.Abstinence and Be Faithful (AB)

The abstinence and Be faithful (AB) program will specifically focus on youth out of school less than 15 years and clients aged 15-49 years who test as a couple. This will comprise the only prevention messaging to children below 15 as these are largely not yet sexually active.

The major aim of this program component is primary prevention of HIV in this population. The focus will be youth out of school and those in casual employment like 'boda boda' (motor) cyclists as these are not reached by the school program implemented by the Uganda Ministry of Education and Sports, also called the PIASCY program or President Initiative AIDS Strategy Communication for Youth.. Special emphasis will be put on the females as they have higher HIV prevalence compared to their male peers. 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.

In the districts of Amuria, Katakwi, Kaberamaido, Soroti, Kumi, Mbale and Tororo and the surrounding communities, this program will support health facilities to implement a basic preventive care package for patients, offer counseling and effective referral for medical male circumcision (MMC) when appropriate, supported disclosure of HIV status to spouses and selected family members. Support will be provided to health facilities within the district hospitals and health centers IV and III 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 with a comprehensive prevention program that combines MMC, condom use and Abstinence Be Faithful initiatives.

TB remains a major challenge in Uganda contributing to significant morbidity and mortality. The estimated TB incidence of all forms of TB is 330 new cases per 100,000 pop/ year with an incidence of 128 new cases per 100,000 pop /year among HIV positive persons. Over 39% of all incident TB cases are HIV positive. Prevalence of all forms of TB is 426 cases per 100,000 population. Mortality is 93 deaths per 100,000 pop /year. The estimated Multidrug resistant -TB (MDR-TB) rate among all new TB cases is 0.5%. (Global Tuberculosis control WHO report 2009). The Uganda TB control indicators remain below target despite implementation of DOTS throughout the country. Treatment success rate is 74% against a target of 85% due to high proportion of patients who either die, default or whose treatment outcome is not evaluated. The TB Case Detection Rate is 57% versus the target of 70%.

This program will promote integration of TB and HIV through the following activities:

1. Provide intensified case finding among clients in HIV care and treatment ensuring 100% of them are screened for TB;

2. Institute TB Infection Control measures in health facilities;

3. Support provider-initiated counseling and testing in TB clinics and wards;

4. Enhance cross referral and linkages between HIV and TB clinics;

5. Strengthen HIV Care and treatment for TB patients through provision of OI prophylaxis such as cotrimoxazole, regular assessment for ART eligibility, and provision of ART for those eligible according to national treatment guidelines;

6. Promote directly observed treatment (DOTS) for TB HIV co- infected patients.

The program will provide TB screening for HIV positive clients in care and treatment at each visit; offer HIV Counseling and testing to all TB patients, and those found to be HIV positive will be linked to HIV care and treatment. 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.

Health facility staff will be trained in TB Infection control, and facilitated to conduct risk assessment of health facilities, develop and implement TB infection control measures such as promoting natural ventilation in waiting and examination rooms. Health workers will be trained in HIV/TB co-management. Innovative approaches such as co-location of TB and HIV services will be applied.

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. Staff in supported Health facilities will be supported in data management and analysis using the existing Ministry of Health (MOH) tools.

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

Number of service outlets providing treatment for TB to HIV-infected individuals in a palliative care setting

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

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

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