It is estimated that 1,200,000 Ugandans are living with HIV/AIDS and about 38% (456,000) know their HIV status. At least 135,000 new HIV infections occur in Uganda each year of these 80% are adults. Currently, the number of PHA accessing care and antiretroviral treatment (ART) nationally is estimated at 357,108 and 193,746 (60% of eligible) respectively; with adults comprising 91.5 % of recipients at 350 facilities countrywide. However, the number of people in need of ART is approximately 358,000 implying an unmet need of more than 50% (UNAIDS). Of the estimated 42,140 children in urgent need of antiretroviral treatment, only 39% are receiving it as compared to 63% of eligible adults. In relation to TB/ 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%. With the introduction of various models to scale up HIV counseling and testing; the number of PHA identified and therefore need to access HIV care and treatment services continues to increase. Although efforts have been made by the Ministry of Health (MOH), PEPFAR and other stakeholders to scale up HIV/AIDS care and treatment services nationally, only about 60% of the need is being met. There are several challenges encountered in the delivery of HIV/AIDS 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.

This mechanism is comprehensive in scope and coverage in an effort to address the above challenges. The program will ensure coordinated and cost efficient comprehensive HIV/AIDS service provision in support of the national and district health systems. Support will be provided for comprehensive HIV prevention, care, support and treatment services in public and private not for profit health facilities in 7 districts in the West Nile region of Uganda, namely Arua, Moyo, Adjumai, Maracha, Koboko, Yumbe and Nebbi. These districts have an estimated total population of 2,543,900 people, with a regional HIV sero prevalence of 2.3%; about 58,510 are estimated to be HIV infected. Currently about 20% of the population know their HIV status, therefore potentially about 11,702 PHA will seek HIV/AIDS care and treatment services in this region. The total number of health service facilities planned to have HIV/AIDS services are 140, ranging from district hospitals to HC IIIs. The regional hospitals found will not be included in this mechanism as they are being covered by other programs.

The objectives of this mechanism are to support: Comprehensive HIV/AIDS care and treatment including: increase of coverage, scope of HIV/AIDS services for PHA and their families; pediatric care and treatment services; strengthen linkages across PMTCT, OVC, care and treatment services; Respond to existing gaps and minimize overlaps and duplication of services and reporting; Support systems strengthening as follows: improve the capacity of facilities to effectively integrate HIV/AIDS services through support to M&E, laboratory, infrastructure /space; training and routine supportive supervision of healthcare workers; harmonized procurement of logistics and commodity supplies to enhance comprehensive HIV/AIDS care and treatment; and support sustainability planning at the health facility level. Furthermore, the mechanism will support human resources for health through the recruitment of additional staff where applicable, using the Government of Uganda public service salary scales. Eventually, these staff will be absorbed onto the government pay roll to ensure sustainability of services and avoid parallel systems. The mechanism will also 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 and ensure these reports are channeled along the MOH information system. The mechanism M&E will align with goals and outcomes of CDC/Global AIDS Program and PEPFAR, using data for ongoing improvement of HIV/AIDS services. In all these activities the mechanism will work in close collaboration with other providers to ensure improved coordination and leverage of resources and ensuring comprehensive care for families affected by HIV/AIDS while avoiding multiple partners at facilities and service duplication. The mechanism will be implemented in close collaboration with the MOH, district health management, and other providers to ensure improved coordination and leverage of available resources.

It is estimated that 1,200,000 Ugandans are living with HIV/AIDS and about 38% (456,000) have tested and know their HIV status. Currently, the number of PHA accessing care and support nationally is estimated at 357,108; with adults comprising 91.5 % of recipients at 350 facilities countrywide. With the introduction of various models to scale up HIV counseling and testing; the number of PHA identified and therefore need to access HIV/AIDS care and support services continues to increase. Although efforts have been made by the Ministry of Health (MOH), PEPFAR and other stakeholders to scale up HIV/AIDS care and support services nationally, only about 60% of the need is being met. Challenges to providing greater coverage of adult care and support services include: limited human resources, limited access to HIV counseling and testing, incoherent measurement of HIV/AIDS care and support outcomes, weak laboratory infrastructure and several uncoordinated logistics supply chain systems.

This mechanism will support MOH, the district health services and other stakeholders to implement comprehensive HIV/AIDS care and support services in the West Nile region using a variety of approaches. Effective and active linkages to care and support for all HIV-infected adults identified through PITC activities will be established. The coverage and scope of available HIV/AIDS services for PHA and their families under this mechanism will be increased, working with other stakeholders providing similar services in the identified geographical locations to respond to existing gaps in order to minimize overlaps and duplication of services and reporting. Implementation of comprehensive HIV/AIDS care and support activities in health facilities will support the Ministry of Health to scale up and ensure high quality of effective HIV/AIDS care services that are fully integrated into the national health system and will mainly focus on the following activities:

Use existing nationally approved training materials to ensure that effective HIV/AIDS care, support and Prevention with Positives (PWP) programs are instituted for all HIV-infected individuals and their families, including discordant couples; Support the delivery of comprehensive HIV/AIDS care and support services including; OI management, TB management, pain management, psychosocial support, PWP, nutrition management and sustainable livelihood interventions; Establish effective laboratory networks with other related programs, to ensure health facilities have adequate laboratory services for HCT, ART monitoring, TB and OI diagnosis, in line with Ministry of Health Laboratory Services policy; Support functions of the National TB Reference Laboratory including National External Quality Assurance for TB microscopy, and TB drug resistance surveillance in HIV care and treatment settings; Utilize existing community structures including village health teams (VHT) and PHA networks to mobilize communities to access HIV/AIDS services and conduct community follow up of PHA; Support health facilities to provide comprehensive reproductive health services to existing female HIV-infected clients of reproductive age, including support for family planning method use, effective ARV prophylaxis for pregnant or postpartum women and their babies, infant feeding counseling and ongoing support, cervical cancer screening, partner HCT, STI diagnosis and treatment, infant diagnosis, care and treatment and a family-centered approach; Offer counseling and effective referral for medical male circumcision when appropriate and supported disclosure.

The mechanism will also support the improvement of existing infrastructure and systems. This will include the improvement of data management and reporting to all stakeholders within the district structure; strengthening of logistics management information system and internal technical support supervision by health managers in facilities. In order to further mitigate the human resource gaps in the facilities, the program will implement in-service training for staff including task shifting and implementing a strategy for involvement of PHA in aspects of patient care and follow up.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR: Number of eligible adults and children provided with a minimum of two care services, one clinical and one non-clinical (including cotrimoxazole prophylaxis, CD4 count, OI management, TB/HIV and on-going counseling), Number of eligible adults and children provided/receiving with a minimum of one care service; Number of PHA receiving cotrimoxazole prophylaxis; Number of PHA clinically malnourished clients who received therapeutic/ supplementary food and /or nutrition services; Proportion of sexually active female HIV clients using family planning; Number of HIV positive pregnant women newly enrolled into HIV care and support services; Number and percentage of facilities providing care and treatment integrated with PWP; Number of health facilities with operational Home Based Care services; Number of health facilities with capacity to provide a minimum palliative care package (minimum is HCT, TB diagnosis [smear] and treatment, oral morphine and cotrimoxazole prophylaxis)

The goal of the National Orphans and other Vulnerable Children (OVC) 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, civil society organizations (CSO) and community based organizations (CBO); to promote sustainable livelihood interventions, income generation, economic strengthening and /or microfinance activities; to develop participatory community dialogues and facilitate problem solving about OVC issues. Challenges of the OVC response in Uganda include weak coordination mechanisms at both national and local government levels; inadequate national and district level OVC management information systems; limited monitoring of quality of care in OVC programs especially the family centered approach; and high demand for services.

This mechanism will be implemented in facilities and communities of the West Nile districts, building on existing OVC services and improving referral systems across the mapped OVC providers in the districts. The target population will include the following OVC; children affected and infected with HIV, street children, children under extreme labor conditions and other forms of child abuse. The needs of OVC as appropriate to age and gender will be addressed, including HIV/AIDS care and support, education, psychosocial support, food security, economic strengthening, basic health care, child protection and legal support. The mechanism will support the development of a census based approach to achieve access of these services to all segments of the vulnerable communities through community development officers, relevant CBO and CSO, using collected data to inform strategies and activities. Major activities include:

1. Improve the lives of OVC and families affected by HIV/AIDS, with emphasis on strengthening communities to meet the needs of OVC affected by HIV/AIDS.

2. Identify HIV positive children through partnerships 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, 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; Number of eligible children (OVC) provided services in 3 or more OVC core program areas beyond psychosocial/spiritual support; Number of eligible children (OVC) provided services in 3 or more OVC core program areas beyond psychosocial/spiritual support; Number of eligible clients who received food and/or food security; Number of eligible clients who received food and/or other nutrition services

By June 2009, 193,746 (60% of eligible) persons with HIV/AIDS (PHA) were receiving ART nationally; a significant increase from 40% in June 2008. PEPFAR contributed 153,024 to the national total by March 2009. Of the PHA receiving ART, adults comprised 91.5 % of recipients at 350 service outlets are countrywide. The national target for ART is 203,000 PHA by September 2009 while that of PEPFAR is 164,397. However, the number of people in need of ART is approximately 358,000 (UNAIDS) implying an unmet need of more than 50%. Children comprise 8.5% of national ART recipients against a target of 15%. The proportion of ART eligible HIV-infected pregnant women receiving treatment is still low; 5,263 (21%) of the estimated eligible 25,000 in the year ending June 2009.

This mechanism will support the national ART program, the district health services and other stakeholders to implement HIV/AIDS treatment services in the West Nile region. Effective and active linkages to treatment for clients receiving PMTCT, care and support services will be established. Health facilities will provide adult treatment services, including community and outreach services to lower level health facilities as appropriate. The coverage and scope of available HIV/AIDS services for PHA and their families under this mechanism will be increased, working with other stakeholders providing similar services in the identified geographical locations to respond to existing gaps in order to minimize overlaps and duplication of services and reporting.

Implementation of HIV/AIDS treatment activities in health facilities will support the Ministry of Health, to scale up and ensure high quality of effective HIV/AIDS treatment that are fully integrated into the national health system and will mainly focus on the following activities: Expand the number of health care facilities/sites providing ART to PHA and their families; Provide ART to current recipient PHA and increase the number of PHA newly initiating ART at supported health care facilities/sites in accordance with PEPFAR and National guidelines; Increase the total number of HIV treatment sites with active monitoring, evaluation and quality improvement programs; Ensure the availability of post exposure prophylaxis services for occupational and non-occupational exposure; Establish a logistics and commodity supplies system through harmonized procurement of HIV testing commodities, laboratory supplies, ART and OI drugs with National Medical Stores and/or using existing public and private sector procurement mechanisms.

The mechanism will reinforce adherence counseling and support and follow up of ART patients through current adherence support mechanisms at all clinics and in the community. As a quality improvement strategy, stable PHA on ART may be attended to at pharmacy-only and nurse-only visits. Routine ART monitoring tests and related activities will be conducted including CD4 cell count for both pre-ART and ART PHA, hematology, blood chemistries, TB screening, prevention with positives counseling, support for couples including HIV testing for partners and family members.

The program will provide comprehensive HIV/AIDS care and treatment for families including children in collaboration with other providers where applicable. HIV positive pregnant women will be evaluated for ART eligibility and provided with ART in accordance with the national PMTCT guidelines. HIV/AIDS care and support services will be provided to complement the ART and where necessary, referrals made for specialized care. The clinic based activities will be further supported by community initiatives and home based care to conduct follow up visits to PHA, support disclosure, trace treatment defaulters, provide support on home care for PHA, counsel and test family members and refer those identified HIV positive to the clinics for further care.

This mechanism will support the procurement of first and second line adult ARV drugs in accordance with the Uganda national policies and guidelines. Funding will support various stages of the ARV drug procurement and distribution cycle, in collaboration with other HIV/AIDS treatment providers, MOH Medicines and Supplies Department, MOH- AIDS Control Program, National Medical Stores, Joint Medical Stores and Medical Access. The mechanism will also support the improvement of existing infrastructure and health systems. This will include the improvement of data management and reporting to all stakeholders within the district structure; strengthening of logistics management information system and internal technical support supervision by health managers in the supported facilities. In order to further mitigate the human resource gaps in the facilities, the program will implement in-service training for staff including task shifting and implementing a strategy for greater involvement of PHA in aspects of service provision.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR; Number of adults with advanced HIV infection newly enrolled on ART; Number Pregnant women with advanced HIV infection newly enrolled on ART; Number of adults with advanced HIV infection receiving antiretroviral therapy (ART); Number of adults with HIV known to be on treatment 12 months after initiation of antiretroviral therapy; Percent of adults with HIV known to be on treatment 12 months after initiation of antiretroviral therapy; Number of naïve adults with advanced HIV-infection who ever started on ART (excludes all transfer-in clientele); Percent of adults with advanced HIV infection receiving antiretroviral therapy; Percentage of health facilities providing ART using CD4 monitoring in line with national guidelines/policies on site or through referral.

It is estimated that 1,200,000 Ugandans are living with HIV/AIDS and about 38% (456,000) have tested and know their HIV status. At least 135,000 new HIV infections occur in Uganda each year; of these 80% are adults.

This mechanism will implement HCT activities in support of the Ministry of Health, district health services and other stakeholders to scale up high quality and effective HCT services that are fully integrated into the national health system and will mainly focus on the following activities:

1. Expand access to HIV counseling and testing through a variety of collaborative community testing and counseling services; Provider initiated testing and counseling (PITC) in facility units including outpatient departments and inpatient wards; HCT for household members of index clients (through selected home based programs, health visitors, or outreach programs); Early Infant Diagnosis for all HIV exposed infants

2. Provide couple and family based counseling and testing; and ensure that identified HIV positive persons and discordant couples are provided with support, facilitated disclosure and appropriately referred for HIV care and treatment

3. Provide services that should include provision of appropriate prevention messages, and clear linkages should be established to ensure adequate referrals and follow-up services.

This mechanism will support partnership with Uganda Virus Research Institute to establish quality assurance systems for HIV counseling and testing at all levels of care in line with Ministry of Health guidelines. Effective repeat HIV testing and reporting will be conducted to minimize wastage of resources and double counting. Additionally the mechanism will establish and monitor active and effective linkages to HIV care and treatment services for all HIV-infected clients identified through HCT activities.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR: Number of Service outlets providing Testing and Counseling (T&C) services; Number of individuals who received counseling and testing services for HIV and received their test results; Number of individuals who received Testing and Counseling (T&C) services for HIV and received their test results; Number of clients and family members receiving counseling and testing

It is estimated that 1,200,000 Ugandans are living with HIV/AIDS and about 38% (456,000) have tested and know their HIV status. Currently, the number of PHA accessing care and support nationally is estimated at 357,108; with adults comprising 91.5 % of recipients at 350 facilities countrywide. With the introduction of various models to scale up HIV counseling and testing; the number of PHA identified and therefore need to access HIV/AIDS care and support services continues to increase. Although efforts have been made by the Ministry of Health (MOH), PEPFAR and other stakeholders to scale up HIV/AIDS care and support services nationally, only about 60% of the need is being met. Challenges to providing greater coverage of general HIV/AIDS care and support services include: limited human resources, limited access to HIV counseling and testing, incoherent measurement of HIV/AIDS care and support outcomes, weak laboratory infrastructure and several uncoordinated logistics supply chain systems. In addition, challenges specific to pediatric care and support include; limited access to pediatric care and support due to inadequate community education and mobilization for pediatric services, inadequate commodity supplies for pediatric care and support, limited coverage of Early Infant Diagnosis (EID), only 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.

This mechanism will support MOH, the district health services and other stakeholders to implement comprehensive pediatric HIV/AIDS care and support services in the West Nile region. Support will be provided for the identification of HIV exposed and infected children and linking them to care from the family based counseling and testing services, maternal and child health clinics, out-patient and pediatric departments. This will be a core focus area for the mechanism with the aim of increasing the number of children provided care and support to about 15% of the PHA in HIV/AIDS care. The mechanism will support the creation of child friendly clinics at health facilities and also address the special adolescent sexual and reproductive health needs through interventions focusing on this age group. A family centered approach to managing pediatric patients will be implemented to provide support for this particularly vulnerable group, and minimize loss to follow up. Health workers will receive training in pediatric HIV counseling skills to have at least one pediatric counselor at all the supported health facilities.

The coverage and scope of available HIV/AIDS services for children with HIV/AIDS and their families under this mechanism will be increased, working with other stakeholders providing similar services in the identified geographical locations to respond to existing gaps in order to minimize overlaps and duplication of services and reporting

Implementation of comprehensive pediatric HIV/AIDS care and support activities in health facilities will support the Ministry of Health, to scale up and ensure high quality of effective HIV/AIDS care services that are fully integrated into the national health system and will mainly focus on the following activities: Use existing nationally approved training materials to ensure that effective care and support and Prevention with Positives (PWP) programs are instituted for children with HIV/AIDS and their families; Scale up pediatric care services by strengthening effective linkages with PMTCT, EPI, Pediatric HIV/AIDS care and OVC services for proper management of infected/affected children especially those under one year in accordance with Ugandan MOH and WHO ART guidelines; Support the delivery of comprehensive pediatric HIV/AIDS care and support services including; OI management, TB management, pain management, psychosocial support, PWP, nutrition management and sustainable livelihood interventions; Establish effective laboratory networks with other related programs to ensure health facilities have adequate laboratory services for HCT, ART monitoring, TB/HIV and OI diagnosis, in line with Ministry of Health Laboratory Services policy; Support functions of the National TB Reference Laboratory including National External Quality Assurance for TB microscopy, and TB drug resistance surveillance in HIV care and treatment settings; Utilize existing community structures including village health teams (VHT) and PHA networks to mobilize communities to access HIV/AIDS pediatric services and conduct community follow-up of children with HIV/AIDS and their families to ensure that they receive appropriate care and support services; and Support health facilities to provide comprehensive services including effective ARV prophylaxis for pregnant or postpartum women and their babies, infant feeding counseling and ongoing support, family based HCT, infant diagnosis, care and support using a family-centered approach.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR; Number of infants born to HIV positive women who received an HIV test within 12 months of birth; Number of infants born to HIV positive women who received an HIV test within 12 months of birth; Number of infants born to HIV positive pregnant women who are started on CTX prophylaxis within two months of birth; Overall percent of infants born to positive women who received an HIV test within 12 months of birth; Percent of infants born to HIV-positive women who received an HIV test within 12 months of birth; Number of infants born to HIV-Positive pregnant women who are started on CTX prophylaxis within two months of birth; Percent of infants born to HIV-Positive pregnant women who are started on CTX prophylaxis within two months of birth.

By June 2009, 193,746 (60% of eligible) persons with HIV/AIDS (PHA) were receiving ART nationally; a significant increase from 40% in June 2008. PEPFAR contributed 153,024 to the national total by March 2009. Of the PHA receiving ART, adults comprised 91.5 % of recipients at 350 service outlets are countrywide. The national target for ART is 203,000 PHA by September 2009 while that of PEPFAR is 164,397. However, the number of people in need of ART is approximately 358,000 (UNAIDS) implying an unmet need of more than 50%. Children comprise 8.5% of national ART recipients against a target of 15%. Of the estimated 42,140 children in urgent need of antiretroviral treatment, only 39% are receiving it as compared to 63% of eligible adults. In addition, currently, only 9% of all PHA on ART under PEPFAR support are children. Based on the new guidelines, an additional 25,000 infants may require ART in the absence of better PMTCT interventions. The proportion of ART eligible HIV-infected pregnant women receiving treatment is still low; 5,263 (21%) of the estimated eligible 25,000 by June 2009.

This mechanism will support the national ART program, the district health services and other stakeholders to implement pediatric HIV/AIDS treatment services in the West Nile region. Effective and active linkages will be strengthened between pediatric treatment pediatric HIV/AIDS care, PMTCT, EPI and OVC services for proper management of infected/affected children especially those under one year in accordance with Ugandan and WHO ART guidelines. Health facilities will provide pediatric treatment services, including community and outreach services to lower level health facilities as appropriate. The coverage and scope of available HIV/AIDS services for children and their families under this mechanism will be increased, working with other stakeholders providing similar services in the identified geographical locations to respond to existing gaps in order to minimize overlaps and duplication of services and reporting.

The West Nile comprehensive program will support the implementation of HIV/AIDS treatment activities in health facilities will support the Ministry of Health, to scale up and ensure high quality of effective pediatric HIV/AIDS treatment that are fully integrated into the national health system and will mainly focus on the following activities: Expand the number of health care facilities/sites providing ART to children with HIV/AIDS and their families; Continue provision of ART to the current pediatric recipients and increase the number of children newly initiating ART at supported health care facilities/sites in accordance with PEPFAR and National guidelines; Train and build capacity of health workers and care providers to support children on ART and enhance adherence; Disseminate revised pediatric treatment guidelines to all implementing facilities and provide mentorship and refresher training for health workers in pediatric ART; Strengthen peer support networks for children on ART to reduce stigma and enhance adherence; Increase the total number of HIV treatment sites with active monitoring, evaluation and quality improvement programs; Ensure the availability of post exposure prophylaxis services for occupational and non-occupational exposure; Establish a logistics and commodity supplies system through harmonized procurement of HIV testing commodities, laboratory supplies, ART and OI drugs with National Medical Stores and/or using existing public and private sector procurement mechanisms.

The mechanism will also support the improvement of existing infrastructure and systems. This will include the improvement of data management and reporting to all stakeholders within the district structure; strengthening of logistics management information system and internal technical support supervision by health managers in the supported facilities. ARV for pediatric treatment will continue to flow through the MOH and Global fund mechanism. In order to further mitigate the human resource gaps in the facilities, the program will implement in-service training for staff including task shifting.

Measurable outcomes of this mechanism will be in alignment with the following performance goals for PEPFAR; Number of children with advanced HIV infection newly enrolled on ART; Number of children with advanced HIV infection receiving ART; Number of children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy; Percent of children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy; Number of naïve children with advanced HIV-infection who ever started on ART (excludes all transfer-in clientele); Percent of children with advanced HIV infection receiving antiretroviral therapy; Percentage of health facilities providing ART using CD4 monitoring in line with national guidelines/policies on site or through referral.

Under this mechanism, the Abstinence and Be faithful (AB) interventions will specifically focus on youth both in and out of school under 15 years and persons 15-49 years who test as a couple. For youth under 15 years, interventions will comprise only prevention messaging as the majority are not yet sexually active. This is aimed at primary prevention of HIV among this population. For those under 15 years and sexually active, further prevention messaging with strategies like condom provision will be implemented. School interventions will include life skills training, complementing the PIASCY program currently implemented through the Ministry of Education and Sports (MOES).

Couples will be specifically targeted as the majority of new infections in Uganda are occurring among couples in discordant relationships. Specific messaging will aim at reducing concurrent relationships with multiple partners, promoting zero grazing. The mechanism will place special emphasis on females, as they have higher HIV prevalence compared to their male peers; discordant couples; as well as youth out of school and in casual employment not reached by the school programs.

AB prevention activities will be monitored and evaluated through the overall M&E framework using HIV/AIDS prevention focal persons at the district health offices.

This mechanism will support HIV prevention interventions within the West Nile region most of which is on the border with neighboring countries. Health facilities and surrounding communities will be supported to implement a basic prevention package; Offer HIV counseling, testing and supported disclosure; support health facilities to provide family based HCT, provide condoms; offer medical male circumcision or provide effective referrals, provide comprehensive reproductive health services to HIV-infected women of reproductive age including: family planning, effective ARV prophylaxis for pregnant women and their babies, infant feeding counseling and ongoing support, cervical cancer screening, STI diagnosis and treatment in a family-centered approach. Prevention services will be supported for PHA including discordant couples and will combine MMC, condom use and AB. Prevention with Positives interventions will also be instituted for all HIV-infected individuals including discordant couples. Health worker capacity will be built using the existing nationally approved training materials and guidelines. The mechanism will implement 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. 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 mechanism will focus on following activities;

Expand the capacity of communities and Ugandan 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, condom use and medical male circumcision.

Support PHA to reduce their risk of HIV transmission through positive prevention or "prevention with positives" interventions, particularly partner testing.

Promote gender equity and positive role models, and address negative social norm; gender based violence, stigma, and discrimination will be cross-cutting themes.

The Uganda TB control indicators remain below target despite implementation of DOTS throughout the country. According to the Uganda National TB and Leprosy Program (NTLP) report, the TB case detection rate is 57% versus the target of 70%, while the 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. In the West Nile region, the 2009 MEEPP Semi Annual Progress Report estimates 4,875 TB/HIV patients in the region, which accounts for 12-25% of the HIV positive population.

The coverage and scope of available TB/HIV services for PHA and their families under this mechanism will be increased, working with other stakeholders providing similar services in the identified geographical locations to respond to existing gaps in order to minimize overlaps and duplication of services and reporting. Under this mechanism for TB/HIV integration, the aim of this funding will be to: Provide intensified case finding among clients in HIV/AIDS care and treatment ensuring at least 100% of them are screened for TB; Institute TB Infection Control measures in facilities; Support provider-initiated counseling and testing in TB clinics and wards; Enhance cross referral and linkages between HIV and TB clinics; Strengthen HIV/AIDS care and treatment for TB patients; and promote DOTS for TB/HIV co infected patients.

Implementation of TB/HIV activities in health facilities will support the Ministry of Health NTLP, to scale up and ensure high quality of effective TB/HIV services that are fully integrated into the national health system and will mainly focus on the following activities: Routine TB screening of PHA in HIV/AIDS care and treatment at every clinic visit; Provider Initiated Counseling and Testing will be offered to all TB patients, and linking to HIV/AIDS care and treatment identified HIV/TB co-infected patients; Train and build capacity of health workers in facilities in TB Infection control and in conducting risk assessments; Develop TB infection control plans and implement work practice and administrative control measures, and feasible environmental measures including promoting natural ventilation in waiting and examination rooms.

Health workers in facilities will be supported in data management and analysis using the MOH reporting tools. Existing district health workers will be facilitated to conduct support supervision, on job training and logistics for HIV/TB drugs and supplies. Training in HIV/TB co management is also planned for, and the application of innovative approaches such as co-location of TB and HIV services. TB treatment and follow up using the DOTS strategy will be strengthened with sub county health workers being 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 laboratories will participate in the national external quality assurance for sputum microscopy. Awareness among patients and communities about TB and HIV integration will be improved through dissemination of IEC materials and behavior change communication activities.