HIV/AIDS remains a daunting challenge to Uganda despite the country's incredible efforts expended in stemming the epidemic. HIV prevalence among the adult population (15-49 years) has declined considerably from an estimated 18% in the early 1990s to the current 6.5%. However, over the past five years, HIV prevalence has stagnated and no longer shows a downward tendency. There have been shifts in epidemiological patterns, with new infections now occurring more in married and co-habiting couples than in youth, as was the case a few years ago. Available data and analyses highlight that sexual transmission accounts for 76% of all new infections, followed by mother to child transmission at 22%. Women, urban dwellers and those living in the conflict regions are the most severely affected. Approximately 1.1 million Ugandans are HIV positive, of whom approximately 100,000 are children under the age of 18. Of the adults in married and co-habiting relationships, forty percent of those who are HIV positive have an HIV negative spouse.

Uganda has recently concluded a modes of transmission study which indicates, among other things, that there have been shifts in the risk factors and drivers of the epidemic. The key risk factors now include: multiple concurrent sexual partnerships, discordance and non-disclosure among couples, low condom use, transactional sex, cross-generational sex, and relaxed sexual behaviours due to antiretroviral treatment (ART). The study also pointed to serious flaws in programming by government and its partners as most data generated over the years have not been utilized in designing new prevention interventions that respond to the changes in the epidemic. As a result, interventions remain in discord with realities. Consequently, populations where available evidence indicates that are at a higher than average risk of HIV infection are not served with the kind of services that they need. Uganda's HIV/AIDS response is still encumbered by serious challenges, notably the low coverage of services, especially in the rural areas.

Currently, about 23% of Ugandan's aged 15-49 years know their HIV status; HIV/AIDS care and support services reach less than 50% of those in need while approximately 40% of individuals eligible for treatment are able to access it. In addition, high mortality of economically active adults witnessed over the last two decades has led to several children being orphaned and families economically devastated. There are an estimated 7.5 million orphans and other vulnerable children in Uganda. More than half of them are affected by HIV/AIDS and only 20% are receiving care, which often falls short of the total needs. Uganda is reported to have the highest fertility rate in the world, with population projected to hit 36.8 million in 2015 up from 12.6 million in 1980. The age group 10-24 years constitutes 33% of the entire population implying that there are more people who have to be reached with HIV prevention messages and services besides sexual and reproductive health if Uganda is to contain and manage the epidemic

This activity aims to contribute to the national efforts towards increasing access to quality HIV/AIDS prevention, care and treatment services for individuals, families and communities. It will contribute to the national agenda for HIV prevention with particular emphasis on promoting abstinence for youth and mutual faithfulness for couples. The activity will also improve access to and utilization of quality, comprehensive HIV/AIDS care and treatment services by PLHA, orphans and other vulnerable children as well as their immediate families. HIV/AIDS services will have an integral component of family planning information to increase awareness among HIV positive individuals on the importance of making safe and informed reproductive choices that enhance positive living.

The overall goal of this activity is to build a strong, coordinated and sustainable faith-based HIV/AIDS response in Uganda. To realize this goal, the applicant will be expected to focus on the following:

i. Strengthen the overall faith-based HIV/AIDS response in Uganda.

ii. Facilitate access to and utilization of quality, comprehensive HIV/AIDS prevention, care and treatment services for PLHA and their immediate families.

iii. Strengthen the role of religious leaders in advocacy for HIV/AIDS and reproductive health including Family Planning.

Emphasis shall be placed on accessing services to hitherto underserved regions. The recipient will also be expected to work in partnership with other USG and non-USG supported partners to increase access to other essential services such as preventive care commodities, food assistance and support for income generating activities which play a complementary role in the achievement of program objectives.

Uganda is still haunted by the growing burden of HIV/AIDS, with approximately more than 1 million individuals currently infected. HIV/AIDS care and support has been a critical piece of the overall HIV/AIDS response in Uganda since the mid 1980s. Over the years, care and support competence has grown in Uganda and a lot of models have evolved, using both facility and community based approaches. Over the past five years, access to ART has increased in Uganda, with resources from global initiatives, notably PEPFAR and the Global Fund. This has resulted into remarkable improvement in the quality of life for those infected and affected. However, like other developing countries, Uganda does not expect any significant increase in resources for ART in the indefinite future. This implies that care and support must be re-emphasized with particular focus on interventions that directly impact the health of PLHA. This will serve to keep the vast majority of PLHA healthy, hence minimizing the need for ART.

Since 2006, USAID/Uganda has been in partnership with the Inter-Religious Council of Uganda (IRCU), to expand access to HIV and AIDS care and support services through their network of faith-based health units and NGOs. Through this network, IRCU has played an important role in rolling out care and treatment services. By March 2009, IRCU had enrolled over 50,000 individuals into chronic care through its eighteen partner sites. USAID/Uganda's partnership with IRCU ends in December 2009. USAID/Uganda plans to initiate a follow on program (TBD) that will build upon and further expand the current achievements of IRCU.

The follow-on program (TBD) will continue to deliver care and support services through the network of faith-based health facilities and organizations located in various districts of Uganda. A mix of approaches including facility, community and home based care will be applied. Activities will be targeted at men, women and children living with HIV/AIDS and their immediate families with a key focus on sustaining individuals already enrolled in care to mitigate interruption of services. Services will be targeted at both rural and urban areas in response to the burden of the epidemic as reflected in the national prevalence data. Underserved areas (those with little or no coverage of HIV/AIDS services) will continue to be a key consideration of the program.

The new activity will also continue to build care and support competence among providers, with emphasis on updating service providers on emerging challenges and new approaches to AIDS care and support, strengthening linkages with other PEPFAR and non-PEPFAR activities to maximize synergies, continuous improvements in quality of services as well as establishing and institutionalizing user friendly mechanisms for measuring quality and impact of services. IRCU has initiated partnership with the PEPFAR supported Infectious Diseases Institute (IDI) to ensure quality assurance and capacity maintenance. The follow-on program (TBD) will be required to build upon the existing initiatives by working closely with MOH and the USAID supported Health Care Improvement Project and HIVQAL to introduce continuous quality improvement and monitoring approaches in all its supported facilities. The overall aim is to ensure that services delivered conform to the national and international standards and that they are responsive to client needs. The follow-on program (TBD) will also be expected to continue building the capacity for holistic palliative care within faith-based health centers and NGOs. Special focus will be put on integrating pain and symptom management within the exiting AIDS care and treatment services.

The new activity (TBD) will continue to roll out basic preventive care based on its proven efficacy in warding off opportunistic infections. This will entail procurement and distribution of long lasting insecticide treated mosquito nets (ITNs) to PHA and their immediate families, improving access to safe water commodities as well as prescription of prophylactic cotrimoxazole as a standard practice in care and treatment in accordance with the Ministry of Health (MOH) guidelines and policy. The new activity will be expected to build upon the existing partnership with the CDC supported PACE program to ensure sustained delivery of basic care commodities.

Shared care and support will be emphasized to ensure that PLHA access a wide spectrum of services from multiple sources and settings. To the extent possible, care and support services shall be linked with other HIV/AIDS programs, especially counseling and testing, ART, PMTCT and OVC care. To achieve this, the follow-on program (TBD) will be required to build viable inter and intra collaborative networks within facilities and communities to enable PHA access the full continuum of care. In addition, the follow-on program will continue working to further build the skills of religious leaders and harness their respected positions and connectivity with communities in the delivery of home based care, adherence monitoring and referral. Using the network model approach, religious leaders, PLHA and other volunteers will be supported to consolidate their roles in mobilizing and referring individuals for facility based services while at the same delivering intermediate care and adherence monitoring. Feedback mechanisms, initiated under the ending IRCU program will be strengthened and consolidated to facilitate communication and information on PLHA receiving care from multiple partners. This will improve the success and efficacy of referrals and shared care.

With the support of the Chemonics ACE program, IRCU has established a robust monitoring and evaluation systems that captures data on both qualitative and quantitative progress of activities. The new activity will build upon and further strengthen this system by continuously reviewing its relevance and where necessary updating it to ensure that it is in consonance with the current services being delivered. Short-term operational research studies will be undertaken where necessary to provide new evidence on the efficacy of the existing approaches and services.

By the end of FY 2010, the follow-on program (TBD) is anticipated to have provided care and support to 70,000 people living with HIV/AIDS. 100 health workers will have been trained in HIV and AIDS care and treatment, with the aim of ensuring that their knowledge and skills are in currency with modern approaches and practices. In addition, the follow on program will train 2000 community and religious leaders in basic HIV and AIDS care and treatment to serve as community based HIV and AIDS resource persons and to link facilities with communities.

Historically, faith-based organizations were the forerunners in the delivery of health and social services in Uganda. They have since established extensive health and social networks reaching the lowest point in communities. These networks provide an excellent mechanism for rolling out health and social services.

Since 2006, USAID/Uganda has been in partnership with the Inter-Religious Council of Uganda (IRCU), a consortium of the five main traditional religions in Uganda to expand access to HIV and AIDS services through their network of faith-based health units and NGOs. IRCU has been working through its network of community based organizations to deliver a range of services focusing on care and protection of orphans and other vulnerable children (OVC) and their immediate families. Currently IRCU is providing care and support to 11,373 OVC. 4,885 caregivers have been trained in OVC care and micro-enterprise development to reduce economic vulnerability of households and to improve their capacity to offer sustainable care.

USAID/Uganda's partnership with IRCU ends in December 2009. USAID/Uganda plans to initiate a follow on program to build upon and further expand the current achievements of IRCU. The primary priority for the follow-on program will be to transition the OVC program from an emergency to a development outlook by crafting interventions that engender community and household capacity to effectively meet OVC needs in a sustainable manner. While doing this, the follow-on program will also strive to ensure that OVC enrolled for basic education continue to receive services since this is the foundation for their future growth and survival. This will entail building the capacity of teachers to create conducive environments within schools that support and encourage OVC to remain in school. Key strategies include training teachers in basic counseling to be able to detect and address emotional needs of OVC, as well as negotiating flexible regimes for payment of school dues, uniforms and other scholastic materials. Vocational training, sourced through community based schools and apprenticeship arrangements will also continue to be prioritized as a way to fast track the OVC capacity to earn a living.

Other key OVC interventions including health care, psychosocial support, as well as HIV prevention education will continue to be prioritized under the new program. Economic strengthening of caretaker families has also been embarked on, with activities focusing on training in micro-enterprise development and linking groups of caregivers, mainly widows to local markets for their produce. This strategy of linking groups of caretakers to markets has yielded promising results, both in terms of stimulating production of indigenous crops and ultimately reducing poverty and household vulnerability. Psychosocial support and legal protection for orphans and caregivers remain strongly felt needs but least addressed. The follow-on program will work to ensure that psychosocial care becomes a key and integral component of OVC care. Children and their caregivers shall be provided opportunities and trusting environments where they engage in frank discussions about HIV and mutually agree upon plans for the future. The program will continue to emphasize legal and child protection by training caregivers and orphans in succession issues, including writing and discussing of wills at family level. This will also entail training the community on the basic child protection laws and rights in order to make child protection a shared responsibility. Also the follow-on program shall identify community based sources of psychosocial care and child protection to which OVC and their caregivers can turn in case of distress. These include among others, community development officers at sub-county levels, religious leaders, Probation and Welfare Officers, as well as local leaders mandated to oversee children affairs.

The program shall educate OVC caregivers on the availability of PEPFAR care and treatment services within their localities so that they can refer or take their OVC for health care when in need. Using simple job cards, program staff and community level volunteers will undertake routine nutritional assessment of OVC and where OVC are found to be malnourished, they will be referred to other PEPFAR support programs that address nutrition, such as the NuLife program. The program staff will also counsel and educate caregivers will on nutrition, especially on aspects of dietary diversity using locally grown foods.

The follow-on program will adopt a holistic and family based approach to OVC care. This will entail assessing the entire household to determine potential barriers to normal growth and development of children and develop strategies for addressing them. Since most OVC live within households that are vulnerable, picking one OVC for assistance and living others results in stigma, hatred and tension within the family and ultimately compromises program outcomes. Therefore, the family approach will emphasize targeting of care at all eligible OVC in the household. With level funded budgets, it is unrealistic to expect significant expansion of OVC programs under this new activity. Therefore, it is anticipated that the new program will continue to offer care and support to 11, 373 OVC and their households while striving to creatively initiate creative approaches that engender quality and sustainability.

In Uganda faith-based organizations (FBOs) have the most extensive health and community infrastructure and networks, and consequently they are the major providers of health care. This makes them a viable mechanism for rapidly expanding quality health services to the lowest point in the community. Using their infrastructure and networks, FBOs have been and still remain a critical part of the Ugandan HIV/AIDS response.

Since 2006, USAID/Uganda has been in partnership with the Inter-Religious Council of Uganda (IRCU), to expand access to HIV and AIDS treatment services through their network of faith-based health units and NGOs. Through this network, IRCU has played an important role in rolling out care and treatment services. As at March 2009, after two years of initiation of treatment services, IRCU had enrolled 6,167 individuals on treatment through thirteen sites and is poised to reach over 7,200 individuals by December 2009.

USAID/Uganda's partnership with IRCU ends in December 2009. Based on the proven viability of the faith-based networks in quickly expanding access to services, USAID/Uganda plans to initiate a follow on program (TBD) to build upon and further expand the current achievements of IRCU.

Under the follow-on program (TBD) key priority will be to sustain the individuals already enrolled on treatment to ensure that services are not interrupted both in flow and quality. With no guarantee for significant increases in ART resources, the program will be tasked to review the treatment practices formerly used by IRCU with the aim of coming with creative approaches that enhance cost-efficiency and rational use of resources to sustain services. Recent research findings discount the efficacy of CD4 counts in on-going disease monitoring, signaling the need to adopt new monitoring protocols that enhance treatment success. Although hitherto minimal, resistance to first line treatment is rising, with an average about 2%-5% of all patients failing across all the sites. Despite its shortcomings, CD4 monitoring continues to be the most cost effective and most commonly used approach for monitoring treatment outcomes. Renal and liver function tests are also used prior to initiation of ART and during monitoring of drug toxicity. Viral load, which is currently the most reliable and confirmatory approach to disease monitoring remains largely inaccessible due to its prohibitive cost. These factors pose new challenges to the treatment program for which preparedness has to be built in order to be able to detect early warning indicators for treatment failure. Therefore the new program (TBD) will put emphasis on building and improving health worker skills to monitor and manage ART drug resistance through in-service training and mentorship. Exchange programs will also be facilitated to allow short-term placements and internships for health workers within the larger national PEPFAR supported treatment programs such as JCRC, IDI and TASO. This will provide opportunities for cross-sharing of expertise and ultimately standardization of treatment practices. The new program will also be expected to keep monitoring new developments and to engage actively with MOH and other stakeholders as new disease monitoring options are discussed.

With support from the Clinton Foundation, access to reagents for DNA/PCR tests has improved greatly ultimately improving early infant diagnosis. DNA/PCR is largely used for early infant diagnosis, but use of these tests for on-going disease monitoring is limited due to high costs. Based on CD4 tests, current treatment outcomes look impressive with majority of individuals on treatment scoring above 400 cells/cubic mm on average. Treatment adherence has been the biggest single factor contributing to the treatment success. The adherence approaches currently in use include nomination and training of adherence partners/supporters at the time of treatment initiation, routine pill counts, and home visits by community volunteers. Provider organizations have also established monthly outreach clinics in communities where drug refills, counseling and treatment of opportunistic infections is done. These approaches are paying off and currently adherence is estimated at over 95% across all IRCU sites. For those failing, poor adherence has been attributed largely to lack of food to support therapy, migration which takes individuals away from treatment sites and in few cases failure to disclose HIV status to partners. The new program is expected to build upon and consulate these approaches to further strengthen adherence with particular emphasis on building networks to enable clients access other wrap around services, notably food. The partner will also strengthen referral systems across the various PEPFAR and non-PEPFAR treatment sites to enable individuals to remain on treatment even after change of location.

Treatment services will continue to target both men and women. Currently women constitute about 60% of the total number of individuals receiving treatment. The new activity will continue to build on the existing initiatives to improve treatment seeking behavior for men. IRCU has been providing a broad spectrum of treatment services. Besides ART, other supportive services include relentless diagnosis, treatment and prophylaxis for opportunistic infections. TB screening and diagnosis is steadily gaining ground as a routine care practice within all IRCU sites. All HIV+ individuals attending clinics are screened for TB symptoms using a job card with a set of questions. Those suspected to be exposed are taken through laboratory investigations. All TB-positive individuals are treated. The follow-on program (TBD) will be expected to continue building the capacity for and expanding access to holistic treatment services.

It is anticipated that by the end of FY 2010, the follow-on program (TBD) will have enrolled 7,200 individuals on treatment. With a level funded budget, further recruitment of new individuals will have to be considered carefully and will be done only when there is assurance of resources for continued care. A total of 100 health workers will be trained in HIV and AIDS treatment, especially in the new disease monitoring protocols and management of second line therapy. In addition, the follow on program will train 1000 community and religious leaders in basic HIV and AIDS treatment to serve as HIV and AIDS resource persons and to link facilities with communities.

Ensuring a steady and demand sensitive system for supplying ARVs and other supplies will be essential for the successful implementation of this activity and achievement of targets. IRCU is working in partnership with Supply Chain Management System (SCMS) to procure ARVs as well as other drugs essential in managing critical OIs. The follow-on program (TBD) will be expected to build upon this partnership with SCMS to enhance steady and timely procurement of drugs. The program will also be required to partner with the new USAID funded SURE program to further strengthen the logistics management systems both for itself and its partners.

Quality assurance is key to the success of the treatment services. IRCU has initiated partnership with IDI to ensure quality assurance and capacity maintenance. The follow-on program (TBD) will be required to build upon the existing initiatives by working closely with MOH and the USAID supported Health Care Improvement Project and HIVQAL to introduce continuous quality improvement and monitoring approaches in all its supported facilities. The overall aim is to ensure that services delivered conform to the national and international standards and that they are responsive to client needs. A key focus will be to ensure that criteria for ART eligibility, prescription practices and adherence monitoring protocols are all in line with the national policy.

To the extent possible, treatment services shall be linked with other HIV/AIDS programs, especially counseling and testing, PMTCT and OVC care. To achieve this, the follow-on program (TBD) will be required to build viable inter and intra collaborative networks within facilities and communities to enable PHA access the full continuum of care.

Over the past three years, USAID/Uganda has been supporting the Inter-Religious Council of Uganda (IRCU), a consortium of the five main traditional religions in Uganda to expand access to HIV and AIDS services through their network of faith-based health units and NGOs. This network has been of impeccable utility is rapidly expanding HIV/AIDS services including counseling and testing. In 2008 IRCU counseled and tested 110, 000 individuals.

USAID/Uganda's partnership with IRCU ends in December 2009. USAID/Uganda plans to initiate a new program (TBD) to build upon the networks and structures that IRCU has built and further expand access to counseling and testing. Activities will be primarily targeted at youth in and out of school and adult men and women, particularly those living in marriage and cohabiting relationships. In Uganda HIV incidence is reported to occur mostly among married couples, mainly as a result of multiple concurrent partnerships, but also due to sero-discordance and poor partner disclosure. Therefore couple testing and partner disclosure will be a key priority in programming counseling and testing services. The follow-on program is expected to come up with more creative ways, particularly in the area of strengthening couple communication to enhance partner counseling and testing and disclosure. The program will also extend services to reach other high risk and vulnerable groups. IRCU has trained several community level religious leaders in basic HIV/AIDS prevention and care. The leaders have played a major role in mobilizing and referring individuals for counseling and testing. The new program will be expected to build upon and consolidate this imitative to build strong community based resources for provision of HIV/AIDS intermediate care and referral.

IRCU has been delivering counseling and testing using two main approaches namely, voluntary (client-initiated) and routine (provider-initiated) testing and counseling. Voluntary counseling and testing has been undertaken using both facility and community based approaches. Given the high opportunity cost of seeking medical care in Uganda, facility based delivery of counseling and testing services have been found to severely limit access. The follow-on program will emphasize and devote substantial resources in supporting the outreach model of counseling and testing. Priority will be given to areas located further away from health units, targeting populations such as house wives, taxi drivers, fishermen, subsistence farmers, and pastoral communities whose activities entail a high opportunity cost of seeking facility based care services. Routine, opt-out counseling and testing will also continue to be consolidated as an integral component of health care within all supported health facilities. This will entail further building human resource capacity of health facilities through initiatives like task shifting of basic CT roles such as pretest counseling, phlebotomy, records management and referral to paraprofessionals and volunteers.

IRCU has also initiated counseling and testing within TB care settings. This will require further focus under the new program, particularly training and orientation of health workers in TB facilities to integrate counseling and testing as a routine practice within TB care. The follow on program will also be required to continue consolidating and streamlining the existing referral systems between HCT, care, treatment and PMTCT units to ensure access to comprehensive HIV/AIDS services for its clients.

All the IRCU supported health units that offer counseling and testing also receive support from Ministry of Health with support from the Global Fund. To maximize resources, the follow on program will only provide counseling and testing at these sites during periods when MOH supplies have stocked out. The National Counseling and Testing Policy is based on a three-tier algorithm using Determine® to screen for HIV infection, Statpac® to confirm infection and Unigold® as a tie breaker. Unless modified, the follow-on program will be required to conduct counseling and testing in line with this policy. In case of stock outs of testing kits from MOH, the program will use PEPFAR resources to procure buffer stocks for MOH sites to enable facilities deliver services in a reliable manner. Besides aligning the services to the national policy, the follow-on program will be required to ensure that counseling and testing services offered at its facilities pass for quality on both clinical and behavioral aspects. The new program will be required to institute or further strengthen the existing mechanisms for monitoring of quality across all counseling and testing sites.

The follow on program will be required to ensure that counseling and testing services offered at all supported sites are linked to other HIV and AIDS services, particularly PMTCT, ART and OVC services. Based on the achievements registered by IRCU, it is expected that by the end of FY2010 the new program will have counseled and tested approximately 130,000 by intensifying cost-effective approaches such as outreaches.

An estimated 200,000 children are living with HIV in Uganda and another 25,000 get infected annually. Although the need for pediatric care is enormous, human resource constraints, poor accessibility to services and limited pediatric care skills have in combination limited wide-scale accessibility to pediatric AIDS care. Expanding access to pediatric and adolescent HIV and AIDS care is outlined as a critical priority in the National Strategic Plan.

Since 2006, USAID/Uganda has been in partnership with the Inter-Religious Council of Uganda (IRCU), which is a consortium of the five main traditional religions in Uganda to expand access to HIV and AIDS care and treatment services through their network of faith-based health units and NGOs. IRCU has taken a leadership role in expanding access to pediatric care. Through its partnership with the Infectious Disease Institute (IDI) and Mildmay International, both PEPFAR partners, IRCU has trained health workers in its partner sites in comprehensive pediatric HIV care including pediatric counseling skills. USAID/Uganda's partnership with IRCU ends in December 2009. Based on the proven viability of the faith-based networks in quickly expanding access to services, USAID/Uganda plans to initiate a follow on program to build upon and further expand the current achievements of IRCU.

One of the critical roles of the follow-on program will be to build upon and consolidate the achievements that IRCU has attained in rolling out pediatric care. Priority activities will, among others, include continuing to build capacity of health workers in pediatric care and update them on emerging challenges and new approaches to management of HIV and AIDS care among children. Many parents and caregivers rarely discuss HIV infection with children under their care. As a result, many HIV infected children live in situations of uncertainty and often exhibit signs of serious depression. To address these challenges, the follow on program will emphasize building skills in pediatric counseling among health workers to be able to engage children and their caregivers in ongoing discussion of HIV and AIDS, and the implications of HIV infection for their future. The program will offer further training to clinical staff to standardize prescription practices and develop job aides for health workers to ensure that services are of uniform quality across all sites and that they conform to national and international standards.

In the context where majority of the children are under the care of poor widows and grandparents, the threat of malnutrition is real. Efforts will be made to routinely assess children for malnutrition and if symptoms occur, therapeutic foods will be provided through linkages with other PEPFAR partners such as the USAID funded NuLife. Caregivers including parents and guardians will also be counseled on infant and child nutrition. Emphasis will be made to ensure that all children born to HIV+ parent(s) access counseling and testing, using both PCR and ELISA technology as determined by the age of the children. A total of 100 health workers will be trained in pediatric HIV and AIDS care, with the aim of ensuring that their knowledge and skills are in currency with modern approaches and practices. Quality assurance is key to the success of the care and treatment programs. IRCU has initiated partnership with IDI to ensure quality assurance and capacity maintenance. The follow-on program (TBD) will be required to build upon the existing initiatives by working closely with MOH and the USAID supported Health Care Improvement Project and HIVQAL to introduce continuous quality improvement and monitoring approaches in all its supported facilities. The overall aim is to ensure that services delivered conform to the national and international standards and that they are responsive to client needs.

With a total of 58,000 individuals enrolled in chronic care, it is anticipated that the new program will provide care to 11,000 children in FY2010.

200,000 children are living with HIV in Uganda and another 25,000 get infected annually. However, access to pediatric treatment is still very limited, particularly due to a dearth of diagnostic and case management skills among health workers, stigma among parents, and the high opportunity cost of seeking services, especially in rural areas. Currently 11,000 children are accessing treatment, representing only 22% of all those in need. Expanding access to pediatric and adolescent HIV and AIDS care and treatment is outlined as a critical priority in the National Strategic Plan.

Since 2006, USAID/Uganda has been in partnership with the Inter-Religious Council of Uganda (IRCU), which is a consortium of the five main traditional religions in Uganda to expand access to HIV and AIDS care and treatment services through their network of faith-based health units and NGOs. Through this network, IRCU has played an important role in rolling out care and treatment services. As at March 2008, it had enrolled 23,746 individuals into care and 2,433 on treatment through its eighteen partner sites. Using FY 2007 and FY 2008 resources, IRCU has taken a leadership role in expanding access to pediatric ART beyond the major urban areas. Through its partnership with the Infectious Disease Institute (IDI) and Mildmay International, both PEPFAR partners, IRCU has trained health workers in its partner sites in comprehensive pediatric HIV care including pediatric counseling skills. IRCU is currently setting up systems at its sites to enhance pediatric care, in particular ART, by initiating HIV testing for all exposed infants. USAID/Uganda's partnership with IRCU ends in June 2009. Based on the proven viability of the faith-based networks in quickly expanding access to services, USAID/Uganda plans to initiate a follow on program to build upon and further expand the current achievements of IRCU.

One of the critical roles of the follow-on program will be to build upon and consolidate the achievements that IRCU has attained in rolling out pediatric care. Priority activities will, among others, include continuing to build capacity of health workers in pediatric care and update them on emerging challenges and new approaches to management of HIV and AIDS care among children. Many parents and caregivers rarely discuss HIV infection with children under their care. As a result, many HIV infected children live in situations of uncertainty and often exhibit signs of serious depression. To address these challenges, the follow on program will emphasize building skills in pediatric counseling among health workers to be able to engage children and their caregivers in ongoing discussion of HIV and AIDS, and the implications of HIV infection for their future. The program will offer further training to clinical staff to standardize prescription practices and develop job aides for health workers to ensure that services are of uniform quality across all sites and that they conform to national and international standards. Children will receive quality HIV medical care which includes full access to ARV therapy as well as prophylaxis and treatment of opportunistic infections to reverse disease progression. The program will also put emphasis on follow up of children enrolled in the care and treatment program. This will involve regular periodic CD4 testing to determine ART eligibility in accordance with the national standards. Children will also be monitored and assessed for other health and growth indicators.

In the context where majority of the children are under the care of poor widows and grandparents, the threat of malnutrition is real. Efforts will be made to routinely assess children for malnutrition and if symptoms occur, therapeutic foods will be provided through linkages with other PEPFAR partners such as the USAID funded NuLife. Caregivers including parents and guardians will also be counseled on infant and child nutrition. The program will undertake home visits to be able to assess the living environment of enrolled children initiated on treatment, anticipate potential barriers to treatment adherence and hence develop a supportive foundation and individualized care plan for each child. By the end of FY2009, the follow-on program (TBD) will have provided care to 2,000 children living with HIV and AIDS of whom 200 will be on treatment. In addition, a total of 100 health workers will be trained in pediatric HIV and AIDS care and treatment, with the aim of ensuring that their knowledge and skills are in currency with modern approaches and practices. Quality assurance is key to the success of the care and treatment programs. IRCU has initiated partnership with IDI to ensure quality assurance and capacity maintenance. The follow-on program (TBD) will be required to build upon the existing initiatives by working closely with MOH and the USAID supported Health Care Improvement Project and HIVQAL to introduce continuous quality improvement and monitoring approaches in all its supported facilities. The overall aim is to ensure that services delivered conform to the national and international standards and that they are responsive to client needs. A key focus will be to ensure that criteria for ART eligibility, prescription practices and adherence monitoring protocols are all in line with the national policy.

With a total of 7,200 individuals enrolled on treatment, it is anticipated that the new program will treat 1,200 children in FY2010.

Uganda has recently concluded modes of transmission study which indicates, among other things, that there have been shifts in the risk factors and drivers of the epidemic. The key risk factors now include: multiple concurrent sexual partnerships, discordance and non-disclosure among couples, low condom use, transactional sex, cross-generational sex, and relaxed sexual behaviors due to antiretroviral treatment (ART). The study also pointed to serious flaws in programming by government and its partners as most data generated over the years have not been utilized in designing new prevention interventions that respond to the changes in the epidemic. Over the past three years, IRCU has implemented a variety of HIV prevention interventions focusing on promotion of abstinence and faithfulness through sixteen community based faith-based organizations. In 2008, IRCU reached 529,000 individuals with HIV prevention messages, of whom 343,000 were youth who received abstinence only interventions. A total of 2,070 individuals were trained in activities that promote abstinence and/or being faithful.

USAID/Uganda's partnership with IRCU ends in December 2009. USAID/Uganda plans to initiate a new program (TBD) that will build upon the achievements of IRCU to further expand HIV prevention through interventions that promote abstinence and mutual faithfulness. Abstinence programs will be targeted at youth aged 13-24 years, both in and out of school. The implementing partner will use different strategies to reach the youth, depending on their context and perceived vulnerability. Faithfulness interventions will target adult men and women living in both marriage and cohabiting relationships. Activities will aim to promote behaviors that enhance mutual partner communication, disclosure and reduction in concurrent partnerships.

With regard to youth in school, innovative approaches shall be used to create a free and supportive environment in schools to allow children to seek and access age appropriate information on health, HIV/AIDS and sexuality. This will be achieved through training teachers in HIV and AIDS communication to be able to give accurate information as well as realistic options to children. Other creative approaches such as use of anonymous opinion and question boxes will be applied to collect issues and challenges that children face. Such issues shall then be discussed with children in age-segmented sessions. In addition, panel discussions will be held with youth in school in which students will be allowed opportunities for open interaction with experts on issues of HIV/AIDS. In addressing these issues, the moderators will blend scientific facts with religious teachings. The program will continue to strengthen the role of students' bodies such as Anti AIDS Clubs and Straight Talk Clubs to act as channels for HIV/AIDS education. These clubs shall be encouraged to organize and lead discussions on key issues identified by the young people themselves.

Regarding youth out of school, the new program (TBD) will also continue to address HIV prevention among high risk youth groups especially street children as well as youth engaged in informal sector occupations such as taxi drivers and touts, bar maids and housekeepers. The program will build upon and expand initiatives begun by IRCU such as youth fellowships, outreach and revival ministries as well as targeted workshops to reach the youth. Through the faith-based youth ministries, one on one, and where appropriate, small group sessions will be held with youth to address high risk behaviors such as alcohol and drug abuse that increase vulnerability to HIV infection. Through weekly sermons, religious leaders will continue to implore and encourage youth to access HIV counseling and testing and to internalize and use it as a precondition for entering a marriage relationship.

Mutual faithfulness interventions will be predominantly implemented through the religious structures, including the Mothers/Fathers Union, Women Catholic Guild, the Muslim Women League and weekly cell meetings. These structures provide opportunities for constant and continuous dialogue on HIV/AIDS, relationships, reproductive health and sexuality. Mutual accountability, self efficacy and sound judgment will be emphasized in these meetings. Individuals with problems shall be counseled, either individually or through group therapy. The program will work to integrate HIV/AIDS prevention as a key issue for discussion into these structures. HIV/AIDS information and counseling will also be delivered in a faith-based context, by complementing scientific facts with relevant scriptures from the religious books.

Where necessary, the structures will be facilitated to mobilize more members in the community in order to expand attendance and hence coverage. Faithfulness in marriage will also continue to be addressed through other religious gatherings including weekly prayer sermons, weddings and funerals.

The follow on program will continue to build the capacity of religious leaders at community level to enable them to deliver accurate HIV/AIDS information and integrate HIV preventions in their routine clerical duties. By the end of FY 2010, the new program (TBD) is expected to have reached 780,000 individuals with HIV prevention information, 400,000 of whom will be youth.

Approximately, 200,000 children are living with HIV in Uganda and another 25,000 get infected annually. Peri-natal transmission remains the single most significant cause of HIV infection among children. Uganda is among the countries in Sub-Saharan Africa with the highest fertility rates. With HIV prevalence equally high, HIV transmission among children is bound to continue on the rise unless interventions to prevent mother to child transmission are scaled up. Prevention of mother to child transmission interventions began in Uganda in the year 2000 on a pilot basis. Early success of the pilot initiative resulted into wide scale implementation and development of supportive policy and guidelines. Currently PMTC services are available in over 500 health facilities and over half a million women have benefitted from the services.

Since 2006, USAID/Uganda has been in partnership with the Inter-Religious Council of Uganda (IRCU), which is a consortium of the five main traditional religions in Uganda to expand access to HIV and AIDS care and treatment services through their network of faith-based health units and NGOs. PMTCT was one of the interventions under this program and activities focused on mobilization of rural women to access services as well as creating a supporting environment at household and community level for women seeking these services. USAID/Uganda's partnership with IRCU ends in December 2009. Based on the proven viability of the faith-based networks in quickly expanding access to services, USAID/Uganda plans to initiate a follow on program to build upon and further expand the current achievements of IRCU.

The new program anticipated to be awarded by December 2009 will work to roll out comprehensive PMTCT services in faith-based facilities. The new activity will continue intensifying advocacy for PMCTC at community level, particularly strengthening the role of men in the program. This will involve provision of incentives such as free mosquito nets and delivery kits to mothers in order to encourage them to seek antenatal and post-natal services. Routine, opt-out HIV counseling and testing will be accessed to all pregnant women attending antenatal services. Those found HIV+ will be assessed for HAART eligibility using CD4 count or clinical staging in facilities where laboratory services are underdeveloped. In line with the national policy, mothers with CD4 counts above 350 will be given the combined HIV prophylaxis regimen and those with CD4 counts below 350 will be initiated on HAART.

IRCU had initiated partnership with the Joint Clinical Research Center through which it outsourced Early Infant Diagnosis (EID) services. The new program will build upon this partnership to facilitate timely initiation of treatment for children. The linkages between PMTCT and ART will also be further strengthened through provider training, better referral management and minimizing bottlenecks such as stigma and bureaucracies that encumber entry of clients into new service arenas. The new activity will continue to provide PMTCT as a preventive approach to save the unborn child from HIV infection, and not a solution for having an HIV negative baby even when the mother's HIV status is known. Therefore, reproductive health, and in particular, family planning will be a strong component of PMTCT under the new program. The activity will link with the new USAID supported STRIDES program to ensure that family planning services and contraceptives are available and consistent, especially the female controlled devices that may not require engagement of an unwilling partner.

Efforts will be made to routinely assess children for malnutrition and if symptoms occur, therapeutic foods will be provided through linkages with other PEPFAR partners such as the USAID funded NuLife. Caregivers including parents and guardians will also be counseled on infant and young child nutrition.

Quality assurance is key to the success of the care and treatment programs. The new program will build upon the existing partnerships with programs such as IRCU has initiated partnership with IDI to ensure quality assurance and capacity maintenance. The follow-on program (TBD) will be required to build upon the existing initiatives by working closely with MOH and the USAID supported Health Care Improvement Project and HIVQAL to introduce continuous quality improvement and monitoring approaches in all its supported facilities. The overall aim is to ensure that services delivered conform to the national and international standards and that they are responsive to client needs.

By the end of FY2009, the follow-on program (TBD) will have provided PMTCT services to 1,000 women. In addition, a total of 100 health workers will be trained in PMTCT with the aim of ensuring that their knowledge and skills are in currency with modern approaches and practices.

Efficient laboratory services including HIV counseling and testing as well as monitoring of individuals on care and treatment remains at the helm of an effective HIV/AIDS program. However, access to laboratory services still remains a challenge, especially to individuals living in rural areas. In many of the rural areas in Uganda, diagnostic services are deplorable. Health facilities, especially those at level III and below lack laboratories and where they exist, there are acute shortages of staff, equipment and/or reagents. Despite these limitations, these facilities serve the largest number of people, given that they the most easily accessible.

Since 2006, USAID/Uganda has been in partnership with the Inter-Religious Council of Uganda (IRCU), which is a consortium of the five main traditional religions in Uganda to expand access to HIV and AIDS care and treatment services through their network of faith-based health units and NGOs. Improvement in laboratory infrastructure has been an integral component of this program. Over the past two years, IRCU has worked with faith based 18 health facilities to strengthen the existing laboratory infrastructure to enable them carry out basic tests that enhance HIV/AIDS care and treatment. This included procuring basic laboratory equipment, limited refurbishment of facilities, training of laboratory staff and reinforcing the human resource needed to carry out the laboratory tests. Of these 18 labs, 12 are hospital labs while the remaining six are lower health center labs

USAID/Uganda's partnership with IRCU ends in December 2009. USAID/Uganda plans to initiate a follow on program (TBD) to build upon and further expand the current achievements of IRCU. One of the primary priorities for the follow-on program will be to further strengthen clinical investigative capability among the supported faith-based partners and to further improve quality assurance mechanisms to enhance state of the art service delivery.

The follow on program will further work with the faith-based facilities to expand the scope of their laboratory services to cover organ function tests as well. IRCU currently has 58,000 clients enrolled in chronic care all of whom will require routine medical tests to better inform care and treatment choices. In addition, they will need routine baseline CD4 tests; lymphocyte and hemoglobin level counts in order to effectively monitor their eligibility for ART. This is essential in order to ensure that individuals initiate ART at the most optimum time. Also over 6,000 patients currently enrolled on ART will continue to have quarterly hemoglobin and lymphocyte estimates, and where possible, viral load tests. The new program (TBD) will be required to ensure that there is adequate preparedness for this growing need by improving the capacity of the existing laboratories and training laboratory staff to ensure that they keep updated on the newly emerging laboratory practices and protocols. Networking with other partners will be prioritized to rationalize access and use of laboratory services across and among the various PEPFAR partners.

Currently all IRCU supported laboratories are accredited by the Ministry of Health and meet the minimum required standards in terms of space and equipment. However, most of them are limited in capacity and can only perform basic microscopy and hematology tests including hemoglobin estimations and total lymphocyte counts, and are unable to carry out more advanced tests like CD4 counts and biochemistry tests although these tests are a key ingredient to an efficient ART service. Therefore, IRCU entered into a Memorandum of Understanding with JCRC to provide laboratory services for advanced disease monitoring from its regional centers of excellence. Under this arrangement, most IRCU supported facilities with proximal JCRC centers of excellence access services, particularly specific tests like full blood counts, organ biochemistry, CD4 cell counts, Polymerase Chain Reaction (PCR) for infant HIV testing and resistance testing. The follow on program will be required to further consolidate this partnership. However, as access and utilization of ART services continues to grow, it is realistic to expect that JCRC regional laboratories will be overwhelmed. Therefore, the follow-on program will explore establishment of auxiliary laboratories building upon the investments already made by IRCU in its faith-based health units, basing on factors like distance between JRC regional labs and the faith-based partners as well as the workload, handling capacity and efficiency of the existing JCRC regional labs.

The follow on program will be expected to work with the Ministry of Health, Program for Supply Chain Management Systems (SCMS) and Joint Clinical Research Centre (JCRC) to train laboratory staff in ordering and forecasting of laboratory reagents and other relevant inputs to ensure a reliable supply; HCT and other HIV/ART monitoring tests and finally good lab practices. The program will undertake routine reliability and quality assurance checks to ensure that lab services conform to nationally acceptable standards. The laboratory activities are coordinated by the Ministry of Health through the Central Public Health Laboratory which will provide quality control, guidelines and where necessary, technical assistance.

With level funded budgets, the program does not anticipate to expand the current care and treatment program beyond the eighteen sites. Therefore, activities will focus on consolidation of services in these sites, particularly in the ears of quality and building technical capacity for the existing laboratory staff.

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 in HIV positive people. It is estimated that 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. Estimated Multidrug resistant -TB (MDR-TB) 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 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%. In 2008, 43,493 TB patients were notified to the Ministry of health National TB/Leprosy Program (NTLP), 22,561 of these were sputum smear positive.

Since 2006, USAID/Uganda has been in partnership with the Inter-Religious Council of Uganda (IRCU), which is a consortium of the five main traditional religions in Uganda to expand access to HIV and AIDS care and treatment services through their network of faith-based health units and NGOs. Over the past three years, IRCU has established HIV/AIDS care and treatment programs in 18 faith-based health units and four non-governmental organizations. Through these facilities, IRCU has embraced the national policy to integrate TB into HIV/AIDS care. Initiatives undertaken in this endeavor include routine screening of all PLHA for any leading TB symptoms, training of health workers in TB management, strengthening of TB laboratories and quality assurance and promoting TB infection control in health care settings. By March 2009, of the 20 palliative care sites supported by IRCU, 13 carried out TB diagnosis and treatment while others were yet to be accredited by MOH with support from IRCU. A total of 1221 (672 males and 549 females) received counseling and testing in TB settings and got their results while 1,297 (675 male and 622 female) individuals were reported on TB treatment.

USAID/Uganda's partnership with IRCU ends in December 2009. USAID/Uganda plans to initiate a follow-on program to build upon and further expand the current achievements of IRCU. The follow-on program will aim to further strengthen the existing TB/HIV integration initiatives with a key focus on further training of health workers to orient their attitudes and practices towards integrated HIV/TB care and further improvement in infection control procedures.

The follow-on program will continue to work to ensure that routine TB screening of HIV-infected clients and adherence counseling and support for both TB and HIV/AIDS clients are internalized across all health workers. The program will also continue to improve TB diagnostic capacity at its partner health units by further strengthening laboratory infrastructure, provision of key laboratory equipment and reagents as well as training laboratory staff. More importantly the follow-on program will strive to ensure that all TB microscopy equipment and protocols are routinely tested for proficiency in order to sustain the validity of the test results.

Integrating TB care within an immune compromised population requires a high degree of care to minimize cross infection. Therefore, the follow-on program will strive to ensure that adequate infection control procedures are in place within the partner facilities health facilities to prevent TB transmission among PHA and health workers. This will entail expansion of and improvements in ventilation within waiting areas, training health workers in effective waste disposal procedures and counseling PLHA to be part of the infection control agenda.

Albeit a few challenges, IRCU has initiated counseling and testing within TB clinics at all its facilities. Initially, only TB-confirmed individuals were offered counseling and testing, wherefore, the follow-on program will build upon and consolidate this initiative by introducing routine counseling and testing for all individuals attending TB clinics.

In FY 2010, the follow-on program will be expected to provide counseling and testing to at least 80% of registered TB patients, provide co-trimoxazole to > 80% of TB/HIV co-infected clients and provide ARVs to at least 40% of TB/HIV co infected clients. The program will also carry out TB screening to at least 80% of patients in HIV care and treatment IRCU supported sites. Follow up of individuals on treatment is great factor in treatment success. Prior to initiation on treatment, individuals will be required to report with an adherence monitor who will be counseled on the importance of adherence in addition to infection control in the household. The program will also invoke the community based religious leaders trained by IRCU to periodically visit the patients and report progress on adherence. Monthly drug refills will be followed as a mechanism for treatment monitoring.

The follow-on program will continue to coordinate and collaborate with other PEPFAR partners implementing TB and TB/HIV activities. The program will also work with National TB and Leprosy program to provide standardized TB/HIV recording and reporting, streamline TB diagnostic tools and dissemination of TB related IEC materials. The NTLP will also be expected to provide on-going support supervision and maintain oversight on the quality of TB care and efforts towards TB/HIV integration.