NuLife Food and Nutrition Interventions for Uganda is three-year project implemented by University Research Co., LLC (URC), in partnership with Save the Children and ACDI/VOCA. It is funded through a USAID Cooperative Agreement under PEPFAR. The program goal is to improve the quality of life of PLHIV and to increase use of and adherence to antiretrovirals (ARVs), as well as to improve the effectiveness of treatment through food and nutrition interventions that complements antiretroviral therapy. The program builds on URC's work in Uganda under the Health Care Improvement Project (HCI), to support 54 health facilities scattered across 51 districts through the Ministry of Health and USG partners. The primary beneficiaries for the program are: PLHIV including adults and children (aged below 18 years) in ART and care programs; HIV-positive pregnant & lactating women/mothers with children less than six months; and Orphans and Vulnerable Children (OVC) irrespective of the Sero status.

The program's three primary objectives include: 1) provision of technical support to the MOH, USG partners to integrate food and nutrition interventions in HIV care and treatment programs; 2) development of a high quality, low-cost, nationally acceptable Ready to Use Therapeutic Food (RUTF) made from locally available ingredients and 3) the establishment of a supply chain system for the delivery of RUTF to participating health facilities.

To meet these objectives, NuLife uses the following interventions: 1) At the national level, provide technical support to the MOH in the development nutrition related policies, guidelines, training manuals and the establishment of competent team of national trainers; 2) Strengthening human capacity by training and coaching health workers at community, facility, and district levels in nutrition care and support for PLHIV; 3) Strengthen capacity of health facilities to sustain the management of acute malnutrition for people living with and affected by HIV using ready to use RUTF, Fortified Blended Foods (FBF) and counseling, as part of Outpatient Therapeutic Care (OTC); 4) Improving the health facility-community linkages for active case finding, referral and follow-up care to improve treatment adherence, loss to follow up and recovery for HIV individuals receiving treatment for acute malnutrition; 5) Building local capacity for the development and manufacture of RUTF that meets national and international standards.

NuLife made substantial progress in FY 2009 in integrating food and nutrition interventions for PLHIV at all levels. At the national level, NuLife supported the development of the infant and young child feeding (IYCF) guidelines and its accompanying job aids, finalized the National Nutrition and HIV and TB Strategy (2009-2014), supported activities for the Sub-Committee on Nutrition (SCN) within the MOH and trained a team of 204 national and regional trainers in nutrition care and support for PLHIV. At the facility level, the program trained over 625 facility-based health workers to provide nutritional care for PLHIV. Over 14000 PLHIV were vassessed for nutritional status and 3000 treated for malnutriton through the OTC program; developed data collection tools; supplied sets of anthropometric equipment and related job aides and using the quality improvement approach successfully integrated nutrition in HIV care at 34 health facilities across 29 districts. Through the supply chain system, a total of 57.4 Metric Tons (MT) of RUTF were positioned to 34 facilities and 32 MT distributed to program beneficiaries. At the community level, the program strengthened the communityfacility links through the mobilization of partners and district officials and training of 1039 community volunteers to identify refer, and follow up nutritionally compromised HIV-positive individuals.

Monitoring, evaluation and reporting will be the basis for documenting needs, activities, results and decision-making for the program and will be integral to realizing integration of food and nutrition into the national HIV care and treatment programs. In FY 2010, NuLife will focus on strengthening reporting systems at the 54 health facilities, district USG partners and national level for improved data collection of nutrition care and support for PLHIV. Specifically, the program will continue to work with the MOH-ACP program to pretest and review the HIV care monitoring tools especially the HIV care card to ensure that all nutrition related indicators are captured. At the facility and district level, the program will train 180 health facility staff responsible for data collection at the HIV clinics. The new HIV care monitoring tools and the new MOH Integrated Management of Acute Malnutrition (IMAM) tools for will be utilized for data collection and reporting. At the community level, the program will pilot use of the community nutrition data collections tools and encourage partners to integrate nutrition indicators into their data collection tools, as initaited in FY2009. Health worker and partner community volunteer coordinators will have the sole responsibility for data collection at the facility and community level respectively. Following on with the process of integrating nutrition indicators into partner reporting tools, the program will proactively work with each USG partner to support facility level staff to collect all nutrition related data for PLHIV.

Strategies implemented in Phase I facilities have yielded positive and rapid results, which need to be sustained. NuLife will continue to use the quality improvement (QI) approach to expand the provision of comprehensive nutrition care for PLHIV to 20 additional health facilities and their catchment areas across the country, bringing the total number of directly supported facilities to 54. In FY2010, the program will support 26,360 HIV-positive adults (including pregnant women and mothers with children less than 6 months) with nutritional assessment for admission into Outpatient Therapeutic Care (OTC). Treatment for acute malnutrition through OTC will be provided to 3500 HIV positive individuals primarily using RUTF. Coupled with treatment for acute malnutrition, the adults will be counseled to prevent development of new episodes of malnutrition. Major topics/issues for which they will be counseled include eating well, relationship between HIV and nutrition, increasing their energy and nutrient intake, dealing with symptoms and signs of opportunistic infections, food and drug interactions, dealing with loss of appetite, preventing infections, maintaining physical fitness, encouraging positive living and seeking early treatment. To support nutrition service delivery to the PLHIVs, the program will conduct a total of 20 training workshops through which 470 health workers will be retrained and 200 health workers newly trained in comprehensive nutrition care and support for adult PLHIV.

In order to facilitate nutrition assessment and counseling, the program will develop, purchase and distribute a set of anthropometric equipment and accompanying materials to the 20 additional sites. For anthropometric equipment, the program will purchase and supply 2,500 MUAC tapes, 10 adult weighing scales, and pallets for selected health facilities. With the finalization of the national guidelines for Integrated Management of Acute Malnutrition (IMAM), Uganda now has a blue print to guide all organizations supporting nutrition. The IMAM guidelines focus on the treatment of acute malnutrition in all groups including PLHIV. NuLife contributed four of the seven chapters in the guidelines focusing on Nutrition and HIV and Community Mobilization. Similar to the IYCF component, NuLife will support the MOH to print and disseminate the guidelines, the training curriculum and accompanying job-aids to the focus facilities.

Technical support to USG Partners: As the major mandate, the program will focus collaborative efforts and provide technical support to USG partners implementing Adult Care and Treatment programs to integrate nutrition into HIV care and support for the adults. Technical support will range from training health workers in partner facilities, provision of a minimum technical package required to integrate nutrition, through meeting and special training workshops. The major Adult Care and Treatment partners include JCRC, TASO, World Vision/SPEAR, NUMAT, CRS/AIDSRelief, where programming overlaps with the NuLife Phase I and II Sites. Technical assistance will be through regular meetings, training of partner staff, support to integrate nutrition indicators into data collection tools and reporting system, provision of all training manuals and job aides developed.

Support to Ministry of Health: NuLife has provided technical support to the Uganda MoH through development and updating of guidelines, development of training manuals, training a team of national trainers and job aides. This support will be mainly through the established HIV taskforce under the MOH Sub-Committee on Nutrition in the MCH cluster whose role is to provide overall guidance and coordination for development of policies, strategies, materials and curriculum related to nutrition. This taskforce which meets quarterly is responsible for the selection of national trainers, approval and revision of materials and provision of overall policy and technical guidance for implementation of nutrition and HIV activities in the NuLife supported facilities and those of collaborating organizations. In addition, the program will advocate for inclusion of nutrition and HIV/AIDS in pre- and in-service training for Village Health Teams (VHT), nurses and midwives, clinical officers and doctors.

Support to districts: Districts have responsibilities for support to and supervision of health facilities. The district health teams access budgets to implement health activities. During FY 10, NuLife will build the capacity of districts to understand and support nutrition interventions. This will be accomplished in collaboration with the Health Care Improvement project, which is setting up Quality Improvement teams at district level. NuLife already has contributed a chapter on nutrition in the curriculum being used to train districts. The NuLife team will orient trainers of district QI teams and as much as possible participate in the training sessions. Progress and outcomes of data generated monthly from health facility sites will be shared with district leaders, the District Health Officer and the District Health Team to generate discussion and influence programming and budgeting.

Support to the health facility: Building on the quality improvement process established last FY, NuLife will form additional nutrition and HIV coaching teams for Mbale, Mbarara, and West Nile regions to support the facilities in integrating nutrition into HIV care and treatment clinics at the 54 sites. The teams will make bi-monthly visits to the facilities to mentor facility QI teams to systematically integrate nutrition into HIV care and treatment using the developed seven steps developed from the training manual to simplify activity implementation at the facility. The visits will jointly be supported by HCI. The seven steps include: nutrition assessment for all HIV positive individuals; the second is categorization into normal, moderate and severe acute malnutrition based on the colour of the MUAC tape; the third is nutrition counseling of malnourished HIV positive individuals; the fourth is RUTF prescription using the recommended dosing charts; the fifth is client follow-up for those receiving RUTF; the sixth is general nutrition education for all PLHIV at the HIV clinics; and the seventh being community mobilization at the community level for identification and follow-up. To augment the coaching team, the NuLife technical team will provide quarterly technical support visits to support and follow-up on technical issues raised through the coaching and mentoring visits.

To facilitate sharing of experiences and challenges of integrating nutrition into HIV routine care using data from the process indicators, the program will hold up to six learning sessions for the facilities. These learning sessions are aimed at improving service delivery at facilities when facilities share challenges and successes. The first phase learning sessions will be for the 34 Phase I sites, while the second phase will be for the 54 Phase II and I sites and the target people will be the nutritional focal person and the head of the facility QI team. In addition NuLife will mentor and support those health workers who are interested in preparing abstracts and papers around emerging good experiences at facility and community levels to write and where possible, submit/present these to national and international workshops and conferences.

Support at community level: Establishing a functional link between the community and the health facility in support of client treatment is a key aspect of any outpatient therapeutic care intervention. It is this link that increases adherence, minimizes default rates and results in good treatment outcomes. With health facilities now equipped and organized to treat malnutrition and volunteers trained in assessment, referral and follow-up, NuLife seeks to ensure sustained implementation. Early results and anecdotal from facilities show a positive trend towards increased community and health facility capacity to collectively identify clients in need of nutrition services and link with each other to provide quality nutritional support and care for PLHIV and those affected. NuLife will thus train and equip an additional 500 community volunteers in 20 facility catchment areas using the revised set of training manuals. Training topics include adult learning and effective facilitation skills, effective communication skills, basic nutrition care and support for PLHIV, the role of the community in integrated management of acute malnutrition, counseling materials for nutrition care and support, management of HIV related symptoms, and management of malnutrition at community level. The community volunteers are drawn from USG partner organizations and their primary role will be to identify, refer and follow up malnourished HIV positive individuals within the 54 facility catchment areas to health facilities for nutrition care and support. To facilitate active case finding through nutrition assessment and counseling at the community level, the program will develop, purchase and distribute 11000 MUAC tapes and 1400 national counseling cards to the community volunteers. Furthermore, the program will proactively support the inclusion of the community volunteer coordinator as part of the facility QI team. The role of the community coordinator will be share with the facility QI teams successes and challenges and the operationalization of the bi-directional referral mechanism established by the program.

Support to the community volunteers for quality activity implementation, capacity building meetings at each of the 54 facilities and the composition of the participants will be QI team leader, the nutrition focal person, member of the district health team, and a USG filed officer responsible for that facility catchment area. Topics for these meetings will range from discussion of the developed follow-up strategy, technical support issues for the volunteers, reporting and documentation as well as addressing challenges for integrating nutrition into HIV care and support activities for the community volunteers. Field Officers for the partner organizations and selected community volunteer coordinators will be responsible for provision on site support for the community to monitor and mentor community volunteers on how they are integrating nutrition into care and treatment services. The frequency and fora of support will be dependent on the partners' plans for supporting community volunteers. NuLife will also support and advocate for inclusion of nutrition into the village health team training manual currently being revised.

Based on lessons from FY2010, it will be critical that the program strengthens and develops new linkages with partners implementing livelihood programs in the 54 facility catchment areas to take on graduates from the outpatient therapeutic care. We envisage that this will lead to a reduction in the number of relapses and allow for continuity of nutrition care and support when the patients graduate from the OTC program. The program will develop a comprehensive "graduation and continuum of care strategy" that involves the provision of (or graduation to) supplemental foods for PLHIV suffering from moderate acute malnutrition and livelihood support for PLHIV and their families. Examples of organizations that the program will work with are ACDI-VOCA who implement Title II MYAP program, World Vision, World Food Program, Lutheran World Federation and Africare among others.

In FY2010, the program will support targeted food and nutritional support services to 2500 HIV negative clinically malnourished OVC aged 0-17 years identified at both the facility and community level. In most cases, these OVCs will be identified at other clinics other than the HIV clinic which the outpatient department, Young Child Clinic, the MCH clinics and acute care clinics. The nutrition related services to be provided to the OVCs will include nutritional assessment, counseling, Infant and Young Child Feeding, and treatment for acute malnutrition. The malnourished children and their care takers will be counseled on eating well, relationship between HIV and nutrition, increasing their energy and nutrient intake, dealing with symptoms and signs of opportunistic infections, food and drug interactions, infant and young child feeding practices, dealing with loss of appetite, preventing infections, encouraging positive leaving and seeking early treatment. In addition to counseling, the malnourished will be treated using RUTF so as to improve on their nutritional status.

To facilitate nutrition assessment and counseling for OVC at the facility level, the program will develop, purchase and distribute a set of anthropometric equipment and accompanying materials to the 20 additional sites. For anthropometric equipment, the program will purchase and supply 7500 MUAC tapes, 80 pediatric weighing scales, and pallets for selected health facilities. The program will also support printing IMAM guidelines when they are finalized. To accompany the IYCF and IMAM guidelines, the following job aides will be printed and distributed to the new sites national counseling cards for comprehensive nutrition care and support, facility level job aids, accurately measuring MUAC wall chart, RUTF dosing chart, target weight wall chart, and eligible client wall chart.

Technical support to USG OVC Partners: As the major mandate, the program will focus collaborative efforts and provide technical support to USG partners implementing OVC programs to integrate nutrition into their OVC programs. Technical support will range from training health workers in partner facilities, training of partner staff as trainers, provision of a minimum technical package required to integrate nutrition, regular one on one meetings, and organized workshops to update partners on the minimum package and new developments in the area of nutrition, support to integrate nutrition indicators into data collection tools and reporting system, provision of training manuals and job aides developed. The major OVC partners include Baylor College of Medicine, TASO, ICOBI, NUMAT, the STAR program in central and Eastern Uganda, CRS/AIDSRelief, where programming overlaps with the NuLife Phase I and II Sites.

Building on the quality improvement process established last FY, NuLife will form additional nutrition and HIV coaching teams for Mbale, Mbarara, and West Nile regions. The coaching team will support facility level QI teams in integrating nutrition care and support into service delivery for OVC at the facilities. Working with the facility nutrition focal person, the Q.I teams will support the identification of clinically malnourished children in the HIV clinic, PMTCT clinic, the young child clinics, the nutrition unit and the outpatient department. The coaching teams will make monthly visits to the facilities to mentor facility QI teams to systematically integrate nutrition into OVC services at the facility level using the seven steps developed from the training manual to simplify activity implementation at the facility. The first step is nutrition assessment for all OVCs; the second is categorization into normal moderate and severe acute malnutrition based on the colours of the MUAC tape; the third is nutrition counseling of malnourished OVC; the fourth is RUTF prescription using the recommended dosing charts; client follow up for those receiving RUTF; the sixth is general nutrition education for all OVC and their caretakers at the clinics; and the seventh being community mobilization at the community level for identification and follow up of malnourished OVC. To augment the coaching team, the NuLife technical team will provide quarterly technical support visits to support and follow up on technical issues raised through the coaching and mentoring visits.

To facilitate sharing of experiences and challenges of providing nutrition care to OVC at HIV clinics and the nutrition units, the program will hold up to six learning sessions for the facilities. These learning sessions are aimed at improving service delivery at facilities when facilities share challenges and successes. The first phase learning sessions will be for the 34 phase I sites, while the second phase will be for the 54 phase II and I sites and the target people will be the nutritional focal person and the head of the facility QI team. In addition NuLife will mentor and support those health workers who are interested in preparing abstracts and papers around emerging good experiences at facility and community levels to write and where possible, submit/present these to national and international workshops and conferences.

As a strategy for strengthening the facility-community linkages for increased accessibility for nutrition care and support services for OVC, the program will train and equip 500 new community volunteers using the community training cascade model and the revised set of training manuals. Training topics include adult learning and effective facilitation skills, effective communication skills, basic nutrition care and support for OVCs, the role of the community in integrated management of acute malnutrition, counseling materials for nutrition care and support, management of HIV related symptoms, and management of malnutrition at community level. The community volunteers are drawn from USG partner organizations and their primary role will be to identify, refer and follow up malnourished OVC to health facilities providing nutrition care and support. The community volunteers will be drawn from the 54 health facility catchment areas. To facilitate active case finding through nutrition assessment and counseling at the community level, the program will develop, purchase and distribute 11000 MUAC tapes and 1400 national counseling cards to the community volunteers. Furthermore, the program will proactively support the inclusion of the community volunteer coordinator as part of the facility QI team, whose role will be to be to share successes and challenges, the operationalization of the bi-directional referral mechanism established by the program with the facility QI teams.

Support to the community volunteers for quality activity implementation, capacity building meetings will be conduct at each of the 54 facilities and the composition of the participants will be QI team leader, the nutrition focal person, member of the district health team, and a USG filed officer responsible for that facility catchment area. Topics for these meetings will range from discussion of the developed follow up strategy, technical support issues for the volunteers, reporting and documentation as well as addressing challenges for integrating nutrition into HIV care and support activities for the community volunteers. Field Officers of partner organizations and selected community volunteer coordinators will be responsible for provision on site support for the community to monitor and mentor community volunteers on how they are integrating nutrition into care and treatment services. The frequency and fora of support will be dependent on the partners plans for supporting community volunteers.

Based on lessons from FY2010, it will be critical that the program strengthens and develops new linkages with partners implementing livelihood and food security programs in the 54 facility catchment areas to take on graduates from the outpatient therapeutic care. We envisage that this will lead to a reduction in the number of relapses and allow for continuity of nutrition care and support when OVCs graduate from the OTC program. The program will develop a comprehensive "graduation and continuum of care strategy" that involves the provision of (or graduation to) supplemental foods for PLHIV suffering from moderate acute malnutrition and livelihood support for PLHIV and their families. Examples of organization that the program will work with are ACDI-VOCA who implement Title II MYAP program, World Vision, World Food Program, Lutheran World Federation, Africare among others.

Strategies implemented in Phase I facilities have yielded positive and rapid results, which need to be sustained. NuLife will continue to use the quality improvement (QI) approach to expand the provision of comprehensive nutrition care for PLHIV to 20 additional health facilities and their catchment areas across the country, bringing the total number of directly supported facilities to 54. In FY2010, the program will support 11,600 HIV positive adults (aged 15 years and above) receiving ART with nutritional assessment for admission into Outpatient Therapeutic Care (OTC). Treatment for acute malnutrition through OTC will be provided to 2700 HIV positive individuals receiving ART primarily using RUTF. Coupled with treatment for acute malnutrition, the adults will be counseled to prevent development of new episodes of malnutrition. Major topics/issues for which they will be counseled include eating well, relationship between HIV and nutrition, increasing their energy and nutrient intake, dealing with symptoms and signs of opportunistic infections, food and drug interactions, dealing with loss of appetite, preventing infections, maintaining physical fitness, encouraging positive leaving and seeking early treatment. To support nutrition service delivery to the PLHIVs, the program will conduct a total of 20 training workshops through which will be 470 health workers will be retrained and 200 health workers newly trained in comprehensive nutrition care and support for adult PLHIV.

In order to facilitate nutrition assessment and counseling, the program will develop, purchase and distribute a set of anthropometric equipment and accompanying materials to the 20 additional sites. For anthropometric equipment, the program will purchase and supply 2,500 MUAC tapes, 10 adult weighing scales, and pallets for selected health facilities. With the finalization of the national guidelines for Integrated Management of Acute Malnutrition (IMAM), Uganda now has a blue print to guide all organizations supporting nutrition. The IMAM guidelines focus on the treatment of acute malnutrition in all groups including PLHIV. NuLife contributed four of the seven chapters in the guidelines focusing on Nutrition and HIV and Community Mobilization. Similar to the IYCF component, NuLife will support the MOH to print and disseminate the guidelines, the training curriculum and accompanying job-aids to the focus facilities.

Technical support to USG Partners: As the major mandate, the program will focus collaborative efforts and provide technical support to USG partners implementing Adult Care and Treatment programs to integrate nutrition into HIV care and support for the adults. Technical support will range from training health workers in partner facilities, provision of a minimum technical package required to integrate nutrition, through meeting and special training workshops. The major Adult Care and Treatment partners include JCRC, TASO, World Vision/SPEAR, NUMAT, CRS/AIDSRelief, where programming overlaps with the NuLife Phase I and II Sites. Technical assistance will be through regular meetings, training of partner staff, support to integrate nutrition indicators into data collection tools and reporting system, provision of all training manuals and job aides developed.

Support to Ministry of Health: NuLife has provided technical support to the Uganda MoH through development and updating of guidelines, development of training manuals, training a team of national trainers and job aides. This support will be mainly through the established HIV taskforce under the MOH Sub-Committee on Nutrition in the MCH cluster whose role is to provide overall guidance and coordination for development of policies, strategies, materials and curriculum related to nutrition. This taskforce which meets quarterly is responsible for the selection of national trainers, approval and revision of materials and provision of overall policy and technical guidance for implementation of nutrition and HIV activities in the NuLife supported facilities and those of collaborating organizations. In addition, the program will advocate for inclusion of nutrition and HIV/AIDS in pre- and in-service training for Village Health Teams (VHT), nurses and midwives, clinical officers and doctors.

Support to districts: Districts have responsibilities for support to and supervision of health facilities. The district health teams access budgets to implement health activities. During FY 10, NuLife will build the capacity of districts to understand and support nutrition interventions. This will be accomplished in collaboration with the Health Care Improvement project, which is setting up Quality Improvement teams at district level. NuLife already has contributed a chapter on nutrition in the curriculum being used to train districts. The NuLife team will orient trainers of district QI teams and as much as possible participate in the training sessions. Progress and outcomes of data generated monthly from health facility sites will be shared with district leaders, the District Health Officer and the District Health Team to generate discussion and influence programming and budgeting.

Support to the health facility: Building on the quality improvement process established last FY, NuLife will form additional nutrition and HIV coaching teams for Mbale, Mbarara, and West Nile regions to support the facilities in integrating nutrition into HIV care and treatment clinics at the 54 sites. The teams will make bi-monthly visits to the facilities to mentor facility QI teams to systematically integrate nutrition into HIV care and treatment using the developed seven steps developed from the training manual to simplify activity implementation at the facility. The visits will jointly be supported by HCI. The seven steps include: nutrition assessment for all HIV positive individuals; the second is categorization into normal, moderate and severe acute malnutrition based on the colour of the MUAC tape; the third is nutrition counseling of malnourished HIV positive individuals; the fourth is RUTF prescription using the recommended dosing charts; client follow up for those receiving RUTF; the sixth is general nutrition education for all PLHIV at the HIV clinics; and the seventh being community mobilization at the community level for identification and follow up. To augment the coaching team, the NuLife technical team will provide quarterly technical support visits to support and follow up on technical issues raised through the coaching and mentoring visits.

To facilitate sharing of experiences and challenges of integrating nutrition into HIV routine care using data from the process indicators, the program will hold up to six learning sessions for the facilities. These learning sessions are aimed at improving service delivery at facilities when facilities share challenges and successes. The first phase learning sessions will be for the 34 Phase I sites, while the second phase will be for the 54 Phase II and I sites and the target people will be the nutritional focal person and the head of the facility QI team. In addition NuLife will mentor and support those health workers who are interested in preparing abstracts and papers around emerging good experiences at facility and community levels to write and where possible, submit/present these to national and international workshops and conferences.

Support at community level: Establishing a functional link between the community and the health facility in support of client treatment is a key aspect of any outpatient therapeutic care intervention. It is this link that increases adherence, minimizes default rates and results in good treatment outcomes. With health facilities now equipped and organized to treat malnutrition and volunteers trained in assessment, referral and follow-up, NuLife seeks to ensure sustained implementation. Early results and anecdotal from facilities show a positive trend towards increased community and health facility capacity to collectively identify clients in need of nutrition services and link with each other to provide quality nutritional support and care for PLHIV and those affected. NuLife will thus train and equip an additional 500 community volunteers in 20 facility catchment areas using the revised set of training manuals. Training topics include adult learning and effective facilitation skills, effective communication skills, basic nutrition care and support for PLHIV, the role of the community in integrated management of acute malnutrition, counseling materials for nutrition care and support, management of HIV related symptoms, and management of malnutrition at community level. The community volunteers are drawn from USG partner organizations and their primary role will be to identify, refer and follow up malnourished HIV positive individuals within the 54 facility catchment areas to health facilities for nutrition care and support. To facilitate active case finding through nutrition assessment and counseling at the community level, the program will develop, purchase and distribute 11000 MUAC tapes and 1400 national counseling cards to the community volunteers. Furthermore, the program will proactively support the inclusion of the community volunteer coordinator as part of the facility QI team. The role of the community coordinator will be share with the facility QI teams successes and challenges and the operationalization of the bi-directional referral mechanism established by the program.

Support to the community volunteers for quality activity implementation, capacity building meetings will be conduct at each of the 54 facilities and the composition of the participants will be QI team leader, the nutrition focal person, member of the district health team, and a USG filed officer responsible for that facility catchment area. Topics for these meetings will range from discussion of the developed follow up strategy, technical support issues for the volunteers, reporting and documentation as well as addressing challenges for integrating nutrition into HIV care and support activities for the community volunteers. Field Officers for the partner organizations and selected community volunteer coordinators will be responsible for provision on site support for the community to monitor and mentor community volunteers on how they are integrating nutrition into care and treatment services. The frequency and fora of support will be dependent on the partners' plans for supporting community volunteers. NuLife will also support and advocate for inclusion of nutrition into the village health team training manual currently being revised.

Based on lessons from FY2010, it will be critical that the program strengthens and develops new linkages with partners implementing livelihood programs in the 54 facility catchment areas to take on graduates from the outpatient therapeutic care. We envisage that this will lead to a reduction in the number of relapses and allow for continuity of nutrition care and support when the patients graduate from the OTC program. The program will develop a comprehensive "graduation and continuum of care strategy" that involves the provision of (or graduation to) supplemental foods for PLHIV suffering from moderate acute malnutrition and livelihood support for PLHIV and their families. Examples of organization that the program will work with are ACDI-VOCA who implement Title II MYAP program, World Vision, World Food Program, Lutheran World Federation, Africare among others.

NuLife will use the quality improvement (QI) approach to expand the provision of comprehensive nutrition care for HIV Positive and exposed children to 20 additional health facilities and their catchment areas across the country, bringing the total number of directly supported facilities to 54. Specific to pediatric care and support, the program will support nutritional assessment of 3600 HIV positive children for admission into outpatient therapeutic care. Those found to be malnourished will be provided with treatment for acute malnutrition using Ready to Use Therapeutic Foods (RUTF) and approximately 2400 HIV positive and exposed children will receive treatment for acute malnutrition. Coupled with treatment for acute malnutrition, the children and care takers will be counseled to prevent development of new episodes of malnutrition. Major topics/issues for which they will be counseled are eating well, relationship between HIV and nutrition, increasing their energy and nutrient intake, dealing with symptoms and signs of opportunistic infections, food and drug interactions, infant feeding, dealing with loss of appetite, preventing infections, encouraging positive leaving and seeking early treatment.

Skilled health workers are critical to the provision of quality nutritional care for HIV positive children. As such, the program will conduct training workshops in which 470 health workers will be trained through refresher training, and 200 health workers will be newly trained to provide nutrition care and support.

In order to facilitate nutrition assessment and counseling, the program will develop, purchase and distribute a set of anthropometric equipment and accompanying materials to the 20 additional sites. For anthropometric equipment, the program will purchase and supply 7500 MUAC tapes, 80 pediatric weighing scales, and pallets for selected health facilities. With the finalization of the national guidelines for Integrated Management of Acute Malnutrition (IMAM), Uganda now has a blue print to guide all organizations supporting nutrition. The IMAM guidelines focus on the treatment of acute malnutrition in all groups including PLHIV. NuLife contributed four of the seven chapters in the guidelines focusing on Nutrition and HIV and Community Mobilization. Similar to the IYCF component, NuLife will support the MOH to print and disseminate the guidelines, the training curriculum and accompanying job-aids to the focus facilities. Technical support to USG Partners: During FY2009, interested USG implementing partners were identified, their activities mapped in relation to the NuLife facility catchment areas and mutually acceptable formal arrangements were made between the two parties to clarify roles and responsibilities, including cost share. During FY2010, the program will focus on building on the established collaborative efforts and provide technical support to partners integrate nutrition care into their pediatric Care and Treatment programs. Technical support will range from training health workers in partner facilities, provision of a minimum technical package required to integrate nutrition, through meeting and special training workshops. The major pediatric Care and Treatment partners include Baylor College of Medicine, JCRC, TASO, EGPAF, PREFA, NUMAT, the STAR program in central and Eastern Uganda, CRS/AIDSRelief, where programming overlaps with the NuLife Phase I and II Sites. Technical assistance will be through regular meetings, training of partner staff, support to integrate nutrition indicators into data collection tools and reporting system, provision of all training manuals and job aides developed.

Support to Ministry of Health: NuLife has provided technical and financial support to the Uganda MoH through development and updating of guidelines, development of training manuals, training a team of national trainers and job aides. This support will be mainly through the established HIV taskforce under the MOH Sub-Committee on Nutrition (SCN) in the MCH cluster. The role of the SCN is to provide overall guidance and coordination for development of nutrition related policies, strategies, materials and curriculum for the health sector. This taskforce which meets quarterly is responsible for the selection of national trainers, approval and revision of materials and provision of overall policy and technical guidance for implementation of nutrition and HIV activities in the NuLife supported facilities and those of collaborating organizations. As a request from MOH, NuLife to support the dissemination and distribution of the national IYCF guidelines launched last year especially to districts and facilities supported by the ;program.

Support to health facilities: Building on the quality improvement process established in FY 2009, NuLife will form additional nutrition and HIV coaching teams for Mbale, Mbarara, and West Nile regions to support the facilities in integrating nutrition into HIV clinics at the 54 sites. The teams will make bi-monthly visits to the facilities to mentor facility QI teams to systematically integrate nutrition into HIV care and treatment using the developed seven steps developed from the training manual to simplify activity implementation at the facility. The first step is nutrition assessment for all HIV positive individuals; the second is categorization into normal moderate and severe acute malnutrition based on the colours of the MUAC tape; the third is nutrition counseling of malnourished HIV positive individuals; the fourth is RUTF prescription using the recommended dosing charts; client follow up for those receiving RUTF; the sixth is general nutrition education for all PLHIV at the HIV clinics; and the seventh being community mobilization at the community level for identification and follow up. To augment the coaching team, the NuLife technical team will provide quarterly technical support visits to support and follow up on technical issues raised through the coaching and mentoring visits.

To facilitate sharing of experiences and challenges of integrating nutrition into HIV routine care using data from the process indicators, the program will hold up to six learning sessions for the facilities. These learning sessions are aimed at improving service delivery at facilities when facilities share challenges and successes. The first phase learning sessions will be for the 34 phase I sites, while the second phase will be for the 54 phase II and I sites and the target people will be the nutritional focal person and the head of the facility QI team. In addition NuLife will mentor and support those health workers who are interested in preparing abstracts and papers around emerging good experiences at facility and community levels to write and where possible, submit/present these to national and international workshops and conferences.

Support at community level: Early results and anecdotal from facilities show a positive trend towards increased community and health facility capacity to collectively identify clients in need of nutrition services and link with each other to provide quality nutritional support and care for PLHIV and those affected. As a strategy for strengthening these established facility-community linkages for increased accessibility for nutrition care and support services, the program will train and equip 500 new community volunteers using the community training cascade model and the revised set of training manuals. Training topics include adult learning and effective facilitation skills, effective communication skills, basic nutrition care and support for PLHIV, the role of the community in integrated management of acute malnutrition, counseling materials for nutrition care and support, management of HIV related symptoms, and management of malnutrition at community level. The community volunteers are drawn from USG partner organizations and their primary role will be to identify, refer and follow up malnourished HIV positive children areas to health facilities for nutrition care and support. The community volunteers will be drawn from the 54 health facility catchment areas. To facilitate active case finding through nutrition assessment and counseling at the community level, the program will develop, purchase and distribute 11000 MUAC tapes and 1400 national counseling cards to the community volunteers. Furthermore, the program will proactively support the inclusion of the community volunteer coordinator as part of the facility QI team. The role of the community coordinator will be to share with the facility QI teams successes and challenges and the operationalization of the community-facility referral mechanism established.

To support to the community volunteers for quality activity implementation, capacity building meetings will be conduct at each of the 54 facilities and the composition of the participants will be QI team leader, the nutrition focal person, member of the district health team, and a USG filed officer responsible for that facility catchment area. Topics for these meetings will range from discussion of the developed follow up strategy, technical support issues for the volunteers, reporting and documentation as well as addressing challenges for integrating nutrition into HIV care and support activities for the community volunteers. Field Officers for the partner organizations and selected community volunteer coordinators will be responsible conduct follow-up and mentoring visits to the trained volunteers, organize progress review meetings to share experiences, discuss challenges and find solutions, supporting community volunteers to ensure data on referral process is collected, among others. Based on lessons from FY2010, it will be critical that the program strengthens and develops new linkages with partners implementing livelihood programs in the 54 facility catchment areas to take on graduates from the outpatient therapeutic care. We envisage that this will lead to a reduction in the number of relapses and allow for continuity of nutrition care and support when the children graduate from the OTC program. The program will develop a comprehensive "graduation and continuum of care strategy" that involves the provision of (or graduation to) supplemental foods for PLHIV suffering from moderate acute malnutrition and livelihood support for PLHIV and their families. Examples of organization that the program will work with are ACDI-VOCA who implement Title II MYAP program, World Vision, World Food Program, Lutheran World Federation, Africare among others.

NuLife will use the quality improvement (QI) approach to expand the provision of comprehensive nutrition care for HIV Positive and exposed children to 20 additional health facilities and their catchment areas across the country, bringing the total number of directly supported facilities to 54. Specific to pediatric care and support, the program will support nutritional assessment of 1600 HIV positive children receiving ART for admission into outpatient therapeutic care. Those found to be malnourished will be provided with treatment for acute malnutrition using Ready to Use Therapeutic Foods (RUTF) and approximately 1050 HIV positive children receiving ART will be treated for acute malnutrition. Coupled with treatment for acute malnutrition, the children and care takers will be counseled to prevent development of new episodes of malnutrition. Major topics/issues for which they will be counseled are eating well, relationship between HIV and nutrition, increasing their energy and nutrient intake, dealing with symptoms and signs of opportunistic infections, food and drug interactions, infant feeding, dealing with loss of appetite, preventing infections, encouraging positive leaving and seeking early treatment.

Skilled health workers are critical to the provision of quality nutritional care for HIV positive children. As such, the program will conduct training workshops in which 470 health workers will be trained through refresher training, and 200 health workers will be newly trained to provide nutrition care and support.

In order to facilitate nutrition assessment and counseling, the program will develop, purchase and distribute a set of anthropometric equipment and accompanying materials to the 20 additional sites. For anthropometric equipment, the program will purchase and supply 7500 MUAC tapes, 80 pediatric weighing scales, and pallets for selected health facilities. With the finalization of the national guidelines for Integrated Management of Acute Malnutrition (IMAM), Uganda now has a blue print to guide all organizations supporting nutrition. The IMAM guidelines focus on the treatment of acute malnutrition in all groups including PLHIV. NuLife contributed four of the seven chapters in the guidelines focusing on Nutrition and HIV and Community Mobilization. Similar to the IYCF component, NuLife will support the MOH to print and disseminate the guidelines, the training curriculum and accompanying job-aids to the focus facilities. Technical support to USG Partners: During FY2009, interested USG implementing partners were identified, their activities mapped in relation to the NuLife facility catchment areas and mutually acceptable formal arrangements were made between the two parties to clarify roles and responsibilities, including cost sharing. During FY2010, the program will focus on building on the established collaborative efforts and provide technical support to partners integrating nutrition care into their pediatric Care and Treatment programs. Technical support will range from training health workers in partner facilities, provision of a minimum technical package required to integrate nutrition, through meeting and special training workshops. The major pediatric Care and Treatment partners include Baylor College of Medicine, JCRC, TASO, EGPAF, PREFA, NUMAT, the STAR program in central and Eastern Uganda, CRS/AIDSRelief, where programming overlaps with the NuLife Phase I and II Sites. Technical assistance will be through regular meetings, training of partner staff, support to integrate nutrition indicators into data collection tools and reporting systems, provision of all training manuals and job aides developed.

Support to Ministry of Health: NuLife has provided technical and financial support to the Uganda MoH through development and updating of guidelines, development of training manuals, training a team of national trainers and job aides. This support will be mainly through the established HIV taskforce under the MOH Sub-Committee on Nutrition (SCN) in the MCH cluster. The role of the SCN is to provide overall guidance and coordination for development of nutrition related policies, strategies, materials and curriculum for the health sector. This taskforce which meets quarterly is responsible for the selection of national trainers, approval and revision of materials and provision of overall policy and technical guidance for implementation of nutrition and HIV activities in the NuLife supported facilities and those of collaborating organizations. As a request from MOH, NuLife to support the dissemination and distribution of the national IYCF guidelines launched last year especially to districts and facilities supported by the ;program.

Support to health facilities: Building on the quality improvement process established in FY 2009, NuLife will form additional nutrition and HIV coaching teams for Mbale, Mbarara, and West Nile regions to support the facilities in integrating nutrition into HIV clinics at the 54 sites. The teams will make bi-monthly visits to the facilities to mentor facility QI teams to systematically integrate nutrition into HIV care and treatment using the developed seven steps developed from the training manual to simplify activity implementation at the facility. The first step is nutrition assessment for all HIV positive individuals; the second is categorization into normal moderate and severe acute malnutrition based on the colours of the MUAC tape; the third is nutrition counseling of malnourished HIV positive individuals; the fourth is RUTF prescription using the recommended dosing charts; client follow up for those receiving RUTF; the sixth is general nutrition education for all PLHIV at the HIV clinics; and the seventh being community mobilization at the community level for identification and follow up. To augment the coaching team, the NuLife technical team will provide quarterly technical support visits to support and follow up on technical issues raised through the coaching and mentoring visits.

To facilitate sharing of experiences and challenges of integrating nutrition into HIV routine care using data from the process indicators, the program will hold up to six learning sessions for the facilities. These learning sessions are aimed at improving service delivery at facilities when facilities share challenges and successes. The first phase learning sessions will be for the 34 Phase I sites, while the second phase will be for the 54 Phase II and I sites and the target people will be the nutritional focal person and the head of the facility QI team. In addition NuLife will mentor and support those health workers who are interested in preparing abstracts and papers around emerging good experiences at facility and community levels to write and where possible, submit/present these to national and international workshops and conferences.

Support at community level: Early results and anecdotal from facilities show a positive trend towards increased community and health facility capacity to collectively identify clients in need of nutrition services and link with each other to provide quality nutritional support and care for PLHIV and those affected. As a strategy for strengthening these established facility-community linkages for increased accessibility for nutrition care and support services, the program will train and equip 500 new community volunteers using the community training cascade model and the revised set of training manuals. Training topics include adult learning and effective facilitation skills, effective communication skills, basic nutrition care and support for PLHIV, the role of the community in integrated management of acute malnutrition, counseling materials for nutrition care and support, management of HIV related symptoms, and management of malnutrition at community level. The community volunteers are drawn from USG partner organizations and their primary role will be to identify, refer and follow up malnourished HIV positive children areas to health facilities for nutrition care and support. The community volunteers will be drawn from the 54 health facility catchment areas. To facilitate active case finding through nutrition assessment and counseling at the community level, the program will develop, purchase and distribute 11000 MUAC tapes and 1400 national counseling cards to the community volunteers. Furthermore, the program will proactively support the inclusion of the community volunteer coordinator as part of the facility QI team. The role of the community coordinator will be to share with the facility QI teams successes and challenges and the operationalization of the community-facility referral mechanism established.

To support to the community volunteers for quality activity implementation, capacity building meetings will be conduct at each of the 54 facilities and the composition of the participants will be QI team leader, the nutrition focal person, member of the district health team, and a USG filed officer responsible for that facility catchment area. Topics for these meetings will range from discussion of the developed follow up strategy, technical support issues for the volunteers, reporting and documentation as well as addressing challenges for integrating nutrition into HIV care and support activities for the community volunteers. Field Officers for the partner organizations and selected community volunteer coordinators will be responsible conduct follow-up and mentoring visits to the trained volunteers, organize progress review meetings to share experiences, discuss challenges and find solutions, supporting community volunteers to ensure data on referral process is collected, among others. Based on lessons from FY2010, it will be critical that the program strengthens and develops new linkages with partners implementing livelihood programs in the 54 facility catchment areas to take on graduates from the outpatient therapeutic care. We envisage that this will lead to a reduction in the number of relapses and allow for continuity of nutrition care and support when the children graduate from the OTC program. The program will develop a comprehensive "graduation and continuum of care strategy" that involves the provision of (or graduation to) supplemental foods for PLHIV suffering from moderate acute malnutrition and livelihood support for PLHIV and their families. Examples of organization that the program will work with are ACDI-VOCA who implement Title II MYAP program, World Vision, World Food Program, Lutheran World Federation, Africare among others.

Strategies implemented in Phase I facilities have yielded positive and rapid results, which need to be sustained. NuLife will continue to use the quality improvement (QI) approach to expand the provision of comprehensive nutrition care for HIV positive pregnant women and lactating mothers with children up to six months to 20 additional health facilities and their catchment areas across the country, bringing the total number of directly supported facilities to 54. In FY2010, the program will support 3000 HIV positive pregnant and lactating women in a PMTCT setting with nutritional assessment for admission into Outpatient Therapeutic Care (OTC). Treatment for acute malnutrition through OTC will be provided to 200 HIV positive pregnant and lactating women primarily using RUTF. Coupled with treatment for acute malnutrition, these women will be counseled to prevent development of new episodes of malnutrition. Major topics/issues for which they will be counseled include eating well, relationship between HIV and nutrition, increasing their energy and nutrient intake, dealing with symptoms and signs of opportunistic infections, food and drug interactions, dealing with loss of appetite, preventing infections, maintaining physical fitness, encouraging positive leaving, good infant and young child feeding practices and seeking early treatment. To support nutrition service delivery to the HIV positive pregnant and lactating women, the program will train 50 peer counselors using the existing training module (Theme 3 of the Community Volunteers Training Module and the section on flash heating of breast milk).

In order to facilitate nutrition assessment and counseling, the program will develop, purchase and distribute a set of anthropometric equipment and accompanying materials to the 20 additional sites. For anthropometric equipment, the program will purchase and supply 2,500 MUAC tapes, 10 adult weighing scales, and pallets for selected health facilities. With the finalization and launch of the national guidelines for Infant and Young Child Feeding (IYCF), Uganda now has a blue print to guide all organizations supporting maternal and young child nutrition. NuLife will support the MOH to disseminate these guidelines, the training curriculum and accompanying job-aids to the focus facilities and districts where NuLife is present at the request of MOH.

Support to Ministry of Health: NuLife has provided technical support to the Uganda MoH through development and updating of guidelines, development of training manuals, training a team of national trainers and job aides. In coordination with EGPAF, support to MOH will be mainly through the established Sub-Committee on Nutrition in the MCH cluster whose role is to provide overall guidance and coordination for development of policies, strategies, materials and curriculum related to nutrition. This subcommittee which meets quarterly is responsible for the selection of national trainers, approval and revision of materials and provision of overall policy and technical guidance for implementation of nutrition and HIV activities in the NuLife supported facilities and those of collaborating organizations.

Coordination with other USG Partners: During FY2009, USG partners implementing PMTCT programs at community and facility level were identified, their activities mapped in relation to the NuLife facility catchment areas and mutually acceptable formal arrangements were initiated between the two parties to clarify roles and responsibilities, including cost share. During FY2010, the program will focus on building on the established collaborative efforts and provide technical support wherever necessary to partners integrate nutrition care into their PMCT programs. Coordination efforts will range from training health workers in partner facilities, provision of a minimum technical package required to integrate nutrition, and printing of developed IYCF guidelines, training materials and accompanying job aids. The major PMTCT partners include Baylor College of Medicine, ICOBI, THETA, EGPAF, PREFA, NUMAT, the STAR program in central and Eastern Uganda, CRS/AIDSRelief, where programming overlaps with the NuLife Phase I and II Sites. Technical assistance will be through regular meetings, training of partner staff, support to integrate nutrition indicators into data collection tools and reporting system, provision of all training manuals and job aides developed.

Support to districts: Districts have responsibilities for support to and supervision of health facilities. The district health teams access budgets to implement health activities. During FY 10, NuLife will build the capacity of districts to understand and support nutrition interventions. This will be accomplished in collaboration with the Health Care Improvement project, which is setting up Quality Improvement teams at district level. NuLife already has contributed a chapter on nutrition in the curriculum being used to train districts. The program will support Village Health Team (VHT) Coordinators in the District Health Offices to provide intensive coaching and mentoring to trained peer counselors and community volunteers. Progress and outcomes of data generated monthly from health facility sites will be shared with district leaders, the District Health Officer and the District Health Team to generate discussion and influence programming and budgeting.

Support to the health facility: Building on the quality improvement process established last FY, NuLife will form additional nutrition and HIV coaching teams for Mbale, Mbarara, and West Nile regions to support the facilities in integrating nutrition into HIV care and treatment clinics at selected regional referral and general hospitals. The teams will make bi-monthly visits to the facilities to mentor facility QI teams to systematically integrate nutrition into the PMCTC package using the developed seven steps developed from the training manual to simplify activity implementation at the facility. The visits will jointly be supported by HCI. The seven steps include: nutrition assessment for all HIV positive pregnant and lactating women; the second is categorization into normal, moderate and severe acute malnutrition based on the colour of the MUAC tape; the third is nutrition counseling (including IYCF) of malnourished HIV positive pregnant and lactating women; the fourth is RUTF prescription using the recommended dosing charts; client follow up for those receiving RUTF; the sixth is general maternal nutrition education for all pregnant and lactating at the PMTCT clinics; and the seventh being community mobilization at the community level for identification and follow up. To augment the coaching team, the NuLife technical team will provide quarterly technical support visits to support and follow up on technical issues raised through the coaching and mentoring visits.

To facilitate sharing of experiences and challenges of integrating nutrition into HIV routine care using data from the process indicators, the program will hold up to six learning sessions for the facilities. These learning sessions are aimed at improving service delivery at facilities when facilities share challenges and successes. The first phase learning sessions will be for the 34 Phase I sites, while the second phase will be for the 54 Phase II and I sites and the target people will be the nutritional focal person and the head of the facility QI team. In addition NuLife will mentor and support those health workers who are interested in preparing abstracts and papers around emerging good experiences at facility and community levels to write and where possible, submit/present these to national and international workshops and conferences.

Support at community level: Establishing a functional link between the community and the health facility in support of client treatment is a key aspect of any outpatient therapeutic care intervention. It is this link that increases adherence, minimizes default rates and results in good treatment outcomes. With health facilities now equipped and organized to treat malnutrition and volunteers trained in assessment, referral and follow-up, NuLife seeks to ensure sustained implementation. Early results and anecdotal from facilities show a positive trend towards increased community and health facility capacity to collectively identify clients in need of nutrition services and link with each other to provide quality nutritional support and care for PLHIV and those affected. NuLife will thus train and equip an additional 500 community volunteers in 20 facility catchment areas using the revised set of training manuals. Training topics include adult learning and effective facilitation skills, effective communication skills, basic nutrition care and support for PLHIV, the role of the community in integrated management of acute malnutrition, counseling materials for nutrition care and support, management of HIV related symptoms, IYCF and management of malnutrition at community level. Specific to IYCF, NuLife will train additional 50 peer counselors using the existing training module on IYCF (Theme 3 of the Community Volunteers Training Module and the section on flash heating of breast milk) to equip them with IYCF counseling skills. The community volunteers and peer counselors are drawn from USG partner organizations and health facility catchment areas with their primary role being to identify, refer and follow up malnourished HIV positive pregnant and lactating women within the 54 facility catchment areas to health facilities for nutrition care and support as well as counseling on IYCF practices. To facilitate active case finding through nutrition assessment and counseling at the community level, the program will develop, purchase and distribute 11000 MUAC tapes, growth promoters' kits and 1400 national counseling cards to the community volunteers and peer counselors. Furthermore, the program will proactively support the inclusion of the community volunteer coordinator as part of the facility QI team. The role of the community coordinator will be share with the facility QI teams successes and challenges and the operationalization of the bi-directional referral mechanism established by the program.

Support to the community volunteers for quality activity implementation, capacity building meetings will be conduct at each of the 54 facilities and the composition of the participants will be QI team leader, the nutrition focal person, member of the district health team, and a USG filed officer responsible for that facility catchment area. Topics for these meetings will range from discussion of the developed follow up strategy, technical support issues for the volunteers, reporting and documentation as well as addressing challenges for integrating nutrition into HIV care and support activities for the community volunteers. Field Officers for the partner organizations and selected community volunteer coordinators will be responsible for provision on site support for the community to monitor and mentor community volunteers on how they are integrating nutrition into care and treatment services. The frequency and fora of support will be dependent on the partners' plans for supporting community volunteers. NuLife will also support and advocate for inclusion of nutrition into the village health team training manual currently being revised.

Based on lessons from FY2010, it will be critical that the program strengthens and develops new linkages with partners implementing livelihood programs in the 54 facility catchment areas to take on graduates from the outpatient therapeutic care. We envisage that this will lead to a reduction in the number of relapses and allow for continuity of nutrition care and support when the patients graduate from the OTC program. The program will develop a comprehensive "graduation and continuum of care strategy" that involves the provision of (or graduation to) supplemental foods for PLHIV suffering from moderate acute malnutrition and livelihood support for PLHIV and their families. Examples of organization that the program will work with are ACDI-VOCA who implement Title II MYAP program, World Vision, World Food Program, Lutheran World Federation, Africare among others.