AIDSRelief Uganda is comprised of three of the five AIDSRelief global consortium members, Catholic Relief Services (CRS), Futures Group International, and the Institute of Human Virology of the University of Maryland School of Medicine (IHV). In Uganda, the program also partners with Children's AIDS Fund (CAF). AIDSRelief is funded by PEPFAR through HRSA and CDC and is currently in its sixth year of program implementation.

As the lead agency in the consortium, CRS provides overall program coordination and oversight for grant administration and compliance, in addition to coordinating overall representation of the grant to USG, local government and other stakeholders. CRS oversees the implementation of all project activities within an effective planning framework and manages the necessary USG financial resources for each consortium member, enabling them to carry out their work based on clear program deliverables within donor-approved funding limits.

The Institute of Human Virology of the University of Maryland School of Medicine (IHV) serves as the clinical lead for AIDSRelief in developing and implementing activities that build our local partners' capacity to provide comprehensive high-quality HIV care and treatment within the framework of National policies and guidelines. IHV oversees services that include testing and counseling; medical, pediatrics, prevention of mother to child transmission, nursing and psycho-social care; adherence training and monitoring; health system strengthening; laboratory services; technology selection; support of palliative care staff; and continuing medical education. The medical strategy is aimed at implementing high quality and sustainable care at each of the sites.

Futures Group manages strategic information through data collection, analysis, monitoring, and generation of reports for donors, government and other key stakeholders. Futures Group is involved in building LPTF capacity in collecting, managing, and analyzing clinical and programmatic information, and is building an accessible patient database. Future sustainability plans include a focus on building partner capacity to use this data not only to practice adaptive patient management but also to ensure improved LPTF planning and management of treatment and care. Finally, Futures Group facilitates sharing and transmission of internal reporting data among consortium members for use in various activities.

Overall site management responsibilities are shared between CRS and CAF. Both organizations ensure that LPTFs receive the strengthening and support they need to provide care and treatment services within the protocols developed by the country's Ministry of Health guidelines and AIDSRelief Uganda.

Currently, AIDSRelief Uganda supports 18 LPTFs providing comprehensive HIV care and treatment services in Northern, Western and Central Uganda. Through these LPTFs and their satellites, the program has provided care to 66,000 patients, of whom 22,000 are on treatment as of April 2009. The program plans to enroll 25,908 patients on treatment by the end of Year 6.

AIDSRelief Uganda is divided into structured program areas including the following: Adult care and treatment, pediatric care and treatment, counseling and testing, supply chain management for ARV and OI, prevention including AB, laboratory infrastructure, prevention of mother to child transmission, orphans and vulnerable children, finance and compliance, strategic information, community based treatment support, health care management and quality improvement program. The program has also established linkages with the Uganda Ministry of Health (MOH) and other organizations such as the Clinton Foundation and Population Services International in order to increase the services available to HIV patients and their families (e.g. ARV provision, PMTCT, nutrition, and basic care package provision).

AIDSRelief supports a comprehensive continuum of care for adults and adolescents (male and female) living with HIV with the goal of prolonging their lives while enhancing its quality. These services are provided at 18 hospitals and clinics and at associated satellites across Northern, Western and Central Uganda with a total of more than 70,000 patients ever being enrolled into care. The adult care and support component builds on existing clinical and social services in all Local Partner Treatment Facilities (LPTFs), extending the scope and reach of these services by integrating facility based care delivery systems with community and home-based mechanisms. This is accomplished by employing networks of community-based organizations, community health workers and volunteers, treatment supporters and patient support groups.

The program provides access to a comprehensive care package that includes routine scheduled clinical follow-up, access to unscheduled clinical visits for the management of acute illness and routine CD4 testing for all patients enrolled in care. In addition it provides for comprehensive diagnosis and treatment of opportunistic infections and HIV associated conditions including but not limited to TB, cryptococcal meningitis, pneumocistis jeroverci, Kaposi's sarcoma; diagnosis and treatment for other acute illnesses including but not limited to malaria, community acquired pneumonia; facilitation with hospitalization for enrolled patients; and with the management of co-morbid chronic conditions such as cardiovascular disease, diabetes and hypertension; routine health screening including TB, STI and pregnancy screening. In Y2010 AIDSRelief will explore the possibility of piloting routine cervical cancer screening for women. The AIDSRelief OI Drug Policy and treatment manual, including a list of essential OI drugs and reporting template, provides a guide the sites in the procurement, utilization and reporting on consumption of OI and other non-ARV drugs used in the program.

A guiding principle of the AIDSRelief program is to provide services as close to the end user as possible and to link those services to facilities through an integrated system of referrals. In order to ensure that this happens efficiently while preserving the quality of patient care AIDSRelief encourages and supports LPTFs to open satellite clinics and community based outreach centers. The decentralization of HIV services through satellite sites and outreaches increases accessibility of these services for those who live in remote areas. As such, this is an important component of the AIDSRelief strategy to reduce loses to follow-up and promote patient retention. All LPTFs have outreach teams led by a community nurse or a clinical officer. These teams are linked with community based volunteers, many of whom are PLWHAs, emphasize adherence to clinical appointments and assist the facilities in tracking patients who have missed appointments. As a result there has been very good retention rate for patients in care. The teams also provided community based and household preventative services which included education on the importance of disclosure, prevention among positives, using Insecticide Treated Mosquito Nets (ITNs), basic hygiene, use of safe water and good nutrition. The teams have also been trained to provide basic health and symptom assessments and to refer ill patients to the parent facility for timely medical management. These strategies are intended to limit mortality and morbidity among patients in care who have not yet qualified for ARVs.

The AIDSRelief program emphasizes the strengthening linkages among the different services provided at the LPTFs and among the LPTFs and other service providers. This increases overall service delivery, and ensures greater coordination and integration of services provided within the community. In particular, the referral linkages between ANC, PMTCT and ART services enable HIV positive mothers who don't yet require ARVs, their partners and their exposed babies to access ART services including community follow-up. This promotes partner testing and loses to follow-up of women and their infants after delivery. The program has recognized the strong link between access to nutritional support and the successful provision of care to HIV infected individuals. However, providing this access remains a significant challenge. LPTFs have been encouraged to link with other organization able to provide food, especially for severely malnourished PHAs. Training and guidance (national guidelines in nutrition and HIV/AIDS) is provided to staff at LPTFs so that they can conduct nutritional assessment, education and counseling at facility and community and clinical levels.

AIDSRelief also employs a training model that includes didactic trainings, on site supportive supervision and clinical preceptorship for service providers, with a special emphasis on maximizing the role of nurses, adherence counselors and community workers. Activities included training of health workers in improved pain and symptom evaluation and control; recognition of signs and symptoms opportunistic infections and other common illnesses and appropriate referral for management. Activities include comprehensive training for 720 non-medical community workers as well as 290 medical staff to support and maintain care and treatment for all PLWHAs and their home caregivers. Extensive technical support is also provided to all LPTFs through quarterly week-long site visits made by the technical team and regular comprehensive CMEs.

FY 2010 activities

In FY2010 AIDSRelief AIDSRelief will continue to support a comprehensive and integrated continuum of care for HIV infected patients building on existing services at the LPTFs. Services provided will comprise psychosocial support, prevention for positives, clinical follow-up and assessment for ART eligibility, laboratory testing (including CD4), treatment of opportunistic infections, HIV associated conditions and other illnesses, and nutrition counseling and education for the 43,146 adult HIV + patients enrolled in care in 18 LPTFs and their satellites. AIDSRelief will also be strengthened linkages with other health facility services, especially for PMTCT and TB. Technical support activities will be concentrated in these areas of focus: On consolidating the quality of services provided at existing LPTFs and satellite sites in order to support the 43,146 adult and adolescent patients in care; on building capacity at LPTFs for greater technical independence in view of transitioning; on the devolution of services to alternate cadres of service providers through 'task shifting,' networking with other service providers, and on greater integration into the overall Ministry of Health response in view of sustainability.

At the LPTFs, the strategy for task-shifting will focus on protocols enabling nurses and other cadres be more involved in the routine follow-up of stable patients, in the management of non-critical acute symptoms, in routine medication dispensing to stable patients; in routine TB screening of patients and in the recognition of patients requiring transition from care onto treatment.

The AIDSRelief technical team will continue to provide comprehensive training and technical assistance to 200 medical and 30-40 non-medical staff aimed at increasing the capacity of LPTFs to appropriately manage patients with HIV infection. This technical assistance will target the recognition and management of opportunistic infections (particularly TB), treatment failure, adult counseling, and psycho-social assessments.

AIDSRelief will follow-up didactic training with on- site clinical mentorship for clinicians and site level support for other cadres of workers. AIDSRelief will continue the development a network of model centers from exemplary LPTFs, where practitioners can gain practical clinical experience in a controlled setting. Regional Continuous Medical Education Sessions and Partner Forums will complement LPTF's staff training, allowing experience sharing, and reinforcing knowledge and skill transfer from AIDSRelief technical staff. The AIDSRelief team will develop a training and mentorship program that prepares senior medical officers, clinical officers, nurses and counselors at the LPTFs to provide supportive supervision and mentorship to dependent satellites and to newly hired staff. A structured program of nurse refill services will also be implemented at selected LPTF

At the community level, AIDSRelief will encourage further development of community based satellite clinics and outreach staffed by clinical officers and nurses for the routine care of stable patients and a community health team for the delivery of home based care and medications; this will include the development of linkages to MoH supported village health teams. The decentralization of HIV services through the use of satellites and outreach will aim at increasing access to those who live in remote areas. This approach reinforces AIDSRelief's model of providing integrated services to families at the community level by inter-linking facility-based health providers and community health workers and volunteers in order to meet the needs of HIV/AIDS patients. AIDSRelief will continue providing education on the importance of using ITNs, basic hygiene and good nutrition at household and community levels. It will further enhance its community health programs by promoting family-based care through home-based symptom monitoring, disclosure counseling, comprehensive secondary prevention (prevention among positives), and family-based testing and education.

In FY 2010, LPTF community volunteers will continue to support patients in care through the dissemination of HIV care and prevention literacy. AIDSRelief will identify gaps in the media and adapt or develop locally appropriate Information Education and Communication (IEC) and Behavior Change Communication (BCC) materials on prevention, care, and treatment of HIV. AIDSRelief will also assist LPTF develop networks with PLHA groups serving as volunteers in the community to strengthen adherence programs. Emphasizing the importance of adherence and community linkages at all AIDSRelief supported sites has enabled the program to achieve high rates of retention.

The program will also strengthen linkages with other service providers operating within the communities served by AIDSRelief supported facilities. Current relationships with organizations such as PACE and UHMG (Uganda Health Marketing Group) will be strengthened in order to increase access to ITNs (to prevent spread of malaria) and clean water at all LPTFs. In addition, the program will link LPTFs to the Ministry of Health to access cotrimoxazole and malaria treatment. Reinforcing the integration of services that can be accessed through LPTFs will enhance the overall package of care available to adults.

AIDSRelief implements the OVC program along side its care and treatment programs targeting children ages 0-17 years, which are infected with and/or affected by HIV. The goal of the OVC program is to increase access to services for children infected with and/or affected by HIV. The program directly provides psychosocial support to OVC as one of the OVC core program areas and ensures that linkages for other OVC core services are created to reduce the OVC service gap.

During FY010, the OVC program will focus on strengthening families, community support and coordination as well as increasing data development for use in strategic planning. All 18 AIDSRelief LPTFs will work with community leadership to mobilize the caregivers and children to respond to the identified needs of the vulnerable children aged 0-17years (male and female). The identified needs will include food security, with special focus on training and supporting households with food production (e.g. Kitchen Gardens, support with farms inputs and seeds). In addition to provision of inputs, the program will also train caregivers and OVC peer leaders in nutritious feeding, safe food storage and appropriate use. This intervention will target the entire household while directly working with the caregivers who will, in turn, work with their children to improve food security within their respective households. A total of approximately 2000 care givers/households will be trained and receive seeds to do kitchen gardens which will in turn benefit a total of 8000 children .

Education support will be extended to children in primary and secondary schools. The program will support the government initiative to promote universal primary and secondary education in government funded schools. Children will be provided with scholastic materials such as exercise books, pens/ pencils, school uniforms. Those already out of school OVC will be encouraged to return to school to complete at least senior four while others will be linked to other organizations supporting vocational skills training. A total of 6400 children are expected to be supported with education. Indirectly, the program will reach out to the 0-5 year olds through their caregivers by providing training programs in early childhood development, with specific emphasis on communication skills with children, socialization, self confidence, and motor skills.

Psychosocial support will be a cross cutting activity during FY010. The program will continue to ensure that it provides a comprehensive OVC psychosocial package that caters for the provision of age appropriate life skills to meet their social, physical, emotional and spiritual needs. A total of 8000 OVC both infected with and affected by HIV will be targeted.

This program will mainly be implemented through the OVC peer support groups already formed at each AIDSRelief implementing site (at the community level). These groups will be encouraged to come up with innovative ways to engage and sensitize members about various issues of concern to the OVC. Each group will be attached to one or two community volunteers who will act as the patron of the group. Such innovative ideas might include activities like music, dance and drama, weekly sensitization meetings and methods for economic empowerment.

Retreats will also be major activity to be implemented under psychosocial support and these will be organized twice a year. The purpose of the retreats is to promote peer to peer learning. HIV awareness talks will also be conducted during the retreats by the counselors and community health workers.

Community mobilizations for voluntary counseling and testing will be done to ensure that caregivers are aware of their HIV status as well as their children's status and thus be able to obtain HIV support services early enough. Children found to be HIV positive and their caregivers will be referred to AIDSRelief sites for enrollment into care. A total of about 10,133 children are expected to be reached with VCT community services to be provided either through AIDSRelief or through leveraged support from organizations such as GOAL, TASO etc.

Child protection services will be another core program area to be implemented under the AIDSRelief OVC program. This program will ensure that children are protected from harm and abuse and can exercise their rights as elaborated in the UN convention on the rights of a child. The program recognizes that all children are vulnerable but orphans and children living with HIV or whose parents or guardians are living with HIV are more at risk of facing various forms of emotional, physical and psychological abuse, including neglect and exploitation. Children's rights need to be protected in full. During FY2010, the program will develop active collaboration and referral mechanisms with local authorities responsible for child protection and labor such as the probation officers under the police department and the women and child welfare officers within the local council administrative units. It will also support training of caregivers and older children and communities in child rights and conduct sensitization on rights to property inheritance. Trainings will also cover the recognition of signs of abuse and how to obtain appropriate support services from within their localities. This program will also work hand in hand with teachers and school authorities to create protective learning environments in school to encourage retention. A total of about 2000 care givers/ 8000 children will benefit from this program.

The program will also sensitize local authorities such as the local council representatives (women leaders, child welfare officers, youth leaders) as well as the community volunteers on the right of children to protection. One training per implementing site will be organized during the year targeting a total of ten leaders in each site.

Lastly, the program will continue to build capacities of health workers, social workers and community volunteers at LPTFs , enabling them to identify OVC both at the health facilities and in the community, enroll them into the program, and link them for comprehensive OVC packages. Specific regional trainings in OVC management will be provided for LPTF health workers and volunteers with facilitators from the consortium member staff and Ministry of Health, Ministry of Gender, Labor and Social development. The trainings for health workers will enhance skills for providing OVC friendly services such as empathy skills, counseling and listening skills as well supervision and monitoring of OVC activities. Training for community health workers will include identification and referral of sick OVC to health facilities for necessary health services. A total of 600 health workers and community volunteers / OVC peer educators will be trained.

With respect to strategic information activities, Futures Group International will continue to utilize paper-based and computerized patient monitoring and management systems. All the 18 LPTFs will continue to receive site visits and technical assistance, in order to ensure continued quality data collection, data entry, date validation, analysis and dissemination of findings across a range of stakeholders. In FY 2010, further efforts will be made to track OVC at community level using existing infrastructure and resource persons like community volunteers. LPTF staff will be trained to acquire additional skills in tracking, monitoring and reporting on OVC activities using the update OVC tracking tools. The training will also focus on understanding the various definitions of OVC activities, core program areas and as well as means of avoiding double counting.

Sustainability lies at the heart of the AIDS Relief program, and is based on durable therapeutic programs and health systems strengthening. AIDSRelief will focus on the transition of management or care and treatment activities to indigenous organizations by actively using its extensive linkages with faith based groups and other key stakeholders to develop a transition plan that is appropriate to the Ugandan context. The plan will be designed to ensure the continuous delivery of quality OVC ctivities to be implemented in close collaboration with the Government of Uganda to ensure coordination, information sharing and long term sustainability. For the transition to be successful, sustainable institutional capacity must be present within the indigenous organization and the LPTFs they support, therefore, the AIDSRelief will strengthen the selected indigenous organizations according to their assessed needs, while also continuing to strengthen the health systems of the LPTFs.

AIDSRelief provides a comprehensive care and treatment program emphasizing strong links between PLWHAs, their family, communities and the health institutions. Its goal is to ensure that people living with HIV/AIDS have access to Antiretroviral Therapy (ART) and quality medical care in order to prolong their lives and to enhance its quality. As of the end of February 2009, AIDSRelief in Uganda will be supporting 18 LPTFs and 33 satellite sites to provide antiretroviral treatment to 22,908 adult patients.

The adult care and treatment component has built on existing clinical and social services in all LPTFs extending the scope and reach of these services by integrating facility based care delivery systems with community and home-based mechanisms for delivering care and treatment support. This is accomplished by employing networks of community-based organizations, community health workers and volunteers, treatment supporters and patient support groups. The program provides adult and adolescent men and women with 1st line, alternative 1st line, and 2nd line therapies. To date the program has provided ARV treatment to more than 22,000 adult patients. The choice of first line regimens supported by the program are consistent with national guidelines while using best evidence for optimizing tolerability, limiting toxicity, reducing pill burden and preserving the activity of second line options. In addition, the comprehensive care package that the program supports includes access to routine scheduled clinical follow-up, access to unscheduled clinical visits for the management of acute illness and routine CD4 testing for monitoring patient response to therapy. It provides access to targeted clinically driven viral load testing to assist in the management of patients whose response to treatment is not readily ascertained by clinical and immunologic means alone. In addition to assuring access, through MOH, donor and private means, to cotrimoxazole prophylaxis and alternatives for sulfa-allergic for all patients, the program provides for comprehensive diagnosis and treatment of opportunistic infections and HIV associated conditions including but not limited to TB, cryptococcal meningitis, pneumocistis jeroverci, Kaposi's sarcoma; diagnosis and treatment for other acute illnesses including but not limited to malaria, community acquired pneumonia; hospitalization linkages for enrolled patients; and with the management of co-morbid chronic conditions such as cardiovascular disease, diabetes and hypertension; routine health screening including TB, STI and pregnancy screening.

In Y2010 AIDSRelief will explore the possibility of piloting routine cervical cancer screening for women as well as the introduction of INH prophylaxis for patients with preserved immune systems, evidence of TB exposure and no evidence of active TB disease. The AIDSRelief OI Drug Policy and treatment manual, including a list of essential OI drugs and reporting template, provides a guide to the sites in the procurement, utilization and reporting on consumption of OI and other non-ARV drugs used in the program.

AIDSRelief encourages and supports LPTFs to open satellite clinics and outreach centers. The decentralization of HIV services through satellites and outreaches increases accessibility of these services for those who live in remote areas, facilitates clinical follow-up, monitoring of adherence and tracking of patients who may be lost to follow-up. All LPTFs have outreach teams led by a community nurse or a clinical officer. These teams were linked with community based volunteers, many of who are PLWHAs themselves on treatment. These volunteers are trained to assess for side effects and to monitor adherence at the community and in patient's homes. These teams are an integral component of the structured treatment preparation and treatment support program that is emphasized by AIDSRelief. This program includes an emphasis on disclosure to a partner, family member or close friend, on treatment buddies, home visitation, membership in a support group, individual and group treatment preparation sessions, on going facility and community based adherence assessment and counseling. As a result there has been very good retention rate for patients on ART and an average adherence rate of over 95%. The teams also provided community based and household preventative services which included education on the importance of using ITNs, basic hygiene and good nutrition.

The AIDSRelief program emphasizes maintaining and strengthening linkages and networks among the different services provided at the LPTFs and among the LPTFs and other service providers. These linkages promote a more efficient provision of health care delivery by promoting overall health systems strengthening. In particular, the referral linkages between ANC, PMTCT and ART services enable HIV positive mothers, their partners and their babies to access ART services at the facilities. This promotes greater male involvement, facility based delivery; and reduces losses to follow-up of positive mothers and their exposed infant.

AIDSRelief employs a training model that includes didactic sessions, on site supportive supervision and clinical mentorship, and periodic CMEs for service providers. The program emphasizes maximizing the role of nurses, adherence counselors, dispensers and community workers. Activities include training of health workers in improved pain and symptom evaluation and control, recognition of and appropriate referral for management of signs and symptoms of ARV toxicity, treatment failure and opportunistic infections (OIs).

In addition to the use for routine CD4 testing for monitoring response to treatment, AIDSRelief evaluates the clinical outcomes of the program by systematically relating patient outcome measures such as viral suppression rates, adherence, and treatment support models to program level characteristics at each LPTF. This assessment is done on a random selection of 15% of the patients on treatment. This assessment has demonstrated viral suppression rates over 15 months of greater than 85%.

FY 2010 activities

In FY2010 AIDSRelief support will comprise provision of ARVs, OI drugs, laboratory supplies and technical assistance to the LPTFs. Technical support activities will be concentrated in the following areas of focus: On consolidating the quality of services provided at existing LPTFs and satellite sites; on building capacity at LPTFs for greater technical independence in view of transitioning; and on the devolution of services to alternate cadres of service providers through 'task shifting', on networking with other service providers, and on greater integration into the overall Ministry of Health response in view of sustainability. At the LPTFs, the strategy for task-shifting will focus on protocols enabling nurses and other cadres to be more involved in the routine follow-up of stable patients, in the management of non-critical acute symptoms, and routine medication dispensing to stable patients. This will increase service delivery, and ensure greater coordination and integration of services provided within the community.

The AIDSRelief technical team will continue to provide comprehensive training and technical assistance to medical and non-medical staff aimed at increasing the capacity of LPTFs to appropriately manage patients with HIV infection. This technical assistance will target the recognition and management of opportunistic infections (particularly TB), treatment failure, adult counseling, and psycho-social assessments. AIDSRelief will follow-up didactic training with on- site clinical mentorship for clinicians and site level support for other cadres of workers. Regional Continuous Medical Education Sessions and Partner Forums will complement LPTF's staff training, allowing experience sharing, and reinforcing knowledge and skill transfer from AIDSRelief technical staff. The AIDSRelief team will develop a training and mentorship program that prepares senior medical officers, clinical officers, nurses and counselors at the LPTFs to provide supportive supervision and mentorship to dependent satellites and to newly hired staff. A structured program of nurse refill services will also be implemented at selected LPTFs.

At the community level, AIDSRelief will encourage further development of community based satellite clinics and outreaches staffed by clinical officers and nurses for the routine care of stable patients and a community health team for the delivery of home based care and medications; this will include the development of linkages to MoH supported village health teams. The decentralization of HIV services through the use of satellites and outreach will aim at increasing access to those who live in remote areas. This approach reinforces AIDSRelief's model of providing integrated services to families at the community, satellite sites and LPTFs level by inter-linking facility-based health providers and community health workers and volunteers in order to meet the need of HIV/AIDS patients. AIDSRelief will further enhance its community health programs by promoting family-based care through symptom monitoring, disclosure counseling, secondary prevention, and family-based testing and education.

In FY 2010, LPTF community volunteers will continue to support patients on therapy, but will additionally disseminate HIV care and prevention literacy. AIDSRelief will identify gaps in the media and adapt or develop locally appropriate Information Education and Communication (IEC) and Behavior Change Communication (BCC) materials on prevention, care, and treatment of HIV. AIDSRelief will also assist LPTF to strengthen networks with PLHA groups serving as volunteers in the community to strengthen adherence programs. Emphasizing the importance of adherence and community linkages at all AIDSRelief supported sites has enabled the program to achieve high and durable viral suppression.

In FY2009 AIDSRelief procured test kits to carry out tests through community outreaches and at the health facilities. The program, in addition, integrated counseling and testing services into AB and OVC activities. This encouraged couples who participated in the Faithful House trainings and the youth who participated in the Value of Life trainings to undergo HIV testing. The program encouraged LPTFs to strengthen their linkages with the Ministry of Health for additional support in provision of HIV Test kits to supplement on those procured by AIDSRelief.

AIDSRelief has built strong community networks and has also provided mentoring at all LPTFs on counseling and testing. In Northern Uganda Community based organization Comboni Samaritans of Gulu, Meeting Point and Christian HIV/AIDS Prevention and Support (CHAPS) have been following up patients on ART treatment as well as carrying out community mobilization and sensitization. In other LPTFs AIDSRelief has encouraged the enrollment of community volunteers who have played a key role in mobilizing the community, linking them to counseling and testing facilities. The clients that test positive are further linked to AIDSRelief care and treatment facilities. Those that test negative are encouraged to join existing community groups that assist in the retention of the negative HIV status.

In FY2010, through greater coordination and integration of services provided within the community by networking with other service providers including the Ministry of Health, AIDSRelief will endeavor to strengthen counseling and testing services. In the area of testing and counseling the program will focus on three essential aspects: strengthening the capacity of LPTFs to perform CT at satellites, at community outreaches; integrating RTC in all clinical areas of the facilities it supports; enhancing referral networks between the LPTFs and other service providers in their areas to ensure that all patients identified as positive are referred to HIV care and services. Due to limited funding AIDSRelief will support LPTFs to build strong referral networks to access C&T and those people who test positive are referred for care and treatment to other service providers.

Decentralizing counseling and testing services to satellite sites, community outreaches and integrating RCT will enable community members to have easier access to testing and counseling services and will increase HIV status awareness particularly among under-represented populations such as men and children in line with Ministry of Health Guidelines. Community volunteers, especially people living with HIV/AIDS (PLHA) who have been trained on how to engage communities, will mobilize communities to come for these services and will continue to be supported in this role by AIDSRelief. These will serve as key agents in linking household members, communities and CT services. The existing system of networks from the service provision all the way to the household level will ensure that couples, children and adolescents receive CT services in line with the Ministry of Health Guidelines.

In FY2010, AIDSRelief will continue to emphasize the importance of providing pediatric CT services in line with the Ministry of Health Guidelines. This emphasis will be supported by ongoing pediatric counseling training aimed at enhancing the capacity of LPTFs to increase the number of children being tested for HIV.)

In FY2010, AIDSRelief will support LPTFs to provide CT services through which the program expects to have 40,000 people tested, counseled and receiving their results. In order to address LPTFs challenges of test kits shortages, AIDSRelief will strengthen the linkages of the sites with MOH supply chain system and will purchase kits for 8,000 tests to temporarily fill the gap created. Linkages will be created between the MCH, out- and in-patient departments promoting routine counseling and testing and targeting families of infected patients. A concerted effort will be made to reach adolescents through collaborations with organizations that target adolescent services.

AIDSRelief will further strengthen the existing PLHA networks and will utilize them to sustain the active referral systems between communities and care and treatment services. Community volunteers will be trained to increase knowledge on HIV care and treatment and to reinforce their role in conducting community sensitization on CT services. A total of 200 health workers and 30-40 community volunteers will be trained.

AIDSRelief will support the LPTFs to integrate Counseling and testing services within the AB trainings and community activities that focus on OVCs. This will encourage couple testing as well as the OVCs will know their HIV status and those that are positive will be linked into care and treatment facilities.

Coordinated by Futures Group International, strategic information (SI) activities incorporate program level reporting, enhancing the effectiveness and efficiency of both paper-based and computerized patient monitoring and management (PMM) systems, assuring data quality and continuous quality improvement, and using SI for program decision making across all LPTFs. AIDSRelief has built a strong PMM system using in-country networks and available technology at 18 LPTFs in FY 2009. In FY 2010, it will ensure compilation of complete and valid HIV patient treatment/ARV data; enhance analysis of required indicators for quality HIV patient treatment and ARV program monitoring and reporting; and provide relevant, LPTF-specific technical assistance to develop specific data quality improvement plans. The program will promote M&E systems through a Training of Trainers (TOT) and peer to peer training model in SI, where "expert" LPTF staff will train others in various skills. AIDSRelief will promote the data use culture, to enable LPTFs use data for informed clinical decisions and adaptive management. The program will work with LPTFs to document and report individuals counseled, tested, and received results, including family members. This information will show those eligible to enroll into care, discordant couples, and those who should be targeted with prevention messages. Technical assistance will be provided to LPTFs on how to eliminate double counting of repeat testers, identifying clients testing under other program areas such as PMTCT and TB, and putting in place data collection tools to track CT information

In FY 2010, the program will work with LPTFs to implement and strengthen integration of the HIV clinics into mainstream hospital/facility M&E systems. This will involve: cross program training on different data needs and indicators; linking both paper and electronic data collection and storage systems for the facilities; working with LPTF management and boards to understand and respond to their data demand and information use needs; use the data to inform and support decisions for the HIV clinics and entire facility. It will also involve organizing joint meetings to share information. To enhance data access and utilization across a wide spectrum of the facility, various sections within the facility will be linked to the patient management system, and staff trained in the use of the system.

Sustainability lies at the heart of the AIDSRelief program, and is based on durable therapeutic programs and health systems strengthening. AIDSRelief will focus on the transition of the management of care and treatment activities to indigenous organizations by actively using its extensive linkages with faith based groups and other key stakeholders to develop a transition plan that is appropriate to the Ugandan context. The plan will be designed to ensure the continuous delivery of quality HIV care and treatment, and all activities will continue to be implemented in close collaboration with the Government of Uganda to ensure coordination, information sharing and long term sustainability. For the transition to be successful, sustainable institutional capacity must be present within the indigenous organizations and LPTFs they support; therefore, AIDSRelief will strengthen the selected indigenous organizations according to their assessed needs, while continuing to strengthen the health systems of the LPTFs. In FY2010, the program will support linkages between LPTFs and the MOH to tap into locally available training institutions.

AIDSRelief supports a comprehensive continuum of care for children and adolescents (male and female) below the age of 18 living with HIV with the goal of prolonging their lives while enhancing its quality. These services are provided at 18 hospitals and clinics and at associated satellites across Northern, Western and Central Uganda. The pediatric care and support component builds on existing clinical and social services in all LPTFs, extending the scope and reach of these services by integrating facility based care delivery systems with community and home-based mechanisms. This is accomplished by employing networks of community-based organizations, community health workers and volunteers, treatment supporters and patient support groups.

The program provides access to a comprehensive care package focused on a holistic family-centered approach. This package includes routine scheduled clinical follow-up, access to unscheduled clinical visits for the management of acute illness and routine CD4 testing for all patients enrolled in care. In addition it provides for comprehensive diagnosis and treatment of opportunistic infections and HIV associated conditions including but not limited to TB, cryptococcal meningitis, pneumocistis jeroverci, Kaposi's sarcoma; diagnosis and treatment for other acute illnesses including but not limited to malaria, community acquired pneumonia; hospitalization linkages for enrolled patients; routine health screening including TB and, where appropriate, STI and pregnancy screening. The AIDSRelief OI Drug Policy and treatment manual, including a list of essential OI drugs and reporting template, provides a guide the sites in the procurement, utilization and reporting on consumption of OI and other non-ARV drugs used in the program.

The AIDSRelief family centered approach acknowledges the central role of the family as the unit of health care provision for children and adolescents. It also acknowledges the importance of delivering health care service to children in a manner that is 'child-friendly and that engages the child whenever possible as an active, essential and valued participant in their health care. This includes the provision of a program of pediatric psycho-social support that encourages disclosure of their status to children when it is possible and appropriate.

The program has recognized the strong link between nutritional inputs and the provision of comprehensive HIV care for children. However this remains a significant challenge. While AIDSRelief supports limited access to therapeutic nutrition these resources are hardly sufficient to meet the need. To bridge the gap, LPTFs have been encouraged to link with other organizations to able to provide food, especially for severely malnourished patients. Training and guidance according to national guidelines in nutrition and HIV/AIDS is provided to staff at LPTFs so that they can conduct nutritional assessment, education and counseling at community and clinical levels.

In FY2010 AIDSRelief will concentrate on consolidating the quality of services provided at existing LPTFs and satellite sites. In many of the regions supported by AIDSRelief access to pediatric care and treatment services is limited. AIDSRelief has identified bringing more infants and children into care and treatment as an area of targeted expansion and urges increased funding for this. AIDSRelief will assure integration and linkages between ANC, Labor and Delivery Services, Maternal and Child Health and Immunization services to identify and enhance the follow-up of HIV infected mothers and their exposed children. AIDSRelief will maintain linkages with JCRC and other groups, which provide access to early infant diagnosis so that all HIV exposed infants delivered can be diagnosed in a timely manner, receive their results and be referred for comprehensive HIV care. To assure continuity of care and to minimize losses to follow-up all exposed children will be followed up in the ART program until they are at least 2 years old and are documented negative. After this they will continue to access services through the OVC program. Strengthening provider-initiated testing in out and inpatient pediatric services has also been recognized as an important strategy for identifying HIV infected children. Consequently, AIDSRelief will strengthen referral linkages among pediatric OPDs, pediatric inpatient services and the ART clinic in order to assure increased testing and that those children found positive are referred for comprehensive HIV care.

In FY2010, AIDSRelief will, in accordance with national guidelines promote prophylaxis with cotrimoxazole from 6 weeks of age with a goal of assuring that all exposed infants and positive children receive this service. In an effort to ensure that all children and their families have access to the basic care package, linkages with organizations such as PACE and UHMG will be strengthened in order to increase access to a basic health care package comprising ITNs and water guard. In addition, the program will continue to ensure that nutritional assessment, education and counseling are provided to caretakers and their children at LPTFs. The program will strengthen integration of the nutrition component into the LPTFs adherence and community outreach activities. In order to assure that all children receiving services at AIDSRelief supported facilities receive comprehensive age appropriate psycho-social counseling and treatment and adherence support, the AIDSRelief program will provide training and technical assistance to all service providers in the area of pediatric psycho-social counseling. This training and TA will utilize both the existing technical expertise within AIDSRelief as well as collaboration with regional networks such as ANNECA.

Task shifting to maximize human resources will be emphasized at facility and community levels. At LPTFs, the strategy will focus on using nurses and clinical officers for the routine follow-up of stable patients, using protocol driven nurse and clinical officer management of non-critical acute symptoms; nurses and pharmacy staff will also be trained in routine medication dispensing to stable patients. In line with a family centered approach to care, at the community level, AIDSRelief will encourage the development of community based satellite clinics and outreaches staffed by clinical officers/nurses/community health workers for the routine care of stable patients and the use of community health teams for the delivery of home based care and for medication delivery.

The decentralization of HIV services satellites and outreaches will increase access to those who live in remote areas. This approach reinforces AIDSRelief's model of providing integrated services to families at the community by inter-linking facility based health providers and community health workers and volunteers. AIDSRelief supported facilities are currently providing varying levels of home based care, ARV treatment support and community preventative services using outreach teams led by a community nurse or a clinical officer. The outreach teams coordinate with CHWs and community based volunteers, many of whom are motivated PLHAs themselves on treatment to support patients in their communities. Further development of these community health programs to provide integrated HIV care, support adherence and promote preventative services is critical to ensuring sustainable treatment programs and maximizing funding investments. Community health programs will be structured to promote family based care through symptom monitoring, disclosure counseling, secondary prevention, and family based testing and education. In addition, the LPTFs' community volunteers will be used as resources to support patients on therapy, disseminate HIV care and prevention literacy. AIDSRelief will adapt existing, locally appropriate Information Education and Communication (IEC) and Behavior Change Communication (BCC) materials. AIDSRelief will provide education on the importance of using ITNs, basic hygiene and good nutrition at household level and to communities. AIDSRelief will assist LPTF to strengthen their networks with PLHA groups who serve as volunteers in the community in support of adherence programs. AIDSRelief supports several LPTFs in Northern Uganda and will continue to assist them in developing outreach programs that provide support to those affected by internal displacement. The program will also strengthen linkages within the LPTFs, particularly those between PMTCT, TB and CT services with ART services. LPTFs will also be linked to organizations that provide community based therapeutic feeding programs to support the malnourished. In addition, the program will link LPTFs to the Ministry of Health to access cotrimoxazole and malaria treatment. Reinforcing LPTFs external and internal integration will ensure that core AIDSRelief care and treatment activities will be integrated with ancillary services and program activities of other providers in the same region.

Pediatric technical capacity is an area of emphasis for AIDSRelief. The program will continue to assure that all involved cadres of service providers have the capacity to provide age appropriate services to children. To accomplish this, the technical team, using a model of clinical training and on-site mentoring, will provide comprehensive pediatric training and technical assistance to medical and non-medical staff to increase the capacity of LPTFs to appropriately manage and monitor pediatric patients with HIV infection. AIDSRelief will provide training in pediatric counseling and will strengthen LPTF staff capacity to develop community based psycho-social assessments. AIDSRelief is developing a network of model centers where practitioners can gain practical clinical experience in a controlled setting. 12 Regional CME (including 3 focusing on pediatrics and 3 on PMTCT) and one partners' forum will complement LPTF's staff training, allow experience sharing and reinforce knowledge and skill transfer from AIDSRelief technical staff.

AIDSRelief provides a comprehensive care and treatment program emphasizing strong links between PLWHAs, their family, communities and the health institutions. Its goal is to ensure that people living with HIV/AIDS have access to Antiretroviral Therapy (ART) and quality medical care in order to prolong their lives and to enhance its quality. As of the end of February 2009, AIDSRelief in Uganda will be supporting 18 LPTFs and 33 satellite sites to provide antiretroviral treatment to 3,000 children.

The pediatric care and treatment component has built on existing clinical and social services in all LPTFs extending the scope and reach of these services by integrating facility based care delivery systems with community and home-based mechanisms for delivering care and treatment support. This is accomplished by employing networks of community-based organizations, community health workers and volunteers, treatment supporters and patient support groups. The program provides children and adolescents with 1st line, alternative 1st line, and 2nd line therapies. The choice of first line regimens supported by the program are consistent with national guidelines while using best evidence for optimizing tolerability, limiting toxicity, reducing pill burden and the preserving the activity of second line options.

The comprehensive care package that the program supports includes access to routine scheduled clinical follow-up, access to unscheduled clinical visits for the management of acute illness and routine CD4 testing for monitoring patient response to therapy. It provides access to targeted clinically driven viral load testing to assist in the management of patients whose response to treatment is not readily ascertained by clinical and immunologic means alone. In addition to assuring access to cotrimoxazole prophylaxis and alternatives for sulfa-allergic for all patients, the program provides for comprehensive diagnosis and treatment of opportunistic infections and HIV associated conditions including but not limited to TB, cryptococcal meningitis, pneumocistis jeroverci, Kaposi's sarcoma; diagnosis and treatment for other acute illnesses including but not limited to malaria, community acquired pneumonia; hospitalization linkages for enrolled patients; routine health screening including TB screening. In FY2010 AIDSRelief will initiate the introduction of INH prophylaxis for children with evidence of TB exposure and no evidence of active TB disease.

AIDSRelief in Uganda will provide antiretroviral treatment for 3,000 HIV-infected children below 15 years of age. In FY2010 AIDSRelief will concentrate on consolidating the quality of services provided at the existing LPTFs and satellite sites with the goal of maintaining these 3,000 pediatric patients on AIDSRelief provided ART (13%)

The program has recognized the strong link between nutritional inputs and the provision of successful HIV treatment for children. However this remains a significant challenge. While AIDSRelief supports access to therapeutic nutrition these resources are hardly sufficient to meet the need. To bridge the gap, LPTFs have been encouraged to link with other organizations to able to provide food, especially for severely malnourished patients. Training and guidance according to national guidelines in nutrition and HIV/AIDS is provided to staff at LPTFs so that they can conduct nutritional assessment, education and counseling at community and clinical levels.

In many of the regions supported by AIDSRelief access to pediatric care and treatment services is limited. AIDSRelief has identified bringing more infants and children into HIV care and treatment as an area of targeted expansion and urges increased funding for this. AIDSRelief will assure integration and linkages between ANC, Labor and Delivery Services, Maternal and Child Health and Immunization services to identify and enhance the follow-up of HIV infected mothers and their exposed children. AIDSRelief will maintain linkages with JCRC and other groups which provide early infant diagnosis so that all HIV exposed infants delivered can be diagnosed in a timely manner receive their results and be referred for comprehensive HIV care. To assure continuity of care and to minimize losses to follow-up all exposed children will be followed up in the ART program until they are at least 2 years old and are documented negative. After this they will continue to access services through the OVC program at least until the age of 5 years. Strengthening provider-initiated testing in outpatient and inpatient pediatric services has also been recognized as an important strategy for identifying HIV infected children. Consequently, AIDSRelief will strengthen referral linkages among pediatric OPDs, pediatric inpatient services and the ART clinic in order to assure increased testing and that those children found positive are referred for comprehensive HIV care.

In FY2010, AIDSRelief will promote prophylaxis with cotrimoxazole from 6 weeks of age. In an effort to ensure that all children and their families have access to the basic care package, linkages with organizations such as PACE and UHMG will be strengthened in order to increase access to a basic health care package comprising ITNs and water guard. In addition, the program will continue to ensure that nutritional assessment, education and counseling are provided to mothers/caretakers and their children at LPTFs. The programs will strengthen integration of the nutrition component into the LPTFs adherence and community outreach activities in order to assure that all children receiving services at AIDSRelief supported facilities receive comprehensive age appropriate psycho-social counseling and treatment and adherence support, the AIDSRelief program will provide training and technical assistance to all service providers in the area of pediatric psycho-social counseling. This training and TA will utilize both the existing technical expertise within AIDSRelief as well as collaboration with regional networks such as ANNECA.

Task shifting to maximize human resources will be emphasized at facility and community levels. At LPTFs, the strategy will focus on using nurses and clinical officers for the routine follow-up of stable patients, using protocol driven nurse and clinical officer management of non-critical acute symptoms; nurses and pharmacy staff will also be trained in routine medication dispensing to stable patients. In line with a family centered approach to care, at the community level, AIDSRelief will encourage the development of community based satellite clinics and outreaches staffed by clinical officers/nurses/community health workers for the routine care of stable patients and the use of community health teams for the delivery of home based care and for medication delivery.

The decentralization of HIV services satellites and outreaches will increase access to those who live in remote areas. This approach reinforces AIDSRelief's model of providing integrated services to families at the community by inter-linking facility based health providers and community health workers and volunteers. AIDSRelief supported facilities are currently providing varying levels of home based care, ARV treatment support and community preventative services using outreach teams led by a community nurse or a clinical officer. The outreach teams coordinate with CHWs and community based volunteers, many of whom are motivated PLHAs themselves on treatment to support patients in their communities. Further development of these community health programs to provide integrated HIV care, support adherence and promote preventative services is critical to ensuring sustainable treatment programs and maximizing funding investments. Community health programs will be structured to promote family based care through symptom monitoring, disclosure counseling, secondary prevention, and family based testing and education. In addition, the LPTFs' community volunteers will be used as resources to support patients on therapy, disseminate HIV care and prevention literacy. AIDSRelief will adapt existing, locally appropriate Information Education and Communication (IEC) and Behavior Change Communication (BCC) materials. AIDSRelief will provide education on the importance of using ITNs, basic hygiene and good nutrition at household level and to communities. AIDSRelief will assist LPTF to strengthen their networks with PLHA groups who serve as volunteers in the community in support of adherence programs. AIDSRelief supports several LPTFs in Northern Uganda and will continue to assist them in developing outreach programs that provide support to those affected by internal displacement. The program will also strengthen linkages within the LPTFs, particularly those between PMTCT, TB and CT services with ART services. LPTFs will also be linked to organizations that provide community based therapeutic feeding programs to support the malnourished. In addition, the program will link LPTFs to the Ministry of Health to access cotrimoxazole and malaria treatment. Reinforcing LPTFs external and internal integration will ensure that core AIDSRelief care and treatment activities will be integrated with ancillary services and program activities of other providers in the same region.

Pediatric technical capacity is an area of emphasis for AIDSRelief. The program will continue to assure that all involved cadres of service providers have the capacity to provide age appropriate services to children. To accomplish this, the technical team, using a model of clinical training and on-site mentoring, will provide comprehensive pediatric training and technical assistance to medical and non-medical staff to increase the capacity of LPTFs to appropriately manage and monitor pediatric patients with HIV infection. AIDSRelief will target the recognition and management of medication side effects, treatment failure and opportunistic infections (particularly TB), and will provide training in pediatric counseling and will strengthen LPTF staff capacity to develop community based psycho-social assessments. AIDSRelief will follow-up didactic training with on- site clinical mentorship for clinicians and site level support for other cadres of workers. Regional CME s and partners' forums will complement LPTF staff training, allow experience sharing and reinforce knowledge and skill transfer from AIDSRelief technical staff. The AIDSRelief team will develop a training and mentorship program that prepares senior medical officers, clinical officers, nurses and counselors at the LPTFs to provide supportive supervision and mentorship to dependent satellites and to newly hired staff. A structured program of nurse refill services will also be implemented at selected LPTF

The AIDSRelief program emphasizes maintaining and strengthening linkages and networks among the different services provided at the LPTFs and among the LPTFs and other service providers. These linkages promote a more efficient provision of health care delivery by promoting overall health systems strengthening. In particular, the referral linkages among ANC, PMTCT, MCH, pediatric inpatient and ART services enable HIV affected families and their children and infants to access ART services at the facilities.

In addition to the use for routine CD4 testing for monitoring response to treatment, AIDSRelief evaluates the clinical outcomes of the program by systematically relating patient outcome measures such as viral suppression rates, adherence, and treatment support models to program level characteristics at each LPTF. This assessment is done on a random selection of 15% of the patients on treatment. This assessment has demonstrated viral suppression rates over 15 months of greater than 85%.

AIDSRelief supports partners to strengthen behavior change activities aimed at reducing the risk of HIV transmission due to multiple and concurrent sexual partners. With the main focus continuing to be on the promotion of abstinence and being faithful, some additional prevention activities will also be included in COP 2010.

Abstinence will be encouraged through building the confidence of the youth to delay sexual debut until marriage and through empowering the already sexually active youths and adolescents with life skills to practice secondary abstinence. This will be accomplished through the using the "Value of Life" curriculum to train the youth and adolescents. The intervention will reach 6,762 males and 7038 females, ages 10-14 and 16170 males and 16,830 females ages 15-24.Faithfulness is encouraged through community sensitization and training using the "Faithful House" curriculum for the married couples through small focused trainings. A total of 13,200 married persons will be reached through trainings conducted by 18 LPTFs and three community based organizations.

A total of 541 people already trained as facilitators for both curricula will carry out the trainings. Facilitators will train couples, youth and adolescents at community level. Prevention priorities will include: behavior change, risk reduction, risk avoidance, counseling and testing, education to patients, community health and secondary prevention. AB activities will be integrated with the PMTCT, OVC, care and treatment activities through linkages. Pregnant women testing negative in ANC will be encouraged to attend the trainings with their spouses. To promote male involvement, spouses of PMTCT mothers will be invited to attend the Faithful House curriculum trainings where they will be able to access VCT services so that those testing HIV positive can be linked to the ART clinic. LPTFs will receive technical assistance in the area of prevention with mentoring and coaching.

HIV positive persons shall further be linked to facilities that provide care and support, while negative couples and youths will form support groups that help them to maintain their status through behavior change enhancement and mutual support. Secondary prevention messages will also be further integrated into the care and treatment activities at the LPTFs through providing training to counselors, social workers and nurses in positive prevention. In addition an emphasis will be put on discordant couples to adopt risk reduction strategies.

Coordinated by Futures Group International, strategic information (SI) activities incorporate program level reporting, enhancing the effectiveness and efficiency of both paper-based and prevention activities monitoring and management (PMM) systems, assuring data quality and continuous quality improvement, and using SI for program decision making across all LPTFs. AIDSRelief has built a strong PMM system using in-country networks and available technology at 18 LPTFs. Futures Group International carries out site visits to all LPTFs to provide technical assistance to ensure continued quality data collection, data entry, data validation and analysis, and dissemination of findings across a range of stakeholders. Using standard data collection tools, the program tracks and reports on Sexual Prevention activities.

AIDSRelief will continue to encourage increased uptake of comprehensive PMTCT services at 18 LPTFs. The program will directly support a comprehensive package of PMTCT and HIV care services at 10 LPTFs. The key strategies the program will include: primary prevention of HIV infection among women of child bearing age through AIDS education, behavior change programs at the LPTFs and communities; clinical and immunological staging of HIV positive women; prevention of mother to child transmission of HIV through the provision of ARV prophylaxis and HAART where appropriate, promotion of exclusive breast feeding or replacement feeding where AFFAS through infant and young child feeding counseling and support and support for maternal nutrition; promotion of male partner involvement and testing; increased access to care and treatment for HIV infected women, their infected children and their families through the promotion of linkages between ANC, MCH and ART services; community follow-up of pregnant and breast-feeding mothers and exposed infants to promote the timely delivery of ARV prophylaxis to infants not delivered in health care facilities, early infant diagnosis and to minimize loses to follow-up.

The primary focus of the program will be on the following groups: HIV + pregnant who have been identified from ANC, Delivery Suite or MCH clinic; HIV+ women on ART who become pregnant; HIV + women in non-ART care who become pregnant, and HIV exposed and HIV positive children.

In FY2010, AIDSRelief proposes to reach 40,000 pregnant women with HIV counseling and testing for PMTCT and 2,800 HIV + pregnant women and their exposed infants (2800) with antiretroviral prophylaxis, in accordance with Uganda National Guidelines and supported by treatment preparation and adherence support. The program will strengthen the linkages between the ANC and ART clinics, and ensure that the community component of the PMTCT program is also strengthened. This will be promoted through LPTF/field exchange visits and technical support visits. Through the ART clinic, the program will provide ARVs for treatment, and will supplement ARVs for provided by the Ministry of Health. Existing PMTCT focal persons will be supported to ensure that the referral linkage between the ART clinic, ANC, Labour and Delivery and MCH clinic are in place and fully operational. AIDSRelief will provide CD4 testing for all HIV positive women pregnant women and those eligible will be initiated onto HAART.

HIV positive infants will be enrolled into care. AIDSRelief laboratory staff will facilitate the collection of DBS for early infant diagnosis and these will be sent to JCRC centers for laboratory investigations per the collaboration between AIDSRelief and JCRC. The HIV infected infants/children will be linked to the AIDSRelief treatment clinics for pediatric care and treatment.

For FY 2010, community activities will include the following: Increased male partner involvement, strengthening existing mother-to-mother support groups and initiating additional groups, supporting already existing psychosocial support groups, community outreaches for ANC, strengthening TBA and LPTF collaborations as a strategy to increase delivery at health facility, community sensitization in regard to PMTCT', strengthening community follow up of the pregnant/lactating mother and her infant.

AIDSRelief has strong community programs and strategies already in place to promote primary prevention through various community mobilization and sensitization programs targeting the women of child bearing age. Through its AB prevention strategy, AIDSRelief will focus on training couples to promote faithfulness in their marriages in order to maintain their HIV negative status or to encourage open communication and disclosure among HIV positive or discordant couples. All women who attend the antenatal clinic and live in an area where a Faithful House training will take place, will be linked and encouraged to attend the training together with their spouses. The spouses will be tested and if positive will be referred to care facilities at the AIDSRelief LPTFs for counseling in prevention of infection to their partners. The PMTCT program will continue to be emphasize strong community outreach and follow-up of all HIV positive women during pregnancy and after delivery. HIV positive pregnant women will be linked with a community volunteer, who will follow up with her through home visits to promote adherence to treatment, provide information about PMTCT, and to encourage her and her family members to deliver her baby from a health facility.

Maternal nutrition and infant and young child feeding nutrition counseling and education will be provided by health workers at the facilities. This component will be further enhanced by additional information provided at community level by community volunteers during home-based follow up visits. Provision of maternal nutritional information and counseling on infant and young child feeding will continue through ANC and ART clinics. Malnourished HIV + pregnant and lactating mothers (216) will also be linked to therapeutic nutritional support programs as part of a commitment to promoting better maternal and infant health.

Training, including updates on the new MOH adopted PMTCT guidelines, blood collection for CD4 screening and dry blood spots, and HIV rapid tests will be provided to 200 health workers, including midwives, at ANC clinics providing PMTCT services. Activities targeting TBAs will also be

strengthened at LPTF level in order to better engage the widely utilized informal health sector. TBA engagement will be evidenced-based, in line with the Ministry of Health National Policies and Guidelines, and will focus on initiating and improving TBA and LPTF relationships, and incorporating TBAs into the already existing community structures such as VHTs and community volunteers. Specific issues addressed with TBAs will include: HIV/AIDS and PMTCT basic knowledge; issues of confidentiality; encouraging HIV positive women to deliver at a health facility and referring them to facilities for delivery; supporting women who deliver at home to receive the prophylaxis for their infants with prompt referral of those mother infant pairs to health facilities; encouraging women with unknown HIV status to test and referring them to testing centers.

Support to HIV positive mothers at the AIDSRelief supported clinics will include clinical and immunological assessment of eligibility for HAART for all HIV + women and provision of HAART to the eligible women identified through the PMTCT clinics. To encourage male involvement, LPTFs will adopt strategies such as writing love letters, and inviting partners of HIV positive pregnant women to the Faithful House trainings as a precursor to VCT. Long lasting insecticide treated nets will continue to be provided to the mothers and their families through linkages with PACE/CDC. 30-40 additional community volunteers will be trained as trainers of reinforcing malaria prevention

messages during their outreach activities and given skills to identify patients with the symptoms of malaria and to refer them to a health institution. There will be increased sensitization of care providers to provide intermittent Sulphadoxine-Pyrimethamine (SP) or Cotrimoxazole to pregnant women in care.

Coordinated by Futures Group International, strategic information (SI) activities incorporate program level reporting, enhancing the effectiveness and efficiency of both paper-based and computerized patient monitoring and management (PMM) systems, assuring data quality and continuous quality improvement, and using SI for program decision making across all LPTFs. Using the MOH standard guidelines and data collection tools, Futures Group International will ensure compilation of complete and valid PMTCT data that relate to adult and infant patient information at the sites.

On-site technical assistance and training will be provided to LPTF staff, focusing on identifying barriers to data collection, avoiding double counting and reporting, and timeliness of reports. In addition to capturing data in IQCare, a new electronic

data base will be rolled out to all LPTFs implementing PMTCT that will capture relevant PMTCT data, from ANC to L&D. The same will be used to efficiently and effectively report on PMTCT indicators to all stakeholders, including USG, MOH,

and the donor. Staff will be trained in using the data base for sustainability purposes. On a monthly basis, LPTFs will compile and disseminate a PMTCT report based on already agreed upon indicators, but also compile similar reports on a quarterly, semi-annual, and annual basis. Feedback from these reports will be used by AIDSRelief and LPTFs to improve service delivery, provide forecasting for drugs and testing kits, and gauge the need for human resource planning. Using available data, AIDSRelief will strengthen the linkages between ANCs and HIV/AIDS clinics, and provide information

for accurate tracking of pregnant mothers in the community and at health facilities during the duration of a pregnancy.

Sustainability lies at the heart of the AR program, and is based on durable therapeutic regimen choices and health systems strengthening. AR will focus on the transition of the management of care and treatment activities to indigenous organizations by actively using its extensive linkages with faith based groups and other key stakeholders to develop a transition plan that is appropriate to the Ugandan context. The plan will be designed to ensure the continued delivery of quality HIV care and treatment, and all activities will continue to be implemented in close collaboration with the Government of Uganda to ensure coordination, information sharing and long term sustainability. For the transition

to be successful, sustainable institutional capacity must be present within the indigenous organizations and the LPTFs they support; therefore, AR will strengthen the selected indigenous organizations according to their assessed needs, while continuing to strengthen the health systems of the LPTFs. In FY2010, the program will support linkages between LPTFs and the MOH to tap into locally available training institutions and enhance LPTF/MoH systems and collaborations relevant for sustainability. LPTFs will be encouraged to explore approaches in the health systems that are efficient and effective for sustainability purposes. This will include better allocation of resources that will increase cost effectiveness.

The program provided a total of 18 LPTFs with laboratory equipment and supplies. Equipment procurement was done in accordance with CDC and MOH guidelines through local vendors; AIDSRelief identified local service providers for the procurement and distribution of lab reagents needed for the tests to support treatment of HIV infected patients (CD4 tests, LFT, RFT, cryptoccocal antigen, malaria, syphilis, HIV& TB, HB, TOXO, CBC, WBC count). AIDSRelief also provided support for viral load testing at selected LPTFs and linked others to nearby facilities that provide such services. The program continued its collaboration with Center for Disease control (CDC) Uganda to get support for viral load testing for CQI, and referral CD4 testing, and 9/18 AIDSRelief LPTF laboratories participated in UKNEQAS external assessment scheme for CD4 proficiency testing with support from CDC. AIDSRelief also provided support to LPTFs to enhance continuous power supply so that reagents and other lab materials are properly stored at all times. These included solar powered backup systems and inverters. Accessories such as surge protectors, stabilizers and UPS were also supplied in order to protect delicate equipment from frequent power surges.

The program additionally conducted on-site, regional continuing medical education trainings, and at AIDSRelief laboratory centers of excellence for laboratory staff to strengthen their capacity to initiate and monitor patients on ARVs, and to conduct diagnostic tests for opportunistic infections. A total of 96 laboratory personnel received refresher courses in standard operating procedures, good laboratory practices, reagents forecasting and procurement , quality assurance and quality control, infection control, DBS collection techniques, Direct & Flourescent TB smear Microscopy, HIV rapid testing, basic flow cytometry, equipment maintenance techniques and viral load techniques. These trainings were conducted in accordance with the national guidelines. As AIDSRelief focused on decentralization of services, it further increased the laboratory capacity of 33 LPTF satellite sites, enabling them to perform rapid HIV tests, malaria smears, TB smears and other diagnostic tests and to collect and process specimens for other tests that are performed at referral laboratories. Pediatric diagnostic capacity was accessed by all LPTFs and their satellite sites and early infant diagnosis enabled the earlier initiation of therapy as required. AIDSRelief provided support for viral load testing at Some LPTFs. AIDSRelief provided clinical management and reagents inventory management tools to ensure collection and compilation of laboratory data for all HIV patients and reagents consumed

FY 2010 Activities

In FY 2010, Laboratory technical assistance visits will be expanded to be performed monthly, for which purpose number of laboratory technical teams will be increased from 3 to 4. The FY 2010 request will include provision for lab supplies and technical assistance to the LPTF. AIDSRelief laboratory support will continue to include the procurement and distribution of necessary reagents from local distributors (HIV test kits, CD4 reagents and reagents for the diagnosis of opportunistic infections including CrAG and PCP testing, and viral load testing reagents). Laboratory equipment will also be upgraded and renewed to meet the increased testing needs, including innovative equipment for point-of-care testing of CD4 and HIV viral load. AIDSRelief will establish regional excellence labs to serve as referral, training, and external quality assurance centers. AIDSRelief in collaboration with WHO, Find diagnostics and NTLP will roll out modern TB diagnostic procedures such as Flourescent microscopy to all LPTFs, as well as testing for MDR-TB.

AIDSRelief anticipates increased demand for viral loads measurements due to increased number of patients accessing ART. Regional excellence labs will be equipped to conduct viral load measurements, while others will access it through referral of samples. Tools and reference materials to monitor OIs and ARV drug toxicities will also be revised. The program will continue the provision of clinical management tools to ensure collection and compilation of laboratory data for all HIV patients. Through strengthening internal controls, and with support from CDC, AIDSRelief will ensure that all laboratories build on the current quality assurance program through participation in external quality assurance schemes such as UKNEQAS. External Quality Assurance schemes will be expanded to involve all LPTF labs into EQA for HIV rapid testing, all CD4 testing, clinical chemistry, hematology, and OI diagnosis. Excellence labs will be involved in EQA programs for HIV viral load testing. AIDSRelief will expand service contracts with local and regional providers to cover all laboratory equipment currently serving AIDSRelief purposes to ensure that routine preventative service visits and prompt maintenance and repair occur. The program will also maintain support for the maintenance of solar back up power systems and surge protectors, and all major equipment will be put on power management systems. To enforce sustainability the program will strengthen local capacity in country to perform equipment maintenance/ service.

AIDSRelief will develop unified and comprehensive training curriculum for lab personnel to cover the full continuum of HIV- and OI-related laboratory services, including latest HIV testing and monitoring technologies and testing strategies and algorithms; CD4-testing technologies; microbiology and molecular biology techniques used for OI diagnosis; laboratory biosafety, quality assurance and quality control; principles of laboratory management, to include personnel management, financial management, planning and budgeting; laboratory logistics management and control; laboratory equipment maintenance; laboratory information and data management; and professional ethics of HIV laboratory work. The revised curricula will include new, innovative topics to address latest developments in the field of HIV/AIDS/OI laboratory science and service provision. To maximize teaching effectiveness, the curricula will be designed in modular format, each module covering key conceptual areas mentioned above. The curriculum development will be closely coordinated with the Ministry of Health, with subsequent endorsement by MOH. AIDSRelief will again provide refresher trainings for 96 laboratory personnel to emphasize standard operating procedures, good laboratory practices, laboratory commodities management and quality control to ensure a safe working environment, personal safety and reliable laboratory test results. AIDSRelief will expand laboratory training to involve all laboratory staff at LPTFs. Additionally, in order to address the shortage of laboratory personnel, the program will shift HIV rapid testing to non-laboratory cadres such as Counselors, nurses and midwifes to conduct HIV rapid tests and link them to MOH and CDC for quality assurance. LPTFs will also be encouraged to send less qualified staff for further trainings in order to improve their skills. Additional efforts will be made to create linkages between LPTFs and training institutions in order to facilitate the recruitment of qualified staff. As AIDSRelief continues its focus on decentralization of services, it will continue support for the 33 satellites laboratories. This includes continued training for these sites in rapid HIV testing, malaria smears, TB smears and other diagnostic tests and in the collection processing and transportation of specimens for other tests that are performed at referral laboratories.

Support to home based and community HIV testing will also be expanded. Selected satellite labs will be strengthened to initiate and monitor patients on ART if sufficient funding is made available for this.

In FY 2010, AIDSRelief will continue engagement with the Ministry of Health to ensure that AIDSRelief is represented in the Laboratory Technical Working Group, and diffuse relevant information from this group to LPTFs. The program will continue its collaboration with Center for Disease control (CDC) Uganda to get support for viral load testing for QA/QI program, and referral CD4 testing. AIDSRelief LPTF laboratories will continue to participate in UKNEQAS external assessment scheme for CD4 testing with support from CDC and TB slide rechecking supported by NTLP. Through Futures Group International, AIDSRelief will continue to support all sites to accurately document and track laboratory tests. All data will be captured in the current electronic data base for easy retrieval. On a monthly basis, reports will be made indicating number of tests performed and staff trained. The PMM system will help to identify those clients that need monitoring tests like CD4s, and link up with relevant personnel to have the tests performed. The close monitoring and reporting will eventually feed into forecasting and procurement of laboratory reagents and supplies.

In FY 2010, the program will work with LPTFs to implement and strengthen integration of the HIV clinics into mainstream hospital/facility M&E systems. This will involve: cross program training on different data needs and indicators; linking both paper and electronic data collection and storage systems for the facilities; working with LPTF management and boards to understand and respond to their data demand and information use needs; use the data to inform and support decisions for the HIV clinics and entire facility. It will also involve organizing joint meetings to share information. To enhance data access and utilization across a wide spectrum of the facility, various sections within the facility will be linked to the patient management system, and staff will be trained in the use of the system.

Sustainability lies at the heart of the AIDSRelief program, and is based on durable therapeutic programs and health systems strengthening. AIDSRelief will focus on the transition of the management of care and treatment activities to indigenous organizations by actively using its extensive linkages with faith based groups and other key stakeholders to develop a transition plan that is appropriate to the Ugandan context. The plan will be designed to ensure the continuous delivery of quality HIV care and treatment, and all activities will continue to be implemented in close collaboration with the Government of Uganda to ensure coordination, information sharing and long term sustainability. For the transition to be successful, sustainable institutional capacity must be present within the indigenous organizations and LPTFs they support; therefore, AIDSRelief will strengthen the selected indigenous organizations according to their assessed needs, while continuing to strengthen the health systems of the LPTFs. In FY2010, the program will support linkages between LPTFs and the MOH to tap into locally available training institutions. AIDSRelief will particularly focus on its relationship with indigenous organizations such as the Uganda Catholic Medical Bureau, Uganda Protestant Medical Bureau, and Joint Medical Stores to build their institutional capacity to support LPTFs integrate ART and other care and support programs into their health care.

AIDSRelief will procure adult and pediatric preferred and alternative 1st and 2nd line ARVs for 22,908 adults and 3,000 children. These are generics which are relatively cheaper but are of good quality, safe and efficacious. The bulk of the drugs will be FDCs for both adults and children to ensure adherence and minimize occurrence of resistance. AIDSRelief has not experienced any stock outs in the last year due to its efficient and effective supply chain management systems and has mechanisms in place to ensure no stock outs in the FY 2010. These include: policy of 2 months buffer stock at LPTFs and 3 months buffer stock at JMS; timely placement of orders; ensuring that deliveries are made within the lead time; efficient LMIS; use of ART Dispensing Tool at LPTFs for accurate and timely reporting.

AIDSRelief will continue to procure 1st and 2nd line ARVs for adults and children through a global procurement mechanism that provides very competitive pricing. Joint Medical Stores (JMS), an FBO will continue to warehouse and distribute ARVs on behalf of the Program with continued support from the AIDSRelief supply chain team.

The Program will continue to leverage ARVs for pediatric patients from Clinton Foundation, and also cover other ART related support including purchase of OI drugs, laboratory supplies and Technical Assistance to LPTFs.

AIDSRelief Supply Chain Management Team will continue with capacity building/systems strengthening through technical backstopping and on-going training and mentoring in supply chain management. In-depth training and mentoring of the LPTFs pharmacy staff in use of SOPs and Dispensing Tool, forecasting and quantification, ordering and quality reporting for ARVs and OI drugs, will continue to be conducted.

As of the end of February 2009, AIDSRelief in Uganda will be supporting 18 LPTFs and 33 satellite sites to provide care and support to 36,746 patients, including 25,908 on antiretroviral treatment of whom 3,000 will be children.

In FY 2009 AIDSRelief supported 18 LPTFs and 33 satellite sites to provide a family-centered approach to diagnosis and treatment of 1,770 TB, co-infected HIV positive patients. This incorporated routine opt out counseling and testing for HIV within TB treatment facilities, systematic referral for TB screening within HIV testing facilities, and systematic TB screening within HIV care and treatment facilities. Family members of TB patients were also encouraged to be screened for TB. HIV prevention messages, such as avoidance of high risk behaviors and secondary prevention, were integrated into counseling and testing sessions for TB patients. AIDSRelief followed the Government of Uganda policy guidelines and AIDS Control Program guidance on TB/HIV integration and TB/HIV communication strategy.

LPTFs' laboratory infrastructure was strengthened to assure safe and quality processing of TB samples. AIDSRelief continued linking LPTFs to the Ministry of Health's National TB and Leprosy Program for TB drugs and supplies for basic laboratory investigations. Referral linkages within the LPTFs and between LPTF and satellite sites for TB patients were improved, and HIV + patients who required care were referred to HIV/AIDS clinics. These patients were also treated for other opportunistic infections and received the basic care package through the CDC/PSI program.

Training of health workers and community volunteers were key activities in FY 2009. AIDSRelief trained 290 community health nurses and 720 volunteers as trainers of trainers on how to recognize TB signs and symptoms. On-going training of medical and clinical officers in TB X-ray interpretation and clinical mentorship on TB diagnosis and care was also provided. Additionally, three regional continuous medical education (CME) sessions, focused on TB and the integration of TB and HIV care and treatment services, were held in FY 2009. The AIDSRelief technical team made an average of one week-long visit each quarter to all LPTFs to provide technical assistance related to TB/HIV. The program also encouraged LPTFs to coordinate with the MOH's District Health Department to train health workers in TB/HIV.

Coordinated by Futures Group International, strategic information (SI) activities incorporated program level reporting, enhancing the effectiveness and efficiency of both paper-based and computerized patient monitoring and management (PMM) systems, assuring data quality and continuous quality improvement, and using SI for program decision making across all LPTFs. AIDSRelief has built and maintained a strong PMM system using in-country networks and available technology at 18 LPTFs in FY 2009. Futures Group carried out site visits to all LPTFs to provide technical assistance to ensure continued quality data collection, data entry, data validation and analysis, and dissemination of findings across a range of stakeholders.

By the end of FY 2009, AIDSRelief will have evaluated the program by relating patient outcome measures such as viral suppression rates, adherence, and treatment support models to program level characteristics at each LPTF. Over 1500 patients receiving care and treatment from 14 LPTFs will be included in this analysis, grouped into three cohorts (36, 24 and 12 months) representing the length of time they had received therapy.

FY 2010 activities

In FY2010, AIDSRelief program will intensify the diagnosis and treatment of TB/HIV co-infected patients by ensuring that all HIV+ patients presenting with symptoms suggestive of or previous history of TB infection are appropriately evaluated and properly managed if found to be positive. AIDSRelief will provide TB treatment to 2,500 HIV + patients, and all family members of TB patients will be screened for TB. A total of 2,000 registered TB patients will receive HIV counseling and testing results at AIDSRelief supported LPTFs and all patients testing positive will be referred to HIV care and treatment. Routine, opt-out counseling and testing for HIV within TB treatment sites will continue, as will systematic referral for TB screening at HIV testing sites.

The program will continue implementing a family-centered approach to both HIV testing and TB screening. Under this approach AIDSRelief will assist the LPTFs to implement a contact tracing strategy that ensures that family members of all HIV+ patients diagnosed with TB be screened for TB. This will be accomplished using the community based treatment support mechanisms that are implemented at all AIDSRelief supported centers. AIDSRelief will strengthen the TB-DOTS system through integration with the existing HIV community follow-up programs. A total of 200 LPTF staff will be trained in the provision of clinical treatment for TB to HIV + patients, and 30-40 community volunteers will be trained as trainers of trainers to provide community-based treatment support for TB patients. On-going training clinical mentorship of medical and clinical staff (including laboratory personnel) will also be provided by the AIDSRelief technical team. This will include TB diagnosis and management (including TB X-ray interpretation), preparation and handling of specimens, proper infection control procedures. In addition, AIDSRelief will continue to encourage LPTFs to coordinate with the MOH's District Health Department to train health workers in TB/HIV.

AIDSRelief will ensure that all Uganda National TB reporting requirements are followed and collaborate with the Uganda National regional and District TB programs to assist all LPTFs to become MOH-registered TB/HIV treatment centers. The ability to treat co-infected patients at one site will increase adherence to treatment and simplify monitoring, lessen the health-care burden on co-infected patients, and enhance sustainability. The program will continue strengthening LPTF laboratory and clinical infrastructure to assure safe and quality processing of TB samples and effective infection control. AIDSRelief will also ensure participation of all supported labs in an external and internal quality control program for TB specimens. In addition, through linkages with the NTLP labs will increase surveillance for MDR- and XDR-TB.

To enhance TB tracking and reporting, Futures Group, the monitoring arm of AIDSRelief, will ensure compilation of complete and valid HIV patient treatment/TB data; enhance analysis of required indicators for quality HIV patient treatment and ARV program monitoring and reporting; and provide relevant, LPTF-specific technical assistance to develop specific data quality improvement plans for tracking TB cases. The program will use IQCare, the current PMM system, to track TB patients who are counseled, tested, and receive their HIV results and HIV + patients screened for TB. In addition, all patients accessing care and treatment, and being treated for TB, will be captured using the existing clinical management tools, and their data captured in the data base for further analysis and reporting.

To enhance tracking and reporting of comprehensive TB data, LPTF staff will receive training in the following areas: TB indicator definitions; analysis of TB data captured on the different tracking tools-both manual registers and electronic; and tracking and reporting on patients completing treatment, and capturing defaulters. In FY 2010, TB indicators (from screening, diagnosis, treatment, and outcome monitoring) will be fully incorporated in IQCare for all LPTFs to enhance tracking and reporting to various stakeholders.

AIDSRelief will promote the data use culture, to enable LPTFs use data for informed clinical decisions and adaptive management. It will ensure that different data systems at health facilities are harmonized for effective and efficient reporting.

In FY 2010, the program will work with LPTFs to implement and strengthen integration of the HIV clinics into mainstream hospital/facility M&E systems. This will involve: cross program training on different data needs and indicators; linking both paper and electronic data collection and storage systems for the facilities; working with LPTF management and boards to understand and respond to their data demand and information use needs; use the data to inform and support decisions for the HIV clinics and entire facility. It will also involve organizing joint meetings to share information. To enhance data access and utilization across a wide spectrum of the facility, various sections within the facility will be linked to the patient management system, and staff trained in the use of the system.