The Uganda Ministry of Health's (MoH) core mandate is formulating national technical policies, guidelines and standards, building the implementation capacity of lower level entities, and tracking the implementation of the policies by the lower level entities, countrywide in line with the national guidelines. The MoH is also responsible for tracking and responding to epidemics. The MoH is expected to provide support and monitor the activities of all health sector implementing entities countrywide including public, private, NGOs as well as district and sub-district health teams.

The MoH conducts activities to achieve the objectives of the Second National Health-Sector Strategic Plan, (HSSP II) 2006-2010, and the public health component of the National HIV/AIDS Strategic Plan (NSP) 2007-2012, aimed at expanding access to quality HIV prevention, care, and treatment to HIV infected/affected individuals and their families. Currently, MoH is engaged in formulation of the national health policy and third Health Sector Strategic Plan that will align with the National Development Plan that is also still under formulation.

Specifically, this cooperative agreement supports the MoH AIDS Control Programme (ACP), Resource Centre, Central Public Health Laboratories (CPHL) and National Tuberculosis and Leprosy Programme (NTLP) to undertake the following: i) HIV Prevention, Palliative Care, Treatment and Support to improve the quality and scale-up of HIV/AIDS programs including: coordination of local and international partners to increase access to confidential counseling and testing (CT), PMTCT, palliative care and treatment services; improved integration of HIV prevention, care and treatment into comprehensive primary health care; and, support for countrywide access to confidential HCT through provider-initiated and home-based testing approaches; ii) TB/HIV integration to strengthen integrated prevention and clinical management of HIV and TB and increase access to confidential HCT for TB patients and TB diagnosis and treatment for HIV-infected individuals; iii) Policy and Systems Strengthening to identify gaps and develop, revise and update Uganda national policies and technical guidelines for HIV/AIDS related health services and to develop and implement policies and technical guidelines to improve the management of TB/HIV co-infection; iv) Laboratory Infrastructure to support the national CPHL to develop policies, standard operating procedures and quality assurance and quality control process; to conduct training and support supervision to peripheral, district and, regional laboratories; to improve access to early infant HIV diagnosis; and, to develop the capacity for related diagnosis of HIV, TB and OI in health center IVs and IIIs laboratories; v) Strategic Information to implement HIV/TB/STI surveillance activities and support national and decentralized monitoring and evaluation of HIV/TB/STI programmes and population-based studies. In all, 22 technical staff and 30 support staff have been recruited to support the MoH ACP, CPHL, and Resource centre staff to do achieve these objectives.

The activities of the MoH supported under this award aim overall to strengthen health systems in all areas including i) human resources for health through training and skills building, ii) health infrastructure particularly laboratories and equipment, iii) health information systems through the support to the Health Management Information System, HIV/AIDS Surveillance and programme M&E, iv) Logistics management for medical and pharmaceutical supplies, v) policy development for technical interventions and human resources including policies for task shifting, lay counselors and expert patients. Other cross cutting areas that are supported include i) nutrition policies related to safe infant feeding, therapeutic nutrition for ART adherence, TB treatment, and ii) Gender consideration in all HIV/AIDS prevention, care and treatment services.

Under this award, the MoH is progressively implementing cost cutting measures to increase efficiency and gaurantee sustainability. These measures include i) integration of service delivery especially reproductive health and PMTCT, AIDS care / ART and Tuberculosis and PMTCT, STI and reproductive health etc, ii) Integration of activities during implementation such as integrated support supervision involving all technical units, integrated dissemination of policies and guidelines, integrated development of educational materials, etc. iii) the MoH is also planning to integrate M&E activities for various interventions through an integrated M&E plan, iv) the MoH is also considering integrated training through an integrated curricular for various interventions, v) a programme evaluation which will among others, explore other avenues for improving cost-efficiency is also planned.

The activities under this award will be tracked in line with existing monitoring mechanisms. Because the MoH is not a direct service delivery entity, most PEPFAR output level performance measurement indicators do not lend themselves to tracking the performance of this award. Therefore, tracking of performance will be based on performance indicators and targets set out in the budget narrative. Tracking of outcome and impact will be based on the indicators for tracking overall health sector performance in HSSP. This activity will also generate data and capacity for tracking the overall performance of the health sector. Quarterly reports, an interim and final annual report will be prepared in line with the terms of the award, and will report performance against targets.

Ministry of Health strategy is to have a strong HIV care and support programme for HIV clients through out the country, this to be done through the continuum of care approach where village health teams will be trained to offer HIV care through home based care (HBC) programme for HIV clients. The target audience for this care and support are HIV clients.

The continuum of care approach, comprises of various types of HIV care and support which are offered at three main levels namely; health facility, community, and home levels. The various types of HIV care and support include; counselling and testing for HIV, psychosocial support, adherence counselling, nursing and palliative, provision and monitoring of treatments, nutritional support among others.

The continuum of care approach is arranged in such a way that the HIV clients are identified at the health facility and referred to the community/home or vice versa. This form of referral mechanism ensures that the HIV clients can easily be tracked down the system there by avoiding high rates of loss to follow up for HIV clients in care, especially those on treatments like antiretroviral treatment (ART) and other medications.

The HIV care described above is being strengthened and scaled up throughout the country as part of the response to increasing burden of care for HIV/ AIDS patients in the health care delivery system. The total number of HIV clients who need ART stand at about 350,000 persons and those on ART are more than 180,000 clients and most of these clients require HIV care and support of various types. Because of the chronic nature of HIV/AIDS, the major part of the HIV client's life is spent in the community or home environment where they need a lot of care and support of various forms to enable them have an improved .

Currently, the continuum of care and support for HIV clients is being provided in about 60 out of 80 districts by both public and private partners but this HIV care is not fully offered at all the three levels, the HIV care is relatively strong at the health facility level, where a few health workers have been trained but still weak at community/home level. Because the VHT strategy is relatively new, there is weak link between health facilities and community/home level for HIV care at present which require strengthening. Also the inter linkages between the HIV care sites and others service points providing other forms of essential HIV support like nutrition, reproductive health and family planning services is still weak and all need to be strengthened at all levels.

The home based care policy guidelines and implementation guidelines have been developed and will be printed and disseminated by the end of 2009 to all key partners involved in HIV care provision and these will help in guiding scale up of HIV care and support. The Ministry of Health strategy is to have a strong HIV/AIDS care programme by utilising the VHT strategy to strengthen the home based care programme in the country. The HIV care team members at health facility level will train and supervise the VHT members and these in turn will provide HIV care by working closely with the care givers of HIV clients who stay in close contact with those clients. On average each VHT member will care for at least five to eight HIV clients in the community and the care giver will look after one client in the community. This kind of HIV care program is hoped to reach about 80% of the districts in Uganda by end of 2011.

There will be need to strengthen inter linkages between various programs/key stakeholders in HIV care through out the country by enhancing coordination at national, district and community levels. This will be done through coordination meetings and as well as sharing of information between stakeholders among others.

HIV care and support will be monitored and evaluated through ensuring the client records regarding all HIV care and support are regularly passed on to the nearest health facilities, so that these can be captured in the routine health management information system (HMIS). To ensure uniform implementation of this activity, data collection tools will be developed and availed to all stakeholders to address this issue.

The national level will continue with the following roles in order to address HIV care and support;

Updating and availing national guidelines, coordination activities, mobilising resources, support supervision, monitoring and evaluation of the program.

There have been a number of key limiting factors to HIV care and they include lack of guidelines, inadequate coordination at various levels and limited supervision and monitoring of HIV care, plans to minimise these negative factors are underway.

Goal: To strengthen HIV care through home based care programme as a continuum of care for HIV/AIDS in Uganda

Objective: To provide quality HIV/AIDS care and support in all districts both in public and private health sector.

Performance/effectiveness of HIV/AIDS care will be measured by the number of districts providing quality home based care (HBC) as will be judged from standard supervision and HMIS tools on specific indicators in relation to HIV care.

The support sought under this proposal will address the current existing gaps and the priority activities including i) strengthening capacity building for human resource to enable effective delivery of the services within 20 districts ii) strengthening support supervision, monitoring and evaluation of HIV care and support activities, every quarter iii) strengthening collaboration and coordination of HIV care including HBC activities within both public and private stakeholders , to be held twice a year (iv) provision of essential equipments and supplies to strengthen HIV care and support at various levels, iv capacity development of health care providers on nutrition assessment, management of malnutrition and/or linkage to food support and IGAs services.

Antiretroviral drug treatment is the main type of treatment for HIV or AIDS and it falls under the Care and support Unit of the STD/AIDS Control Programme. It was rolled out as a national programme in 2002 after it was successfully piloted under the UNAIDS Drug Access Initiative. Care and support for HIV-infected individuals is a priority programme area of the health sector response to the HIV epidemic in Uganda. The ART Unit is charged with the planning, management and coordination of the scale-up of the provision of Antiretroviral Therapy in the country.

Uganda adopted the Comprehensive HIV care and treatment training guidelines based on the Integrated Management of Adulthood and Adolescent Illnesses (IMAI) approach for training of its first level health workers. The mandate of the ART Unit is to build the capacity of districts to plan and manage their ART services. This has been done through training of trainers and coordinators for Comprehensive HIV care and treatment at the district and regional level and through supervision of district-based trainings in ART in order to ensure their quality. The ART Unit also carries out accreditation of health facilities for ART and monitoring and evaluation of ART services. Tracking and evaluation of clinical outcomes is conducted through carrying out quarterly cohort analyses of HIV care and treatment data for health facilities providing ART, which activity will be carried out as part of the quarterly support supervision and mentoring for ART sites.

Objective of the National ART Programme

To increase access to ART for those in need to reach 240,000 by 2012

Target: Increase the proportion of health Centre IVs offering comprehensive HIV/AIDS care with ART to 95% by 2011

Core Intervention: Comprehensive HIV/AIDS for both adults and children including access to ART at health Centre IV.

Outcome measures:

The number of HIV-infected adults and children accessing ART services in the country.

The proportion of health facilities actively providing ART services in the country.

Proportion of HIV-infected individuals that are accessing Antiretroviral therapy

Proportion of HIV-infected individuals that are accessing chronic HIV care including Cotrimoxazole Prophylaxis.

Achievements

The ART Unit has been able to carry out a number of activities over the past one year. These include:

Increased access of adults to ART in the country from 17,500 in June 2004 to 153,101 by December 2008 and to 180,000 by June 2009; thereby reaching coverage of 50% for those who currently need ART.

Increased number of health facilities providing ART from 26 in 2004 to 340 by end of December 2008 to the current 355 sites by June 2009.

Provide support supervision and mentoring of health workers from 100 health facilities in ART data management.

Accreditation of 50 new health facilities as ART sites.

Supported the districts of Mukono, Jinja, Bushenyi to train 30 health workers in Pediatric ART.

Trained 38 health workers from Lira region in patient monitoring for ART.

Reviewed HIV Care/ART data collection tools to incorporate more data variables for TB, PMTCT, paediatric clinical monitoring and to improve follow up of HIV-exposed infants.

Validated ART data in all 352 health facilities providing ART in the country

Revised ART training materials.

Activities planned for 2010/11

The National ART Committee is an important forum of the Ministry of Health for the coordination of partners and stakeholders in ART at the central level. It provides oversight and guidance for implementing ART activities in the country. Quarterly working meetings for the National ART Committee and its constituent eight subcommittees will be facilitated.

The ART Unit plans to carry out accreditation of new health facilities as ART centres in newly-created districts and to cover more of the lower healthy facilities; namely all health centre IVs and some of the health centre IIIs with adequate capacity for ART. Accreditation of lower health facilities is crucial because it will facilitate the decongestion of hospitals that are over-burdened with high HIV patient-loads. In addition, it will bring services nearer to the population that is being served.

District health managers will be empowered through trainings in the District HIV/TB Managers course in order to enable them to plan, manage and coordinate the scale-up and consolidation of ART services within their districts. This will increase their stewardship and ownership for ART activities. The ART unit will support districts to carry-out ongoing training in ART for the hard-to reach regions and also in order to cover training gaps resulting from staff attrition and transfers. A total of 160 health workers from 40 health facilities from the hard-to-reach districts will be identified and from health facilities greatly affected by staff transfers.

The ART Unit will also support districts to hold regional inter-site coordination meetings in order to provide health workers with updates on ART management and to facilitate sharing and learning from each others experiences.

Quarterly support supervision and mentoring in ART logistics and ART data management will also be carried out as an ongoing activity for all health facilities providing ART targeting health facilities that are poorly performing in ART data management and service delivery. Periodic ART data audits will be carried out in 80 of the health facilities that are providing ART in order to assess and ensure quality of ART data. In addition, cohort analysis for ART services will be carried out during all these data audit visits and during support supervision.

HIV counseling and testing (HCT) is the cornerstone and entry point for most HIV interventions globally. In Uganda, the HCT service provision started in 1990 with stand alone VCT services delivery as the only approach. Over the last 19 years the Uganda has scale up of the HCT interventions to include Provider initiated Testing and counseling, and Home based counseling and testing and a number of variations of VCT. The HCT policy was first developed in 2005 and revised in 2007 to cater for all the different approaches of HCT as well as including the national testing algorithms. The UDHS 2006 and UHSBS 2004/5 showed a 70% unmet need for HCT at 70%. The health facility coverage has increased from about 100 sites in 2002 to over 800 in 2008. The population tested increased from 10% in 2000 to about 25% in 2006 and about 38% in 2008. The number of partners supporting HCT also increased from 3 in 2001 to 60 in 2008.

In May 2009, the first Uganda National HCT conference was held in May 2009 and it was proposed that this becomes a two yearly event. Therefore the second HCT conference is planned for 2011. In addition a number of task shifting strategies for delivery of quality HCT are being tried in the country

In order to scale up HIV counseling and testing to facilitate universal access as stated in the National Strategic Plan, the MOH will support the following strategic actions: i) Strengthen capacity for HCT training by increasing the number of trainers and accredited training institutions; ii) Scale up PITC, VCT, and HBCT; iii) Strengthen the management of logistics systems; iv) Scale up HCT support to sero-discordant couples; v) Ensure availability of trained counselors throughout the health care systems; and vi) Enhance coordination support, supervision and quality assurance of HCT.

According to HSSP2, HCT should be expanded to at all HCIIIs by 2010. Currently only 50% of the HCIII are providing HCT. In FY2010, the other 50% will be supported to start testing and the main activities will be training and supervision.

This activity will support the MOH/ACP to meet its mandate of leading the public health response to HIV prevention through coordination, standardization, and training in the area of HCT.

In FY10, we plan to increase HCT coverage by at least 20% given other national efforts. Activities in FY 2010 will be geared towards identification of HIV positive individuals and couples for linkage to care, treatment, strengthen positive prevention among discordant couples; and focus of strategies for HCT in identified most at risk populations (MARPS). We shall strengthen coordination of all the HCT partners through regular quarterly meetings of the HCT national coordination committee and its 5 subcommittees. To further strengthen coordination there will be regional forums where quarterly regional meetings will be held.

In FY09/10 the HCT policy will be reviewed and PITC will be scaled up as one of the most appropriate approaches in identifying HIV infected individuals. There is a need to scale up PITC and the positive prevention. PITC is currently in all regional hospitals and in 20% of general hospitals. In FY09/10 we propose to increase PITC in general hospitals to 50% and are expected to increase to 100% in FY2010. The main activities in scaling up are training of health workers and other service providers followed by focused supervision

Both focused and integrated support supervision will be conducted to ensure quality HCT service delivery given the many HCT actors in the country and those that are using task shifting and therefore support supervision is critical for ensuring quality. All districts will be visited as least twice in a year. We shall provide support supervision to all 42 PNFP facilities and 50% 0f the grade A private for profit facilities

Monitoring and Evaluation: Some of the key indicators for HCT services are already integrated in the MOH HMIS. We propose to continue using data collected under PEPFAR, MEEP that collects data that is not captured in the National HMIS. The new USAID projects implemented during that period of time propose to apply LQAS as an M&E methodology at community level. This data would be useful for community coverage estimates and complements MOH implementation of the VHT strategy. This health facility and community based methods are expected to strengthen the M&E of the HCT intervention.

Paediatric treatment falls under the jurisdiction of the ART Unit of the STD/AIDS control Programme and refers to the HIV treatment of children aged 15years and below. Despite increased availability of paediatric ARV formulations and increased access to Early Infant HIV diagnosis in Uganda, improvements in the enrolment of children onto HIV treatment have been slow. Without access to HIV care and treatment, 50% of children infected with HIV will die before their second birthday. There were 20,200 new HIV infections in children in 2008 in Uganda. By end of 2008, 33,151 of the 130,000 children living with HIV were estimated to have advanced HIV disease and are therefore in need of ART.

Only 68% of the 352 active ART sites are currently offering ART to children. Furthermore, linkages between paediatric ART and services for Prevention of Mother-to Child HIV services are still inadequate in many health facilities. Ministry of Health has adopted the IMCI Complementary HIV course for building the capacity of first level health workers in paediatric HIV care and treatment.

The target for Uganda is to put 75% of children with advanced HIV disease on ART. This translates to 25,000 children on ART by end of 2010, and 32,500 by end of 2011.

Achievements

Increased number of children accessing ART; from 10,418 by December 2007 to 14,297 in December 2008 up to the current 16,000 by June 2009; which is 48% of children with advanced HIV disease.

Revision of the National ARV guidelines to include Early Infant Treatment (initiation of ART for all children under one year of age diagnosed with HIV, regardless of HIV disease stage or CD4 cell percentage).

Trained 24 health workers from 12 health facilities performing poorly in Paediatric HIV care, through placements at Mildmay centre and to Baylor Uganda.

Trained 56 health workers in the IMCI complementary HIV course

In order to avoid overlap and duplication of services, activities to strengthen laboratory support, to improve diagnosis of HIV in children and to promote integration and linkage with routine paediatric care, nutrition and maternal health services have been covered under the section for Early Infant HIV diagnosis (EID). In addition, the activities for improved quality of care will be covered under Quality Improvement activities under the HIVQUAL Program.

In order to coordinate and harmonize contribution of the various stakeholders in paediatric HIV care, quarterly meetings of the national Paediatric ART subcommittee will be supported. This committee has representation of all the major providers and stakeholders in paediatric HIV care in Uganda. Furthermore, regional paediatricians, regional ART coordinators and district health officers will be supported to attend quarterly regional inter-site ART coordination meetings and the annual National Conference for Paediatric HIV care and Treatment.

There is need to train health workers in Paediatric ART while targeting those facilities that are not yet proving ART to children. Training in the IMCI Complementary HIV course will be provided to 120 health workers from 40 of these poorly performing ART sites. The trainings in ART will be followed two-weeks later with a post-training support supervision and accreditation of 40 health facilities as ART sites. Regional paediatricians and regional ART support teams from regions of Uganda with no other partner support will be facilitated to mentor and supervise quarterly all ART sites that are poorly performing in paediatric treatment. They will support initiation of paediatric ART, paediatric counselling and HIV care/ART data management, which are still weak in many ART sites.

None

None

Uganda has MC prevalence of about 25%, which is still too low to impact on the HIV/AIDS epidemic. Male circumcision is a common traditional practice for Muslims and some cultural groups in the Eastern and West Nile regions and in a few districts in central and mid-western regions of Uganda. In order to popularize the concept to benefit many uncircumcised men in the country it is imperative to disseminate MMC messages to the right target audience and facility based health providers. In view of this, the National Task Force and the MMC Secretariat conducted consultative regional meetings with stakeholders in Eastern, Northern, West Nile and South western regions to solicit support for MMC. A number of stakeholders have been sensitized on MMC. By the end of 2009, 250 (70%) out of the 350 targeted stakeholders country wide had been reached. The sensitizations have resulted in high demand for MMC services. Currently, the MMC Policy guidelines are being developed.

The objectives include:

To strengthen partnerships for advocacy and mobilization for MMC services in all districts in Uganda

To scale up MMC services across the country within a comprehensive HIV prevention package

To ensure standards in the delivery of MMC services

Funds under this budget code will be specifically used for the following activities:

Conducting meetings with the district political and health leadership to disseminate the MMC policy as well as build partnerships for advocacy and mobilization for MMC services

Developing training materials and implementation guidelines for MMC

Training service providers in MMC

Developing MMC communication strategy

Conducting support supervision of MMC services

Conducting monitoring and evaluation of MMC services

Injection Safety is an integral component of Infection Prevention and Control practices which aim at preventing medical transmission of HIV and other blood borne pathogens. The mandate of this area include strengthening district capacity to plan and implement Infection Prevention strategies, and creating mechanisms of promoting safe work practices in the entire health care system. The emphasis areas of this plan have been placed on Standard Precautions, injection safety, health care waste management, Post Exposure Prophylaxis and TB Infection Control. However, successful implementation of infection prevention control still poses a big challenge within the country's health care delivery system, including at the community level.

Some main achievements have been made from implementation of previous work plans. Infection prevention and control guidelines were developed to provide standardized national guidance regarding infection control practices. Infection Control has been institutionalized through formation of Infection Control Committees thus ensuring sustainability of activities. The number of hospitals with committees has steadily increased from 20 to 60. Training of health workers to impart knowledge and skills, and support supervision has been on going.

Despite the above achievements, critical gaps still exist in the area of Infection Control. According to the report on the Implementation of National HIV and AIDS Strategic Plan FY 2007-2008, the coverage of services for injection safety and HIV infection prevention in the health system is still inadequate. Only 52 out of 80 districts have been trained in injection safety and health care waste management. Another gap is the limited interventions addressing HIV medical transmission at community level. This is a critical issue because most of the care givers in communities are informal, and are vulnerable to acquiring and transmitting infections. Medical practitioners in private practice have not been adequately targeted for infection prevention interventions. They need to be brought on board to be able to follow national guidelines for infection control.

During FY 2010 this activity will strengthen and consolidate previous strategies and bring in new areas of intervention. The activity area will also aim to promote prevention and control of HIV and other infections in the communities through building capacity of districts to support community interventions. This will enable establishment of community strategies aimed at promoting infection control measures, with emphasis on Injection Safety. During FY 2010/11, Health workers in 15 districts will be trained in injection safety in order to increase coverage of services for Injection safety. The training will be preceded by sensitization meetings for district leaders to create awareness of the role of safe injections, in prevention of HIV medical transmission. District leaders will be expected to mobilize communities not to demand for injections and to allocate resources for procurement of injection safety supplies.

To build district capacity, training of trainers in comprehensive infection prevention, targeting 120 members of infection control committees will be conducted. The training covers all infection control components, including Injection Safety, and PEP. To strengthen facility-level infection control committees, 25 hospital committees that were trained previously will be given support supervision to ensure that the training will be translated into practice. Identified gaps, challenges and good practices will be discussed with managers.

The programme area intends to create community awareness on infection prevention and control to contribute to prevention of HIV medical transmission within communities. Initially, six districts will be targeted for this activity. Meetings will be held with the district leaders to empower them to support community infection control interventions. To empower districts to implement community infection interventions, 90 district trainers will be trained. The training will enable trainers to mobilize and sensitize Village Health Teams and other voluntary groups for participating in community infection control interventions.

The program area will conduct TB infection control activities in collaboration with NTLP and other stakeholders. 25 hospitals will be assessed for TB transmission risks factors. Identified gaps will be shared with hospital management teams for possible interventions. 375 health workers will be given on job training in TB infection control (15 per hospital for 25 hospitals).

Uganda is committed to re-invigorating HIV prevention to stem the tide of new HIV infections. This is in line with the goal of the second Health Sector Strategic Plan 2006-2010 and the national HIV/AIDS Strategic plan 2007-2012. The Ministry of health by its mandate leads the public health response to HIV prevention, which is the key component of Uganda's multisectoral HIV/AIDS response.

Under previous support to the technical area of other prevention (STD control, condom promotion, focus on most-at-risk population groups, etc) the MoH in collaboration with other partners have initiated activities that address the risk factors and key drivers in the HIV epidemic e.g. HIV discordance, transactional sex, low level or lack of consistent and correct condom use, STI services for Most-at-risk populations etc. Capacity building activities at district, regional and pre-service health training schools were also implemented and support supervision conducted. Some specific achievements include, ongoing efforts to integrate HIV prevention into AIDS care programmes, setting up a dedicated HIV prevention services for sex workers clinic in Kampala and Wakiso for sex workers and other MARPs including condom provision, STI treatment, building STD training capacity in about half of the districts, piloting interventions for most-at-risk populations, IEC materials, developing and implementing a strategy for condom distribution beyond health facilities, pre-service training of health workers has also been conducted.

During FY 2010, support under this technical area will support the MoH to provide technical guidelines and support for STD treatment in primary health care facilities, condom promotion and distribution activities to build on previous efforts, and will support collaboration with other activity areas including AB in order to address the rise in unprotected sexual behavior and the high prevalence of STIs among Most At Risk Populations, cohabiting and married couples. Furthermore, the MoH will also scale up training pre-service and in service health care providers to build their capacity in other HIV prevention activities through training of trainers and mentoring and coaching. Other activities will focus on development/review and updating of tools, policies, guidelines and protocols in the areas of condom and STIs.

Target Population:

Activities under this activity area will mainly target mainly adults, especially those aged over 30 years among whom HIV prevalence and incidence are highest, married and cohabiting couples, urban residents, most-at-risk population groups particularly sex workers and their clients, couples particularly discordant couples, vulnerable populations like students in tertiary institutions, long distance truckers, migrant workers, fish mongers etc. Activities will also target health workers both pre and in service to equip them with skills and knowledge to provide relevant HIV prevention services.

Type of activities:

The specific activities that will be supported under this activity area include: i)Regional Training of Trainers for HIV/ STI prevention and Control among the most at risk populations. This will include district trainers and organizations that offer HIV prevention, development and production of targeted IEC materials for Condom promotion, HIV/ STI prevention for the sexually active agegroups, couples and MARPs group in central and northern regions and IEC campaigns, to increase comprehensive knowledge on HIV/STI prevention and Condom use; ii) building capacity for HIV prevention through training, mentoring and coaching of pre and in service Providers on STI management where 120 district STD trainers from 20 districts will be trained and 6 pre-service health training schools' tutors will also be trained, iii) training of 300 peer educators for promotion of both male and female condoms and STI treatment for CSWs in two districts of Kampala and Wakiso and 2 hotspots along the northern Kampala Juba route, iii) procurement and setting up 500 Condom dispensers to make condoms more available and accessible to most at risk communities in selected urban centres.

Target Populations:

The target population for this activity will comprise of: i)In the general populations/the sexually active the activities will involve mainly provision of information and messages to increase comprehensive knowledge on HIV/STI prevention and condom use, ii) At district, regional level and pre-service training schools, the activities will focus on building capacity, targeting district trainers and organizations that offer services e.g. NGOs, civil society organizations and tutors in pre-service training schools; iii) Most at risk populations will be specifically targeted with specific interventions like strengthening condom promotion and distribution through production of condom promotion materials, training of peers leaders and condom distributors for both male and female condoms and RH/STI services. Mobilization, sensitization and education of the general population on condom use will also be part of the mix, iv) Development of Policy and guidelines will mainly target central and key stakeholders. I t will involve review of technical guidelines and policies to take care of changing circumstances.

Coverage:

This activity will support the activities of the MoH and will have a nation-wide coverage through provision of capacity building, technical assistance, materials and support supervision. However, here will be particular focus on weak or underserved districts, particularly those with a disproportionate burden of HIV such as districts with high HIV prevalence and concentration of risky behaviours or most-at-risk population groups.

Quality assurance and support supervision

Quality assurance will be ensured through use of standardized training tools, protocols and guidelines. Skills development will be enhanced through capacity building, mentoring and coaching. Technical people in specific areas will be used to deliver capacity building sessions. Support supervision will done using standardized tools approved by Ministry of health. Reference materials will be provided where necessary. Feed back mechanisms will be also put in place.

Integration of activities

Activities will be integrated at district level where applicable. Comprehensive HIV/STI prevention package will be encouraged. Programs and activities like male circumcision, condom programming, RH/STI, PMTCT and others will be implemented with a more integrated approach. For example, ensuring that all mothers who access PMTCT are also screened for syphilis at the same time. Collaboration with partners like UNFPA, WHO, UNAIS etc PACE, Civil society organization, etc will be promoted. Some activities like support supervision will be implemented jointly.

The PMTCT program in Uganda is aimed at achieving an HIV free generation. The services are available in all the districts and in over 68.6% of health facilities. The uptake by June 2009 was 61.1% and out of the 33,523 HIV positive pregnant women who received ARV in FY 2008/09, 53.5% received single dose (sd) Nevirapine, 30.8% for combination regimen and 15.7% for HAART. The Early Infant HIV Diagnosis (EID) programme was started in 2007 with the aim of providing services for early identifications of HIV infected infants so as to guide early interventions. To date, over 400 health facilities (30% of the recommended health facilities) are providing these services in all districts of Uganda. In 2008 alone, over 17,000 (19%) of exposed infants for that year were tested for HIV. From 2007 to date over 36,000 exposed babies have been tested for HIV and over 5,000 have been confirmed HIV positive.

Of the estimated 1,596,400 pregnant women in 2010, the PMTCT programme is targeting 90% of those who will attend the ANC at least once during pregnancy. This is estimated to be 1,200,493 of pregnant women. With the HIV sero-prevalence of 6.5% in pregnancy, about 103,766 pregnant women will be living with HIV in 2010. The PCR programme targets to reach at least 30% of these exposed babies in 2010. To achieve these targets requires the PMTCT services to be provided in over 80% of all the health facilities providing these services. The PMTCT programme also recommends all HIV positive women to receive family planning services to prevent unintended pregnancies and targets to reach at least 50% of the with FP services in 2010. To reach the targets above, the programme will continue to have strong links with other departments in the Ministry notably the Community Health Department, Reproductive health, Child health, nutrition and the health education and promotion. At health unit level (service delivery), the programme will continue to be fully integrated into existing services.

The overall planned activities for FY 10 include; Support refresher training of at least 100 Trainer of Trainers (TOT's) each year on the integrated PMTCT training packages, new policies and guidelines to enable rapid scale up and consolidation of more efficacious regimens that includes ART for eligible women in the ANC care setting. Support updating, printing and dissemination of policies and guidelines to all stakeholders and implementing partners to ensure quality PMTCT services in the country. Strengthen data management and utilization capacity at all levels and especially at the sub national levels through mentoring and regular technical support supervision. Together with Resource Center and Pharmacy division at MoH, support the Logistics Management Information Systems (LMIS) for PMTCT and EID by printing and disseminating of at least 5000 copies of each the relevant tools. These tools include; Daily Consumption log sheet for ARV's, Bimonthly order and reporting forms for ARVS and PMTCT Monthly summary reporting forms. Support the printing and dissemination of at least 5000 copies of the revised and updated PMTCT policy guidelines of 2010 as well as the development of the related implementation guidelines. The programme will continue to expand the capacity for early treatment for HIV infected infants and children and to retain those started on ART through institutionalizing and operationalising linkages between PMTCT, EID, and HIV care (including co-trimoxazole preventive therapy and treatment programs). Support identification, diagnosis and entry into care for infants and children during the Child Days Plus (CDP) immunization campaigns so as to increase access to EID services by training service providers to conduct DBS collection in immunization outreaches. Coordination of EID services through regional stakeholders meetings will also be strengthened by this support. The programme will continue to review, update, develop and disseminate effective and relevant IEC /BCC interventions, materials, guidelines and job aides for strengthening integration of TB screening in ANC/MCH among others. Promote health facility based education and psychosocial support for PMTCT and paediatric clients. Promote sustainable, coordinated and effective interventions at the community level including community mobilization, promotion of meaningful engagement of PLHIV especially mothers with recent PMTCT experience and the local and national networks of PLHIV in the community response embracing GIPA principles.

Finally, in an effort to foster and promote integration, the PMTCT programme will continue to work closely with other departments and division in the Ministry of Health in particular with Reproductive health, Child health, and Nursing, Nutrition and Clinical services among others. The priority areas will include, but are not limited to advocating for incorporation of MTCT issues in pre-service training, revising, updating and printing the data collection and reporting tools, training packages in line with new international evidence. The integration activities with RH will include among others; FP/HIV integration, integrated support supervision and printing of at least 5000 copies of each of the assorted materials including the integrated antenatal, maternity and postnatal registers .

During FY06, the component of laboratory infrastructure was added to the MOH/CDC Co-Ag. The Major activities therein include support to the Central Public Health Laboratories (CPHL), in-service training, development of guidelines and policies, external quality assessment schemes, coordination of early infant diagnosis of HIV (EID), coordination of logistics and management laboratory information. Training in HIV rapid testing which set out to cover 3500 personnel over 5 years has now reached the 1770 mark. Training in T.B smear microscopy commenced during FY09. Its target is to reach 2 personnel from each of 800 facilities at a rate of 400 personnel per year. The first year of training achieved 90 personnel. CPHL has worked with CDC-Atlanta to pilot a task based approach to training in laboratory management. A total of 19 laboratory personnel were trained during the pilot. The training package shall be used to prepare ground for implementation of the WHO AFRO laboratory accreditation scheme and is now being customized for use in Uganda. Training packages have in the areas of sexually transmitted infection and opportunistic infections, biosafety, logistics management have also been developed. During FY09, the proficiency testing scheme for malaria microscopy, AFB smear microscopy and stool microscopy reached 250 laboratories. Results from the scheme have informed the program on areas of emphasis during support supervision and on identifying training needs. A total of 80 districts have been supported to conduct at least 2 rounds of supervision for each of 703 laboratories while up to 140 laboratories in the 80 districts are visited once from the center. A major milestone has been completion of the Nation Health Laboratories Policy which is due for launching this year. In addition, a 5-year strategic plan for implementation of the policy is in advanced stages of development. The plan is expected to rationalize utilization of resources for laboratory services. To facilitate coordination of laboratory services, the National Health Laboratories Technical Committee (LTC) and its 6 subcommittees are supported to meet periodically. The LTC has played a key role in the development of the National laboratory policy and strategic plan. The committee has also contributed to development/customization of a number of documents including; the HIV rapid testing manual, laboratory SOPs, Safety guidelines, T.B smear microscopy training manual, Laboratory management training manual, laboratory quality assurance guidelines and the laboratory equipment management guidelines. To enhance awareness on laboratory programs and promote networking between laboratories, the CPHL has launched 'Confirm', a newsletter with the first edition being published during FY09. During FY09, CPHL set out to build capacity of regional laboratories to conduct microbial cultures with emphasis on bacterial and fungal infections. As such, laboratory personnel from 6 regional referral laboratories have been supported to rotate in specialized laboratories for 1 month. In addition, basic equipment for installment in one regional laboratory (Jinja regional hospital laboratory) is under procurement. With regards to EID, a total of 403 facilities have been reached with 36,000 infants tested to date. In the area of laboratory logistics and laboratory information management, an evaluation of the laboratory data management needs has been conducted to inform the on going process of review of data management tools. A logistics verification exercise carried out during FY09 has provided data for quantification of reagents and HIV test kits and has helped identify needs of the 40 facilities where automated equipment to be procured under the Global Fund shall be deployed. CPHL is making final preparations to perform viral load monitoring for specimens referred from regional hospitals. Equipment and reagents are under procurement.

The focus of laboratory services and quality improvement activity during FY09/10 shall continue to be in-service training, quality assurance and overall coordination of laboratory activities. Development and implementation of a national accreditation scheme for laboratories as recommended by WHO AFRO shall be an additional area of focus. REDACTED. In the meantime, central coordination functions shall require funds for continued renting premises for CPHL, to support personnel and for transport, communications and utilities. The LTC shall be supported to advise the Ministry on policy and technical matters. A total of 3 editions of the CPHL bulletin shall be published to keep the laboratory and other healthcare professionals abreast with developments in the field. Technical laboratory support supervision shall continue both at district and central level using the network of District laboratory focal persons and personnel from CPHL and other national institutions. A total of 800 labs nationwide shall be targeted, focusing on HIV testing, logistics management and EID in addition to routine laboratory activities. Special attention and mentoring shall be paid to 50 laboratories in 10 districts that have been earmarked for accreditation using the WHO based National accreditation scheme. Development and implementation of the scheme shall require meetings to develop the relevant documents, raise awareness and orient the laboratory personnel. The proficiency testing scheme shall be scaled up to cover 400 laboratories and shall continue to cover malaria, AFB microscopy and stool microscopy. However, its frequency shall be increased from one round to 2 rounds annually and additional tests (HIV and syphilis serology) shall be included for the 50 being prepared for accreditation. Review of data collection shall be completed and the approved tools printed and distributed. Data collection and analysis for quantification of reagents and supplies requirements shall continue. A consultant shall be engaged to establish the best mechanisms for collation and transmission of laboratory data and its integration into the national resource center. CPHL shall be supported to work with the National Medical Store and the Sure Project in coordinating laboratory logistics. One regional laboratory (Soroti Regional Hospital) shall be strengthened to perform microbiological culture through mentoring, training of personnel and provision of essential equipment. Regional laboratories are being strengthened one a year with a selection of those that are not part of the 5 earmarked by an upcoming World Bank project. In-service training shall continue to cover areas of HIV rapid testing, AFB smear microscopy, laboratory management and laboratory quality assurance. HIV rapid testing shall target 400 personnel to build towards the required 3,500 estimated in the initial needs assessment. AFB smear microscopy shall target 150 personnel. The task based laboratory management training though rather costly, shall be implemented to support the National accreditation scheme. As such, the 100 laboratory personnel from the laboratories to be accredited shall be trained. EID shall scale up to an additional 250 sites and plans to test 30,000 babies during FY10/11. Funds shall be required to pa the testing laboratories, courier services and conduct training of the personnel. To ensure continuous function of automated equipment for HIV monitoring, equipment maintenance contract shall be procured for 25 government facilities that have equipment without proper preventive maintenance plans. Monitoring of viral load shall be scaled up from serving 6 regional hospitals to serving 12 regional hospitals. Implementation of all these activities shall coordinate closely with partners to ensure complementarity.

Indicator Target

09/10 Target

10/11

Number of testing facilities (laboratories) that are accredited according to national or international standards 0 50

Number of laboratories with satisfactory performance in external quality assurance/proficiency testing (EQA/PT) program for CD4 (patient monitoring). 74 100

Number of laboratory personnel successfully completing training 900 900

Number of new facilities offering HIV screening among infants 150 250

Number of infants screened for HIV 25,000 30,000