REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, and related laboratory services at regional referral and district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner. The mechanism will be responsible for maintaining the delivery of quality HIV/AIDS care and treatment, and related laboratory services to patients previously enrolled in the TREAT program in at least 11 regional referral hospitals and 13 district hospitals. This activity will also implement a phased transition for 22 additional facilities currently supported through the TREAT program. SUSTAIN will devise cost-efficient strategies for sustainable access to ART treatment. SUSTAIN will focus on enhancing the Ministry of Health (MoH) stewardship - including developing innovative means of measuring benchmarks of stewardshipexpanding MoH capacity to coordinate, support, deliver and monitor quality HIV/AIDS care, treatment, and laboratory services. SUSTAIN will collaborate with the USAID Health Initiative for the Private Sector (HIPS) project to develop sustainable models of HIV care and treatment. In a global environment of leveling resources for HIV/AIDS programs, the successful offeror will develop a program that innovates and adapts based on principles of cost-efficiency and cost-savings, primarily focuses on maintaining quality services for those who have been reached during the rapid scale-up phase of PEPFAR, and works collaboratively with the GOU, the private sector, and donors to expand sustainable access to services whose needs have not yet been met SUSTAIN will also provide quality HIV/AIDS diagnostic and treatment monitoring laboratory tests, working collaboratively with Central Public Health Laboratory (CPHL), Uganda Virus Research Institute (UVRI) and other stakeholders.

This activity is scheduled to be awarded by January 2010.

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at regional 11 referral and 13 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner. The activity will also successfully transition 22 current TREAT sites over a period of two years to MoH or other capable partners.

The activity will support approaches that improve the quality of care for patients who are on pre-ART, aiming to delay the onset of ART eligibility and improve quality of life through a variety of innovative care and support strategies. SUSTAIN will provide care services for 120,000 ART and pre-ART patients.

Moreover, this activity will increase stewardship by the MoH in provision of quality HIV/AIDS care and support within the public health system through joint planning and technical assistance with MoH, DHTs, facility managers and other stakeholders. SUSTAIN will build regional capacity building mechanisms which will function as knowledge hubs in HIV/AIDS care and support within the MoH.

This activity will also address the human resource gap by working with the regional referral hospital (RRH authorities and the DHTs. Jointly, they will undertake human resources needs assessments for ART services at the 11 RRHs and 13 district hospitals and identify critical additional staff requirements. SUSTAIN will work with the Capacity Project and other USG projects at district level to help the RRH authorities and DHTs develop realistic human resource plans for recruitment and retention.

This activity supports approaches to provide a variety of services to patients at the 11 regional referral and 13 district hospitals. Major activities in this technical area will include:

OI management

Pain and symptom management

Provision of basic package of preventive care services

Positive prevention

Regular clinical mentoring

TB screening and treatment referrals

Family Planning services

Pre-ART care and monitoring

Referrals to other services at the facility and community-level

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at regional referral and 13 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner.

As a first priority, SUSTAIN will aim to build on the successes of the scale-up of the TREAT program by continuing to provide high-quality HIV treatment, care, and lab services to patients that have been served by the TREAT program. The activity will focus on increased consolidation and efficiency, leveraging of resources and capacity building of MoH systems. Also, SUSTAIN will work to build the capacity of Regional Referral and selected district hospitals to serve as knowledge hubs for their geographic area and to provide quality services in a consistent manner.

Moreover, this activity will increase stewardship by the MoH in provision of quality ART services within the public health system through joint planning and technical assistance with MoH, district health teams (DHTs), facility managers and other stakeholders. This activity will also address the human resource gap by working with the regional referral hospitals (RRH) authorities and the DHTs. Jointly, they will undertake human resources needs assessments for ART services at the 11 RRHs and 13 district hospitals and identify critical additional staff requirements. The activity will also successfully transition 22 current TREAT sites over a period of two years to MoH or other capable partners. SUSTAIN will work with the Capacity Project and other USG projects at district level to help the RRH authorities and DHTs develop realistic human resource plans for recruitment and retention.

SUSTAIN will work closely with the MoH at national level and at supported ART sites to facilitate the development of a chronic care model for HIV/AIDS care and treatment. The model is based on the WHO principles of chronic HIV care and provides patients a holistic range of services, either through direct provision, specific services or through reliable referral networks. The project ensures that emerging issues in HIV/AIDS care and treatment (e.g. care and treatment of adolescents and older persons, HIV/AIDS mental health care) are addressed. This activity will support facilities to implement approaches aimed at organizing client records for rapid identification in active care and follow up on ART services. It will also facilitate the identification of those who fail to attend follow-up and, at high volume sites, the computerization of records as soon as this is feasible.

For holistic care beyond the facility, the project will build and strengthen facility linkages with external partners including the networks of people living with HIV and local community based organizations. In addition to enhancing service quality from a technical/professional perspective within appropriate budgets for Ugandan RRHs and district hospitals, the activity will implement innovative strategies for involving patients in assessing the quality of care and treatment services. SUSTAIN will draw upon existing resources including network support agents, expert clients and other stakeholders.

SUSTAIN will provide TA to improve monitoring of treatment outcomes by enhancing MoH patient and program monitoring systems to inform the roll-out and provision of effective ART services, including:

Streamlining client record keeping with enhanced client clinical record filing, storage and retrieval;

Supporting cohort analyses and periodic summaries of treatment outcomes;

Expanding the co-management capacity of TB/HIV;

Estimating ART treatment needs and impact of treatment; and

Monitoring early warning signs of drug resistance

Expected Program Results

Support of MoH on development and dissemination of standard operation procedures for ART and lab services;

Supported sites fully adhere to MoH guidelines and SOPs;

Supported sites implement a comprehensive continuing education program for their health workers;

Support to MoH to conduct semi-annual supportive supervision to hospitals and lower level facilities within districts hosting SUSTAIN sites;

Supported sites rated favorably on Early Warning Indicators for ARV resistance surveillance; and

Supported sites utilizing monitoring systems in accordance with MoH's standard operating procedures.

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at 11 regional referral and 13 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner. The activity will also successfully transition 22 current TREAT sites over a period of two years to MoH or other capable partners.

SUSTAIN will work closely with the MoH at national level and at supported ART sites to facilitate the development of a chronic care model for HIV/AIDS care and treatment, which is based on WHO principles and provides patients a holistic range of services, either through direct provision, specific services or through reliable referral networks. Moreover, SUSTIAN will be building capacity for pediatric health care staff through training, mentorship and supervision. Moreover, it will build capacity of community care groups such as PHA networks, religious leaders and volunteers to assist with pediatric care. The existing prevention with positives (PWP) interventions will be strengthened to enhance disclosure at the family level and support parents and guardians to test children for HIV. TREAT has been the PEPFAR flagship program for supporting the MoH Early Infant Diagnosis (EID) program in Uganda and support will continue under SUSTAIN. The program will introduce innovative approaches and enhance coordination among MoH, PEPFAR partners, referring facilities and testing labs to ensure quick result turnaround so that infected infants are diagnosed and treated in a timely manner. This will significantly reduce mortality among HIV positive infants and increase the number of children and infants identified for HIV care and treatment.

SUSTAIN will support the strengthening the linkage between facilities, which provide pediatric care and support services, and community based organizations providing OVC and youth friendly services. The program will emphasize the importance of improved quality of services for children infected and affected with HIV/AIDS, including adherence counseling, copying, and prevention with positive, and sexual and reproductive health issues among adolescents and young adults.

SUSTAIN will support implementation of nutrition assessment and counseling for infants and children. The program will coordinate with Nulife and other nutrition partners to ensure that infants and eligible children receive therapeutic and nutrition supplementation as per the OGAC and national nutrition guidance.

All infants born to HIV infected mothers at SUSTAIN-supported sites will receive cotrimoxazole prophylaxis starting at the age of six weeks until HIV infection is excluded after weaning. SUSTAIN will coordinate with the President's Malaria Initiative and PEPFAR supported social marketing partners to ensure that infants and children receive other Basic Care Package (BCP) commodities, such as insecticide treated bed nets, safe water systems, treatment for malaria and other OIs. SUSTAIN will also ensure that MCH units in the supported facilities provide quality services for HIV/AIDS-infected and exposed infants including: growth monitoring, routine child immunization, de-worming for helminthes, nutrition education and supplementation.

In accordance with WHO/MoH guidelines, all HIV-positive infants will initiate ART. Children above 12 months will be routinely monitored for treatment eligibility using WHO staging and CD4 percentage. SUSTAIN will directly support 35 facilities during FY2010 and FY2011 and transition 11 of them by the end of 2011.

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at 11 regional referral and 13 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner.

SUSTAIN will work closely with the MoH at national level and at supported ART sites to facilitate the development of a chronic care model for HIV/AIDS care and treatment, which is based on WHO principles and provides patients a holistic range of services, either through direct provision, specific services or through reliable referral networks. SUSTAIN will be building capacity for pediatric health care staff through training, mentorship and supervision. Moreover, it will build capacity of community care groups such as PHA networks, religious leaders and volunteers to assist with pediatric ART services. TREAT and Baylor Uganda have been PEPFAR flagship programs for pediatrics ART services in the country. SUSTAIN will build on the achievements of TREAT program in the area of ART services and in supporting the MoH Early Infant Diagnosis (EID) program. SUSTAIN will coordinate with the Health Communication Partnership (HCP) program to ensure that young children and adolescents enrolled in ART programs receive adequate counseling on treatment adherence and on sexual and reproductive health issues. SUSTAIN will follow a family-oriented approach in identifying, counseling, treating, monitoring and tracking children on ART.

This mechanism will procure ARVs for more than 3500 patients currently receiving drugs through the JCRC/TREAT mechanism in addition to providing substantial technical support on pediatric ART to 35 sites directly supported by SUSTAIN (11 of them will transition in FY11). SUSTAIN will enable these sites to support lower level facilities on training and mentoring for pediatric ARV services. This includes patients whose drugs are procured by the Clinton Foundation HIV/AIDS Initiative (CHAI) that ends December 2010.

SUSTAIN will encourage the MoH and other partners to ensure that consistent and adequate quantities of pediatric ARVs drugs are available at supported sites. Facilities that secure consistent supply of pediatric ARV drugs through MoH will receive the necessary technical capacity to enroll more infants and children on ART. Children above 12 months will be routinely monitored for treatment eligibility using WHO staging and CD4 percentage. HIV positive infants less than 12 months will be initiated on ART despite their CD4 levels.

SUTAIN will also ensure that infants and children on ART services access other relevant services including nutrition counseling and treatment, OI prophylaxis, TB screening, OVC support, immunization and growth monitoring among others.

SUSTAIN PMTCT

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project hereinafter will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally).The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at 11 regional referral and 13 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner. To ensure sustainability and partner rationalization, this mechanism will transition 11 lower level health facilities that are currently supported through the TREAT program.

PMTCT services will be a major component of the SUSTAIN program. This mechanism will support the WHO/MOH four-pronged PMTCT approach. SUSTAIN will work with ANC and MCH providers in the regional and district hospitals to ensure that a basic package of essential RH services is available for pregnant women and mothers, including lab tests and equipment, STI screening, iron, multivitamins and folic acid supplements, intermittent preventive malaria treatment, de-worming and infection control, for all women attending ANC, maternity and post-natal care units. This collaboration with ANC and MCH providers will strengthen SUSTAIN's PMTCT activities including HIV counseling and testing of pregnant women, screening for ART eligibility and the provision of more efficacious ARV regimens including HAART to HIV positive pregnant women and their infants according to national guidelines, and implementing safe early infant feeding practices. HIV positive women and their infants identified through the PMTCT program will be linked to SUSTAIN care and treatment services.

s.

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at regional 11 referral and 13 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner.

The long term management of HIV disease and monitoring of treatment requires chronic care services including a range of basic laboratory services. Also needed are HIV/AIDS diagnostic and treatment monitoring laboratory tests. However, most hospital laboratories at regional and district-level provide only hemoglobin, ESR and microscopy services.

Most public and private laboratories lack the staff competency, equipment, systems and infrastructureincluding reliable power supplyto provide adequate quality services and quality control and assurance. There are significant gaps in the following areas: recording and monitoring storage temperature of laboratory supplies; performing daily internal quality control tests on all laboratory analyzers and tests; and overall documentation. Most laboratories do not operate at good clinical laboratory practice standards, with the exceptions being some PEPFAR-supported laboratories like the JCRC Regional Centers of Excellence.

Analyzers and equipment in MoH and some NGO laboratories are out of service, sometimes because of lack of reagents and often due to lack of maintenance servicing and damage caused by irregular power supplies and fluctuations in voltage. For example, significant number of the MoH/Global Fund purchased CD4 machines are non-functional. There is inadequate utilization and adherence to best practices for sustainable maintenance of laboratory equipment through service agreements with vendors.

Laboratory related documentation is often inadequate with inconsistently completed request forms that do not include provision for the date and time of sample collection; no laboratory workbooks detailing who undertook which tests when; and sometimes poor turnaround of reports.

This program will ensure that laboratory personnel in regional and district hospitals are capable of providing high-quality lab monitoring and services. SUSTAIN will collaborate with MoH, PEPFAR partners and other relevant stakeholders in developing and updating QA/QC standards for basic hospital laboratory services and HIV diagnosis and treatment monitoring laboratory services. The project will develop a QA/QC strategy and plan for basic hospital laboratory services and HIV/AIDS laboratory services.

In coordination with CDC supported efforts, SUSTAIN will assist CPHL in implementing laboratory support and training activities at SUSTAIN-supported regional and district hospitals. SUSTAIN will coordinate with CPHL to provide any specific technical assistance (TA) to the development/enhancement of HIV/AIDS care and treatment and laboratory policy, service standards, quality assurance, standard operating procedures (SOPs), training curricula and training provisions to the MoH and its national level partners.

Expected Program Results

Support provided to MoH on development and dissemination of SOPS for ART and lab services;

Adherence to MoH guidelines and SOPs by supported sites;

Implementation of a comprehensive continuing education program for their health workers by supported sites;

Support to MoH to conduct semi-annual supportive supervision to hospitals and lower level facilities within districts hosting SUSTAIN sites;

Undertaking and recording daily QC for all assays/diagnostic tests by supported laboratories;

Participating in external Q/A for all major assays/tests;

Favorable quality standards met through external Q/A by supported laboratories;

Favorable ratings of supported sites on Early Warning Indicators for ARV resistance surveillance; and

Utilization of monitoring systems in accordance with MoH's standard operating procedures by supported sites.

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at regional 11 referral and 13 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner. This activity will also transition 22 current TREAT sites to MoH or other partners over a period of two years.

This activity is follow-on to the Time Table for Regional Expansion of ART (TREAT) project which is currently implemented by the Joint Clinical Research Center (JCRC). It is scheduled to be awarded by January 2010. The project is expected to take over more than 32,189 patients. 85% of the patients are on adult 1st line, 9% on pediatric 1st line, 5.6% on adult second line, 0.3% on pediatric second line and 0.1% on salvage therapy. More than 5000 patients will be transitioned to a USAID district based program during the first year of the project.

TB/HIV SUSTAIN

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at regional referral and 11 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner.

This mechanism will improve quality of TB-HIV/AIDS services in 11 regional referral and 13 district hospital. Facilities will be supported for coordinated and integrated HIV/AIDS services. Sites will be supported to hold regular TB/HIV and meeting where they will discuss and track patient transfer between two programs. Moreover, they will assess quality of services, treatment outcome, and appropriateness of regimen, drug side effects, and major HIV/TB co-management issues during the period.

The implementing partners will support facilities to implement innovative approaches for improving quality TB/HIV services.

The implementing partner will coordinate with NTLP and the AIDS Control program and other lead technical partner to ensure that supported facilities receive timely technical and programmatic guidance on TB/HIV collaboration.

REDACTED. The program will build upon the successes of The Timetable for Regional Expansion of Antiretroviral Therapy (TREAT) project. The new project will be referred to as SUSTAIN (Strengthening Uganda's Systems for Treating AIDS Nationally) in this and accompanying documents. The purpose of the project is to provide quality HIV/AIDS care and treatment, PMTCT, TB/HIV and related laboratory services at regional referral and 13 district hospitals in Uganda and to build the capacity of the public and private sector to provide care and treatment in a sustainable manner.

This activity being a comprehensive HIV/AIDS care and treatment project has a unique opportunity to reach TB patients who under HIV/AIDS care and treatment services. In addition this activity will work with TB clinics in supported sites to implement TB/HIV collaborative activities as defined by WHO and the national TB program.

Major focus areas for the mechanism will include

1. Provide HIV Counseling and testing of more than 85% TB patients

2. Provide co-trimoxazole prophylaxis to more than 80% of TB/HIV co-infected clients

3. Provide ARVs to at least 40% of TB/HIV co-infected clients

4. TB screen to >90% of patients on HIV care and treatment at supported sites

5. Support sites to implement TB infection control measures based on the revised WHO guidelines. The partner will support facilities to conduct their own risk assessment for TB transmission

Based on specific assessment finding, sites will be supported to develop and implement TB infection control plans. Which will include but not limited to assigning Infection Control officer, proper design and use of space, improved patient flow minimizing time spent in a health-care facility, personal protective measures; training of providers, patients and community member.

This mechanism being a lead partner for building lab capacity at regional hospital level, will support introduction of improved and cost effective TB diagnostic in selected facilities including introduction fluorescence microscopes with Light-Emitting Diodes in all 11 regional referral hospitals in coordination with other key players in TB diagnostics including the US Center for Disease Control and Prevention (CDC), Foundation for Innovative Diagnostics (FIND) and the Central Public Health Lab (CPHL).