USAID awarded a five-year award to Mulago-Mbarara Teaching Hospitals' Joint AIDS Program (MJAP) on August 20th, 2009 to implement the HIV counseling and testing project in 20 underserved districts in Uganda. The goal of the program is to scale up access to and coverage and utilization of quality HIV counseling and testing (HCT) services to populations at risk of HIV infection. The project has four objectives: 1) To increase the number of people accessing and utilizing HIV counseling and testing (HCT) services in Uganda; 2) improve the quality and efficiency of HCT services in Uganda by strengthening the appropriate support systems; 3) strengthen the referral network between the community and health facilities to allow expansion of HCT services and HCT linkage to HIV prevention, care, treatment and support; and 4) increase the demand for HCT services.

The project's strategic approaches to scale up HCT services include: a) Enhancing the capacity of the districts health services delivery system to manage HCT services; b) developing partnerships to facilitate capacity building and provision of HCT services to the private sector and community-based organizations; c) expanding a mix of approaches to increase access to HCT including VCT (facility-based and VCT outreaches), RCT for health facilities, and HBHCT (using index HIV infected individuals to test families and their surrounding communities); and d) enhancing human resource capacity for HCT service delivery through multiple approaches i.e. task shifting approaches to PLHIV, volunteers and other lay providers to alleviate the staffing constraints and creatively bridge human resource gaps.

The project will work closely with local government health delivery systems, the private sector, civil society, networks of people living with HIV, families and communities to achieve the objectives of this proposal. Project activities will be fully integrated into the district health plans to ensure local ownership and sustainability. Fiscal year 2010 will focus on rolling out HCT and setting up infrastructures and systems to support the program in eight districts namely: Koboko, Kaabong, Nyadri, Arua, Nebbi, Kampala, Mbarara and Mukono. Program year two will focus on the roll out of HCT activities to the remaining fourteen districts guided by experiences gained in year one.

Community outreach programs will also include activities to create awareness and increase demand for HIV testing. The community mobilization plan will include: community mobilization by drama groups; groups will receive training in presenting messages through music, dance, drama and public speaking; and groups will be trained/re-trained in HCT and referral. Available Information, Education and Communication (IEC) materials will be distributed on behalf of the MoH. MJAP will utilize the MoH communication strategy to educate the community about the importance of testing as couples with a focus on male involvement, disclosure, having multiple partners, fear of domestic violence and lack of couple communication. MJAP will build on their experience with discordant couples support to provide post-test support to couples tested through this program.

The Performance Monitoring Plan designed in line with the National HIV/AIDS Strategic Plan and the Health Sector Strategic Plan (HSSP) will be used to track progress towards achievement of project milestones. In keeping with the principles of "Three ones", all information will be available to support national policies and will be reported to the MoH and the Uganda AIDS Commission. The data for this PMP shall be collected using the MoH HMIS and other project specific tools.

Program objective three focuses on the strengthening of the referral network between the community and health facilities to allow expansion of HCT services and HCT linkage to HIV prevention, care, treatment and support. Program year one activities will focus on: 1) Mapping of all HIV care and support service providers in the 2o target districts to provide detailed information on where both HIV positive and HIV negative individuals can access the services of all types that they need. The mapping exercise will include Government facilities, CSOs, PLHIV networks, post-test clubs, care and treatment partners, OVC and PWD organizations. Providers will be identified from a range of sources including the Directory of HIV/AIDS Care and Support Agencies in Uganda (produced by TASO). Mapping will include GIS social maps as provided by the Uganda Bureau of Standards and also detailed maps of service providers as developed by MJAP; 2) Existing networks (such as the HIV/AIDS Alliance, The National Forum of People Living with HIV/AIDS Networks in Uganda (NAFOPHANU ) and linkages would be used to the maximum, and reinforced and strengthened as necessary, to forge durable, robust, and above all swift linkages between HCT and other HIV services including prevention, care and treatment programs. Networks and referral arrangements within facilities will be identified so that newly diagnosed HIV positive individuals can be linked to care and support services.

This is a new activity that will focus on increasing access to and utilization of HIV/AIDS Counseling and Testing (HCT) through support to 20 districts in the Uganda. Linkages to care, treatment and support services for the newly diagnosed HIV positive individuals is a key component of the HIV Counseling and testing project that is to be implemented by the Makerere Mbarara Teaching Hospital Joint AIDS Program(MJAP). Project focus will include the following interventions:

All individuals who will consent for HIV counseling and testing services will receive information on STIs, Family planning, and TB during the pre- and post-test counseling sessions. Newly diagnosed HIV positive patients will be screened for and/or treated for 1) opportunistic infections (OIs) and minor ailments; 2) STD/STIs; and will receive 3) Septrin prophylaxis; 4) pain and symptom management; 5) Family planning services 6) psychosocial support; and 7) on-going counseling. HIV positive clients will receive CD4+ screening to establish eligibility for ART. Other clinical services include related laboratory services, and nutritional assessment and support.

Provision of support to civil service organizations (CSOs), public and private facilities to strengthen the delivery of comprehensive and integrated services within the network model (management of STIs, malaria, TB, provision of cotrimoxazole prophylaxis and post exposure prophylaxis for health care workers, pain management and symptom control, spiritual and terminal care outside the facility

Training service providers from CSOs, public and private facilities in the provision of comprehensive palliative care services.

Promotion of family approach to the delivery of palliative care services through partnerships with CSOs using the HIV+ client as an entry point into the family and community. The family approach will be complemented with the provision of home based care kit through the trained home care givers.

Support various community based groups in the delivery of care services and referrals at community levels. Groups to be supported will include: post-test clubs, psycho social support groups for HIV+ mothers and spouses, religious leaders, faith-based organizations and volunteers. These groups will address legislative issues such as stigma, discrimination and gender based violence. Part of the 800 trainees (above) will be from these various groups.

Community mobilization activities to promote positive behaviors such as gender equality, couple dialogue, partners counseling and testing, disclosure and accessing treatment together

Support linkages that support leveraging other resources to benefit PLHAs in the areas of malaria, TB, family planning and safe motherhood, nutrition and child survival support, and education

Each person who tests positive will be given a referral card with contact details of a health care worker at the referral facility to help the individual register, receive counseling, be screened for TB and other OIs, and then be treated accordingly. If the client is HIV-positive, referral cards will be given to sexual partners and children under 5 to encourage them to access testing. The cards would be collected and analyzed to check whether the referral system is working as intended, and to pinpoint necessary improvements to the design and operation of the referral system (patient follow up and adherence).

Integrated services will be provided in collaboration with other partners such as Population Services International (PSI) to reach an estimated 1,000 HIV-positive clients with comprehensive HIV basic care packages which include mosquito nets, water vessel guards, information, education and communication (IEC) materials on positive living and Septrin prophylaxis, all of which aim to improve the quality of life of PHAs. The HIV+ client will be encouraged to mobilize other family members and communities to access HCT so as to identify infected clients that require ART and other care and support services beyond what they can offer to other agencies such as Joint Clinical Research Center (JCRC), TASO, Mild May and Regional public health facilities. Training and mentoring of care service providers will enhance the quality of care.

The HCT project will contribute to the national HIV response to scale up HIV counseling and testing to facilitate universal access to treatment by 2012. Despite tremendous achievements registered in the reduction of HIV prevalence in Uganda, only 25% of women and 21% of men reported being previously tested for HIV and receiving their results. The current HIV/AIDS interventions are not evenly distributed across the country, resulting in some districts being over-served while others are underserved. Investment in HCT programming has focused on development of infrastructure for Voluntary Counseling and Testing (VCT) services at freestanding VCT centers, antenatal care clinics, and sexually transmitted disease clinics. Systematic constraints in HIV services delivery in the target districts are: 1) Inadequate numbers and limited HCT knowledge and skills among the existing staff; 2) Frequent stock outs of essential HIV testing supplies and prophylaxis medicines such as Cotrimoxazole. This is due in part to irregular supplies through MoH/NMS supply channels and to inaccurate forecasting, quantification and ordering by the health workers; 3) in districts with several HCT partners supporting, coordination among the partners is poor. This results in duplication of services and therefore wastage of available resources; and 4) inadequate recording and reporting on their HIV services. Nearly all the districts have less than 10% of the eligible population tested for HIV, with Kaboong in particular having less than 1% of their populations tested for HIV.

This new activity will increase access to, coverage and utilization of HCT services through Routine HIV Counseling and Testing (RCT) in the health care settings, home-based HIV Counseling and Testing (HBHCT) for couples and families, and community outreach VCT for most-at-risk populations. Target beneficiaries for this project are under-served high-prevalence populations, discordant couples, children, and most at risk population e.g. fishermen, motorcycle riders ("boda boda"), internally-displaced persons (IDPs), truckers, commercial sex workers, uniformed personnel and mobile populations.

The project will support health systems strengthening through task-shifting approaches for the lower level health units, technical assistance for HCT supply chain management including forecasting, quantification, ordering, stock taking and recording. The program will provide buffer stocks to the MOH to ensure a constant supply of test kits at the health facilities.

The project will strengthen the monitoring and evaluation (M&E) systems including Health Management Information System (HMIS) capturing the HIV testing in both the public and private sector.

Quality of HCT services is affected by limited skills for providing HCT to children, adolescents and couples, as well as obtaining and documenting informed consent. The limited number of trained personnel and inadequate support supervision in the private sector compromise the quality of HCT in the private sector.

The project will review existing SOPs, guidelines and quality assurance systems for delivery of HCT through internal quality control (IQC) and external quality control for HIV tests and support supervision to facilitate adherence to national HCT policy and the associated guidelines. All testing units in the program submit 5-10% of positive and negative samples once a week to a local reference laboratory for re-testing and feedback reports are taken to the units. Corrective actions will be taken in case of any identified errors.

Program objective three focuses on the strengthening of the referral network between the community and health facilities to allow expansion of HCT services and HCT linkage to HIV prevention, care, treatment and support. Program year one activities will focus on: 1) Mapping of all HIV care and support service providers in the 2o target districts to provide detailed information on where both HIV positive and HIV negative individuals can access the services of all types that they need. The mapping exercise will include Government facilities, CSOs, PLHIV networks, post-test clubs, care and treatment partners, OVC and PWD organizations. Providers will be identified from a range of sources including the Directory of HIV/AIDS Care and Support Agencies in Uganda (produced by TASO). Mapping will include GIS social maps as provided by the Uganda Bureau of Standards and also detailed maps of service providers as developed by MJAP; 2) Existing networks (such as the HIV/AIDS Alliance, The National Forum of People Living with HIV/AIDS Networks in Uganda (NAFOPHANU ) and linkages would be used to the maximum, and reinforced and strengthened as necessary, to forge durable, robust, and above all swift linkages between HCT and other HIV services including prevention, care and treatment programs. Networks and referral arrangements within facilities will be identified so that newly diagnosed HIV positive individuals can be linked to care and support services.

This is a new activity that will focus on increasing access to and utilization of HIV/AIDS Counseling and Testing (HCT) through support to 20 districts in the Uganda. Linkages to care, treatment and support services for the newly diagnosed HIV positive individuals is a key component of the HIV Counseling and testing project that is to be implemented by the Makerere Mbarara Teaching Hospital Joint AIDS Program(MJAP). Project focus will include the following interventions:

All individuals who will consent for HIV counseling and testing services will receive information on STIs, Family planning, and TB during the pre- and post-test counseling sessions. Newly diagnosed HIV positive patients will be screened for and/or treated for 1) opportunistic infections (OIs) and minor ailments; 2) STD/STIs; and will receive 3) Septrin prophylaxis; 4) pain and symptom management; 5) Family planning services 6) psychosocial support; and 7) on-going counseling. HIV positive clients will receive CD4+ screening to establish eligibility for ART. Other clinical services include related laboratory services, and nutritional assessment and support.

Provision of support to civil service organizations (CSOs), public and private facilities to strengthen the delivery of comprehensive and integrated services within the network model (management of STIs, malaria, TB, provision of cotrimoxazole prophylaxis and post exposure prophylaxis for health care workers, pain management and symptom control, spiritual and terminal care outside the facility

Training service providers from CSOs, public and private facilities in the provision of comprehensive palliative care services.

Promotion of family approach to the delivery of palliative care services through partnerships with CSOs using the HIV+ client as an entry point into the family and community. The family approach will be complemented with the provision of home based care kit through the trained home care givers.

Support various community based groups in the delivery of care services and referrals at community levels. Groups to be supported will include: post-test clubs, psycho social support groups for HIV+ mothers and spouses, religious leaders, faith-based organizations and volunteers. These groups will address legislative issues such as stigma, discrimination and gender based violence. Part of the 800 trainees (above) will be from these various groups.

Community mobilization activities to promote positive behaviors such as gender equality, couple dialogue, partners counseling and testing, disclosure and accessing treatment together

Support linkages that support leveraging other resources to benefit PLHAs in the areas of malaria, TB, family planning and safe motherhood, nutrition and child survival support, and education

Each person who tests positive will be given a referral card with contact details of a health care worker at the referral facility to help the individual register, receive counseling, be screened for TB and other OIs, and then be treated accordingly. If the client is HIV-positive, referral cards will be given to sexual partners and children under 5 to encourage them to access testing. The cards would be collected and analyzed to check whether the referral system is working as intended, and to pinpoint necessary improvements to the design and operation of the referral system (patient follow up and adherence).

Integrated services will be provided in collaboration with other partners such as Population Services International (PSI) to reach an estimated 1,000 HIV-positive clients with comprehensive HIV basic care packages which include mosquito nets, water vessel guards, information, education and communication (IEC) materials on positive living and Septrin prophylaxis, all of which aim to improve the quality of life of PHAs. The HIV+ client will be encouraged to mobilize other family members and communities to access HCT so as to identify infected clients that require ART and other care and support services beyond what they can offer to other agencies such as Joint Clinical Research Center (JCRC), TASO, Mild May and Regional public health facilities. Training and mentoring of care service providers will enhance the quality of care.

This is a new activity that will focus on increasing access to and utilization of HIV/AIDS Counseling and Testing (HCT) through support to 20 districts in the Uganda. AB messages will be provided during HCT outreaches at H/C II and the communities in collaboration with existing HCT service providers in order to increase access to most-at-risk populations (the MARP will need more of OP than AB services) and remote areas. The MJAP Regional offices will serve as the focal point for coordination of M&E systems, operational research, external quality assurance, training and mentoring of other HCT service providers within the health system. Special emphasis in AB (school going children of ages 10-14); those aged 15+ should get comprehensive HIV/AIDS information including information regarding condoms) and OP will focus on the Most-at-Risk Populations that will include fisher folk military/police establishments, mobile populations including internally displaced persons (IDPs), truck drivers, CSW institutions of higher learning, as well as People with Disabilities. Peers trained for AB and OP will mobilize for HCT among their peer populations.

AB resources will continue to assist the national response in appropriately addressing the shifting nature of the epidemic, and expand attention to faithfulness and partner reduction initiatives among newly married young couples. In addition, resources will specifically address the vulnerability factors of specific categories of youth such as young people involved in transactional or cross-generational sexual relationships, young people living with HIV, and addressing the underlying causes of the vulnerabilities faced by Uganda's youth that increase their risk of exposure to HIV. Cultural norms and practices, sexual coercion and gender discrimination issues that make youth and in particular young girls at increased risk of exposure will be addressed.

This is a new activity that will focus on increasing access to and utilization of HIV/AIDS Counseling and Testing (HCT) through support to 20 districts in the Uganda. Other Prevention (OP) messages will be provided as an integrated component of HCT services at health centre IIIs, IIs and the community levels. The MJAP Regional offices will serve as a focal point for coordination of M&E systems, operational research, external quality assurance, training and mentoring of other HCT service providers within the health system. OP services will focus on the Most at Risk Populations that will include fisher folk military/police establishments, mobile populations including internally displaced persons (IDPs), truck drivers, CSW institutions of higher learning, as well as People with Disabilities. PLWHAs will be trained to offer OP services and will mobilize for HCT among their peer populations.

OP resources will continue to be used to ensure that Uganda's older and at risk youth have access to age and risk appropriate abstinence, faithfulness, behavior change and condom information and services. OP resources will also assist the national response in appropriately addressing the shifting nature of the epidemic, and expand attention to faithfulness and partner reduction initiatives among discordant and married couples.

In addition, resources will specifically address the vulnerability factors of specific categories of youth such as young people involved in transactional or cross-generational sexual relationships, young people living with HIV, and addressing the underlying causes of the vulnerabilities faced by Uganda's youth that increase their risk of exposure to HIV. Cultural norms and practices, sexual coercion and gender discrimination issues that make youth and, in particular, young girls increasingly at-risk of exposure will be addressed.