The military populations, to which Uganda People's Defense Forces (UPDF) belongs, have been identified among the Most at risk populations to HIV transmission. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. They mostly reside in and/or around military bases that are widely distributed all over the country. The majority are young, energetic men and women in the 18-45 age-group that is well known to be sexually actives. While all recruits undergo an HIV test and only HIV negative persons are conscripted, the HIV/AIDS scourge has not spared the military populations. The HIV prevalence, though not officially known, is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Given that the Ugandan National HIV prevalence stands at 6.4%, it could be as high as 15% in the military.

The UPDF HIV/AIDS Control program started way back in 1988 when the President of Uganda, as commander in chief of the armed forces mandated the UPDF's AIDS Control Program to oversee and manage prevention, care, and treatment programs throughout the forces and their families. It is estimated that approximately 10,000 military are living with HIV with up to an additional 10,000 HIV infected family members. Additionally, an increasing proportion of military clinics and hospital attendees are civilians not affiliated to the military institutions; up to 50% of outpatient visits are by non-military.

The Goal of DoD-UPDF HIV/AIDS Prevention Program (DHAPP) in Uganda is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military populations. Specifically, DHAPP's objectives are;

To increase awareness about HIV prevention, care and treatment services among military community.

To increase access to and utilization by military personnel and their family members, of;

Prevention of mother-to-child transmission (PMTCT)

Prevention (AB and ABC)

HIV Counseling and testing

Basic and specialized HIV care and treatment

Diagnosis and management of TB-HIV co-infection

Services for orphans and vulnerable children (OVC).

Sexual and Gender Based Violence services and now

Medical Male Circumcision

To strengthen the monitoring and evaluation systems of the UPDF HIV/AIDS Control Program

To support injection safety initiatives in the military health facilities.

PMTCT: The goal for this performance period is to reach 80% of pregnant women and 25% of spouses and partners of the targeted pregnant women with PMTCT services and reaching 80% with prophylaxis and treatment according to Ministry of Health Guidelines.

The DoD-UPDF implementing mechanism supports Uganda People's Defense Forces (UPDF), a Government institution with mandate to defend and protest the people and territorial integrity of Uganda. Implementation is based on the UPDF HIV/AIDS strategic plan-2007-2012, which was developed in accordance with the National HIV/AIDS Strategic Plan 2007-2012. Therefore, the mechanism fits within the "3-ones" approach namely; one strategic framework, one performance measurement and management plan and one monitoring and evaluation framework. The mechanism mainly adopts and uses the Ministry of Health and WHO recommendations, guidelines and standard Operating Procedures (SOPs). The DoD-UPDF mechanism sub-contracted three partners; Research Triangle Institute (RTI) International; National Medical Research Unit (NAMERU) and University of Connecticut (U-Conn), to strengthen the support to this unique military population. Furthermore, whenever possible, DoD-UPDF partners with other local implementers with comparative advantage in specific implementation areas, to further increase efficiency and cost-effectiveness.

The DoD-UPDF mechanism delivers HIV/AIDS care and treatment services through strategy of integrated clinical care service delivery; (2) with the exception of specific target populations, health education messages are integrated, and delivered through Behavioural Change Communication (BCC) outreaches; (3) Wherever minor infrastructural, logistical and technical capacity is built, the benefits go beyond the specific implementation area that has contributed the budget, and at times beyond PEPFAR supported services. For example procurement of theatre equipment for the MMC program is accomplished using MMC funds but serves all patients.

The DoD-UPDF mechanism was created out of collaboration between the USG and Ugandan Government to build the latter's capacity, and therefore has high sustainability chances. One of the challenges faced by the implementing mechanism is poor distribution systems and working with Supplies chain Management Systems (SCMS), logistics management trainings will be conducted for UPDF health workers and drugs storekeepers as a way of minimizing stock-outs and expiry, thereby improving efficiency.

A comprehensive and integrated Monitoring and Evaluation system is an important tool in the management of any programme, because it helps to focus implementers and hence contributes to causing impact. For DoD-UPDF, this integrated Monitoring and Evaluation plan will generate information on HIV/AIDS Care and Treatment from the implementing sites to the national level.

The overall objective of the M&E plan is to generate comprehensive and timely information for use in decision making, learning, effective planning and implementation of HIV/AIDS prevention control interventions in all implementation sites. DoD-UPDF in collaboration with NAMERU will achieved through strengthening the capacity of the military facilities to collect and use data, developing/modifying data collection tools to capture MEEPP and military specific indicators, routinely collecting data from military clinics, compiling, analysing and preparing reports for dissemination to key stakeholders.

For the upcountry military bases, the key strategies will include use of existing Ministry of Defense reporting structures and channels. A participatory approach is employed in the planning, designing, implementation and subsequent reviews of the plan which are deemed relevant to HIV/AIDS care. The indicators closely relate with the National Monitoring and evaluation framework as well as FY 2010 PEPFAR indicator guidance.

Budget Code Narrative Adult Care and Support The Goal of DoD-UPDF HIV/AIDS program is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military population in Uganda. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. The HIV prevalence, though not officially known, is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Given that the Ugandan National HIV prevalence stands at 6.4% (National sero-behavioral survey), it could be as high as 15% in the military. It is estimated that about 10,000 military are living with HIV and up to an additional 10,000 HIV infected family members and surrounding community. An increasing proportion of military clinics and hospital attendees are civilians not affiliated to the military institutions with up to 50% of outpatient visits being by non-military.

The goal of the adult care and support program area is to extend and optimize quality life for HIV infected clients and their families, through the continuum of illness through provision of clinical, psychological, spiritual, social and prevention services. The services are provided using mainly the facility based approach, in 12 ART accredited centres. They are; Bombo, Gulu, Acholi Pii, Moroto, Rubongi, Kakiri, Nakasongola, Katabi, Makindye, Mbuya, Mbarara and Mubende. The DoD-UPDF mechanism employs the Ministry of Health guidelines for comprehensive management of PHAs. In FY 2010, the DoD-UPDF will expand its support to provision of comprehensive HIV care services to an additional 2 facilities and facilitate their accreditation as ART centres making a total of 14 ART facilities. Basing on the results of the needs assessment Research Triangle Institute (RTI) International conducted at the beginning of this year, there is great need for basic patient care commodities and quality gaps in services currently delivered at a number of facilities. In view of that, we propose to; i) strengthen linkage between diagnosis and chronic care through improved patient referral. The referrals will be made primarily to the 14 chronic care clinics. A total of 2,400 patients will be newly enrolled into chronic care clinics to bring the total enrolled to 15,000. In addition, 1,000 adults and children with advanced HIV will be newly enrolled on ART; ii) REDACTED. iii) Sponsor medical, clinical officers and senior nurses teams for short courses in HIV chronic care management-pediatric HIV care will be given special emphasis. These courses will be provided at nationally recognized training institutions like Infectious Disease Institute and of course by our partners like RTI and University of Connecticut. A total of 75 health workers will be trained in comprehensive HIV care and treatment. To further bridge the existing human resource gaps in the facilities, volunteer health workers and/or PHAs will be trained to support the provision of on-going counseling, psychosocial support and helping patients to develop sexual behavior, care and treatment plans in order to prevent HIV transmission and improve adherence at least 4 volunteers per facility; iv) support quality control measures like conducting basic hematological tests for patient monitoring. We will also promote CME meetings and on job training during technical support supervision to bridge the existing quality gaps; v) Work in collaboration with the MOH-ACP to distribute the revised standard operating procedures, protocols and job aids on HIV patients' care; vi) In order to improve patient adherence, DoD-UPDF will work in collaboration with University of Connecticut to develop client education materials that can be used in group and individual counseling sessions and orient health workers in effective counseling skills.

. In addition, working with University of Connecticut, DoD-UPDF will support the Prevention with Positives (PwP) program, which is modeled on the South African Options for Health Program in Bombo and Nakasongola, and where possible scale it up. A master trainer course will be organized to cater for transfers and new facilities we bring on board. The program will also distribute MOH standard operating procedures, protocols and job aids on Palliative Care to all supported health facilities. In order to minimize stock-outs for drugs used in prophylaxis, DoD-UPDF, in collaboration with SCMS, will train health unit staff in forecasting and requisition for the right amounts of drugs and other basic care supplies.

In collaboration with PACE, all families of HIV positive military persons will be provided with a Safe Water Vessel (20 liter) and insecticide treated bed nets. All HIV positive persons attending chronic care HIV clinics will be screened for TB and treated accordingly.

The Goal of DoD-UPDF HIV/AIDS program is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military population in Uganda. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people.

The goal of the OVC program is to increase access and utilization of comprehensive quality services for most vulnerable children and their households. An Orphan and Vulnerable Child (OVC) in the military is defined as a child below 18 years who has lost a parent/s or affected or infected by HIV residing within or in close proximity to the military facility/barracks. It includes: all HIV positive children; children affected by HIV i.e. parent/s or guardian is HIV infected and unable to adequately support them; children lacking protection, education, adequate nutrition, access to health, accommodation, clothing, legal redress and psychosocial (parental /guardian) support; and children unable to have the basic necessities of life due to long time absence of the parent/s or guardian, including children whose earning parent is deployed to an operational area for prolonged periods.

With the DoD/PEPFAR support, Uganda People's Defense Forces, together with Research Triangle Institute (RTI) International held a series of stakeholder meetings to build consensus on military OVC definition and strategies for identifying them. A customized military OVC program framework was formulated. Consequently, RTI is in the process of developing OVC implementing guidelines. Coordinators were indentified for every ART centre, to coordinate and report on OVC activities. A total of 958 orphans were provided with education, medical care and psychosocial services. Other services include mitigation of the impact of conflicts provided to children in northern Uganda. In addition, AIDS Alliance trained OVC providers in Bugema and provided OVC data capture tools.

However, a lot still needs to be done. Basing on the 2004/05 National HIV/AIDS sero-behavioral survey, only 23% of OVCs receive some form of external assistance in Uganda. This could be worse for OVCs in military populations, considered to be hard to reach by civilian providers. The UPDF OVC program specifically lacks adequate human resource to provide technical supports and there are as yet no system at community level for identification, planning and support of beneficiaries for OVC services.

During FY 2010, the DoD-UPDF program will focus more on completing military specific OVC implementation guidelines and disseminate them to stakeholders. We acknowledge the fact that military facilities provide services to the civilians but our primary target will be the OVCs within the facilities and those of patients attending the chronic care clinics at the facilities. The DoD-UPDF program targets to reach 1,000 military OVCs with at least one OVC need. However, only 600 eligible OVC (presumed to have the most pressing needs) will be provided in 3 or more OVC core program areas beyond psychosocial support. The program will train 50 service providers from the 14 ART centers, on OVC service delivery and comprehensive HIV management. The program actual support packed will be determined at a later date guided by the needs assessment results that is to be conducted in September 2009.

Budget Code Narrative Adult treatment The Goal of DoD-UPDF HIV/AIDS program is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military population in Uganda. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. The HIV prevalence, though not officially known, is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Given that the Ugandan National HIV prevalence stands at 6.4% (National sero-behavioral survey), it could be as high as 15% in the military. It is estimated that about 10,000 military are living with HIV and up to an additional 10,000 HIV infected family members and surrounding community. An increasing proportion of military clinics and hospital attendees are civilians not affiliated to the military institutions with up to 50% of outpatient visits being by non-military.

The goal of the adult treatment program area is to extend and optimize quality life for HIV infected clients and their families, through management of common illnesses, improving clinical infrastructure and provision of monitoring laboratory tests. The services are provided at the 12 ART accredited centres. They are; Bombo, Gulu, Acholi Pii, Moroto, Rubongi, Kakiri, Nakasongola, Katabi, Makindye, Mbuya, Mbarara and Mubende. The DoD-UPDF mechanism employs the Ministry of Health guidelines for comprehensive management of PHAs. In FY 2010, the DoD-UPDF will expand its support to provision of comprehensive HIV care services to an additional 2 facilities and facilitate their accreditation as ART centres bringing the total ART facilities to14. Basing on the results of the needs assessment Research Triangle Institute (RTI) International conducted at the beginning of this year, there is great need for basic patient care commodities and quality gaps in services currently delivered at a number of facilities. in addition, the University of Connecticut conducted focus group discussions with UPDF health workers in Mbuya, Bombo and Nakasongola. They identified informational and behavioural issues preventing clients from consistently adhering to ART. In view of these facts, we propose to; i) strengthen patient adherence to medications. Working with University of Connecticut, job aids will be developed to facilitate health workers to give adherence support services to all the clients in care; ii) REDACTED; iii) Support counselor, clinical officers and nurses teams for short courses in HIV chronic care management including adherence support. These courses will be provided by our partners RTI and University of Connecticut. A total of 30 health workers will be trained in Art adherence support skills. To further bridge the existing human resource gaps in the facilities, volunteer health workers and/or PHAs will be trained to support the provision of on-going counseling, psychosocial support and helping patients to develop sexual behavior, care and treatment plans in order to prevent HIV transmission and improve adherence at least 4 volunteers per facility; iv) develop client education materials for both group and individual counseling sessions; v) Work in collaboration with the MOH-ACP to distribute the revised standard operating procedures, protocols and job aids on HIV patients' treatment; vi) In order to improve patient adherence, DoD-UPDF will work in collaboration with University of Connecticut to develop client education materials that can be used in group and individual counseling sessions and orient health workers in effective counseling skills.

. In addition, working with University of Connecticut, DoD-UPDF will support the Prevention with Positives (PwP) program, which is modeled on the South African Options for Health Program in Bombo and Nakasongola, and where possible scale it up. A master trainer course will be organized to cater for transfers and new facilities we bring on board. The program will also distribute MOH standard operating procedures, protocols and job aids on Palliative Care to all supported health facilities. In order to minimize stock-outs for drugs used in prophylaxis, DoD-UPDF, in collaboration with SCMS, will train health unit staff in forecasting and requisition for the right amounts of drugs and other basic care supplies.

The Goal of DoD-UPDF HIV/AIDS program is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military population in Uganda. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. The HIV prevalence, though not officially known, is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Given that the Ugandan National HIV prevalence stands at 6.4% (National sero-behavioral survey), it could be as high as 15% in the military. The UPDF employs the following HIV testing models; 1) Voluntary Counseling and Testing (VCT); 2) Provider Initiated HIV Testing and Counseling (PITC) and where appropriate 3) Mandatory HIV Testing and Counseling (for persons selected for external military training). The DoD-UPDF mechanism contributes over 60% of the HIV test kits used in military populations.

During FY 2010, the program will focus more on PICT, in line with Ministry of Health guidelines. Every opportunity will be employed to reach soldiers who have not been tested. The program has targeted to reach 29,130 unique persons with HCT services, using the above named strategies. Services will be provided at 20 static facilities and through community outreaches. Additionally, HCT services will be offered at all Military gatherings where the leaders are encouraged to test and act as role models to their subordinates. In order to minimize double reporting, the monitoring and evaluation system, will be strengthened through our partner; National Medical Research Unit (NAMERU). NAMERU will ensure all testing centres are provided with HIV test registers and are regularly reporting to UPDF headquarters. There will be cross-referral between this crucial service and others like Medical Male Circumcision, TB/HIV co-infection, HIV prevention outreaches (health talks, film and drama shows).

To further build capacity for sustainability and to ensure quality of CT, in-service training and technical support supervision will be provided to health workers by the project technical staff and external facilitators with specialized skills. To further enhance quality of counseling and testing, external quality control for HIV testing will be conducted. Proficiency testing for health care workers involved in HIV rapid testing will be periodically conducted and blood samples from field tests will be re-tested at a reference laboratory at least once every quarter. The project will facilitate the collection and transportation of blood samples for re-testing from the facilities to the reference laboratory and pay for analysis when need be. Commodities like; tables, chairs working tops, timers, testing protocols and SOPs will be provided to the established testing points. Internal referral mechanisms will be built where all newly diagnosed HIV-positive patients will be immediately linked to care.

The Goal of DoD-UPDF HIV/AIDS program is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military population in Uganda. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. The HIV prevalence, though not officially known, is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Given that the Ugandan National HIV prevalence stands at 6.4% (National sero-behavioral survey), it could be as high as 15% in the military. It is estimated that about 10,000 military are living with HIV and up to an additional 10,000 HIV infected family members and surrounding community. An increasing proportion of military clinics and hospital attendees are civilians not affiliated to the military institutions with up to 50% of outpatient visits being by non-military. Assuming the WHO proportions apply in military populations, there are about 2000 children aged 0-14 years living with HIV/AIDS.

The goal of the pediatric HIV care and support program is to extend and optimize quality life for HIV infected children of military families and surrounding communities, through the continuum of illness by provision of clinical, psychological, spiritual, social and prevention services. The services are provided using mainly the facility based approach, in 12 ART accredited centres. They are; Bombo, Gulu, Acholi Pii, Moroto, Rubongi, Kakiri, Nakasongola, Katabi, Makindye, Mbuya, Mbarara and Mubende. Employing the Ministry of Health guidelines for comprehensive management of PHAs, the DoD-UPDF mechanism supports pediatric HIV care and support services in 3 facilities of Bombo, Kakiri and Nakasongola. Basing on the results of the needs assessment Research Triangle Institute (RTI) International conducted at the beginning of this year, there is great need for basic patient care commodities and quality gaps in services currently delivered at a number of facilities. In FY 2010, the DoD-UPDF will expand its support to provision of comprehensive pediatric HIV care services to an additional 3 facilities among the Ministry of Health accredited ART centres. We propose to do the following; i) strengthen linkage between diagnosis and chronic care through improved patient referral. We will support collection of DBS samples and their transportation to testing centres and returning of results to referring facilities; ii) routine provision of services to children. A total of 2,250 HIV positive children have been targeted to receive care and support service through the DoD-UPDF mechanism. Using the same referral mechanism as for DBS, the program will support referral of blood samples for HIV positive children for CD4 testing and timely return of results, for patient monitoring. In addition, ii) All clinics will be provided with basic commodities like Septrin buffer stock (including pediatric formulations); iii) Sponsor medical, clinical officers and senior nurses teams for short courses in HIV chronic care management and pediatric HIV care will be given special emphasis. These courses will be provided at nationally recognized training institutions like Mildmay or Baylor-Uganda and of course by our partners RTI. A total of 50 health workers will be specifically trained in pediatric HIV care and treatment. We will also promote CME meetings and on job training during technical support supervision to bridge the existing quality gaps; V) Work in collaboration with the MOH-ACP to distribute the pediatric HIV care and treatment guidelines and job aids; vi) In order to improve program monitoring, DoD-UPDF will work in collaboration with NAMERU and MOH-ACP care and treatment team to provide and orient health workers to the MoH standard data collection tools and to provide regular technical support to enhance knowledge and skills.

All new health care workers in the supported health facilities and in the two new facilities will be trained to provide facility-based palliative care and /or referral for further assessment and specialized care for HIV+ patients. Refresher training and technical support supervision will be provided as needed to ensure quality delivery of Palliative Care services for children. In order to minimize stock-outs, DoD-UPDF will support health unit staff in forecasting and requisition for the right amounts of drugs and other basic care supplies.

The Goal of DoD-UPDF HIV/AIDS program is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military population in Uganda. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. The HIV prevalence, though not officially known, is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Given that the Ugandan National HIV prevalence stands at 6.4% (National sero-behavioral survey), it could be as high as 15% in the military. It is estimated that about 10,000 military are living with HIV and up to an additional 10,000 HIV infected family members and surrounding community. An increasing proportion of military clinics and hospital attendees are civilians not affiliated to the military institutions with up to 50% of outpatient visits being by non-military. Assuming the WHO proportions apply in military populations, there are about 2000 children aged 0-14 years living with HIV/AIDS.

The goal of the pediatric HIV care and support program is to extend and optimize quality life for HIV infected children of military families and surrounding communities, through the continuum of illness by provision of clinical, psychological, spiritual, social and prevention services. The services are provided using mainly the facility based approach, in 12 ART accredited centres. They are; Bombo, Gulu, Acholi Pii, Moroto, Rubongi, Kakiri, Nakasongola, Katabi, Makindye, Mbuya, Mbarara and Mubende. Employing the Ministry of Health guidelines for comprehensive management of PHAs, the DoD-UPDF mechanism supports pediatric HIV care and support services in 3 facilities of Bombo, Kakiri and Nakasongola. Basing on the results of the needs assessment Research Triangle Institute (RTI) International conducted at the beginning of this year, there is great need for basic patient care commodities and quality gaps in services currently delivered at a number of facilities. In FY 2010, the DoD-UPDF will expand its support to provision of comprehensive pediatric HIV care services to an additional 3 facilities among the Ministry of Health accredited ART centres. We propose to do the following; i) strengthen linkage between diagnosis and chronic care through improved patient referral. We will support collection of DBS samples and their transportation to testing centres and returning of results to referring facilities; ii) routine provision of services to children. A total of 2,250 HIV positive children have been targeted to receive care and support service through the DoD-UPDF mechanism. Using the same referral mechanism as for DBS, the program will support referral of blood samples for HIV positive children for CD4 testing and timely return of results, for patient monitoring. In addition, ii) All clinics will be provided with basic commodities like Septrin buffer stock (including pediatric formulations); iii) Sponsor medical, clinical officers and senior nurses teams for short courses in HIV chronic care management and pediatric HIV care will be given special emphasis. These courses will be provided at nationally recognized training institutions like Mildmay or Baylor-Uganda and of course by our partners RTI. A total of 50 health workers will be specifically trained in pediatric HIV care and treatment. We will also promote CME meetings and on job training during technical support supervision to bridge the existing quality gaps; V) Work in collaboration with the MOH-ACP to distribute the pediatric HIV care and treatment guidelines and job aids; vi) In order to improve program monitoring, DoD-UPDF will work in collaboration with NAMERU and MOH-ACP care and treatment team to provide and orient health workers to the MoH standard data collection tools and to provide regular technical support to enhance knowledge and skills.

All new health care workers in the supported health facilities and in the two new facilities will be trained to provide facility-based palliative care and /or referral for further assessment and specialized care for HIV+ patients. Refresher training and technical support supervision will be provided as needed to ensure quality delivery of Palliative Care services for children. In order to minimize stock-outs, DoD-UPDF will support health unit staff in forecasting and requisition for the right amounts of drugs and other basic care supplies.

The DoD-UPDF HIV/AIDS Other Prevention program target population is the soldiers, their spouses and adults in the surrounding communities. The military population is estimated to be 200,000, residing in military barracks all over Uganda. The DoD-UPDF mechanism provides a comprehensive package of HIV services in over 20 military health facilities and military bases, ranging from prevention, counseling and testing, clinical care and OVC. The goal of SI program is to have a vibrant monitoring and evaluation system, able to provide up to date information to program managers and timely reports for stakeholders (ministry of health, ministry of defense and MEEPP). The SI component of PEPFAR support is implemented in collaboration with National Medical Research Unit (NAMERU), a local NGO with experience of Ugandan healthcare system.

During FY 2010, the Strategic information program will focus on: training a critical mass of health workers in UPDF health facilities in data management and reporting skills; 1) continue to support the UPDF M&E Officer and HMIS Focal Persons with on-job training and technical support. In this regard, 100 health workers will be trained; 2) in collaboration with ministry of health, procure data capture tools and distribute them to UPDF health facilities; 3) equip 14 HIV clinics with physical and electronic data storage facilities including computers, internet, filing cabinets and book-shelves; 4) transform the paper-based HMIS into a computerized system and promote internet-based reporting; and in collaboration with NAMERU and Ministry of Defense, conduct quarterly technical support supervision to all implementing facilities.

The SI program will be guided by the National "three ones" strategy.

The Goal of DoD-UPDF HIV/AIDS program is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military population in Uganda. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. The HIV prevalence, though not officially known, is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Given that the Ugandan National HIV prevalence stands at 6.4% (National sero-behavioral survey), it could be as high as 15% in the military. Medical Male Circumcision has been proven to be effective in reducing the risk of heterosexual HIV transmission. The DoD-UPDF mechanism started supporting this intervention in FY 2009, with central funding from OGAC, with the goal of increasing access to MMC services. Achievements included: 1) sensitization of the top and mid level military leadership regarding the benefits of male circumcision on HIV prevention. Fifty military leaders were reached, and advocacy is still ongoing; 2) equipping theatres at 04 health facilities; the equipment were procured basing on a checklist developed from the WHO MMC training manual. 3) Procurement of supplies; this was again guided by the WHO training manual and health workers' experience. 4) Training of health workers by Rakai Health Sciences Program; 5) sensitization for over 12,000 soldiers on the benefits of MMC and 6) UPDF leadership supported to conduct site visit to Kayunga Walter Reed Project. UPDF is working with Ministry of Health to develop appropriate IEC materials and orient VCT counselors (including the post-test club counselors), peer educators and health care personnel to provide appropriate health education. Over 100 MMC circumcisions have been performed.

In FY 2010, the DoD-UPDF mechanism will employ the following strategies in an inter-linked approach: (1) make MMC services available through a strategy of integrated clinical care service delivery; (2) mobilize communities, especially young newly recruited uniformed officers, for services utilization through Behavioural Change Communication (BCC) strategy; (3) ensure that there is an infrastructural, logistical and technical capacity to provide the MMC minimum package; (4) intensify advocacy to secure support; and (5) conduct operational research to provide evidence & document lessons learned. The DoD-UPDF mechanism will scale up MMC services from the current 4 facilities to an additional 2 that are considered to be distant from the existing sites. Bombo General Military Hospital will be equipped as a COE to provide training to health professionals and support supervision to lower facilities. MMC clinic outreaches and special day clinics on weekends will be organized so as to cater for busy officers and also overcome the inadequate staffing shortage. Additional surgeons will be recruited and supported to provide the services, alongside the existing staff.

A total of 1,500 MMC operations will be performed at the supported military hospitals. In addition, 5,000 clients will be provided HCT services and screening for STIs. All supported facilities will be provided with basic MMC equipment and supplies. REDACTED. New equipment will be procured for the 2 new facilities, while for the facilities already supported; only equipment to replace damaged items will be procured. Bombo General Military Hospital will be fully equipped and strengthened to work as a centre of excellence for mentoring healthcare providers and hosting key experts for technical support supervision of lower facilities. A total of 50 health workers will be trained in delivery of MMC minimum package and an additional 300 peer educators and community groups oriented in delivery of appropriate MMC messages. To further bridge the existing human resource gaps in the facilities, 2 clinical officers will be recruited and trained as MMC surgeons to support heavy

Safe Male Circumcision (SMC) has been scientifically proven to reduce the risk to HIV infection by 40-60%, making it the most plausible prevention strategy in generalized epidemics. SMC can synergistically work with other prevention strategies. However, in Uganda where the bulk of HIV infections are through heterosexual transmission, no program has been able to implement a circumcision program at a scale that would have an appreciable effect on HIV incidence. The military attracts mainly energetic sexually active young men, who are HIV negative at recruitment. The military SMC program offers an easy opportunity to reach, and as respected members of society, these could potentially serve as agents of change in their traditionally non circumcising communities.

The military population, the constituent group served by the DoD-UPDF mechanism, comprises; uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. The current number of males not circumcised in the military population is not known. However, assuming the 2002 National Housing and Population Census circumcision rates of 25% of males, and the fact the Ugandan security forces are male dominated, over 50,000 people could be un-circumcised in the military population. On the other hand, while the HIV prevalence in this population is not known, it is widely believed to be higher than the 6.4% for the general population. The high HIV burden is widely believed to be driven by a mostly young people who want to experiment; the highly mobile nature of the occupation and long spells they stay away from their families; the risk taking culture their training inculcates in them; the redundancy in between tours of duty; and alcohol abuse (MARPS study).

The uniformed forces in Uganda have been identified among Most at Risk Populations, mainly acquiring HIV through the heterosexual mode of transmission, for which Medical Male Circumcision has been proven to be effective. In addition, although uniformed forces are an organized group, they are hard to reach by civilian health services. They can best be reached through their institutionalized health services. The SMC program will be an opportunity to further strengthen and improve these health facilities. Furthermore, roll out of SMC will provide a platform for more comprehensive HIV prevention service for this elusive group.

Goal: To reduce the incidence of HIV among military populations in Uganda, through increased utilization of quality Medical Male Circumcision services in the broader HIV prevention program.

Program purpose: To strengthen the capacity of UPDF, health facilities for provision of a minimum package of Medical Male Circumcision services integrated into routine clinical care.

Specific Objectives: By the end of the 5 years:

1. To increase by 50% from 2010 figures, the prevalence of male circumcision among military populations in Uganda.

2. To strengthen the capacity of UPDF health facilities to provide a minimum package of SMC integrated into existing health care services.

3. To raise to 80% among uniformed communities the awareness about SMC services and its benefits, in relation to HIV/AIDS preventions.

Accomplishments since last COP

In FY 2009, the DoD-UPDF mechanism supported: 1) sensitization of the top and mid level military leadership regarding the benefits of male circumcision on HIV prevention. Fifty military leaders were reached, and advocacy is still ongoing; 2) equipping theatres at 04 health facilities; the equipment were procured basing on a checklist developed from the WHO SMC training manual. Equipment for an additional 2 facilities will be procured soon; 3) Procurement of supplies; this was again guided by the WHO training manual and health workers' experience. 4) Training of health workers by Rakai Health Sciences Program (16 health professionals have undergone this training; 5) sensitization for over 12,000 soldiers on the benefits of SMC and 6) UPDF leadership supported to conduct site visit to Kayunga Walter Reed Project. UPDF is working with Ministry of Health to develop appropriate IEC materials and orient VCT counselors (including the post-test club counselors), peer educators and health care personnel to provide appropriate health education. Over 300 SMC circumcisions have been performed (report to be compiled by end of March). Using FY 2010 funds, an additional 2 sites will be established, where all the above activities will be implemented.

Identified gaps, which need immediate intervention

There is overwhelming competition for theatre space in UPDF health facilities, making it impossible to increase SMC days to more than once a week.

Understaffing within UPDF makes it almost impossible to have a complete team for SMC service provision.

There is frequent transfer of uniformed personnel including healthcare workers, mostly basing on security rather than health reasons.

Establishment of an M&E system for the SMC program that generates information for program management and reporting requirements.

Areas to be addressed with supplemental funding

The additional funding will specifically address;

Identify and renovate 2 rooms in each of the already existing SMC centres, to work as theatre and recovery rooms

Hire additional staff and enroll volunteers to establish self-reliant SMC clinics alongside the UPDF established theatre infrastructure.

Additional supplies to meet the increased demand for SMC services

Expected outputs

Six theatre rooms renovated

Fifteen (15) health workers recruited and supported

Daily Safe Medical Circumcision services introduced in the 6 MC centres

3,000 safe male circumcisions performed/year, 800 by September 2010

Increased capacity of supported health facilities to perform surgical operations

Improved quality of surgical services in the supported health facilities

Assumptions:

Each facility will be conducting 50 circumcisions per week (10/day), hence a total of 3,000 circumcisions in a year. However, since for this year, the intensive program is likely to start in June, only 800 circumcisions can be done by 30th September 2010.

Less than 5% experience moderate or severe adverse events following a MMC procedure will be experienced.

Blood-borne infections such as HBV, HCV and HIV constitute a major occupational hazard for health care workers. The greatest threat in the military health facility setting is accidental injury with contaminated needles or other sharp objects. The gaps identified in these facilities include; lack of injection safety supplies like safety boxes, single use syringes, needle cutters and others. In addition, there is high demand for unnecessary injections and the health worker injection safety practices are wanting. The DoD-UPDF mechanism, in collaboration with National Medical Research Unit (NAMERU), a local non-governmental organization, is implementing the injection safety program in Uganda People's Defense Forces (UPDF) health facilities. The goal of this program is to reduce HIV transmission through unsafe injections. Specifically the program will build the capacity of health workers in military health facilities in management of safe injections; support the military medical procurement and supply chain; and support behavior change and advocacy campaigns. The program is currently implemented in three Military Hospitals; Rubongi, Mbarara and Kakiri.

FY 2010 Activities will include: 1) Scaling-up the program to 3 more health facilities; 2) training of health workers on the standards for safe injection use, healthcare waste management and PEP; 3) print and distribute National Policy, National Guidelines on Injection Safety and medical waste management, SOPs and related IEC materials; 4) construct 2 incinerators (at Bombo and Gulu Military Hospitals); 5) procure and distribute to UPDF health facilities injection safety materials like auto-destruct syringes, safety boxes, protective gear, colour-coded medical waste disposal bins; 6) ensure availability of and accessibility to PEP services at UPDF health facilities; 7) community sensitization about dangers of unnecessary injections; 8) developing injection safety checklists/guidelines for UPDF HIV managers to use while conducting support supervision.

Target population: The DoD-UPDF HIV/AIDS program target population is the children in 30 primary, 4 secondary (Nakasongola Tororo, Mbarara & Entebbe) and 2 Polytechnic (Mbarara & Mubende) schools, with an estimated population of 12,000 youths. The out of school youths and married couples will be given comprehensive prevention messages including condom use and so will not be counted under AB. Most children who live in military barracks commonly face inadequate parental guidance. Their parents are deployed at short notice; they stay in congested residences; with people from mixed cultural background and with no coherent family structures. They are hence regarded as vulnerable to HIV.

During FY 2010, the AB program will focus on reaching small groups and individuals with consistent messages on abstinence, delays of sexual activity and/or secondary abstinence as well as related community and social norms that impact these behaviors. A total 5,000 children have been targeted to be reached with these messages. To achieve this, school teachers will be equipped with current knowledge about HIV/AIDS and skills to pass on this message to children. The UPDF health educators too will be conduct monthly health education outreaches to schools to address more technical questions.

The specific activities to be implemented by DoD-UPDF in include: 1) training of 120 school teachers and health educators in AB messages; 2) monthly health education outreaches to schools; 3) IEC materials developed by Ministry of Education and Sports will adopted to suit the military environment, and massively produced; 4) Support children's clubs/associations to hold and debate on HIV/AIDS issues; 5) Support drama and film shows with appropriate content for children in schools; 6) Support assay writing competitions and present awards to winners.

The DoD-UPDF mechanism will also identify children with good oratory to make inspiring speeches or poetry about the virtues of abstinence, delayed sexual activity and secondary abstinence. Where applicable, health education outreaches will be integrated with HIV counseling and testing to identify infected children and link them to care.

The DoD-UPDF HIV/AIDS Other Prevention program target population is the soldiers, their spouses and adults in the surrounding communities. The military population is estimated to be 200,000, residing in military barracks all over Uganda, majority of which are in the 15-49 sexually active age group. While all recruits undergo an HIV test and only HIV negative persons are conscripted, the HIV/AIDS scourge has not spared the military. The HIV prevalence is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Heterosexual intercourse is the main mode of HIV transmission. Drivers of the epidemic have been identified as; the young sexually active age; the frequent transfers to different stations and being separated from their main sexual partner and family for long spells of time; alcohol abuse and having a regular income while serving vulnerable communities.

During FY 2010, the other sexual prevention program will focus on increasing access to condoms by the military community. This will be achieved through increasing condom outlets to 30 and orienting community resource persons like peer educators and counselors in condom distribution skills. Condoms will primarily be obtained from the national Ministry of Health procurement system. Other activities will include health education/film shows/drama show outreaches integrated with HIV Counseling and Testing outreaches, health talks at military parades and training institutions, all which will be entry points before peer educators and counselors engage clients in small groups and individual discussions. Similar groups meetings will be organized for soldiers' spouses. The DoD-UPDF mechanism will support 5 drama groups to prepare and stage shows in various military bases. In addition, we shall facilitate teams to go out for monthly outreach visits. 20 Film show equipment (TV sets, DVD players and tapes/DVDs) will be procured and distributed to brigades to support film shows. Peer educators will be engaged in quarterly review meetings to keep track of their performance. Seminars will be held targeting 100 military leaders with correct HIV prevention messages. Messages will be tailored to influence soldiers' perceptions about heroism in regard to HIV infection and alcohol abuse. The ministry of health communication strategy will be adopted to suit the military environment and copies printed and distributed to all levels, as a way of standardizing the delivered messages. We shall also massively produce and distribute army conceptualized IEC materials including posters, leaflets, to re-enforce the messages. UPDF will take advantage of every social event like football shows, army week, world AIDS day to show case for HIV prevention, like supporting a popular commander to address the participants, facilitating PHAs to give testimonies and others.

Where applicable, health education outreaches will be integrated with HIV counseling and testing to identify infected individuals and link them to care. People counseling will be encouraged go for HIV counseling and testing as a couple. Risky behaviors like having multiple sexual partners, transactional sex and trans-generational sex will be discouraged. Peer educators will refer clients for other reproductive health services like family planning.

Target population: The DoD-UPDF HIV/AIDS program target population is the military personnel, their family members and surrounding communities, totaling well above 200,000 people. Given that military populations are male dominated the population of pregnant women is less than the 5%, expected in the general population. During FY 2010, the program will focus on increasing the coverage of women receiving PMTCT services in the 09 PEPFAR supported military facilities; namely Bombo, Gulu, Lubongi, Mbarara, Jinja, Katabi, Kakiri, Nakasongola and Moroto. A total 2,000 mothers are expected to attend ANC in these health facilities, representing 40-50% of the expected number in the population and of these 300 are expected to be HIV positive.

The activities to be implemented by DoD-UPDF in collaboration with Research Triangle International (RTI), a sub-partner include: 1) sensitization and increased awareness for pregnant women to access services; 2) Conduct an assessment to estimate the coverage of counseling and testing of pregnant women and linkage to ART services; 3) training of midwives and nurses in provision of PMTC services according to Uganda WHO and MOH guidelines; 4) procure delivery equipment for supported health facilities; 5) procure protective wear for healthcare providers; support referral of CD4 count samples to testing centres and receipt of results to enhance screening for HAART eligibility; 6) support peer mothers/expert clients to provide psychosocial support to newly diagnosed HIV positive pregnant mothers; 7) procure a buffer stock of HIV test kits to supplement those supplied through the Ministry of health system; and 8) support tracking infants of HIV positive mothers after delivery.

The DoD-UPDF mechanism will also use the pregnant women as index contacts to support the involvement of partners in the PMTCT program by promoting HIV testing for family members, couple counseling, disclosure of sero-status and support for discordant couples. The program will also promote the integration of PMTCT activities within the routine maternal and child health services at the target facilities. Working with RTI, links between community and facility services will be enhanced to complement and reinforce each other for maximum impact on PMTCT and on the health of mothers. DoD-UPDF will also use the pregnant women as index contacts to support the involvement of partners in the PMTCT program by promoting HIV testing for family members, couple counseling, disclosure of sero-status and support for discordant couples.

The Goal of DoD-UPDF HIV/AIDS program is to increase access to and utilization of HIV/AIDS prevention, care and treatment services among the military population in Uganda. The UPDF is comprised of uniformed personnel, their family members and surrounding communities, totaling well above 200,000 people. The HIV prevalence, though not officially known, is believed to be similar to that of the other African militaries estimated at 2-3 times that in the general population. Given that the Ugandan National HIV prevalence stands at 6.4% (National sero-behavioral survey), it could be as high as 15% in the military. It is estimated that about 10,000 military are living with HIV and up to an additional 10,000 HIV infected family members and surrounding community. An increasing proportion of military clinics and hospital attendees are civilians not affiliated to the military institutions with up to 50% of outpatient visits being by non-military.

With the widespread use of cotrimoxazole prophylaxis, TB has become the commonest HIV associated opportunistic infections and the leading cause of death PHAs in the Ugandan military population. The goal of the TB/HIV program is to reduce the burden of TB among HIV patients and reduce the burden of HIV among TB patients. The services are provided using mainly the facility based approach, in 12 ART accredited centres. They are; Bombo, Gulu, Acholi Pii, Moroto, Rubongi, Kakiri, Nakasongola, Katabi, Makindye, Mbuya, Mbarara and Mubende.

The DoD-UPDF mechanism employs the WHO and Ministry of Health guidelines for TB/HIV collaborative activities. In FY 2010, the DoD-UPDF mechanism has targeted to screen 15,000 HIV positive patients for active TB and all those diagnosed to have active TB will be started on treatment. In addition, we targeted to treat 800 TB patients in our supported facilities and using the strategy of Provider Initiated HIV testing and counseling, we will screen all that will accept to test for HIV and whoever tests HIV positive will immediately be linked to chronic HIV clinics for care. We therefore propose to; i) strengthen laboratory services through support to procurement of buffer laboratory reagents and supplies. All supported health units will have functional laboratory services with capacity to conduct a sputum examination. In a few selected cases, we shall pay for X-ray services obtained from private providers. A total of 400 patients are estimated to be present as incident TB patients and these will be given priority. ii) Patients with TB/HIV co-infection will be index patients and their families members will be followed-up and screened for both HIV and TB. Children and infants will be given special consideration; iii) Together with our partners RTI, UPDF health workers will be supported to attend short courses in management of TB/HIV co-infections-using WHO and Ministry of Health recommended curriculum. At least 75 health workers will be trained in this aspect of HIV care and treatment. Some CME sessions will be provided specifically focusing TB/HIV co-infection. To further bridge the existing human resource gaps in the facilities, The Ministry of Health DOTS strategy will continue to be supported due to its proven improvement on drug efficacy; iv) In order to improve program monitoring, DoD-UPDF will work in collaboration with NAMERU and MOH-NTLP team to provide and orient health workers to the standard data collection tools and to provide regular technical support to enhance knowledge and skills. The MoH quality assessment quality control program will be supported.