The Uganda mission of USAID obligated funding to the TB Control Assistance Program (TBCAP) to support the Ministry of Health (MOH) and districts in Uganda to deliver integrated services for Tuberculosis (TB) and HIV and to strengthen Community Based Directly Observed Therapy-Short course (CB-DOTS). The International Union against Tuberculosis and Lung Disease (The Union) is the coordinating partner for TBCAP in Uganda. The goal of the program is to decrease the burden of TB among people living with HIV/AIDS (PLWHs) and the burden of HIV among notified TB patients. The strategic approach for implementation has been to focus efforts on increasing HIV/AIDS Counseling and Testing (HCT) uptake amongst TB clients as an entry point into HIV care, intensify TB case finding in HIV care settings and consolidate CB-DOTS. TBCAP operates within the existing MOH and district health systems and supports the implementation of national policies and guidelines on TB/HIV. TBCAP is currently supporting over seven PEPFAR TB/HIV as well as USAID TB Implementing partners to improve implementation and scale up of TB/HIV interventions. Additional partners will be supported in year three. TBCAP works closely with the Uganda offices of the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and other Uganda Stop TB Partnership (USTP) partners to support the MOH to improve guidance to districts and partners on the implementation of TB/HIV activities. The strategy TBCAP has employed is to build partnerships at all levels and improve existing TB and HIV services.

Selected intervention areas:

The main intervention areas for the project are:

1. Continue to support CB - DOTS and TB/HIV collaborative activities in twelve (12) districts.

2.Provide technical assistance (TA) to USG PEPFAR TB/HIV as well as USAID TB Implementing partners in order to scale up TB/HIV collaborative activities and strengthen CB-DOTS in the PEPFAR supported districts.

3.Provide support to the NTLP to strengthen coordination of the Multi Drug Resistance (MDR) TB response at the national level and implement some MDR activities.

Expected project outputs:

Output 1: Improved quality of CB-DOTS and TB/HIV collaborative activities in the twelve (12) TBCAP districts.

Output 2: TA to PEPFAR TB/HIV as well as USAID TB Implementing partners to scale up TB/HIV collaborative activities and strengthen/ consolidate CB-DOTS to PLWH

Output 3: NTLP supported to strengthen the coordination of the MDR response at national level and implement some MDR activities.

Project technical approach:

Given the resources currently available to TBCAP, supporting existing PEPFAR partners with TA to be able to scale up TB and TB/HIV collaborative activities was identified as the best approach to scale up these services. Although it was envisaged that the USAID mission would identify another partner to support direct implementation of TB and TB/HIV collaborative activities in the twelve (12) districts, this has not been realized. Therefore, TBCAP will continue to build on existing achievements in the twelve (12) districts so as to consolidate and sustain good performance in the area of CB-DOTS and TB/HIV collaboration until that time when another partner will be identified to support direct implementation of activities in those districts.

The strategies used in the 12 districts which have provided good results will be promoted in the other districts supported by PEPFAR partners. TBCAP will continue to support the NTLP with a focus on strengthening the coordination of the MDR response at the central unit in addition TBCAP will support another NGO to follow up TB patients in one other division of Kampala district. Contribution to strengthening of the health systems at national and district level remains core in all TBCAP supported interventions.

The twelve districts that TBCAP will continue to support are:

Central: Kampala, Mukono, Kayunga, Mpigi

Eastern: Soroti, Bukedea, Mbale, Manafwa

Western: Kiboga, Hoima, Masindi, Bulisa

The expected outputs shall be achieved by supporting the following activities:

Output 1: Improved quality of CB-DOTS and TB/HIV collaboration in the 12 TBCAP districts

In order to consolidate CB-DOTS and TB/HIV collaboration in the 12 TBCAP districts, TBCAP will continue its support in the following areas:

1.1 Support the districts' coordination mechanisms for TB/HIV

Support quarterly TB/HIV coordination meetings for the District Health Team and all partners within the districts;

Support the district health team to monitor activities of partners (USG and non-USG) within the district and overall performance indicators.

1.2 Support districts to improve the quality of CB-DOTS

Support supervision activities for CBDOTS including laboratories;

Support Village Health Teams (VHTs), PLWHA networks and CBOs to identify and refer TB suspects and to support adherence to treatment (includes Kawempe Home Care and Mengo homecare)

Support improvement of the drug logistics management system in the 12 districts.

Support maintenance of microscopes in 12 districts.

Support dissemination of laboratory Standard Operating Procedures (SOPs) in 12 districts.

Build capacity for hospitals and HC IVs in 12 districts to reconstitute laboratory reagents.

Support production of TB sign posts for health facilities in three (3) TBCAP supported districts (these signs will help to identify health facilities that provide TB services in these three remaining TBCAP supported districts).

1.3 Increase access of HIV diagnosis and care for TB patients and TB diagnosis and care for PLWH

Support implementation of ACSM activities;

Bridge the gap for HIV test kits and Cotrimoxazole in the 12 districts;

Support the use of the ICF tool (endorsed by the NCC) at HIV care settings and general OPDs among health facilities in TBCAP supported districts.

Support the districts to strengthen the referral system to ensure that TB suspects identified within HIV care settings receive prompt diagnosis and treatment for TB, and HIV patients identified within TB clinics receive ART as soon as recommended; Support Human Resource capacity development issues especially follow-up and on-job support including Nurses and Midwifery schools;

Follow up support supervision for health workers trained on CBDOTS, TB/HIV, Microscopy and Nurse tutors from Kampala area, Lira and Jinja

Support the NTLP to develop a human resources development (HRD) plan

Assessment of the Knowledge and Practice of graduating nursing students in supported Nurses training institutions.

Support M&E activities for TB/HIV, including dissemination of revised NACP recording and reporting tools.

Support supervision activities in the districts including Laboratory Focal Persons

Print and disseminate TB and revised NACP Registers

Facilitate data collection from facilities on a quarterly basis

Conduct data quality assessment exercises

Hold regional performance review meetings to monitor performance

1.4 Support TB-IC activities

Support sharing of best practices and learning from one another in infection control among districts based on updated TB Infection Control guidelines.

Support administrative TB-IC activities at facility level

Support MOH to produce IEC materials on TB-IC, and support partners to reproduce and disseminate

Output 2: Technical assistance to PEPFAR TB/HIV and USAID TB Implementing partners to scale up TB/HIV collaborative activities and strengthen/consolidate CB DOTS

TBCAP will provide TA to PEPFAR partners and District Management Teams to improve implementation of CB-DOTS and TB/HIV collaborative activities and will regularly monitor activities and performance advising on remedial actions in ensuring improvement in performance. TBCAP will specifically:

Support production of a quarterly newsletter to provide updates to partners on TB/HIV issues

Support coordination of partners implementing TB & TB/HIV programs with District Management Team

Support sensitization of all stakeholders on the revised TB guidelines and support them to disseminate the guidelines in the districts

Provide follow up support to partners to ensure that trainings on CB-DOTS TB/HIV collaboration and TB-IC are carried out in PEPFAR supported districts

Support the Health Care Improvement project to incorporate ISTC with in the quality improvement program for HIV and ART scale up

Support TOT for new partners on TB/HIV and TB-IC

Regularly monitor activities of partners in TB/HIV, IC and CB-DOTS in the districts in relation to strengthened M&E systems and tools

Link partners to national bodies for coordination of TB and TB/HIV activities (Uganda Stop TB partnership and the NCC) and national and regional supervisory bodies, to improve coordination and support supervision in partner sites/districts

Output 3: NTLP supported to strengthen the coordination of the MDR response at national level and to implement some MDR activities.

The MDR survey is ongoing, and data will soon be available on patient numbers. Provision has been made under the APA4 work plan to support the NTLP in MDR activities, and a strategic review of the situation will be conducted with these funds. An external consultant will support the national program in the drafting of guidelines for MDR which will form the basis for the future direction in this area. To support the national program to move ahead in this area, TBCAP will specifically support:

A full time Medical Officer to support coordination of all MDR activities

Printing and dissemination of MDR guidelines

Development of M&E tools for MDR

Training of teams of health workers at 5 regional referral hospitals.

Support supervision activities to MDR treatment centres including culture and DST laboratories.

Attribution

The Project will provide TA and financial support to consolidate CB-DOTS and TB/HIV collaborative activities in the 12 TBCAP districts. Additionally, the project will provide TA to PEPFAR partners to improve CB-DOTS and TB/HIV collaboration in the districts they support. Improvement in case detection and treatment success rates in the 12 TBCAP districts and other PEPFAR supported districts will contribute to improvement in the national TB indicators. By sustaining access to HIV diagnosis and care for TB patients in the project districts and supporting PEPFAR partners to do the same in other districts, the project will contribute to an increase in the proportion of TB patients tested for HIV, the proportion started on cotrimoxazole and the proportion of eligible TB/HIV patients started on ART. Likewise, promoting active TB screening among PLWH attending health care facilities will contribute to an increase in TB case finding in addition to improving TB diagnosis and care among PLWH. Through ongoing support to community based interventions, TBCAP will support and promote the involvement of communities in TB and TB/HIV care. Support to laboratory strengthening will contribute to health system strengthening. The Program will continue to collaborate with WHO and CDC on technical issues. The success of the NTLP in increasing its performance indicators can only be partially attributed to TBCAP as much of the commitment and funding for important activities will come from other USG partners and Global Fund.

Next steps and relation with other interventions:

The Union, as the coordinating partner, expects that long term sustainability of the TBCAP activities will be ensured by building the organizational capacity and TB/HIV expertise within PEPFAR partners, and all administrative levels of NTLP and NACP, by facilitating regular coordinating meetings between MoH NTLP and NACP and all stakeholders. The program will continue to build relationships between partners at the district level and facilitate all stakeholders to effectively plan and implement collaborative TB/HIV activities after the end of the project. This project will build new and reinforce existing structures, as well as develop and implement tools, for improved TB/HIV collaboration. The Union anticipates that after three years of program implementation, sufficient skills and knowledge will have been transferred from the project team to local partners for the NTLP and NACP to assume responsibility for TB/HIV collaborative activities. TBCAP has worked with the NTLP, NACP, DHT and partners, most especially USG partners, and ensured that TB and TB/HIV collaborative activities were included in their work plans and strategic plans. These work plans or strategic plans can be presented to other donors, including the Global Fund fight HIV/AIDS, TB and Malaria, for mobilization of resources. The primary challenge to the continuation of TB/HIV collaboration after the project will depend on the ability of the MOH to mobilize resources to fund necessary core activities for TB/HIV and CB-DOTS. Until the Government of Uganda can independently fund these activities, donor support will be needed to continue the implementation of TB/HIV and CB-DOTS activities.

Sustainability of interventions will continue to be considered with every activity in TBCAP, including:

Having established The Union-Uganda office within the NTLP, TBCAP staff has been able to give daily technical assistance and support to the NTLP. This professional partnership will continue to build the technical and management capacity of the NTLP to draft realistic long-term strategic plans, implement effective annual work plans, develop comprehensive budgets and absorb funding more efficiently;

1. The program will continue to strengthen the ability of NACP, NTLP and partners to monitor and evaluate TB and TB/HIV in Uganda by the ongoing improvement of the recording and reporting system, and the inclusion of joint supervision as part of their regular program activities;

2. The trainings supported by the program include a TOT component so that the lessons delivered in the training can then be transferred by trained health care workers to colleagues in the workplace;

3. A conscientious effort is being made to foster Ugandan and MOH ownership of all the tools and policies developed with the support of this program;

4. Throughout the implementation of the program, but with particular emphasis on PLWH in Year 3, the TBCAP will work closely with the NCC, NACP and NTLP to disseminate and encourage adoption and scaling up of best practices to other districts.

The program will continue to work closely with USG partners to ensure that the best practices identified through the project are adopted and diffused to health centers and services supported by the USG partners. It is assumed that the long-term costs of TB/HIV and CB-DOTS activities will be supported through current and future GF rounds and ultimately by the Government of Uganda when donor funds are no longer available.