SPEAR ACTIVITY NARRATIVE FY 2010

World Vision is a Christian humanitarian organization dedicated to working with children, families and their communities worldwide to reach their full potential by tackling the causes of poverty and injustice. World Vision supports communities to improve their lives through integrated programs including HIV/AIDS prevention and care for the affected populations. World Vision is the lead implementing agency for the USAID-funded five year program for Supporting Public sector workplaces to Expand Action and Responses Against HIV/AIDS (SPEAR). This is a five-year USAID/PEPFAR funded initiative for supporting the Ministry of Internal Affairs (MoIA), Ministry of Local Government (MoLG) and Ministry of Education and Sports (MoES) to enhance HIV/AIDS prevention in their respective workplaces through expanded access and utilization of quality HIV/AIDS prevention, treatment and care services. World Vision is the prime implementing agency of SPEAR project and works in collaboration with Research Triangle Institute (RTI). The goal of the SPEAR Project is to enhance HIV/AIDS prevention among adults through expanded access and utilzation of HIV/AIDS prevention, treatment and care services for selected public sector workers in Uganda that shall be attained by achieving three key results and eight intermediate results as summarized below.

R 1 Support public sectors to develop policies, plans and activities that assure availability, integration and utilization of sustainable HIV prevention, care and treatment services for their employees IR 1.1 Enhance capacity of public sector workplaces to adopt/adapt policies and practices that improve employees' access to high quality HIV-related services IR 1.2 Target workplaces and partner service-providers equipped with HIV-related technical and institutional development skills to develop and implement sustainable strategic plans and operational activities IR 1.3 Effective stigma and discrimination reduction programs developed and implemented in target public sector workplaces R 2 Increased access to and utilization of quality HIV prevention, care and treatment services by target public sector workers, with a focus on identifying HIV-positive individuals and facilitating access to networked care and treatment services IR 2.1 Increased personal perception of risk of HIV infection/transmission and utilization of prevention services through aggressive targeted behavior change programs IR 2.2 Increased access to and utilization of HCT services by targeted public sector workers and their families IR 2.3 Improved access to and utilization of palliative care, treatment services, and psychosocial support services for HIV-positive public sector workers and their families R 3 Improved access and use of wrap-around services by target public sector workers living with HIV/AIDS and their families through effective partnerships with other USG and non-USG supported programs IR 3.1 Improved public sector workers' awareness of the value and sources of wrap-around services available and from public, private, faith-based and non-governmental organizations IR 3.2 Increased # of target public sector workers and their families accessing wrap-around services through effective referrals and linkages

In FY 2010, SPEAR will implement a number of activities designed around a needs-driven, transformational development approach that provides a solid foundation for achieving the project's objectives and results listed above. To ensure sustainability of its interventions, SPEAR will strategically mobilize political and popular support to benefit workplaces through coalition building, engagement and networking with governments, universities, donors, USG-funded NGOs/local NGOs, CBOs and key stakeholders. Investments will also be made in institutional capacity strengthening, policy and advocacy as a means of engendering a cultural shift at all levels on the importance of protecting the lives of public sector employee and the urgent need for creative and appropriate HIV/AIDS workplace interventions utilizing readily available resources. In addition, project interventions will be based upon participatory and inclusive decision-making, with a focus on engaging the public sector and targeted workplaces/workforces in decision-making at all levels of the project's implementation, monitoring and evaluation.

Activity Narrative: Adult Care and Support FY 2010

In FY 2010, SPEAR project activities, under this budget code, will contribute towards improving access to and utilization of a range of quality HIV-related care and support services (excluding TB) as well as wrap-around services for HIV-positive public sector workers and their families. Improved access and utilization of care, treatment and support services for HIV-positive public sector workers has direct and positive implications for addressing the impacts of HIV/AIDS in the workplace. Increased access to care and treatment enhances stigma reduction, disclosure and positive prevention lifestyles which contribute to reduction in worker absenteeism, staff turnover and improvements in staff morale and productivity. Activities described here are thus designed to tap into and build upon services being provided by existing family, community, FBO, private and public health and social support systems to increase care, treatment and support to public sector workers living with HIV/AIDS. All care and support activities will target both male and female employees aged 18 and above within the workplace setting and employee community (e.g barracks setting) of the targeted Ministries. SPEAR project activities provide a combination of care and support services - some directly through training and others through referral mechanisms that will contribute towards improving access to and utilization of a range of HIV-related care, treatment and support services as well as wrap around services for HIV-positive public sector workers and their families (adolescents, adults, women etc).

In FY2010, 1,000 eligible adult public sector workers and their family members including their children will be provided with a range of services that include psychosocial support, management and treatment of opportunistic infections, routine Septrin prophylaxis and ART. SPEAR will create awareness among public sector employees of the targeted line ministries, i.e. MoES, MoIA & MoLG on available care and treatment services within their communities and encourage them to seek, participate in and benefit from these programs. After the provision of HCT services, beneficial referral strategies will be implemented and SPEAR will ensure that persons identified to be HIV positive have access to appropriate medical, treatment, and psychosocial support services through effective linkages and referral systems. In addition, SPEAR will identify service providers who are accessible and acceptable by the employees and referrals will be made to these medical service providers to address their HIV care needs. Special referral will be provided to couples identified to be positive, pregnant women, and people susceptible to TB. Follow-up efforts after referral will be done to facilitate initial contact with care and support service providers to verify completed referrals. In addition SPEAR will provide septrin prophylaxis and hygiene kits directly to organized PHA groups and the facilities they frequented use. Uganda Prisons Service and the Ministry of Education and Sports already have a network of PHAs in their sectors and the formation of associations of public sector employees living with HIV/AIDS in other sectors will be encouraged and supported. To ensure continuity of services for the targeted 1000 PHAs, SPEAR will also establish formal collaboration with local and national HIV/AIDS service providers; negotiate mechanisms through which beneficiaries can be linked or referred to their programs. The project will commit to identifying and referring public sector employees that need care and treatment while seeking partner organizations' provision of these services.

To strengthen institutional capacity for sustainability, SPEAR will support the respective ACP units of the target ministries to carry out training of 200 lay volunteers in palliative care to supplement the efforts of health workers providing ART for HIV positive workers and their families in their clinics and facilities in accordance with Ministry of Health standards. Examples of lay palliative care volunteers to be trained include associate counselors, home-based caregivers, ART adherence monitors and adherence counselors. The associate counselors will disseminate information about HIV/AIDS care, support services, and be available for psychosocial support and counseling colleagues in the workplace.

To enhance quality care services for HIV positive workers and their families, in addition to the training of the 200 lay volunteers, SPEAR will also train 200 health care providers in basic ART skills according to MoH protocols and guidelines. Training will emphasize ART clinical skills including HIV diagnosis, disease staging, ART eligibility assessment, treatment adherence monitoring and counseling in addition to prevention and treatment of opportunistic infections (OIs). These health care workers will be selected from the target workplace-based facilities and will include school nurses and health workers in police, prisons and local government health facilities. This activity will be limited to facilities where no other USG partner has already undertaken training or is planning to do so in the target year. To strengthen the delivery of treatment services, health care providers will also be trained in the skills needed to ensure continuity of service provision from testing to care and treatment for HIV positive workers and their families and to recognize the need for referral to clinics and community-based health delivery systems. To reduce costs, SPEAR will seek partnerships with other programs/organizations such as MJAP, PIDC, JCRC, Hospice Uganda, TASO, IRCU, AIDSRelief, and Mildmay to incorporate target health workers in their training programs and provide ongoing mentoring.

The effects of HIV/AIDS transcend the medical challenges of infected individuals to include broad socio-economic impacts on families, communities, and high-prevalence geographic regions. Therefore SPEAR will also enhance access to information on available Wrap-Around services to target HIV positive public sector employees beyond the project's core services of HIV prevention, care, treatment and support targeted at the primary causes of HIV-related illness and death. Improved access to wrap-around services by target public sector workers living with HIV/AIDS will be achieved through effective partnerships and collaboration with ongoing USG funded programs and capacity strengthening of national and district PHA networks for sustainability. To meet the demand for wrap-around services by target PHA and their families, SPEAR will strengthen relationships already established in FY 2009 with CSOs, FBOs and government departments/agencies so as to enroll more PHA in their programs. SPEAR will also establish linkages with various private, public and FBO treatment centers supported by the USG and other donor agencies to provide the 5,000 PHA with a basic health care service package that includes: Insecticide Treated Nets, Nutrition packages including nutrition education and literacy, fortified food supplements, family planning as well as safe water, hygiene and improved sanitation. To make it easy for PHA to identify where to access services, SPEAR will map service providers offering a range of wrap around services and make information/resource lists available to employees as part of the regular information component of the workplace program.

To sustain the provision of wrap-around services, 500 HIV positive public sector employees selected from existing and new workplace-based PHA groups and networks will also be trained in skills that will enable them develop wrap-around services themselves. To maintain quality assurance in the care component, effective monitoring and follow-up, to track the level of care and support will be done using appropriate methods and tools including special studies, record reviews and program reports. Identified PHAs will be enrolled by SPEAR and provided with referral forms to the organizations or health facilities that provide the needed services. SPEAR will then liaise with these organizations or health facilities for proper tracking of complete referrals and the type of services they received. To ensure quality of the data collected, quarterly verifications of the complete referrals will be done by the M&E team. In addition, quarterly follow-ups of the clients retained on the program will be done to ensure efficiency of the program and thus reduce on the drop out rate. Assessments will be done to establish reasons for drop outs and incomplete referrals.

Activity Narrative for Counseling and Testing: FY 2010

In FY 2010, SPEAR project activities under the Testing and Counseling area will be geared towards increasing access to and utilization ofHIV Counseling and testing (HCT) services by 60,000 MoLG, MoES and MoIA public sector workers and their families. SPEAR will focus on increasing demand and utilization of quallity HCT services for public sector employees and their families not only for enhancing HIV/AIDS prevention, but also as a foundation for care, treatment and support services. The HCT target population includes health workers, occupational migrant workers and the uniformed services, such as teachers, police, immigration officers and private security guards. Promotional HCT activities under this budget code will target both male and female employees aged 18 and above within the workplaces of the targeted Ministries. Even though activities will be workplace-based, target employees' families (including spouses and partners) will also be targeted in the context of their communities. Specific activities will include promotion of HCT services to increase individual and social perceptions of the costs and benefits associated with the service and adoption of the health behavior. The campaigns will involve a mix of strategies to address the negative perceptions, reduce the barriers and encourage uptake of HCT among target workers. Development/adaptation of expertly designed IEC materials to support targeted HCT promotional messages will also be accomplished through collaboration and partnership with HCT service providers and other HIV/AIDS educational opportunities by both the project team and other partners. To increase and sustain uptake of HCT services, SPEAR will continue to support the respective AIDS Control Programs units of the ministries and trained Behaviour Change Agents (BCAs) to promote HCT services within their Units with a view of increasing individual and social perceptions of the costs and benefits associated with the service and adoption of the health behavior. Associations of people living with HIV/AIDS (PHAs) will also be mobilized and facilitated to promote HCT by disseminating key messages on the benefits and the importance of early testing and the importance of engaging with support mechanisms like post-test clubs etc. To ensure accurate and consistent messaging, standard HCT promotional guides and protocols developed by the MoH and other International standards will be followed. In addition, SPEAR BCAs will also be trained in peer counseling on HCT to facilitate the development and nurturing of an HIV/AIDS peer counseling program in all targeted workplaces for reaching out to peers with HCT messages and counseling services in a bid to increase HCT uptake.

To increase HCT access and availability, SPEAR will partner with and support 50 workplace-based HCT outlets (20 in Uganda Prisons Service, 14 in Uganda Police Service and 16 in Education sector) in addition to Local Government facilities including district hospitals and Health Center IVs to provide effective outreach and group-friendly HCT services for public sector employees and their families. SPEAR support to the selected 50 HCT outlets and facilities will include service delivery materials/supplies and also offer training to improve the capacity for delivering HCT services that benefit public sector employees. Specific training support from SPEAR will target health workers (not previously trained) from these selected health units in Uganda Prison Service, Uganda Police Force and the Minsitry of Education on the use of HCT protocols and new approaches to HCT including routine counseling testing (RCT), provider initiated testing and counseling (PITC), Couples counseling and testing, home-based counseling. For maximum coverage, SPEAR will target hard-to-reach workplaces in rural under-served remote areas through a mix of innovative approaches that include mobile counseling and testing camps, work place (e.g office, barracks setting, etc) HCT family days and home based HCT. SPEAR's focus on workplaces outside urban settings (e.g immigration and boader post securty employees) is to help meet the unmet demand for HCT among underserved rural and peripheral public employees. In all these activities, SPEAR will encourage and facilitate pre-marital and couples HCT and mutual disclosure among public sector workers and all efforts will be made to bring HCT services as close as possible to the workplace communities. In FY 2010, a the number of Public Sector Workers (PSW) and their family targeted for counseling, testing and receiving results is 60,000 using a mix of strategies outlined above.

To ensure quality assurance, HCT training of health workers will be based on the approved national HCT algorithm, and trained staff will be coached on a routine basis by Sector HCT coordinators with support from SPEAR HCT Technical Specialists. Regular support supervision will be conducted to the HCT providers by the district HCT Coordinators to ensure proper adherence to the National HCT Algorithm, and conformity to the standard operating procedures for HCT services. As part of HCT quality assurance, quality control re-testing samples will be done every quarter to ensure provision of reliable, accurate and dependable HIV test results. In addition, regular training of the HCT team in data collection, use and reporting will be done to achieve data quality control. In addition, SPEAR will carry out limited operations research activities to assess the effectiveness of HCT and enhance the quality of evidenced-based service delivery. Special follow on initiatives will be put in place to provide on going support to both the HIV- and HIV+ employees and family members.

The goal of SPEAR's AB activities is to contribute to the development of healthy and transformed youth who are empowered to practice positive social norms, particularly abstinence and mutual faithfulness in monogamous relationships, within a supportive family and community environment. The overall strategic approach is the promotion and re-enforcement of abstinence and faithfulness behaviors among young people who may be encountered in the targeted communities within which SPEAR workplaces: MoIA, MoLG and MoES in all the 84 districts of Uganda. Behaviors that will be supported and encouraged include:

Abstinence for youth aged 18 and below particularly teacher trainees and recruits in Police and Prisons

Secondary abstinence for sexually active youth

Mutual faithfulness in marriage for married youth and adult Public sector workers

Open communication between youth about sexuality using a life skills and value-based approaches

Open communication between youth, public sector workers and their partners about sexuality

Parent youth communication around abstinence and faithfulness

Key Activities

SPEAR will adopt and modify where necessary the World Vision/John Hopkins tried-and tested Abstinence Risk avoidance and Knowledge (ARK) model in the delivery and achievement of its AB Targets. Key activities will include the following:

Group Dialogue: Monthly community group dialogues and conversations designed around the community melting pot" meeting approach that brings together parents and youth to discuss matters of abstinence and mutual faithfulness will be conducted. The goal of these discussions is to break down communication barriers around sexuality and model communication around sensitive topics such as abstinence, life skills decision making, faithfulness, and youth sexuality. The group dialogue will be designed to foster youth empowerment and enhance communication on sexuality between adults and youth. They will also be structured in accordance with PEPFAR minimum size limits to ensure that they provide opportunities for reflection on HIV risk and vulnerability factors and community/group actions to address them. The parent-child communication approach that has been used by WV in other countries will inform the facilitation and delivery of these 'Melting Pot' discussions that will serve as a forum to foster dialogue and mutual understanding

Training: SPEAR will train 1000 AB agents as youth mentors and coaches Peer Educators to conduct training for youth and adult populations (religious leaders, teachers, service providers, etc). To support the implementation of AB messages, Trainees will form action groups and conduct outreach in their communities, using materials, tools, discussion guides and job aids developed around AB and risk avoidance to facilitate discussion and dialogue among their peers.

Interactive IEC: SPEAR will engage the target youth and PSWs and their partners and their families' audiences through the development and dissemination of age-appropriate and linguistically-appropriate brochures, leaflets, flyers, and posters. In collaboration with target partners, a total of 50,000 IEC materials that support youth to develop and gain, skills in abstinence will be produced in FY 2010. SPEAR will work with existing community structures including faith-based organizations, CBOs, schools, formal and informal workplaces, as well as informal social organizations to ensure that appropriate AB messages are widely disseminated through these mechanisms to facilitate the translation of awareness and knowledge on abstinence and risk avoidance into healthy behaviors that foster mutual faithfulness and practices that reduce HIV vulnerability. Message content for IEC materials will draw on successful national programs to reinforce and sustain the acquisition of risk-free practices and behaviors. Issues of stigma and discrimination will also be addressed to contribute to longer-term behavior change and prevention.

Community radio: Short radio spots and longer interactive discussions will also be developed and broadcasted on community radio stations. These interactive discussions engage experts to speak on AB key messages, and take questions from youth via a call-in format. Specifically AB messages will seek to increase community perception of the benefits of safer behaviors compared to the costs of risky behavior. In addition, messages will re-enforce mutual faithfulness and target the reduction of behaviors that increase risk for HIV transmission such as un unprotected casual, transactional sex, sex with an HIV-positive partner or whose status is unknown, concurrent multiple sexual partners and serial monogamy. To complement radio programming, listener groups will be established in project sites to stimulate discussions among different age groups on abstinence and mutual faithfulness.

ARK Toolkit: World Vision has already developed an AB toolkit which features an array of materials that can be used with both adults and youth to promote and support abstinence and mutual faithfulness. To provide guidance for the adoption and maintenance of Value-Based Life Planning Skills among youth, SPEAR will procure and adapt this toolkit to help youth to abstain or be faithful.

Partnerships: SPEAR will partner and establish linkages with current Ugandan Government and other US Government supported AB activities and initiatives implemented through UAC, the Unity Project, Straight Talk Foundation and the YEAH Project.

SPEAR Prevention activities will be conducted in the workplaces, affiliated private sector workplaces and workstations of three Government of Uganda Ministries: Local Government, Education and Sports, Internal Affairs and their semi-autonomous dependent departments. The target population includes health workers, occupational migrant workers and the uniformed services, such as teachers, police, immigration officers and private security guards. Prevention services under this budget code will target both male and female employees aged 18 and above within the workplaces of the targeted Ministries. Even though activities will be workplace-based, targeted employees' families (including spouses and partners) will also be targeted in the context of their communities. Life skills prevention education will be provided for target family members under the age of 18 and out of school who will be encountered in these programs. Risk factors of the target population includes multiple partners, discordance, lack of condom use, transactional sex, alcohol and drug use that are further accentuated by stigma, denial and discrimination and inadequate and inequitable access to HIV-related services. Sexual and other behavioral risk prevention activities will be geared towards increasing personal perception of risk of HIV transmission and utilization of prevention services through aggressive targeted behavior change communication (BCC) programs to enable beneficiaries to assess their risk for HIV infection, promote behaviors to reduce their risk and acquire skills to enable them to walk away from risky behaviors. BCC initiatives will also focus on Information, Education and Communication (IEC) that encourages employees (and their partners) to learn about STI, avoid transmission and access medical services for diagnosis and treatment as well as dealing with HIV-related stigma and discrimination. SPEAR will also ensure information on correct condom use and sources where condoms can be accessed and made available to all employees and spouses. SPEAR will train 2500 public sector workers and family members as Behavior Change Agents (BCA) to conduct 4000 small group risk reduction education sessions targeting 100,000 adult workers and their family members aged 18 and above.

To promote quality assurance, SPEAR will adapt existing training manuals, develop/adapt IEC materials and communication guidelines in collaboration with partners. All activities will be delivered by well-trained staff in conformity with national and PEPFAR standards. Monthly BCA reports submitted to district BCA coordinators will be reviewed and consolidated by SPEAR staff in addition to quarterly supportive supervision and progress reviews at all levels of implementation. Promotional activities/IEC on behavior change is integrated with advocacy for workplace policies and plans that assure availability, integration and utilization of sustainable HIV/AIDS prevention, care and treatment services including HCT and PMTCT.

Capacity building for workplace HIV/AIDS programming: Capacity building is essential for enhancing sustainability of HIV/AIDS interventions in the workplace. SPEAR project will support the target public sectors to have policies, plans and activities that assure availability, integration and utilization of sustainable HIV/AIDS prevention, care and treatment services for their employees. SPEAR will build the capacity of the three target line ministries to address workplace HIV-related stigma and discrimination by supporting human resource departments and PHA support groups to organize creative events (such as debates, radio seminars, video shows, concerts, testimonies, etc) and anti-stigma and discrimination (S&D) campaigns to highlight dangers of S&D and raise awareness in the respective workplaces and communities. About 750 individuals will be trained as S & D champions and 800 as community mobilizers for prevention.