USAID awarded a cooperative agreement (No. 617-A-00-09-00006-00) to Management Sciences for Health (MSH) to implement the Strengthening TB and HIV/AIDS Responses-Eastern District (STAR-E) project with the goal of increasing access to, coverage of and utilization of quality comprehensive Tuberculosis (TB) and HIV/AIDS prevention, care and treatment services in 8 districts in the Eastern Region of Uganda namely: Budaka, Bududa, Busia, Butaleja, Bukwo, Kapchorwa, Pallisa, and Sironko. The prevalence rate of HIV in Eastern Uganda is 5.3% with an estimate of 42,264 HIV positive people in the area. However, the USG supported service coverage in the region is limited: ART 38%, PMTCT- 16%, CT 4.4%, OVC 10.5%, PC 44%, AB 50% and OP 6%. When the region was analyzed in greater detail, it was found that 8 districts in eastern Uganda were underserved in the context of HIV/TB response.

The mission of the STAR-E project is to empower the communities in eastern Uganda to effectively respond to the challenges of fighting the HIV/AIDS and TB epidemic by focusing their efforts on key relevant interventions for (i) preventing the spread of HIV and TB, (ii) treating, caring and supporting those infected and affected by AIDS/TB and (iii) mitigating the health and social impacts of HIV and TB.

The project has five result areas, namely: 1) Increased uptake of comprehensive HIV/TB services within supported districts; 2) Decentralized service delivery systems strengthened for improved uptake of quality HIV/TB services; 2(a). Lot Quality Assurance Sampling (LQAS) is institutionalized at the national level to support and coordinate district level implementation; 3) Quality HIV/TB services are delivered in all supported health facilities and community organizations/activities; 4) Networks, linkages, and referral systems established or strengthened within and between health facilities and communities to improve access to and uptake of comprehensive HIV/TB services; and 5) Increased demand for comprehensive HIV/AIDS/TB prevention, care and treatment services.

The project will be implemented through two components, namely: the comprehensive HIV/AIDS/TB component and the LQAS component. While the first component will address technical assistance to direct service delivery through health facilities and to the communities, the second will focus on establishing the necessary conditions for institutionalizing LQAS within the country (national and district levels) so that the health sector may improve on its monitoring and evaluation systems accordingly.

Strategic approaches for the attainment of project deliverables will be through 3 main technical approaches: 1) health systems strengthening, 2) building technical capacity of the health services, and 3) strengthening community-based services through performanc-based grants.

Health systems strengthening will support the District Health Management teams and the health facilities to plan, implement and monitor health services more effectively. The project will provide District Support Teams staffed by 3 peoplea District Support Officer, a Clinical Mentor and a Community Mobilizer, who will work with the DHMTs and facility staff to increase access to and improve the quality of comprehensive HIV/AIDS & TB services. This component will also have quality assurance, logistics and laboratory strengthening components.

Technical strengthening will occur through a team of expert advisors in ART, TB, PMTCT, HCT, pediatric HIV/AIDS and BCC/prevention. These components will strengthen implementation of national plans, policies and guidelines in the health facilities, and provide intensive technical training to existing and new health service providers.

Performance based grants will provide resources to a network of CBOs/FBOs/LNGOs to provide case managers in each health facility to provide support to all HIV+ clients and strengthen the referral system; home based care where needed; outreach for HCT in the community to strengthen access to care; and community mobilization to support all comprehensive HIV/AIDS/TB services and decrease stigma and discrimination. This network of CSOs will provide a "safety net" of community services to ensure that all HIV+s are indentified, receive the needed services either in a health facility or in the home, and improve adherence to treatment and reduce the lost-to-follow up rate.

Project results at the end of five years are: 1) Increased uptake of comprehensive HIV/TB services within supported districts; 2) Decentralized service delivery systems strengthened for improved uptake of quality HIV/TB services; 2(a). Lot Quality Assurance Sampling (LQAS) is institutionalized at the national level to support and coordinate district level implementation; 3) Quality HIV/TB services are delivered in all supported health facilities and community organizations/activities; 4) Networks, linkages, and referral systems established or strengthened within and between health facilities and communities to improve access to and uptake of comprehensive HIV/TB services; and 5) Increased demand for comprehensive HIV/AIDS/TB prevention, care and treatment services.

Palliative Care: care and support

The goal for palliative care and support is to improve the quality of life of people with HIV through relief from pain improvement in other symptoms, such as fatigue, nausea, loss of appetite, shortness of breath and stress. Patients will be empowered to better understand their condition so that they can participate in making choices for care, improve their ability to tolerate medical treatments, and carry on with everyday life independently as much as possible.

The package for palliative care will include:

Co-trimoxazole prophylaxis

TB treatment (discussed under separate TB strategy)

Treatment for opportunistic infections (OIs)

Home Based Care (HBC) for the bed ridden and those with disabilities

Symptom and pain management

Terminal care for those with life threatening conditions

Distribution of home care kits through CBOs and NGOs supported by our performance based grants

To achieve the above STAR E project will employ a combination of strategies:

Creation of fully functional service delivery points (FFSDP): This standards based management approach to quality improvement in the health facilities will enable each unit to identify bottlenecks to quality of care, including palliative care. Each health facility will have a quality improvement plan to improve these bottle necks and a phased approach to implementing these plans. This technical approach will create an environment that is client friendly and supports the provision of quality palliative care at all health facilities by incorporating standards for palliation into the FFSDP and evaluating progress towards achieving these standards at regular intervals. The first step is to introduce the principle of FFSDP in a few units, through TOT of STAR-E staff conducted by STRIDES, a sister project in Uganda that is also using the FFSDP.

PHA involvement at every stage of implementation of palliative care interventions improves the services provided, such as senior PHAs trained as case managers, and through organized groups such as posttest clubs. STAR-E partner NACWOLA will take the lead in helping to organize groups of PHAs at every health center who can support the clients needing palliative care both in the health center and in the home. Case managers working in the health facility will coordinate a personalized palliative care plan and ensure that all needed services are received by the client in both locations.

Mentoring of clinical services and case managers by District based STAR-E Clinical Mentors . The Clinical Mentors and project District Support Officers will work with the DHOs to develop and implement a plan for supportive supervision and mentoring visits monthly to each health facility providing ART and comprehensive HIV/TB services. These visits will ensure state of the art and adherence to national standards in palliative care services provision. The FFSDP and supervisory tools adopted from the NACP will be used by the mentors and supervisors to ensure consistency in approaches and service provision.

Leadership and management training to ensure support for quality services. This will target district leaders, health units' management committees, and in-charges to ensure that everything that is needed to provide quality palliative care is in place. There shall be cascade training for the direct services providers. MSH staff from the Leadership and Management Sustainability (LMS) will assist us by doing TOT in the Leadership Development Program .

Family based /home based care approaches will be provided through performance based grants to FBOs, CBOs, LGNOs and other support groups to provide palliative care services in the home, with support of the Village Health Teams and other community volunteers. These grants will allow us to scale up HCT, HBC, Nutrition, client welfare and support services to ensure equity and expansion of services.

Linking patients and their support groups to specialized agencies that can improve livelihoods, food security and social protection through a collaborative partnerships with other programs and projects

Co-trimoxazole prophylaxis will reduce the incidence of Malaria, PCP, and other opportunistic infections. All health units will be supported by STAR-E to access free co-trimoxazole from the National Medical Stores, since the national program provides free co-trimoxazole for HIV and AIDS clients. Additional Cotri-moxazole will be mobilized through Districts, by the District support officers, interacting and encouraging the Sub-Districts to allocate a reasonable amount of funds for Co-trimoxazole under the PHC funds. The logistics advisor will help the Districts to forecast and plan for use of the credit line from the Ministry of Health so that there is a constant flow of Cotri-moxazole to the Districts. Cases managers will check on the adherence patterns and refer to the clinician's in-case there are problems of adherence or the client cannot tolerate Co-tri. All clients who test HIV positive will be put on Cotri-moxazole, as a well as all HIV exposed children. When the status of the child is deemed HIV negative they will be removed from Co-tri.

Terminal care: For patients with terminal illness, a nurse, clinician or midwife from each of the 38 ART health facilities will be trained on terminal care in partnerships with Mildmay, JCRC and Hospice. The units where there is a trained terminal care service provider will work with the logistics officer to forecast and quantify the supplies and medications needed for pain management including codeine, morphine derivatives, naso-gastric tubes, gloves, and other supplies. The training will emphasize how to use and account for pain medications. Pain management and other symptom management will be carried out in these units for admitted patients or in a home based care setting through home visits provide by the community network of local organizations. The health facility will supply the client the pain medications to take home and administration of the medications will be supported by trained home based care personnel. Terminal care also encompasses spiritual care needs for the family, and this shall be extended through the FBO partners at the grass roots. A family based approach will be used to ensure that terminal care is provided not only by the visiting health professional, but also by the network of volunteers, and with full involvement of the family members. Family members will trained by NACHWOLA on writing of Wills, and their implementation, writing of memory books and access to legal aid support. Due to the outreach of HCT, an effort to diagnosis HIV early, and the expansion of ART to clients in need, we feel that the patients who will require terminal care will reduce in numbers as the project matures and as the capacity of the Districts to manage HIV/AIDS /TB clients improves.

The entry point to palliative care will be case managers, who are senior PHAs recruited through NACWOLA and other CBOs, to be placed at each of the 38 ART health units this year. The case managers will ensure that each patient has a personalized care plan, and has the responsibility to follow-up on that plan to ensure that all needed services at both the health facility and the home are received. STAR-E project will use a network of VHTs, COPRS, treatment buddies and case managers to reach every client who needs palliative care. To ensure continuous support to this network, the performance based grants will be used, so that the CBOs, LNGOs and other community groups identify, supervise, recruit, and supply the requirements for home base care. Home based care kits will help patients and their immediate care takers to have access to pain killers, such as paracetamol, antiseptics, cotton, gauze and soap .Through the PBGs, the support groups will procure and distribute home care kits that will contain water guard for water purification, a vessel for keeping clean water and insecticide treated mosquito nets.

The project will implement a training program for the grantees, to have case managers and representatives from CBOs trained as trainers to train the primary care takers on adherence support and home based care. Home based care will include tips on good nutrition, and recognition of side effects from the drugs or from opportunistic infections such as nausea, loss of appetite, diarrhea, and vomiting. STAR-E will strengthen the referral system composed of case managers, health units, primary care takers and patients. Through this referral system it will be possible to refer clients for serious side effects to a unit where there shall be a trained health worker who can handle such conditions, or refer to a clinician in case of more severe side effects.

The supervision and support to home based care will be done by a collaborative network of case managers, CBO trainers and district HIV focal persons. These will monitor the activities under home based care to ensure consistency of approaches, quality and equitable service delivery at community level. Reports generated from these networks will be shared during District project review meetings, and consolidated into one report to be submitted to STARE BCC advisor, FBO Advisor, Gender Advisor and finally the Director Technical programs. Continuous quality improvement activities be take place during the monthly supervision visits to health facilities and the communities based on the project reviews.

ART coverage in the region is estimated to be 25% of the national targets. In PY2, the STAR-E target is to enroll 3112 HIV positive people on ART in addition to the 443 clients recruited in FY09 . We shall reach 960 clients with palliative care services. In order to do this we shall support 5 District hospitals, 11 HCIVs that currently provide ART. Once these 16 facilities become fully functional ART centers, we will expand ART services to an additional a 22 HCIIIs to provide ART.

The ART care, treatment and support package will include: Confirming HIV status through HCT; determining the client's disease status by using WHO clinical staging for adults and monitoring CD4, CD8 and CD3 cells ; and HB ,CBC and blood chemistry at baseline and at six monthly intervals. A system for collecting and transportin CD4 tests samples to the JCRC reference laboratory and getting results back will be established. Enrollment in HAART will be guided by the 2008 National ART and care guidelines for adults and children of the MOH .All children below 12 years who test HIV positive will be prepared and initiated on HAART as soon as possible according to the guidelines discussed above. Inclusion criteria for enrollment on HAART is to be used to ensure adherence, follow up and readiness for HAART.

For palliative care, all adults who test HIV positive in health units and through outreaches will be started on co-trimoxazole prophylaxis at the participating units; all HIV exposed children will be started on co-trimoxazole prophylaxis till proved HIV negative. In addition, all HIV positive clients will receive treatment for any opportunistic infections, as they arise, and all will be screened for TB clinically. If the client has a cough, TB sputum microscopy will be done. All those with suspected or confirmed TB will be managed as per CBDOTS guidelines of the National TB Leprosy program under the MOH (see TB discussion below).

Training activities:

A critical mass of health workers and case managers will be trained on comprehensive HIV/AIDS/TB case management, at the initial 16 health facilities that provide ART through refresher courses. The full ART training package offered by JCRC will be provided during the rest of PY2 to staff in 22 new facilities selected in conjunction with the DHOs to become ART centers. These will all be HC IIIs, and careful consideration to staffing patterns and population density will be made in the rollout plan. Shortages in human resources for health will be addressed through task shifting, clinical mentoring and supportive supervision. The training modules will be from MOH and JCRC will provide the training. Baylor Uganda can support paediatric training.

The STAR-E project will hire and recruit 4 clinical mentors, who shall be trained as mentors by JCRC. JCRC has developed a mentor's manual that support experience ART providers to acquire clinical mentorship skills. The clinical mentor will conduct on job mentoring, coaching and support to all health workers and case managers to ensure quality and equity in clinical care of HIV/AIDS /TB in the health facilities. Each clinical mentor will cover two districts. Clinical mentors will be absorbed into the District establishment after 3 years. (see discussion of clinical mentors under Result 3)

MSH will hire 4 District Support officers to work with the DHTs, to ensure that the different arms of local Government, work together to ensure coordination and mobilization of inputs for quality comprehensive HIV/AIDS/TB care from the project or through local resources. The logistics Advisor will build capacity and support districts and health units to ensure proper commodity management for inputs for care, treatment and support. Procurement of commodities will follow USAID guidelines and will be done through SURE, SCMS and JMS to ensure a continuous supply of ARVs and other needed medications with zero stock outs as the objective. Leadership courses will be run for individual health units to create a client friendly environment at health units and to motivate the political arm of government to allocate more resources for HIV/AIDS/TB case management. A standards-based management performance quality improvement approach will be used to create fully functional service delivery points to ensure quality care, treatment and support services

Tracking and evaluating clinical outcomes:

The aim of ART is to lower the viral load to undetectable levels (50-400 copies/ml3), restore the function of the immune system, improve quality of life and physical function of the body , reduce HIV related morbidity and mortality, and promote growth and neurological development in children. The following mechanisms will help in tracking clinical outcomes:

Client will visit clinicians on a monthly basis and as needed by any change in health status. Lab investigations will be done (hematology, blood chemistry : complete blood count including HB, liver and kidney function tests, serum glucose for those on protease inhibitors, and every 6 month CD4 levels ). When necessary, a viral load will be done for suspected treatment failure (10% of clients). Each client will have a case notes file, to record and register history, physical and clinical findings from the client and to document the personalized care plan and progress made, or problems with, the care plan. The case notes file will be kept secure. The clinicians and relevant project staff will use the case notes to determine clinical state and well being of clients based on weighted and scored variables. There shall be pre-HAART and HAART registers to record and track all prescriptions and a BMI recorded for all adult clients. Weight for age (<36 months olds) and developmental mile stones will be recorded for all children. A performance scale (WHO clinical staging) and monitoring of side effects from the medications will be done at the health facilities by case managers with support from the health service providers. Clinical mentors will support this process on a monthly basis. Cohort analysis for clients on HAART will be done by the ART team to determine and document mortality rate, transfer in , transfer out and lost to follow up. All the information on client status and outcome will be entered into the records and clients data bases, and the data shall be analyzed at each facility to measure overall treatment outcome

There will be case managers in each health unit, who are senior PHAs, one per health unit who will be selected by the community, and seconded to the project by a CBO or NACWOLA. The Case managers are to be trained to guide clients and offer support at the health facility to individual clients. Members of VHTs will be identified and trained on psychosocial support to counsel and support clients after treatment in the health center. The VHTs and treatment buddies will meet with clients in the home to determine how they are using the drugs and will refer back to case managers problematic cases, who in turn will screen and refer to a clinician or relevant health worker. Each client will have a treatment buddy selected by the client, preferably a spouse, and for children, the parent or care giver. The treatment buddy will support clients to take medications as recommended. The treatment buddies will be trained and supported by the case managers and clinicians.

When clients come back for refill they will be asked to bring the containers of the drugs, and a pill count will show whether the client is adhering or not. However, the VHTs will also do home visits to reinforce adherence. Each client will have an adherence calendar and carry away prescription card to assist taking medications as prescribed on a daily basis and to promote adherence. The card will also have return dates for re-visits to the health center. The adherence calendar will be in local language and for those who cannot read, the graphical lay out will support clients to take medications appropriately. Clients with problems of adherence will be given more counseling and guidance by case managers and clinicians, with more frequent follow-up in the home. Clients who live in hard to reach areas will get refills through ART outreaches to be conducted by staff from an accredited site on a regular basis.

Outcomes of these adherence activities:

Our targets for this objective are: 80% of clients achieve adherence rate of 95% to care plan, loss to follow up <10%, reduced need for treatment switch, majority of clients still responding to first line HAART for the period under review, well being of clients (immunological, physical, social) inproved, overall mortality to be below 10% cut off point for 12-24 months ART cohorts and low levels of treatment failure .

We are targeting to reach 60,500 with HCT in PY2, both adults and children. Although 5.3 % of sexually active people 15-49 years are estimated to be living with HIV, only 11 % of men and 13% of women actually know their status, based on data from the 2004-05 National Sero- Behavior prevalence survey. STAR-E will have a BCC advisor on board in PY2, who will spear head the development of a communication strategy (see Result 5). Part of the communication strategy will focus on increasing demand for and uptake of HCT. Community mobilisation for HCT will use inter-personal communication, mass media, theatre for development and group counseling, working with religious and community leaders to provide support to these efforts. This will be done at busy trading centers, at health facilities, tertiary institutions, busy trading centers, drinking joints, special events such as World AIDS day, TB day, Child Health days and political rallies and other cerebrations. MOUs will be developed with the DHOs to provide financial support to mobile HCT teams who can travel to these events and locations on specific days to accomplish this HCT outreach. Communities will be informed about the dangers of HIV, benefits of knowing HIV status and location of available service points. To support social mobilization we will train male peer educators and motivators, religious leaders and case managers in social mobilization for HCT.

We will integrate HCT in all service points within all 97 Health facilities by training and equipping all health workers to conduct provider initiated counseling and testing (PICT) at all service points. Testing kits will be available at all service points in every health facility. Testing will take place at Health centers and in outreaches. Outreaches will be negotiated with communities and could be at schools, trading centre, open markets, or other convenient locality. Hard to reach areas and most at risk people (MARPs) will be given priority.

Trained laboratory staff are limited in the districts' health facilities; however, as part of PICT, all health workers will be trained on rapid testing protocols .The few available lab personnel will provide confirmatory testing and will be trained to offer supportive supervision to other staff doing PICT through spot checks and on-the-job training for staff involved in testing. Ten percent of blood samples will sent to JCRC to check on validity of HIV test results as part of the external quality assurance (EQA) program. Any deficiencies will be followed up to insure the quality of testing results. Determine will be used as a screening test, Stat pack will confirm the positive test result, and Uni-gold will be used as a tie breaker. Dried blood Spots kits will be used to collect blood for children below 12 months born to HIV+ mothers and samples will be sent to JCRC/Mbale for DNA/PCR. At 12 months a rapid test can be used to screen children, those who test positive will need a DNA/PCR confirmatory test as soon as possible.

Each client will have an HCT card capturing demographic and tracking information about the client along with test results. Each client will have a specific code on the HCT card to allow tracking individual clients. The case manager will use this card to track all positives to support active referral to needed treatment services and reduce the lost-to-follow-up rate (LTFUR). Data from the HCT cards will be aggregated and entered into the project data base . This data will be analyzed on quarterly basis and shared with MOH, USAID, MEEPP , Districts, MSH and communities to analyze trends and document successful methods for increasing uptake of HCT over time.

Early identification and diagnosis

PICT is the entry point to care. We will use all departments in all health facilities that offer maternal and child health services to test as many children as possible through in-patient pediatric wards, out-patient clinics, immunization clinics, nutrition clinics, TB clinics, PMTCT programs, post-natal clinics, and family planning clinics. Blood drawn will be sent to JCRC/Mbale regional laboratory for DNA PCR. For every child that tests positive, a family centered approach will be used to identify and diagnose more children within the family. Other family members who test HIV positive through other service outlets can be used to identify more children with HIV. Identification will also be done by inquiring about the status of the mother and/or through systems that document the mother's status on the child's health care card. HIV+ children tend to get sick more frequently, thus PICT through all pediatric services in the health facility should capture more HIV+ children who can participate into early treatment services.

Mobilization and sensitization campaigns of the communities will be integrated with HCT so as to offer the services to those in the hard to reach areas and those who do not come to hospitals for the various reasons Babies born to HIV positive mothers will be followed up on in the communities to ensure that they are tested for HIV infection, referred for DBS, and those that are found positive are initiated into care. The community will be empowered to be able to identify and refer children with signs and symptoms of HIV infection.

Pediatric Care and Treatment

The capacity of health care workers will be built through training in comprehensive pediatric HIV care and treatment, pediatric counseling, and DBS sample collection. The STAR-E project will provide monthly supervision and support to improve the quality of pediatric services offered at the health facilities. Pediatric HIV/AIDS standards will be incorporated into the Fully Functional Service Delivery Point quality improvement tool we will ensure uninterrupted supply of pediatric formulas of ARVs through collaboration with Baylor and the Clinton HIV/AIDS Foundation program, who have agreed to continue to provide these formulas to STAR-E supported facilities. All HIV exposed children will receive cotrimoxazole prophylaxis, until proved HIV negative. Ongoing counseling will be emphasized to ensure that clients adhere to co-trimoxazole & ART, and also to encourage the children/caretakers to keep appointments.

To reduce malnutrition and mortality among children, we shall partner with the NuLife program to have ready-to-eat nutritious foods. Networks and linkages with organizations in the community will also be established to improve on the nutrition of children so as to provide food supplements to even those that are not malnourished.

Introduction

Research has shown that if HIV+ children are not started on treatment early, 50% will die by their second birthday. It is therefore important that all HIV+ children are identified and initiated into care early. This strategic plan therefore seeks to achieve that objective.

Early identification and diagnosis

PICT is the entry point to care. We will use all departments in all health facilities that offer maternal and child health services to test as many children as possible through in-patient pediatric wards, out patient's clinics, immunization clinics, nutrition clinics, TB clinics, PMTCT programs and post natal clinics, and family planning clinics. For children exposed to HIV+ mothers below 12 months , facilities will have good stock of DBS kits; blood drawn will be sent to JCRC/Mbale regional laboratory for DNA PCR (see Strengthening Laboratories, Result 2 below). The children above 12 months will be screened for HIV using rapid tests to be available at all service points in a health facility. Those testing positive will receive DBS PCR tesing up to 18 months. Health units will be facilitated to transport these samples to the JCRC/Mbale reference laboratory and collect results. For every child that tests positive, a family centered approach will also be used to identify and diagnose more children within the family. Other family members who test HIV positive through other service outlets be used to identify more children with HIV. Identification will also be done by inquiring about the status of the mother and/or through systems that document the mother's status on the child's health care card. HIV+ children tend to get sick more frequently, thus PICT through all paediatric services in the health facility should capture more HIV+ children who can feed into early treatment services.

Mobilization and sensitization campaigns of the communities will be integrated with HCT so as to offer the services to those in the hard to reach areas and those who do not come to hospitals for the various reasons (see HCT strategy above and communication strategy in Result 5). Babies born to HIV positive mothers will be followed up in the communities to ensure that they are tested for HIV infection, referred for DBS, and the positive ones initiated into care. Through our community network, with the support of the case managers, the community will be empowered to be able to identify and refer children with signs and symptoms of HIV infection. We will also work with community based organizations offering services to children to ensure that the children in their care are tested for HIV infection.

Pediatric Care and Treatment

Capacity of health care workers will be built through training in comprehensive Pediatric HIV care and treatment, pediatric counseling, and DBS sample collection in collaboration with JCRC. STAR-E clinical mentors will be trained by JCRC in pediatric HIV case management. Through these mentors, monthly supervision and support as need arises will be done in order to improve the quality of pediatric services offered at the health facilities. Pediatric HIV/AIDS standards will be incorporated into the Fully Functional Service Delivery Point quality improvement tool that will be used by clinical mentors (see discussion on clinical mentors and FFSDP in Result 3). We will ensure uninterrupted supply of pediatric formulations of ARVS through collaboration with Baylor and the Clinton HIV/AIDS Foundation program, who have agreed to continue to provide these formulations to STAR-E supported facilities. All HIV exposed children will receive co-trimoxazole prophylaxis, till proved HIV negative. Through case managers and clinicians, on-going counseling will be emphasized to ensure that clients adhere to co-trimoxazole & ART, and also to encourage the children/caretakers to keep appointments.

Health units will be improved to be child friendly by painting sections of the health units in colors, cartoons and pictures on the wall, and stocked with play materials and toys. Where possible, the children will be provided with a drink and snack as they wait to see a clinician. To reduce malnutrition and mortality among children, we shall partner with NuLife program to have ready to eat nutritious feeds, such as PlumpyNut. We will also develop networks and linkages with organizations in the community that work to improve on the nutrition of children so as to provide food supplements to even those that are not malnourished.

Strategies for improving Strategic Information system of STAR-E project

STAR-E aims at improving the health systems of the supported districts. To achieve this STAR- E will support the implementation of robust Strategic Information (SI) activities in the supported districts. This support will cut across the Health Management Information System (HMIS), Monitoring and Evaluation (M&E), Survey and Surveillances and Coordination of SI activities.

HMIS: This is one of the challenging areas in health service deliveries as evidenced by inconsistencies in reporting. STAR-E will therefore support the districts and CBOs to strengthen their HMIS in order to produce timely and accurate data needed for project monitoring and decision making at the various levels. To strengthen the HMIS in the district, the project will develop a comprehensive capacity building strategy that will involve training of personnel, support supervision, provision of supplies and equipment for data management. The specific activities to implement under HMIS strengthening will include the following:

1. Train facility based staff in HMIS according to the national guideline.

2. Train CBOs' personnel in data collection and management with major focus on the STAR-E data requirements.

3. Support the provision (re-print and distribute) of HMIS tools to the supported districts.

4. Develop, print and distribute community based data collection tools which are missing in supported districts.

5. Support 8 districts and 11 HC IVs to acquire computers in order to improve on their HMIS.

6. Develop a comprehensive database at STAR-E to capture both facility and community based data.

7. Support districts to carry out quarterly data quality assessment with the view of addressing any inconsistencies when it is still early.

It is expected that, with the implementation of the above activities, districts will be in position to improve on their HMIS and hence strengthen the system at project and national levels.

Monitoring & Evaluation: The M&E function of the health sector has been weak at both district and national level. This has been partly due to inadequate resources and capacity to execute the M&E tasks. STAR-E plans to strengthen the M&E functions of the districts by building the capacities of the DHMT in M&E skills and provision of logistical support to the districts. This will be done by implementing the following activities:

1. Train DHMT in M&E of HIV/AIDS/ TB programs which will strengthen their capacity to monitor these activities in the future.

2. Train sub-granted CBOs in M&E of HIV/AIDS/TB programs. This will strengthen the M&E capacity at the community level where community based activities are implemented.

3. Support districts to carry out joint and integrated periodic support supervisions in their catchment areas.

4. Support 2 project performance review meetings per district. This will help districts to assess their performance and re-strategies to achieve better results.

5. Hold one annual regional forum for information sharing/ feed-back mechanisms about program project performance. This activity will bring all the 8 districts together and help them to review how the project has performed in the region. The deliverables of this activity will inform the districts about where to draw much attention in the subsequent financial year.

6. Develop a documentary system for success stories. This will be one way of how the project impacts will be will captured and it will be a basis for advocating for additional resources depending on the successes registered. Documented best practices will be replicated to other districts.

7. Advocate for information use during planning and decision making processes. STAR-E will continue to encourage districts to use their data to improve their planning and decision making processes. Information will used in forecasting for logistics, commodities and supplies, prioritization of needs and strategic planning.

With the above activities in place the M&E function will be strengthened in districts and this will have positive impact on the national M&E system.

Surveys and surveillances: Successful program planning depends on the facts collected routinely or periodically about the interventions being implemented. STAR-E will promote collection of data outside the routine mechanism by supporting periodical surveys and surveillances to inform program managers and policy makers. This will be achieved by implementing the following activities:

1. Institutionalize LQAS in districts. The project will support 4 districts to apply LQAS in program monitoring. This will help them to know the extent to which they are meeting the targets.

2. Carry out operations research to indentify program challenges and avenues for performance improvement. The findings of the research will provide a platform for policy making, reviews and program planning.

3. Carry out an annual impact assessment. In the first year the focus will be on the community based interventions. The assessment will look at BCC, KAP, and other socio- economic aspects in the communities with a major focus on the PHA families.

To ensure sustainability and ownership of the program, local capacity will built in relevant fields and the district and the sub-granted CBOs will be involved in these activities.

This result focuses on health system strengthening in the districts, especially at the facility and community level. Client satisfaction and confidence in the services provided is a key factor in promoting the uptake of comprehensive HIV/TB services. This result addresses the system weaknesses that adversely affect client satisfactionpoor infrastructure, weak and absent human resources, lack of medications and commodities, lack of evidence-based practices due to lack of information, weak leadership and management of staff at all levels, poorly functioning laboratories, and a weak community support network.

Objective 1: To strengthen infrastructure at the facility level

Decaying and poorly functional infrastructure at health facilities is an obvious marker for poor quality care. Upgrading infrastructure thus becomes a top priority to improve quality services and client satisfaction at health facilities. For this reason, infrastructure standards are one of the critical standards in the FFSDP quality improvement tool (see discussion under result 3). The baseline facility survey will provide a database on infrastructure needs, eg, building, grounds, furniture, equipment, lab function, etc. This data will help produce an infrastructure improvement plan for each district. REDACTED. Thus, the intial implementation efforts of this improvement plan in each district will focus on the "low lying fruit", the visible and the bottlenecks to improved quality, eg, painting and fixing up the facility to make it "child friendly", clean up of grounds and simple landscaping, essential equipment such as hemoglobinometers, capillary test tubes, or a functional microscope. STAR-E does not have the resources to complete all the improvements needed, but this infrastructure improvement plan will provide a blueprint for all partners so that the DHMT can maximize the resource input from a variety of sources.

Objective 2: To strengthen human resources

Most districts have a 50% vacancy rate and task shifting is the norm, eg, a physician may start the ART services, then leave and a nurse picks up that set of services and continues on input from a variety of sources. While we cannot address all the reasons that staff turnover is so high, especially the economic reasons for why people leave, MSH has developed an approach for improving recruitment and retention using non-monetary incentives developed through our Leadership and Management Sustainability project. We propose some STTA from the LMS human resources staff to help us prepare a master human resource strengthening plan and to train staff in the Work Climate Assessment Tool (WCAT), a tool that can be used by staff in each health facility to develop ways to improve their work climate and, thus, retention. We will also develop a training plan based on the needs assessment and the work plans of the districts, and support implementation of this plan through our district training advisor and technical staff. Result 1 outlines an ambitious training program to upgrade technical skills in key HIV/TB areas. Improved training frequently provides an improved sense of competence and self worth, which can lead to improved retention, especially amongst female nurses which tend to stay longer in a posting. Other activities suggested during our work planning activities with district staff include facilitation of the district recruitment and hiring, since funds don't exist to place newspaper ads or interview potential staff, and facilitation of visits from NACP and NTLP staff to share best practices in Uganda with the local staff in the districts, thus providing a morale boost and incentives for continued productivity.

Objective 3: To strengthen commodities management

Stock outs of medications and commodities, such as test kits and laboratory reagents, are very disappointing to clients and frustrating to staff. Stock outs of ARVs and anti-TB drugs are very dangerous, since they lead to the development of resistance and increased mortality despite treatment. Currently, enough ARV, OI, anti-TB medications and test kits exist in the country to support all project needs. The problem is that they are not flowing very well from the National Medical Stores (NMS) out to the peripheral health service units. The Joint Medical Stores (JMS) has been selected as an intermediary to fill all orders, distribute and store medicines and commodities. By the start of PY 2, an MOU should have been negotiated with SCMS and JMS to support STAR-E, so the delivery to service delivery points should improve. However, much work remains to be done at the individual facility level to ensure proper storage and record keeping systems are functional, and to support ordering re-stocks in enough time to prevent stock-outs. STAR-E has a logistic advisor who will work closely with our sister projectsSURE and SCMSto develop training and supervision processes to improve local commodities management. Logistics standards will be incorporated into the FFSDP quality improvement tool, and the clinical mentors will use these standards when the visit clinical facilities to ensure zero stock outs of ARVs, OIs, and anti-TB meds, as well as test kits, our gold standard for systems improvement. It may take some time to reach zero stock outs in each facility, but it could happen by the end of PY2.

Objective 4: To strengthen district HMIS

Training and mentoring district health staff and health facility management teams in the use of "data-for-decision making" is one of our key project strategies for ensuring that management decisions are based on the best available evidence. However, data collection, flow and analysis is very weak in the districts, and strengthening the HMIS is one of our highest priorities. In order to achieve this, we will focus on very specific activities, such as printing and providing all HMIS forms and registers to the health facilities and DHOs, as well as develop more creative approaches for sharing and analyzing data using cell phone. We will need to develop a community-based information system that captures all community services, adapting one of several that currently exist to the needs of the STAR-E project. And we will need to train and then mentor staff at all levels on the HMIS standards, protocols and forms, how to ensure adequate data flow, and how to analyze the data at each level and use it to make decisions. At the DHMT, a portion of each monthly meeting will be set aside to analyze the HMIS data and the minutes will document what decisions were made based on that data, a good outcome measure of an improved HMIS.

Objective 5: To strengthen leadership and management

Many DHOs, DHMT staff and the in-charge of health facilities have been promoted to positions of senior management responsibility based on years of experience within the health system and not related to any formal preparation in leadership and management. The MSH Leadership Development Program (LDP) has been developed through the LMS project to address this issue, a series of short workshops for key management staff in the districts so they do not have to leave their home base location. The LDP has also been developed into an e-platform and can be provided virtually in district HQs towns that have access to internet, thus decreasing the time away from the work location. Based on the MSH manual, Managers Who Lead, the LDP/VLDP can significantly improve the management capacities of senior staff, leading to improved decision making and more efficient and effective use of the scarce resources available. This, in turn, should lead to improved quality of all health services and increased uptake of comprehensive HIV/AIDS and TB services. Several other activities will support this L&M training, including holding quarterly regional and monthly district coordination meetings where L&M tools are used, inter-district visits to learn best practices from each other, and facilitation of transport for DHMTs for joint supervision and monitoring visits.

Objective 6: To expand access to community services through performance based grants

Result 1 focused on the role of the case managers and their linkages to the communities through PBGs to local organizations. This objective focuses on the "nuts and bolts" of the PBG process, from development of the initial scopes of work to include a wide range of community based services, in addition to the case managers; development of the RFA itself; workshops for local CBOs, FBOs, NGOs on how to prepare a proposal in response to an RFA; then the selection and award process. Development of performance indicators is a key step in awarding and signing a PBG, since progress towards achieving those indicators allows us to monitor grant performance. We anticipate that a minimum of 1 RFA will be issued for the Eastern region (although it could be more than 1), with multiple awards made by March/April. Consistent with our management capacity building approach, we will work closely with the DHMTs in every step of the process so they learn by doing and can then replicate the process in future years. At some point, the districts may receive increased funds from a new USAID project, and this valuable experience will help the district level staff manage increased resources more effectively.

Medical Male Circumcision

According to the 2004/05 HIV/AIDS Sero- behavioral prevalence survey, 55% of men 15-49 years in Eastern Uganda have undergone circumcision, either due to traditional /cultural or religious requirements. However Male circumcision is much more common among Muslim men with over 97% of them having been circumcised by age 15 years. Studies have indicated that Medical Male circumcision is protective against HIV infection, because the removal of the fore skin, where the HIV susceptible Langerhan cells are located, reduces the risk of contracting HIV by almost a half.

In Eastern Uganda most of those who are circumcised do so in a traditional cultural setting. This may pose a risk for acquiring HIV if the knife used is used on more than one person before being sterilized. Therefore cultural circumcision rites pose a risk for HIV transmission. Traditional cultural circumcision is unhygienic and is associated with bleeding, sepsis and complications. On the other hand, men who have been circumcised in health units are regarded as cowards, often regarded as social outcasts, and are sometimes barred from performing other cultural rituals.

This project will design and implement a communication strategy that will be used to change negative attitudes on Medical Male circumcision .A network of CBOs, LNGOs, FBOs and other community resource persons will be used to promote positive messages about medical male circumcision (MMC) that is done in health facilities with trained staff using sterile conditions , and to promote it as one way of the ways recommended by leaders and the government for HIV prevention. Traditional chiefs and traditional circumcisers will be trained as MMC promoters and counselors, to win them over, in order to support Medical Male Circumcision. Faith based organizations will be targeted to ensure that we minimize the bias against circumcision that is promoted by certain religious denominations

Strategically, women will need to be involved in the campaigns, because traditional cirucmisicion is often associated with selection of fiancés and future brides. When women recognize MMC , it will encourage more young men to utilize MMC. Through RFAs and award of PBGs, more CBOs and LGNOs will take the campaign for MMC forward, since we will include promotion of MMC as a performance standard.

MMC will be made addressed by equipping health units with the necessary equipment for MMC, and training of at least two MMC practitioners from among the health workers at each of the Health IVs and all Hospitals this year (16). All HCIVs have mini operating theaters, and all hospitals have full operating theaters that will be upgraded and equipped accordingly to handle MMC.

Our target is to reach 10% of eligible youths and men in the 8 Districts this year with MMC.

In order to promote quality assurance, a series of trainings in support supervision for MMC will be held for the clinical officers by the Clinical mentors and District support officers. We shall adapt training tools from the Walter Reed project in Kayunga to ensure that a critical mass of MMC trained staff are present in the 8 districts based at Health centre IVs and Hospitals. We shall use the LQAS methodology to evaluate uptake of MMC and its impact on communities. More solid operations research will done in partnership with the Walter Reed project and Makerere Institute of Public Health to gauge changes in HIV incidence among the circumcised and uncircumcised men in subsequent years of the project, thus measuring the impact of the MMC interventions.

Although the prevalence rate of HIV/AIDS in the project region is at 5.3%, lower than the national prevalence of 6.4%, the incidence of HIV is feared to be on the rise. Sexual transmission is the major mode of transmission, with the highest new infections rates rising among married couples. Lack of access to HIV/TB-related information and, stigma, discrimination, gender based violence and complacency all play a role in this situation.

Under the STAR-E project, HIV/AIDS prevention mechanisms will be put in place to target the youth (unmarried boys and girls of 15-24 years), married couples (15-49 years), Most at Risk Populations (commercial sex workers, truckers, fisher-folks, incarcerated populations, uniformed Service Groups, Street children) and sexually active adult men and women.

Prevention mechanisms targeting the youth and sexually active adult women and men will involve the use of AB components. The AB strategy is deemed practicable for all age groups, and all people from different walks of life. However individuals need access to correct and appropriate information to Abstain or to be faithful to single sexual partners. This will range from messages targeting individuals to those targeting groups and communities, such as schools, hotspots, drinking joints, internally displaced people's camps and busy centers. Messages will reinforce empowerment of individuals to practice their chosen method of HIV prevention.

The STAR-E project will use the existing wealth of information, including the 2004/5 sero-behavioural survey, and also conduct rapid assessments using participatory methods to identify Knowledge, Attitude, Behavior and Practice gaps to help in the drafting of a communication strategy to guide the roll out and implementation of the AB interventions in the eight Districts. An inventory of existing Information Education Communication (IEC) materials will be conducted, and appropriate materials will be translated into the 3 dominant languages spoken and/or understood in the Eastern region, namely Luganda, Kiswahili and Lugisu. This will help to ensure that the existing materials produced by different partners will be effectively utilized and STAR-E will not need to create new IEC materials.

Appropriate Abstinence (A) messages will be designed for both in and out of school youths (male and female between 18-24 years). The communication strategy will spell out the messages, methods of dissemination, target audiences and the monitoring and evaluation mechanisms. However it is envisaged that mass media will be exploited in relaying these messages. Local radio stations will be used to run appropriate radio slots at an agreed interval for a period of three months per slot. These messages will be redesigned, modified and /or changed based on a continuous feed back from the target audiences. Radio talk shows on Abstinence and Be Faithful will not only help in reaching the hard to reach, but will also have a multiplier effect on neighboring districts where the project is not operational. These talk shows are ideal dissemination mechanisms for those who can not read or write.

Similarly, print media on AB will be used so that the same messages are captured and distributed through leaflets, brochures, pamphlets and posters, to be widely distributed to health units, schools, shops, families and beyond. Print media messages will reinforce the messages provide through radio and through inter-personal communication. Specifically the youth with will be targeted at schools, institutions and organizations that have many youths. In schools, talking compounds will be supported and designed together with school authorities and with full participation of the school children. At strategic points, sign posts and billboards carrying AB messages will be erected to catch a wider audience and to direct the people at service outlets.

Male and female Peer educators will be trained so that they can in turn educate others on how to prevent HIV through Abstinence and Be Faithful messages. Once trained, they will be equipped with necessary job aides for consistency of messages. Youth in schools will be facilitated to form clubs to help in one to one communication (IPC), role-plays, music, dance and drama to pass on messages for abstinence and faithfulness. Teachers will be trained as Senior Health educators, to be able to handle class rooms, on sensitive matters of sex, sexuality and HIV and AIDS.

Religious and other community leaders (like youth leaders) will be encouraged to use religious events to spread the messages and to visit schools and other tertiary institutions, as well as organized youth groups, to share information and encourage abstinence. Youth functions such as youth camps, and football matches will be used as a mobilization strategy in order to reach the youth with messages of abstinence, and provide counseling and testing services to those that might be interested. It is hoped that by September 2010, 10,000 boys and girls in and out of school will have been reached through the above means.

'Being Faithful'

'Be faithful' messages will target the married (being faithful to an uninfected sexual partner, or partners in the case of Muslim men or people in concurrent sexual relationships). Religious leaders will preach the "Be faithful messages" during prayers and other social gatherings as well as during marriage counseling. Community and other leaders of influential character will be used to encourage mutual faithfulness among married couples as well as among discordant couples. Discordant couples who have successfully implemented the 'B' will be encouraged to share their testimonies which will be documented and used as testimonials.

People Living with HIV/AIDS will also be used to give testimonies to the population. Women and men who have AIDS will be facilitated to give these testimonies at HCT outreaches, or during their own social mobilization sessions. In liaison with the clergy and other community and political leaders in the district, PHAs will be encouraged to give these testimonies in churches and during social gatherings, e.g. Funerals, feasts, celebrations and World AIDS day.

Billboards denouncing violence and Trans-generational sex will be designed, translated in the local languages and erected in strategic places. This will give a wider coverage of the population. Other hard to reach areas will also have these billboards and posters erected with appropriate messages.

By September 2010, over 40, 000 clients will have accessed AB messages through the mass media as well as through community case managers, community leaders, religious leaders, and the Village Health Teams (VHTs).

To reach a wider audience with AB messages, RFAs will be issued and performance based grants awarded to enable Community based Organizations (CBOs), Local NGOs and other organized groups to carry forward the prevention campaign using the AB messages. Case managers, VHTs, CBOs, FBOs will form collaborative networks around health units to be trained on reinforcing the AB messages. STAR-E will use LQAS to evaluate the outcome of the AB campaigns and modify the campaign and strategy accordingly to respond to individual community needs.

Correct and Consistent Condom use campaign

Appropriate and accurate information about condoms will be provided to the target populations. This information will include both the health benefits and the failure rates of condoms in HIV/AIDS prevention. Condom promotional activities will pass consistent messages that condoms are an alternative prevention technology for people who are un able to abstain, the discordant, the MARPs, but caution that failure rate range from 5-10%. Condom messages will emphasize that the most effective prevention methods are Abstinence, and having sex with HIV negative person in a mutually faithful relationship, thus re-enforcing the AB approaches. Correct and consistent use of condoms can prevent STDs, unwanted pregnancies and is as pleasurable as unprotected sex between two consenting HIV negative partners.

Young adult men and women who are sexually active and those who engage in concurrent sexual relationships will be targeted with appropriate C messages. Discordant couples and couples where are both HIV positive will be encouraged to consistently use condoms to avoid cross infections and re-infection respectively. Condoms will be distributed to these categories of people through outlets that are accessible for respective groups, including health facilities and social marketing outlets. They will also be included in home care kits and in prevention for positives approaches.

Working with the community leaders and community case managers, we shall organize deliberate HCT outreaches to busy centers, hot spots, and drinking joints and these shall be avenues to make condoms available to the sexually active members of the population, as well to Most at Risk Populations (MARPs) such as commercial sex workers, long distance truck drivers and fisher-folks. Condom distribution will be done in collaboration with bars, hotels, and lodges. Condoms will also be made available at places like offices of the cross border points and health facilities.

A workshop will be held for community leaders eg traditional, youth and religious leaders, family protection officers from the police and prisons, and the district gender officers and law enforcement officers to sensitize them on gender inequalities, gender violence, stigma and discrimination that hinder the uptake of HCT and other HIV/AIDS-related services, and consequently expose women and men to infection by HIV/AIDS. This same workshop will address issues like widow inheritance and polygamy that expose people to HIV infection. This community sensitization will increase demand for HIV-related services and therefore the general public will be well-equipped to prevent infection.

In order to promote quality assurance, a series of trainings in support supervision will be held for the service providers including CBOs, FBOs and NGOs to train more people on condom use .This will be done through Performance Based Grants (PBGs) to increase knowledge and access to condoms. Community Case Managers and health workers will be given appropriate trainings to help in support supervision to help the project identify gaps, and plan how to deal with them. Standardized supervision materials will be designed and distributed accordingly, for consistency.

In collaboration with the Monitoring and Evaluation department, LQAS will be used in all the eight project districts to determine the degree of impact, and to guide planning for future interventions for the C strategy.

Currently, PMTCT uptake is only 16% in the 8 Districts (i.e., only 16% of pregnant women receive any PMTCT services). Challenges to be addressed include low FP uptake (43%), low health facility-based deliveries (34%), gaps in human resources providing health services, heavy work loads for existing staff, poor staff attitude, poor referral systems, and limited awareness in the community on the mechanisms of MTCT of HIV. Our target population is all women of child bearing age, with a focus on most at risk women for testing and referral for PMTCT services: all pregnant women and their spouses (especially pregnant women living with HIV), non-pregnant women living with HIV, and children born to HIV positive women. The four pronged PMTCT approach will be used to reach the target groups: primary prevention of HIV among the uninfected; promotion of family planning services for prevention of unintended pregnancies, especially among those with HIV; reduction of vertical transmission to children among HIV infected pregnant women; increase access to care, treatment and support to HIV positive mothers, their infants and families; and outreach HCT to all women in the community. In order to increase PMTCT coverage, women will be encouraged to use ANC services, deliver at health units, and come back for post-natal services. Women who test positive for HIV will be referred to the case managers at each units, who will coordinate all service delivery and ensure that the women and their children receive a full evaluation of HIV status and have a personalized care plan.

The key to increasing uptake of PMTCT services will be community outreach of HCT services to the populations at risk described above. By involving more women and their partners in testing at community testing sites, the STAR-E program will increase the number of HIV+ women who will receive comprehensive services in the health facilities. Routine opt-out HIV counseling and testing services will be provided during ANC, maternity, post-natal and Well child clinics in the health units. HIV negative women and their spouses will be supported to remain HIV free. Building on efforts already started in the region through PREFA, we will continue training current and new ANC providers on modified obstetric care, counseling and provision of more efficative ARV prophylactic regimens and HAART for eligible HIV positive pregnant women according to national and WHO policy guidelines. Single dose NVP will be given to women found to be HIV+ at labor and delivery but did not receive pre-natal HIV counseling and testing and ARV prohylaxis. Counseling on safe infant feeding practices and support to exclusive breast feeding for the first four months of life will be provided. In the post-natal period, women and children enrolled for PMTCT will continue to be followed up to ensure they adhere to PMTCT protocols through the case manager and the community based network of service providers, such as VHTs, male motivators and grantee CSOs. We will also integrate PMTCT services into RH/FP services for these families with promotion of the use of condoms, and creating links to food security and income generation support agencies.

At district level, PMTCT activities will focus on coordination of all partner activities, transition of PREFA-supported services to STAR-E, improved infrastructure, supplies, and supervision of implementing facilities (see Result 2 below). Health facilities will be supported by clinical mentors to develop the capacity for integrated PMTCT services, protocols and job aids will be posted, and the FFSDP will include all standards related to PMTCT in the quality improvement efforts (see discussion in Result 3). Through our community mobilization and communication strategy, awareness, mobilization and support for PMTCT will be carried out in all districts (see Result 5).

These strategies will allow the project to reach the PMTCT targets by September 2010:

At least 40 health facilities provide PMTCT comprehensive services, 400 health workers trained to provide PMTC services, 150 HIV-positive women access food supplementation through PBGs and 431-positive pregnant women on ARV prophylaxis.

Background

There are 5 district hospitals, 11 HC IVs and 86 HC IIIs in the 8 project target districts. It is envisaged that the entire laboratories in these 102 health facilities shall be upgraded over the next 5 years. Improvement of the laboratory infrastructure will be made in a systematic and phased minor. That is, initially focusing on the 5 district hospitals and 11 HC IVs, and moving on to the HC IIIs based on the results of the baseline survey.

MSH has hired Laboratory and Quality Assurance Advisors (2) who will provide technical inputs including training of the laboratory staff as well as providing oversight towards quality improvement of laboratory infrastructures and functions.

Activities planned for PYII (i.e. October 1, 2009 September 30, 2010)

Conducting refresher training for laboratory staff from all the hospitals and HC IVs and some HC IIIs in HIV/TB services; ensuring regular supply of reagents and test kits; implementing laboratory infrastructure improvement plan in priority hospitals and HCs; facilitating community outreach testing for HIV/ TB; strengthening specimen collection from health facilities and communities with transport to the district hospital or JCRC reference laboratory in Mbale.

Sustainability plan

MSH/STAR-E will advocate for ownership and maintenance of the infrastructures and equipment it will put in place by the district local government (DLG). At the end of the project period, DLG should take over full management. Any training provided to health workers is an investment for the district.

The main objective is to increase case detection to at least 70% and treatment success rates to at least 85% in all the STAR-E districts.

Strategy: Implementation shall follow the National TB/HIV collaborative policy:

The project will establish mechanisms for sharing information and collaboration through support to all the 8 districts and the TB/HIV focal persons at the district. Joint TB/HIV planning, advocacy, communication and social mobilization will be supported and regular meetings held in each district to facilitate this process.

In order to decrease the burden of Tuberculosis in people living with HIV/AIDS, STAR E will train health service providers to use clinical screening for TB for all HIV+ clients, and those with a cough will undergo sputum microscopy. For sputum negatives with clinically suspect TB, and for extra-pulmonary TB, the project will use PBGs to CBOs for transport to Mbale Hospital for additional diagnostic tests, such as X-rays. All active TB cases will receive proper treatment through community based DOTS (CBDOTS), and the project will ensure TB infection control and airborne precautions in health care and congregate settings

In order to decrease the burden of HIV in tuberculosis patients, STAR-E shall distribute tools, offer training and clinical mentoring, and provide necessary inputs for rapid testing for HIV to ensure all TB patients are screened for HIV.

Achieving of the targets for case detection and treatment success will be best achieved through increasing the index of suspicion of all health care providers, especially those that provide HIV/AIDS services, and implementation of the CB-DOTS strategy. This will involve training staff on TB/HIV and CB-DOTS in all the facilities providing TB services. Once a client is diagnosed with TB in the facility, and does not need in-patient treatment, the health service providers will work through the case managers to contact both the District TB focal point and the sub-county health worker of the new case of active TB. The client will receive a 2 week supply of anti-tuberculosis medications, and the sub-county health worker follow up in the community to organize home-based DOTS. The sub-county health worker will then re-visit the patient every two weeks to resupply the medications and work with the family to ensure adherence with the DOTS plan. The case manager will also coordinate with the CBO grantee in the home village and the VHTs to ensure additional visits by home-based care personnel, who will monitor side effects, adherence to therapy, and refer any significant changes in clinical status back to the health facility. The District TB/Leprosy Supervisor and the Health Sub-district TB focal person will be facilitated to carry out their supervisory and monitoring functions. The districts will be supported to have a fully functional supply chain system so that there are no drug stock outs. Innovative ways of improving diagnosis of extra pulmonary TB and Childhood TB shall be done, including X-rays as needed with support of the community network.

The project will support districts to improve access to and performance of TB laboratories in order to ensure the provision of reliable diagnostic services for TB control. JCRC will do the external quality control (see laboratory work plan in Result 2 below). Clinicians and laboratory staff will be trained or given refresher courses in TB/HIV co- management. All the partners working in TB control activities will be invited to attend monthly district review meetings. Quarterly regional partner's coordination meetings will be held.

The NTLP reporting tools will be adopted by the project, and STAR-E will print and distribute the necessary updated registers, the different reporting, referral, and patient cards, and intensified TB case finding forms as needed. The DTLS and HSD TB focal persons, and the records assistants, will be supported to carry out the M&E functions and report accordingly. STAR E will regularly review and report high-quality data using the national TB and HIV M&E framework and tools to track progress toward stated objectives/targets

Support will be given in building the capacity of the local CBO's. STAR-E will work with the community own resource persons (CORPS), in particular the case managers, in community mobilization, advocacy and communication and treatment supporters in improvement of treatment success rates. By supporting the improvement of the existing district and community structures, sustainability will have been built.