1. Overall goals and objectives The goal of Strengthening Uganda's Systems for Treating AIDS Nationally (SUSTAIN) is to provide quality HIV/AIDS care and treatment and laboratory services at regional and district hospitals in Uganda and build the capacity of the public and private sector to provide care and treatment.

The program will focus on maintaining coverage levels achieved at supported health care facilities during the TREAT program as well as building the capacity of the Uganda Ministry of Health (MoH) and private sector to build sustainable systems for achieving access. Specific objectives include: Ensuring the provision of HIV/AIDS care and treatment, laboratory, PMTCT, and TB/HIV services within public regional referral hospitals and district hospitals; Enhancing the quality of HIV/AIDS care and treatment, laboratory, PMTCT, and TB/HIV services within public regional referral hospitals and district hospitals; and increasing stewardship by the MoH to provide sustainable quality HIV/AIDS care and treatment, laboratory, PMTCT, and TB/HIV services within the public health system.

During the year, SUSTAIN will support delivery of care and treatment services in 34 health care facilities previously supported by the JCRC TREAT program. The program will initiate the process of institutional capacity building in target facilities in pursuit of the broad objectives of building stewardship by the MoH in the provision of sustainable and quality HIV/AIDS care and treatment services. This will entail strengthening of governance and supportive systems including laboratory infrastructure assisting facilities to build and internalize mechanisms for quantification, storage and dispensing of HIV commodities, that are customized to their unique conditions and resources. The program will also work to improve the quality of care provided at SUSTAIN-supported sitesby training of staff in approaches of service delivery that address the contemporary challenges of HIV/AIDS and are client centered, strengthen facility- community linkages to enhance shared care and treatment, and expand the scope and quality of services to create incentives for service utilization and retention of clients.

SUSTAIN will also closely work with the MoH, managers and leaders of various health care facilities and district health officers to develop and begin implementing plans for improving human resources for efficient service delivery to the high number of patients, as well as strengthen capacity for facility, district health offices and central MOH/ACP staff to assume more responsibility and accountability for HIV/AIDS service delivery in public health facilities.

2. Target populations and geographic coverage The project will provide support to 34 health public health care facilities: 11 regional referral hospitals, 10 general hospitals and 11 smaller facilities (that include primary health centres and other clinics) that were previously supported by the TREAT program; and 2 regional referral hospitals currently being supported by other partners. All these facilities are spread across all regions of the country. During the year, SUSTAIN will support delivery of clinical services to 103,588 HIV-positive individuals, including 24,315 who are on ART.

3. Enhancing cost effectiveness and sustainability The following strategies will be employed to increase cost-effectiveness and efficiencies: Focusing on improving quality and measuring results at all levels; Building and managing partnerships through joint planning and implementation; integrating all activities into, and leveraging existing public health structures and systems to avoid duplication, through effective and deliberate coordination.

4. Health Systems Strengthening The program will closely work with the MOH/ACP and individual facilities to assess, document and analyze the different human resource strengths and gaps; develop and begin implementing plans for addressing the gaps and building on the strengths, as per priorities identified. Areas to be covered include clinical and laboratory services, HMIS, leadership and management, governance and logistics management. SUSTAIN will also identify and implement mechanisms for supporting additional critically required clinical and laboratory staff in the facilities. Both approaches will ensure continued quality HIV service delivery at the supported facilities.

5. Cross-Cutting Budget Attributions a. Human Resources for Health The program will support in-service training activities for clinical, and laboratory service staff in supported facilities, aiming at enhancing both technical and quality improvement skills for comprehensive HIV service delivery $(500,000)

b. Construction/Renovation REDACTED c1. Food and Nutrition: Policy, Tools, and Service Delivery SUSTAIN will further strengthen capacity of health care service providers to implement the newly revised infant and young child feeding MOH guidelines ($50,000)

c2. Food and Nutrition: Commodities The project will engage, collaborate with, and leverage support from Nulife and other partners implementing food and nutrition programs, to ensure clients in SUSTAIN-supported facilities receive appropriate supplementation, including ready-to-use therapeutic foods ($ 0)

d. Water Use of safe water will be promoted as part of the basic care package through client education and communication, both within facilities and using community approaches $(50,000)

6. Key issues:

a. Health-Related Wraparounds o Child Survival Activities: Will include training and mentoring of service providers to effectively provide PITC to HIV exposed infants, enrolling infected children on treatment as per revised guidelines and following infants and children in care and those on treatment. PMTCT services will also be strengthened through supporting implementation of revised guidelines as per the Uganda MOH 2010 strategy for PMTCT. o Family Planning Family planning services will further be strengthened by ensuring integration in routine MCH and PMTCT services through the family-centred approach, as per the MOH guidelines and policy. o Malaria (PMI) Prevention of malaria in pregnant mothers will be one of the focused-ANC service components in supported facilities. Insecticide treated nets will be obtained from other partners implementing the PMI program, and distributed to all clients receiving services from SUSTAIN-supported facilities, including communities reached through community linkages. o Safe Motherhood Safe Motherhood approaches will be promoted as routine components of PMTCT services. Safety measures during pregnancy and peri-natal periods will be promoted through client education and ensuring availability of safe delivery kits and safe delivery environment in health care facilities. o TB The program will further strengthen the MOH TB/HIV collaborative activities in the supported regional and general hospitals through further training, coaching and support supervision carried out in collaboration with MOH/ACP and the National TB/Leprosy Program.

b. Gender (Including: increasing women's legal rights and protection; increasing gender equity in HIV/AIDS activities and services; addressing male norms and behaviors; increasing women's access to income and productive resources) Through community mobilization and engagement activities, SUSTAIN will work closely with relevant community based organizations and to promote couple counseling, testing and disclosure activities, gender-sensitive HIV prevention innovations that cater for interests of both men and women who are HIV infected or un-infected.

1. Target populations and coverage of target population or geographic area SUSTAIN will support provision of adult HIV care clinical services in 32 public health care facilities across the country (11 regional referral hospitals, 10 general hospitals and 11 smaller facilities). The target population for the support includes adults, adolescents and MARPs (men and women) accessing health care services at the facilities and /or from the respective facility catchment areas. 79,273 adults previously under the TREAT program will be supported.

2. Description of service delivery or other activity carried out Activities will include supporting early identification of HIV-infected persons through provider initiated testing approaches within facilities, together with effective linkages, and mechanisms for retention in care to maximize benefits of the care program. Reduction in HIV-related morbidity and mortality will be achieved by ensuring provision of cotrimoxazole prophylaxis in accordance with MOH guidelines; identification and treatment of opportunistic infections, including TB; prevention of malaria; education and promotion of good hygiene and health practices like use of safe water and hygiene, food and nutrition. Institutionalization of the assessment and management of pain and other symptoms and provision of appropriate psychological, social, and spiritual support will be promoted as routine practices that contribute to improved quality of life for clients. Prevention with positives (PwP) activities will include short term and ongoing behavioral counseling within facilities and through community approaches to reduce high-risk behaviors, and in-turn reduce the risk of ongoing HIV transmission. HIV-positive individuals will be closely and regularly monitored using clinical and laboratory methods (CD4 counts), and appropriately linked to treatment when they do become eligible as per the MOH national guidelines.

3. Integration with other health activities SUSTAIN will also support functional linkages with other facility based health care service components within outpatients and inpatients departments to facilitate bi-directional referrals. Linkages between facility-based and community/home-based services will be enhanced through partnerships with other community and facility based providers in respective geographical areas to ensure a continuum of care. Clients will be involved in their own care through innovative approaches, including a chronic care model. Linkages ad activities with Village Health Team (VHT) networks will be purposely established and strengthened. 4. Relation to the national program SUSTAIN will support adult care services within the framework of the national HIV care and treatment program, adhering to the national guidelines.

5. Health Systems Strengthening and Human Resources for Health During the year 2011, SUSTAIN will work with the MOH and individual facilities to asses and determine human resource strengthening needs for HIV service delivery generally. The program will then support critically needed positions as well as address staff skills gaps at facilities through training and mentoring, and appropriate continuing medical education activities, following guidance from the MOH. Specific skills strengthening in quality improvement will be achieved through appropriate learning and coaching sessions, building upon and working with the MOH Quality of Care Initiative (QoC).

1. Target populations and coverage of target population or geographic area SUSTAIN will support provision of adult HIV care clinical services in 32 public health care facilities across the country (11 regional referral hospitals, 10 general hospitals and 11 smaller facilities). The target population for the support includes adults, adolescents and MARPs (men and women) accessing health care services at the facilities and /or from the respective facility catchment areas. 21,634 clients will be maintained on ART.

2. Description of service delivery or other activity carried out To ensure quality of ART services, facilities will be supported to implement the Uganda national treatment guidelines and protocols to initiate, monitor, follow up and support patients on ART. SUSTAIN will strengthen capacity of facility staff to efficiently manage commodities and eliminated occurrences of stick-outs of ARVs. Clinical staff will be supported to, at all times, rationalize use of laboratory monitoring of patients within the confines of national protocols. Capacity for providing adherence support services, and therefore promoting patient retention on treatment, will be enhanced through training and retraining of staff, as well as supporting positions where needed. Data collection, documentation and reporting will be another focus area where sites will be supported to have capacity for using the newly introduced MOH HMIS tools.

3. Integration with other health activities

Close linkages with other health care delivery points in the hospitals will be promoted to facilitate bi- directional referrals. Prevention with positives activities will be integrated into all care and treatment clinics. All ART and antenatal services provide PMTCT and have referral mechanisms to ensure HIV- infected women and HIV-exposed children have follow-up in the HIV clinic after delivery, preferably in a family context. Linkages with PMTCT and MNCH services will be promoted to ease identification of other family members for testing and access to appropriate interventions. SUSTAIN will also support functional linkages with other facility based health care service components within outpatients and inpatients departments to facilitate bi-directional referrals. Linkages between facility-based and community/home- based services will be enhanced through partnerships with other community and facility based providers in respective geographical areas to ensure a continuum of care. Clients will be involved in their own care through innovative approaches, including a chronic care model. Linkages ad activities with Village Health Team (VHT) networks will be purposely established and strengthened.

4. Relation to the national program SUSTAIN will support adult ART services within the framework of the national HIV care and treatment program, adhering to the national guidelines.

5. Health Systems Strengthening and Human Resources for Health During the year 2011, SUSTAIN will work with the MOH and individual facilities to asses and determine human resource strengthening needs for HIV service delivery generally. The program will then support critically needed positions as well as address staff skills gaps at facilities through training, re-training and mentoring, and appropriate continuing medical education activities, following guidance from the MOH. Specific skills strengthening in quality improvement will be achieved through appropriate learning and coaching sessions, building upon and working with the MOH Quality of Care Initiative (QoC).

1. Target populations and coverage of target population or geographic area SUSTAIN will support provision of paediatric care services in 32 public health care facilities across the country (11 regional referral hospitals, 10 general hospitals and 11 smaller facilities). The target population for the support includes children and infants accessing health care services at the supported facilities and /or from the respective facility catchment areas. All children in care under the previous TREAT program will be supported to remain in care. The RRHs are a critical part of the national scale up strategy for paediatric services, and are some of the high-volume sites.

2. Description of service delivery or other activity carried out Activities to be carried out are: facility-based approaches for identifying HIV infected children/infants through provider initiated testing and counseling (PITC) at all points of entry, including early infant diagnosis; prevention, diagnosis and treatment of OIs (excluding TB) and other HIV-related complications including malaria and diarrhea (anti-malarial drugs, insecticide treated nets, safe water interventions and related laboratory services); pain and symptom relief; and nutritional assessment and support including food supplementation. All supported facilities will be strengthened to provide child-related psychological and counseling services. Clients will be appropriately linked to social and spiritual services. Other routine child health services include immunization, growth monitoring, de-worming, vitamin A supplementation and nutrition counseling, assessment, education and support as per national guidelines. Clear and functional mechanisms for linking HIV infected children below 2 years of age, and the older eligible children to treatment, will be put in place or strengthened and monitored.

3. Integration with other health activities Paediatric care services will be provided within the context of general maternal, newborn and child health services, as on component of general child health services. The program will purposely support

strengthening of the early infant diagnosis (EID) referral system to ensure efficiency, specifically reduce turn-around times for test results and loss to follow-up for mother-infant pairs. Linking of those who test positive to treatment will be a top priority. Both these approaches will ensure optimization of the various interventions listed above. SUSTAIN will also support functional linkages with other facility based health care service components within outpatients and inpatients departments to facilitate bi-directional referrals. Linkages between facility-based and community/home-based services will be enhanced through partnerships with other community and facility based providers in respective geographical areas to ensure a continuum of care. 4. Relation to the national program SUSTAIN will strengthen technical and laboratory capacity for the regional referral hospitals to function as regional knowledge and training hubs for paediatric HIV services. The hospitals will be critical points for the national scale up plan for paediatric HIV services 5. Health Systems Strengthening and Human Resources for Health The project will support critically needed positions as well as address staff skills gaps at facilities through training and mentoring, and appropriate continuing medical education activities for paediatric HIV services, using the newly developed national training curricula. Specific skills strengthening in quality improvement will be achieved through appropriate learning and coaching sessions, building upon and working with the MOH Quality of Care Initiative (QoC). Service provider skills for taking testing specimens from infants (Dry Blood Samples) will be strengthened through training and coaching.

1. Target populations and coverage of target population or geographic area SUSTAIN will support provision of paediatric ART services in 32 public health care facilities across the country (11 regional referral hospitals, 10 general hospitals and 11 smaller facilities). The target population for the support includes children and infants accessing ART services at the supported facilities. A total of 2,681 children on ART under the previous TREAT program (from all regions of the country) will be supported to remain on treatment.

2. Description of service delivery or other activity carried out Activities Activities will include: strengthening follow-up services for HIV-exposed infants and their mothers; diagnosis of HIV in infants and children using antibody and virologic tests as per the national guidelines; ensuring early initiation of ART for all confirmed HIV-infected infants and children below 2 years of age, and eligible older children, as per the newly revised national guidelines; using MOH and facility specific

tools and promote retention of children and their families in care; monitor response to treatment and identifying treatment failures using clinical and laboratory methods (CD4 counts at regular intervals, and viral load where absolutely necessary); promoting and monitoring adherence to ART using facility based and community based innovations. SUSTAIN will support strengthening of laboratory capacity to support pediatric ART activities at each of the facilities: emphasis will be put on improving efficiency of DBS testing systems (specimen collection, transport, and delivery procedures and result turn-around times). QA systems for early infant diagnosis (EID) will be ensured. Further laboratory strengthening activities to support paediatric ART will focus on ensuring availability of capacity for HIV antibody testing, hematology and biochemistry tests and tests for common childhood illnesses (malaria, bacterial infections and HIV-associated opportunistic infections.

3. Integration with other health activities Paediatric ART services will be provided within the context of general maternal, newborn and child health services, as a component of general child health services. The integrated approach will include the folliwng activities: using the modified child health card to identify HIV-exposure status and PMTCT services received; provision of EID services and cotrimoxazole prophylaxis at child health clinics (immunization, well-baby and out-patient) and inpatient wards; institutionalization of PITC, preventive care, and OI treatment into routine MNCH services; collaborative planning and communication among pediatric, PMTCT and MNCH programs to ensure integration of HIV services at all levels of the health care system; screening, diagnosis and treatment of children and families with TB; and coordination with home-based care and OVC programs including identification of HIV infected or exposed children, care and treatment adherence support and follow-up, educational, psychological and nutritional support, economic strengthening, shelter, legal protection, and food security.

Linkages between facility-based and community/home-based services will be enhanced through partnerships with other community and facility based providers in respective geographical areas to ensure a continuum of care. 4. Relation to the national program SUSTAIN will strengthen technical and laboratory capacity for the regional referral hospitals to function as regional referral, knowledge and training hubs for paediatric ART services. Capacity for regional and general hospitals to support lower level facilities through referrals and counter-referrals, training, support supervision and mentoring, will be enhanced.

5. Health Systems Strengthening and Human Resources for Health The project will support critically needed positions as well as address staff skills gaps at facilities through training and mentoring, and appropriate continuing medical education activities for paediatric HIV/ART

services, using the newly developed national training curricula. Specific skills strengthening in quality improvement will be achieved through appropriate learning and coaching sessions, building upon and working with the MOH Quality of Care Initiative (QoC). Service provider skills for evaluating children for ART; initialing and monitoring children on ART; and providing psychological care and support to children and their families will be strengthened through training and coaching activities.

1. Target populations and coverage of target population or geographic area SUSTAIN will support 32 public health care facilities across the country (11 regional referral hospitals, 10 general hospitals and 11 smaller facilities) to provide PMTCT services. The target population for the support includes pregnant women and their spouses (HIV-infected and un-infected), and HIV-exposed infants in the catchment areas served by each of the hospitals. The project will aim at reaching 100% of clients who seek antenatal and delivery services in these facilities.

2. Description of service delivery or other activity carried out The SUSTAIN PMTCT program will focus on improving PMTCT uptake through provision of routine testing and counseling for all mothers attending for antenatal, maternity (delivery) and postnatal/child immunization services. All regional referral and general hospitals will be supported to implement the newly (2010) revised MOH strategic approach for PMTCT: option B or A for maternal and infant ARV prophylaxis as may be feasible at different timeframes and health care facility level, within the framework of all the four prongs for PMTCT. Service providers will be supported to develop skills for proving the various prophylaxis options, including evaluating and starting eligible mothers on HAART, as per the national guidelines. Laboratories in public facilities will be strengthened to perform CD4 tests. Referral systems for infant virologic tests and mothers' CD counts where needed, will be strengthened to ensure efficiency and short turn-around times for results.

3. Integration with other health activities The program will focus on ensuring integration of PMTCT services within routine maternal (antenatal, post-natal and family planning), newborn and child health services by promoting co-localization of these services and functional linkages within facilities and between facilities and community based programs. Linkages to other HIV care and treatment and TB services within the facilities will be promoted and improved at all times. Safe delivery kits and long lasting insecticide treated nets will be distributed to ensure a clean delivery environment, and prevention of malaria in pregnancy, respectively. community mobilization and sensitization aiming at fostering behavior change and creating demand for maternal and

PMTCT services through community dialogue meetings and targeted home visiting will be carried out. 4. Relation to the national program Delivery of PMTCT services at each facility will be closely planned and carried out with the MOH guidance, with regard to the strategic approach, guidelines implementation, training curricula and training activities, supervision and mentoring as well quality improvement. SUSTAIN will also support facilities to report to the national program using the newly developed reporting tools.

5. Health Systems Strengthening and Human Resources for Health During the year 2011, SUSTAIN will work with the MOH and individual facilities to asses and determine human resource strengthening needs. The program will then support critically needed positions as well as address staff skills gaps through training and mentoring. Areas of focus will include capacity to implement the new guidelines for PMTCT, including infant and young child feeding.

1. Target populations and coverage of target population or geographic area Laboratory strengthening start-up activities will be carried out in 11 public health care facilities across the country (11 regional referral hospitals).

2. Description of service delivery or other activity carried out SUSTAIN will conduct a laboratory capacity assessment exercise for 24 public health facilities, focusing at staff technical capacity to efficiently carry out HIV-related tests; equipment available/needed and physical infrastructure. REDACTED. Training in both technical and quality improvement aspects will be give to laboratory staff for all the 24 facilities. Equipment for HIV-related tests will be procured and availed to the 5 RRH laboratories, following an equipment rationalization exercise conducted jointly with MOH/CPHL and the facilities.

3. Integration with other health activities All laboratory strengthening activities supported by SUSTAIN will be carried out in, and with the purpose of, integrating HIV laboratory services within routine health care laboratory services 4. Relation to the national program SUSTAIN-supported laboratory service strengthening activities will be planned with the MOH/ACP and CPHL, to ensure alignment with the national laboratory strengthening program, and avoid duplication.

5. Health Systems Strengthening and Human Resources for Health

Appropriate competency needs-based training and support supervision activities will be conducted to build capacity for laboratory staff in technical and quality improvement areas. Critical positions will be supported, following a staff/tasks rationalization exercise with individual facilities.

1. Target populations and coverage of target population or geographic area SUSTAIN will support provision of collaborative TB/HIV services in 32 public health care facilities across the country (11 regional referral hospitals, 10 general hospitals and 11 smaller facilities). The target population includes adults and children accessing health care services at the supported facilities, and those resident in the respective catchment areas of the facilities

2. Description of service delivery or other activity carried out Activities will include: pro-active, purposeful identification of HIV infected individuals through provider- initiated HIV testing and counseling (PITC) for all TB patients and ensuring functional linkages/referrals of HIV-infected TB patients to HIV prevention, care and treatment. TB service providers will continue to be trained and supported to perform HIV testing and counseling of TB patients (and TB suspects), including children, using rapid HIV tests in TB clinics. Screening all PLHIV for TB will continue to be prmoted as a routine clinical practice approach in supported facilities, to contribute to intensified TB case-finding. SUSTAIN will support strengthening of on-site laboratory diagnostic services for TB (i.e. smear microscopy, TB culture, chest radiography), and monitoring and documentation of TB screening, TB status, and TB treatment of PLHIV.

3. Integration with other health activities TB/HIV activities will be made available in all service delivery points at each facility, including services for children and mothers MNCH/PMTCT settings. Other related activities will include implementation of infection control (IC) measures to prevent TB transmission within the clinical care settings, and promotion of close coordination between TB and HIV programs at all levels to ensure continuum of care for HIV- infected TB patients (through supervision, linkages, training, and strategic information). Linkages between facility-based and community/home-based services will be enhanced through partnerships with other community and facility based providers in respective geographical areas to ensure a continuum of care. 4. Relation to the national program SUSTAIN will ensure that all approaches and activities supported are in alignment with Uganda MOH's policies and strategic plans for TB and HIV. The RRHs will be further strengthened in terms of clinical

and laboratory capacity to function more efficiently as referral sites for respective geographical regions of the country.

5. Health Systems Strengthening and Human Resources for Health The project will support critically needed positions as well as address clinical and laboratory staff skills gaps at facilities through training and mentoring, and appropriate continuing medical education activities for TB/HIV activities. Specific skills strengthening in quality improvement will be achieved through appropriate learning and coaching sessions, building upon and working with the MOH Quality of Care Initiative (QoC).