1. Overall goals and objectives Goals 1. To contribute to primary prevention of HIV 2. To improve the quality of life of HIV-infected persons 3. To strengthen the health systems in the partner institutions Objectives 1. To support scaling up of PITC services and actively link at least 80% of the identified HIV positive patients to HIV care and treatment services 2. To support primary prevention interventions including ABC and medical male circumcision 3. To support provision of PMTCT, strengthen EID and linkages to pediatric care & treatment 4. To support provision of OVC services 5. To support provision of HIV/AIDS basic care and support including TB management 6. To support provision of ART to existing clients and new clients, including SGBV clients 7. To strengthen systems: M&E, laboratory, logistics and supplies, human resource, leadership and management

The MJAP program will serve both children and adults in mulago and Mbarara Teaching Hospitals. Over the last five years, MJAP has been supporting comprehensive HIV/AIDS/TB services in Mulago & Mbarara Teaching hospitals, seven Regional Referral hospitals (RRH) and several clinics in Kampala and Mbarara districts. The package of services included provider-initiated HIV counseling and testing; basic HIV care, antiretroviral therapy; integrated TB/HIV activities, OVC services for children born to HIV infected patients; ABC activities, prevention for positives, services for the Most at Risk Populations (MARPI) including clients who come to the STD unit, commercial sex workers and their communities, and sexual and gender-based violence medical services (SGBV) for survivors of rape and sexual violence.

For FY 2011, MJAP will continue supporting the services in Mulago and Mbarara hospitals, and in a third teaching hospital, Butabika. MJAP will no longer support services in the RRH under this program. In addition, MJAP will support provision of the full package of PMTCT services in Mulago hospital through a sub grant to the Makerere University-John Hopkins Collaboration (MUJHU) but provide PMTCT services directly in Mbarara hospital.

2. Target populations and geographic coverage

This program will be implemented in two districts Kampala and Mbarara through the teaching hospitals of Mulago, Mbarara and Butabika. It will provide comprehensive HIV/AIDS care through all the clinics of mulago and Butabika hospitals. In addition, it will support district wide and comprehensive HIV/AIDS care in mbarara districts through all the accredited public health facilities from Hospitals to HC III.

3. Enhancing cost effectiveness and sustainability Describe strategies that will increase effectiveness and efficiencies and make activities more sustainable.

• The program will leverage drugs and other supplies from other sources when available eg NTLP for TB drugs , CHAI for pediatric and 2nd line ARVs, Pfizer for Fluconazole, MJAP also hopes to support additional clients on ART by leveraging GF and MOH ARVs • Move to generic FDA approved drugs: the program will use cheaper approved generic combinations approved by the MoH • The program will use FDC as opposed to single formulations to reduce drug costs • Innovative clinic models to reduce on staffing requirements / pressures e.g. family model, task shifting efforts, nurse only / pharmacy only etc will be used • MJAP will build the capacity of Districts and health facilities to discuss exit plans, and will support them in writing proposals to mobilize their own resources.

4. Health Systems Strengthening

Human resources for health:

Based on results of thorough needs assessments, MJAP will support the following areas: Training/ re training for service providers in HIV/ TB prevention and care; salary support for additional staff recruited o fill critical gaps in the supported facilities; continuous medical education; regular technical support supervision, together with MOH officials; and orientation of facility-based supervisors to manage the services

Lab strengthening: Based on actual needs, activities will include training, equipment provision and maintenance, technical assistance to ensure timely and accurate reporting to MOH, provision of buffers to minimize stock-outs and strengthening quality assurance.

Infrastructure: MJAP will support minor but essential refurbishments/ remodeling of some facilities to improve quality of HCT and care.

Strengthening logistics management systems: • Training of staff in logistics management • Following a comprehensive needs assessment staff gaps will be filled as appropriate • Introduce dispensing software to track logistics data; consumption/dispensing data, stock on hand as well as losses and adjustments • Support staff in preparing end of cycle reports to NMS to ensure accuracy and correctness of reports • Ensuring timely submission of reports to NMS through the use of program email and fax services as well as hand delivery • Transporting of commodities from NMS to the sites in case of transport challenges to avert the frequent stock outs at the facilities • All clients will be gradually moved to the MoH ARVS to ensure sustainability and we will maintain a 4months buffer stock to ensure uninterrupted supply of commodities to the clinics. • The pharmacy infrastructure will be improved as appropriate to foster good pharmacy practice Monitoring and evaluation

MJAP has supported partner health units to gradually phase out its tools and instead use MOH tools. This process will continue to ensure that all facilities collect, manage and report on data using MOH tools and policies. Needed equipment like computers will be provided. Challenges will be shared with MOH and CDC to develop strategies to ensure that PEPFAR, MOH and MJAP reporting requirements are met without over-burdening the facilities. Monitoring/ technical support visits to facilities will continue and reports will be submitted as required.

Leadership and Management

In order to ensure sustainability of these services, MJAP will work very closely with the managers of partner health units to ensure that they totally own the services. Regular meetings to share progress reports and experiences will be fully supported.

5. Cross-Cutting Budget Attributions-

a. Human Resources for Health- this will include training, re-training, and hiring to fill critical staffing gaps in partner health facilities b. Construction/Renovation: REDACTED

g. Gender: Reducing Violence and Coercion- Services to be supported are the medical aspects of SGBV including PEP, STI treatment, EC, and treatment of injuries. Referrals will be made to police and other service providers for legal and other support

6. Key issues: a. Health-Related Wraparounds o Child Survival Activities- MJAP will support OVC activities including education, vocational training, nutrition, etc o Family Planning- MJAP will provide information, counseling and services to patients who need them; with referrals for other services not provided by MJAP o Malaria (PMI) - MJAP will fully integrated malaria prevention and treatment in the HIV services. Insecticide treated nets a well as anti- malarial drugs will be provided to the patients o Safe Motherhood- counseling and services will be provided to patients attending the HIV clinics, with appropriate referrals to other sites. o TB- MJAP will continue to support integrated TB/HIV diagnosis and treatment in all the sites; through training, technical assistance and logistical support

b. Gender -Medical SGBV services will be offered and referrals will be made from our SGBV program to police and other service centres for services we do not offer

c. End- of-Program Evaluation-MJAP will conduct an end of program evaluation in the final year of the program.

f. Workplace Programs-MJAP will strengthen its own workplace HIV programming through increasing access to essential information and services for all staff and immediate family members

1. Target populations and coverage of target population or geographic area MJAP will provide ART treatment (facility based) to adult men and women aged 18+ years in the following nine clinics: Infectious Diseases Clinic (IDC) at Mulago Hospital, Mulago Hospital ISS, Mulago Hospital TB-HIV, Mulago Communicable Disease, Bwizibwera, Municipal Council, Mbarara ISS clinic, Mbarara TB/HIV clinic and Butabika hospital. The project will target all adult men and women with confirmed and documented HIV positive results attending the above clinics. Patients will be identified from the facility-based Provider Initiated Testing and Counseling for HIV (PITC) and others will come from other testing sites. 2. Description of service delivery or other activity carried out MJAP will provide basic care and support including TB management, Septrin /Dapsone prophylaxis, screening and treatment for opportunistic infections including TB, Cryptococcal meningitis, and Kaposi's sarcomas. The clients will receive basic care supplies including health educational materials, safer water vessel, mosquito nets and condoms. We shall implement Prevention with Positives including ongoing counseling of all HIV positive clients, partner testing, disclosure, discordant couple forum and family planning to reduce the risk of HIV transmission to the partner and unborn child. Palliative care and nutritional counseling with referral for the severally malnourished clients will also be provided. To further increase clinic efficiency we shall increasingly strengthen nurses only and pharmacy only visits so that clients with no or minor complains are attended to by nurses and pharmacy staff and only patients with major/severe complaints are seen by the doctors. These will ensure that more clients will be attended to with equal or less human resource. Routine CD4 monitoring will be done to identify patients who need ART. 3. Integration with other health activities

All the HIV services will be integrated into the existing facility services. Existing facility staff will provide the services and the facilities will be supported to fill only major identified human resource gaps. Where a client requires any other non HIV related service linkages and consultations at each facility will be done to utilize the existing services.

4. Relation to the national program

All the services will be provided together with MOH and host facilities with total alignment to MOH policies, guidelines and M&E systems for HIV care and support. We shall continue to collect and report data using MOH HMIS data tools and introduce them in clinics were they are not yet fully operational.

5. Health Systems strengthening and Human Resources for Health

We shall offer in service training for all new host facility staff and on job training for the existing staff in HIV care and management including TB, data management/ use and logistics management. Based on needs, MJAP will enhance the capacity of partner health facilities for HIV and TB diagnosis and care and improve the necessary infrastructure to offer quality services. Together with MOH and host facilities we shall increasingly strengthen the existing logistic systems for delivery of drugs, reagents and other supplies. MJAP will support the development and maintenance of a robust program Monitoring and Evaluation system based on MOH guidelines. , and use the results for ongoing improvement of program performance. This will include strengthening M&E capacity at the district and service delivery sites by training staff at the DHOs office and the partner institutions to: a) Plan and conduct program evaluations, b) Coordinate and perform data collection, c) Manage and clean data, d) Analyze data, e) Develop data systems and f) Interpret, disseminate and use data for program implementation and policy formulation. The M&E system will also enable them to identify clients lost to follow-up and transferred. The program will support home visitors and organized PLHA groups and networks to track patients within a radius of 30 kms of the partner health facilities. We shall identify CBOs offering complementary HIV care and support services and where appropriate support linkages to ensure bi-directional referral between the communities and health facilities. MJAP will facilitate and work with the DHO's Office to form strategic partnerships with USG and non USG implementing partners, Civil Society Organizations (CSOs), Community Based Organizations (CBOs), People Living with HIVAIDS (PHA) networks and Village Health Teams (VHTs). This will facilitate further integration of project activities, leveraging of resources, and reduction of duplication and overlaps in service provision.

1. Target populations and coverage of target population or geographic area

The target population will be children attending Mbarara hospital, Bwizibwera and Mbarara Municipality

HC IVs who are orphans and/or vulnerable. About 55 % of the Mbarara district populations (500,000

people) are children below 18 years, and the estimated pediatric HIV prevalence rate is 2%.

2. Service delivery and other activities

MJAP will support care and support for orphans and vulnerable children in all three health units, in FY

2011. In order to scale up these services, more children need to be identified, linked to these services

and followed up; more children will be identified by asking index clients to bring their children for HCT and

integration of HCT in child health day's activities. Also others will be identified during immunization and

postnatal visits, among others. MJAP will continue conducting home visit to consenting adult patients;

more children will be identified and supported during these visits. MJAP will provide services in all the

prescribed core program areas. groups.

Integration with other health activities

MJAP will support mechanisms for active and effective linkages and integration between community,

OVC and Paediatric HIV/AIDS care, ART, nutrition, MCH and other services for proper management of

infected and affected children.

Health systems strengthening and HRH

MJAP will work with the relevant district offices and structures to partner with these health facilities to

jointly plan, implement, coordinate and monitor OVC services. The project will also support sensitization

of care providers, local leaders and community members in child health related issues, food security and

proper child nutrition.

Target populations and coverage of target population or geographic area

The target population is adults 15 years and above attending Mbarara hospital, Bwizibwera and Mbarara

Municipality HC IVs. About 45 % of the Mbarara district populations (400,000 people) are adults above

18 years and will be the target under this program area.

Service delivery and other activities

MJAP has been supporting adult care, support and treatment in all three health units, and will continue to

do so in FY 2011. In order to scale up these services, more patients need to be identified, linked to these

services and followed up. MJAP will continue conducting home visit to consenting adult patients; more

children will be identified and supported during these visits. MJAP will scale up adult treatment in health

facilities in line with current MoH guidelines. MJAP will procure OI medicines and ARVs to supplement

those from MOH. The program shall support tracking of patients lost to follow up by strengthening

community follow-up of patients using Community based PHA networks, VHTs and Peer to Peer support

groups.

Integration with other health activities

MJAP will support mechanisms for active and effective linkages and integration between PMTCT and,

ART, nutrition, MCH and OVC services for proper management of those infected.

Health systems strengthening and HRH

MJAP will work with the DHO"s office and partner health facilities to jointly plan, implement, coordinate

and monitor pediatric HIV care. MJAP will support the partner health facilities to strengthen MoH supply

chain systems for essential drugs and medical commodities for children and support training and

supervision of health workers in pediatric care, IMCI and IMAI using the MoH in-service training policy

and materials. The project will also support sensitization of care providers, local leaders and community

members in child health related issues, food security and proper child nutrition. MJAP will support training

of staff in Logistics and supplies management and Good Laboratory Practice. We shall also support

equipping the labs with the necessary equipment to perform HIV basic care and monitoring tests (CD4+

monitoring, DBS, LFTs and RFTs, liquid culture for TB), and support performance of EQA/PT in

collaboration with UVRI

1. Target populations and coverage of target population or geographic area HIV couselling and testing will be done in Mulago, Mbarara ad Butabika hospital 2. Description of service delivery or other activity carried out:

PITC will be offered to consenting persons seeking care at the facilities, and their family members. The MOH testing algorithm (Determine for screening, STAT-PAK for confirmatory testing and Uni-Gold as the tie-breaker test) will be used. Couple-testing will be encouraged both in the testing facilities and in the care clinics. VCT will also be done in the homes of index clients who accept to be visited. During the HIV prevention outreaches to the schools and universities in Mbarara and Makerere/ Mulago, VCT will be offered. Promotional activities to reach the target population will be undertaken on days like the World AIDS day, scientific week and other special events during which HCT will also be offered. The project will support IEC activities including media campaigns, social events e.g. World AIDS Day, Community Meetings and using community support groups. The project will promote the strengthening of networks and linkages between health facilities and community programs like VHTs, PHA networks, FBOs, CSOs

and CBOs to promote HCT activities Mulago and Butabika hospitals will scale up HIV counseling and testing (HCT) services to target 75,000 persons. This will include consenting persons seeking care at the two hospitals and their family members. We will train and re-train health care workers, students, as well as residents in the hospitals in the different HCT approaches (client-initiated, provider-initiated, couple-testing, home based HIV testing and counseling), using the national curriculum. Promotional activities to reach the target population will be undertaken on days like the World AIDS day, scientific week and other special days as designated by different Schools under the College of Health Sciences.

3. Integration with other health activities:

We shall support the DHOs office to coordinate all the partners involved in provision of HCT and care, treatment and prevention programs through regular meetings to share information.. In partnership with the hospital, DHO's Office and the MoH, MJAP will conduct support supervision to ensure adherence to national HTC guidelines and protocols. We shall support performance of both internal quality control and external quality control for HIV tests at the Uganda Virus Research Institute (UVRI). 4. Relation to the national program: We shall support the DHOs office to coordinate all the partners involved in provision of HCT and care, treatment and prevention programs through regular meetings to share information.. In partnership with the hospital, DHO's Office and the MoH, MJAP will conduct support supervision to ensure adherence to national HTC guidelines and protocols. We shall support performance of both internal quality control and external quality control for HIV tests at the Uganda Virus Research Institute (UVRI). HIV testing will be performed with rapid tests using the sequential rapid testing algorithm; Determine for screening, STAT-PAK for confirmatory testing and Uni-Gold as the tie-breaker test. In partnership with the hospital management and MOH, support supervision will be provided to ensure adherence to the national HCT guidelines and protocols, improve data management and linkage to the MOH HMIS. Both internal and external quality control for HIV tests will be performed at regular intervals in order to ensure quality test results at all testing sites. 5. Health Systems Strengthening and Human Resources for Health MJAP will conduct detailed needs assessments to determine the HCT related capacity needs of these facilities and then implement remedial activities. These may include training/ re-training of health care workers, students, as well as residents in the hospitals in the different HCT approaches. MJAP will support efforts to establish and maintain a comprehensive and robust M&E system in line with the MoH. The support will include establishment of electronic databases, computers and training in electronic data processing Using this system, the project will strengthen bi-directional referral networks and feedback mechanisms on linkages between HCT and care, treatment and preventive programs. Patients referred from HCT to care, treatment and preventive will be tracked using unique identifiers which are printed as

serial numbers on HCT forms. Services providers will be sensitized and trained on the need to offer referral cards/notes to clients, indicating the service for which the referral is indicated. Client registration at the service point will include an indicator on where the Client is referred from. Regular monitoring and evaluation will be done to assess and document the effectiveness of referrals using registration data tools at service points within health facilities. In order to ensure effective referrals, services providers will be sensitized and trained on the need to offer referral cards/notes to clients, indicating the service for which the referral is indicated. This will apply for the within and between health facilities referrals. Client registration at the service point will include an indicator on where the Client is referred from. Regular monitoring and evaluation will be done to assess and document the effectiveness of referrals using registration data tools at service points within health facilities.

1. Target populations and coverage of target population or geographic area The target population will be children attending Mbarara hospital, Bwizibwera and Mbarara Municipality HC IVs. About 55 % of the Mbarara district populations (500,000 people) are children below 18 years, and the estimated pediatric HIV prevalence rate is 2%. The estimated pediatric population in need of HIV care in the district is 8,250 children. 2. Service delivery and other activities MJAP has been supporting pediatric care, support and treatment in all three health units, and will continue to do so in FY 2011. In order to scale up these services, more children need to be identified, linked to these services and followed up. Activities aimed at identifying more children will include asking index clients to bring their children for HCT, integration of HCT in child health days activities, identification of exposed children during immunization and postnatal visits, among others. MJAP will continue conducting home visit to consenting adult patients; more children will be identified and supported during these visits. In order to shorten the turnaround time and improve EID, MJAP will work with other Partners and ACP to strengthen EID (collection of DBS, delivery to processing laboratories, provide results to caregivers and referral to HIV care and treatment services).MJAP will strengthen pediatric care in health facilities in line with current MoH guidelines including provision of ART for all confirmed HIV positive infants. MJAP will procure OI medicines and snacks will be provided for children as they wait to be served in the clinics. MJAP will partner with NuLife for the provision of ready-to-use foods and referrals for children in need of food and other commodities will be made as appropriate. We shall support tracking of pediatric patients lost to follow up by strengthening community follow-up of patients using Community based PHA networks, VHTs and Peer to Peer support groups.

Integration with other health activities MJAP will support mechanisms for active and effective linkages and integration between PMTCT and Paediatric HIV/AIDS care, ART, nutrition, MCH and OVC services for proper management of infected and affected children. Health systems strengthening and HRH MJAP will work with the DHO's office and partner health facilities to jointly plan, implement, coordinate and monitor pediatric HIV care. MJAP will support the partner health facilities to strengthen MoH supply chain systems for essential drugs and medical commodities for children and support training and supervision of health workers in pediatric care, IMCI and IMAI using the MoH in-service training policy and materials. The project will also support sensitization of care providers, local leaders and community members in child health related issues, food security and proper child nutrition. MJAP will support training of staff in Logistics and supplies management and Good Laboratory Practice. We shall also support equipping the labs with the necessary equipment to perform HIV basic care and monitoring tests (CD4+ monitoring, DBS, LFTs and RFTs, liquid culture for TB), and support performance of EQA/PT in collaboration with UVRI

Target populations and coverage of target population or geographic area The target population is children attending Mbarara hospital, Bwizibwera and Mbarara Municipality HC IVs. About 55 % of the Mbarara district populations (500,000 people) are children below 18 years, and the estimated pediatric HIV prevalence rate is 2%. The estimated pediatric population in need of HIV care in the district is 8,250 children. Service delivery and other activities MJAP has been supporting pediatric care, support and treatment in all three health units, and will continue to do so in FY 2011. In order to scale up these services, more children need to be identified, linked to these services and followed up. Activities aimed at identifying more children will include asking index clients to bring their children for HCT, integration of HCT in child health days activities, identification of exposed children during immunization and postnatal visits, among others. MJAP will continue conducting home visit to consenting adult patients; more children will be identified and supported during these visits. In order to shorten the turnaround time and improve EID, MJAP will work with other Partners and ACP to strengthen EID (collection of DBS, delivery to processing laboratories, provide results to caregivers and referral to HIV care and treatment services).MJAP will strengthen pediatric care in health facilities in line with current MoH guidelines including provision of ART for all confirmed HIV positive infants. MJAP will procure OI medicines and ARVs to supplement those from MOH. Paediatric MoH ART

regimens that can be sustained by the MoH will be used. MJAP will provide ART to 300 children up to 14 years in the first year as we prepare to transition them to MoH in the subsequent years. Snacks will be provided for children as they wait to be served in the clinics. MJAP will partner with NuLife for the provision of ready-to-use foods and referrals for children in need of food and other commodities will be made as appropriate. We shall support tracking of pediatric patients lost to follow up by strengthening community follow-up of patients using Community based PHA networks, VHTs and Peer to Peer support groups. Integration with other health activities MJAP will support mechanisms for active and effective linkages and integration between PMTCT and Paediatric HIV/AIDS care, ART, nutrition, MCH and OVC services for proper management of infected and affected children. Health systems strengthening and HRH MJAP will work with the DHO"s office and partner health facilities to jointly plan, implement, coordinate and monitor pediatric HIV care. MJAP will support the partner health facilities to strengthen MoH supply chain systems for essential drugs and medical commodities for children and support training and supervision of health workers in pediatric care, IMCI and IMAI using the MoH in-service training policy and materials. The project will also support sensitization of care providers, local leaders and community members in child health related issues, food security and proper child nutrition. MJAP will support training of staff in Logistics and supplies management and Good Laboratory Practice. We shall also support equipping the labs with the necessary equipment to perform HIV basic care and monitoring tests (CD4+ monitoring, DBS, LFTs and RFTs, liquid culture for TB), and support performance of EQA/PT in collaboration with UVRI

1. Target populations and coverage of target population or geographic area The project will be implemented in Mulago, Mbarara and butabika hospitals. In addition Health facilities HC IV-III within Mbarara district will be supported to strengthen their health systems. 2. Description of service delivery or other activity carried out REDACTED. Staff recruitment under MOH structures to fill HR gaps will be done. 3. Integration with other health activities The program will offer and integrated comprehensive package of services. The family based model of care will ensure that all services available including counseling and testing, adult care and support, laboratory services, PMTCT, TB services are available and are implemented in a sustainable manner. A health systems strengthening approach to program implementation will be adopted across all program

areas. 4. Relation to the national program Leveraging resources from the GoU, MoH will enhance the MJAP program. The program will work closely with MoH to implement MoH guidelines regarding supply chain management, providing information to feed into the planning and monitoring process, human resources for health, finance and accountability at the units. The project will ensure that clinics are collecting data related to health systems strengthening to effectively monitor program performance. IDI will upgrade all patient information systems in line with MoH HMIS to ensure a standardized, sustainable and efficient system for data collection, collation, monitoring and feedback 5. Health Systems Strengthening and Human Resources for Health The six WHO building blocks for HSS (service delivery, health work force, information, medical products, vaccines and technologies, financing and leadership/governance) provide a useful framework to guiding this process in order to improve quality, access, coverage and safety of health services that in turn lead to improved health, efficiency responsiveness and sustainability. Strengthening activities will occur in all six building blocks during the project period. The MJAP project will support multiple strategies that include supporting the district service commission to hire any outstanding staff positions, implement task shifting and training of staff

1. Target populations and coverage of target population or geographic area MJAP will support MMC in Mulago and Mbarara hospitals 2. Description of service delivery or other activity carried out MJAP will support MMC services as part of its package for HIV prevention services. In order to increase awareness and uptake of services, MJAP will support communication activities which address negative perceptions towards MMC. These will include printing of flyers, News Paper prints, radio and television talk shows. MMC will be provided after patient education and consent and delivered in the context of comprehensive HIV prevention messages/services that include: on-site offer of pre-operative HIV counselling and testing; active exclusion of symptomatic STIs and syndromic treatment when indicated; post-operative wound care and abstinence instructions; age-appropriate counselling on risk reduction, reducing number and concurrency of sexual partners, and delaying/abstaining from sex; and provision and promotion of correct and consistent use of male and/or female condoms. 3. Integration with other services MJAP will explore mechanisms to increase access to MMC services beyond Mulago & Mbarara hospitals. Such mechanisms will include use of mobile facilities through the use of tents or temporary

structures in schools and churches. Experiences from these explorations will be documented to inform future scale up strategies in the subsequent years. REDACTED 4. Relation to national program MJAP will support the MoH to finalise and disseminate implementation guidelines and policies for MMC. MJAP MMC services will be done in accordance with standard guidelines such as the "WHO/UNAIDS/Jhpiego Manual for Male Circumcision Under Local Anaesthesia." MJAP will support design of data tools for MMC such as; Male circumcision Register, Adverse Events Register and other tools. These will be used to monitor the safety and quality of the MMC services provided.

5. Health Systems Strengthening and Human Resources for Health Pre- and in-service training provided, other capacity building activities, number of healthcare workers supported. MJAP will support training of staff to perform MMC; support establishment of minor theatres for MMC, and provide the necessary logistics.

1. Target populations and coverage of target population or geographic area

Over the last about five years, MJAP has supported Other HIV prevention (OP) interventions in Mulago and Mbarara teaching hospitals, seven regional referral hospitals and several satellite clinics in Mbarara and Kampala districts. In FY 2011, MJAP will support these services in Mulago, Mbarara and Butabika teaching hospitals, as well as Bwizibwera and Mbarara municipality HC IVs. Target groups will include both the students and health workers in those institutions, as well as their family members.

2. Description of service delivery or other activity carried out

Previously, MJAP has been supporting OP interventions by addressing some of the key drivers of the epidemic in the above target populations namely; lack of consistent and correct condom use, STIs. These include promotion and provision of condom use, family planning services to HIV positive women to avoid unwanted pregnancies; management of STIs, support to discordant couples, prevention with positives and services to survivors of sexual and gender-based violence (SGBV). These services are integrated into the HIV counseling and testing (HCT), and care, support and treatment interventions. Discordant couples identified have been supported with counseling on how to protect the HIV negative partner; care for the HIV positive partner; condoms are provided and referrals made to the discordant couple clubs supported by MJAP where they meet regularly for further care, peer support and repeat

testing for the HIV negative partner. Since July, 2008, MJAP has been offering comprehensive medical services to survivors of sexual and gender based violence (SGBV) in Mulago Hospital in collaboration with the Department of Obstetrics and Gynecology. The package of services includes; counseling; HIV counseling and testing (to survivor and perpetrator, if available); Provision of Post-Exposure Prophylaxis for HIV (PEP);Pregnancy tests and provision of emergency contraceptives (females of reproductive age); Screening, prevention and/or treatment of STI's/STDs; Treatment of concurrent injuries; laboratory services and referral to police and other organizations for legal and psychosocial support. Through the Most at Risk populations (MARPI) project, and in collaboration with the Mulago National STD Unit, MJAP has been supporting HIV prevention services for the Most at Risk populations (including commercial sex workers) and other vulnerable populations like the youth in tertiary institutions in Kampala and Wakiso districts.

In FY2011, MJAP will continue supporting all these OP services. SGBV services will be scaled up to Mbarara hospital, which will serve as a referral site for the HC IVs. To increase awareness of the services, stake holders' meetings, Radio talk shows, Posters, Notices and Memos will be made available in all sites MJAP will support. More service providers will be trained in SGBV service delivery as needed. In order, to increase the effectiveness of the HIV/STI prevention efforts, meetings of about 20-25 people will be held to encourage dialogue and information sharing on HIV/ AIDS issues. More condom outlets will be operationalized and condom distribution scaled up in hostels, hotels, bars, entertainment points and other places for people who need them. Discordant couples will continue to be supported with supportive counseling, condom education and referral for care services. The concordant positives will continue to be linked to care and positive prevention reinforced.

3. Integration with other health activities

These OP services are integrated with other HIV/AIDS and health activities. Referral mechanisms and linkages with Hope after Rape, the police, MOH, Ministry of Labor, Gender and Social Development and Ministry of Education will be further strengthened.

4. Relation to the national program

All efforts will be made to align/ harmonize planning, monitoring, evaluation, quality assurance and reporting with MOH standards and guidelines.

5. Health Systems Strengthening and Human Resources for Health

Training for students and staff will be conducted based on identified needs.

1. Target populations and coverage of target population or geographic area and cross cutting system/activity that contributes to PMTCT scale-up.

MJAP will support PMTCT services in Mbarara, Mulago and Butabika hospitals, as well as Mbarara Municipality. MU-JHU Care and the OB Dept oversee and support all PMTCT activities at Mulago Hospital and will continue doing so as a sub-partner to MJAP effective October 2010. Through the Mulago PMTCT program MTCT has been reduced to less than 5%, with postnatal linkage to treatment and care for HIV + mothers and infants. The program encourages male participation with about 15% of partners of HIV+ pregnant women (3300) now receiving RCT services with their partners. 2. Description of service delivery or other activity carried out:

Mothers and their spouses coming for ANC, PNC, immunization and other services will be targeted. MJAP will support facilities to conduct routine rapid same-day HIV testing for ANC & PNC participants and late presenters at labor/delivery wards; provide comprehensive reproductive health services to existing female HIV-infected clients of reproductive age (partner HCT, family planning, STI diagnosis and treatment); support provision of ARVs for PMTCT to both the mothers and babies; delivery of intra- partum interventions to reduce MTCT of HIV and other infections, support provision of care and follow up of HIV exposed infants including infant feeding counseling and EID; support VHTs, and PLHA support groups to follow up HIV exposed infants in communities; strengthen family-centered approaches to care to ease follow up of HIV exposed infants and their mothers; support activities of peer mothers to enhance uptake of PMTCT services; and increase Men's Access activities, both in ANC and PNC 3. Integration with other health activities:

The PMTCT postnatal follow up clinic staff provide linkages to follow up HIV care & treatment, early infant diagnosis and counseling on infant feeding. The PMTCT staff will also assess the use of peers as a task shifting approach to support EBF and reproductive health services. In Mulago, a demonstration kitchen where PMTCT staff will show mothers how to prepare nutritious meals for their families using locally available foods will be set up. Linkages to OVC services for the most vulnerable will also be addressed. PMTCT activities will also be integrated with screening for Human papilloma virus (HPV). 4. Relation to the national program:

All activities will be done I n line with MOH guidelines. As Uganda's National Referral Hospital, the Mulago PMTCT program serves both as a proving ground and a national showcase for the MOH National PMTCT policies. The Mulago PMTCT program follows the MOH national guidelines for both PMTCT and infant feeding Guidance; and is a lead implementer of new PMTCT, HIV and infant feeding policies. 5. Health Systems Strengthening and Human Resources for Health: Based on identified needs, training/re training will be done. Lab capacity for HIV diagnosis and treatment monitoring will be done. MJAP will support joint planning meetings, support supervision, support the provision of resources (ARVs, OI medicines, lab reagents, etc) for implementation of PMTCT services, and carry out joint monitoring and evaluation for PMTCT services. The project will also support the DHOs office to hold PMTCT coordination activities.

1. Target populations and coverage of target population or geographic area The target population will be patients attending to; Mulago, Butabika and Mbarara Hospitals, and the satellite clinics of Mbarara municipality and Bwizibwera Health centre. The program will support laboratory services in these facilities. MJAP will also support national level activities including rolling out and strengthening lab quality assurance systems country-wide. 2. Description of service delivery or other activity carried out MJAP will support laboratory services in; HIV and TB screening, ART laboratory monitoring, physical infrastructure improvement, maintenance of equipment, laboratory records management, Quality Assurance and training. In logistics, the program will provide a buffer stock, however other supplies will be got from National Medical Stores.Substancial efforts will also be made towards medical waste management in these facilities, emphasis will be put on waste segregation at the point of waste generation; essential supplies such as sharps containers, pedal bins and waste liners will be provided. The program is already working closely with AIDSTAR [USAID funded Project] in training health workers in managing medical waste. 3. Integration with other health activities MJAP will work with MOH institutions like Central Public Health laboratories [CPHL] to coordinate a CD4 proficiency scheme with UKNEQAS; the program together with CPHL will work to enable these facilities access samples and result by shipping specimens and training laboratory personnel in these facilities in laboratory accreditation activities which is being initiated by CPHL. The program will work with other institutions such as, the HIV Reference laboratory at Uganda Virus research Institute to expand the external quality assurance program for HIV rapid test by providing testing panels and tools to monitor quality of rapid HIV testing. The program will support Quality Assurance and training activities together NTRL and increase the number of laboratories with satisfactory performance in external quality assurance testing program for AFB smear microscopy. MJAP will work closely with all stakeholders

including, NMS, JMS and MSH who are involved in various aspects of logistics management. 4. Relation to the national program The program will work closely with all stakeholders especially MOH institutions such as; CPHL, NTRL, UVRI and NMS. This is to ensure that these activities are implemented in line with the national laboratory policy. 5. Health Systems Strengthening and Human Resources for Health In-service training will be conducted for laboratory personnel in these sites using training guidelines from CPHL. The MJAP team will work very closely with the CPHL team to conduct regular follow up, mentoring and on-site support of all trained personnel. Other in-service trainings will be done through continuous medical education. The program together with CPHL will set up a training database to track trainings and support supervision activities. For all trainings conducted; emphasis will be placed on targeted post-training support to consolidate knowledge and skills. In addition, MJAP will support student attachments to laboratories within its sites for industrial trainings and provision of training materials to tertiary institutions that are training medical laboratory students.

1. Target populations and coverage of target population or geographic area MJAP procured and distributed ARV drugs for 15 service outlets; Mulago ISS clinic, AIDC, Mulago TB/HIV 2. Service delivery and other activities Between October 1, 2010 and September 30th 2011, MJAP plans to procure and distribute ARVs for a total of 16222 patients distributed at 8 treatment centers; Mulago ISS clinic, Mulago CDC clinic, Mulago TB/HIV clinic, Mbarara ISS clinic, Mbarara Municipal council clinic, Bwizibwera HC4, Mbarara TB-HIV clinic and Butabika hospital ISS clinic. The distribution of the treatment slots shall be based on capacity (human and infrastructure), demand for ART and available space. MJAP will strengthen the uptake of children onto ART in Mbarara Municipal council clinic and Bwizibwera Health centre and linkage of children identified in the other clinics to Baylor Uganda. The program expects to have at least 350 children on ART at these sites with continued support from the Clinton Foundation HIV/AIDS initiative which will provide both the 1st and 2nd line ARVs. We shall continue to give priority to initiate antiretroviral therapy to pregnant women, children and all eligible clients; CD4<250. We estimate that over 200 health care workers and 200 women of sexual and gender based violence shall be provided with post-exposure prophylaxis. 3. Integration with other health activities MJAP will continue to procure FDA approved generic ARV medicines at competitive prices through

Medical Access Uganda limited (MAUL), a UNAIDS drugs access initiative program locally based in Uganda. In addition to the switch to generic medicines, the program will continue to promote the increased use of fixed-dose combination medicines in order to improve patients' adherence to therapy. CHAI will provide the paediatric formulations based on latest listing with preference being given to fixed- dose formulations and dispersible tablets and capsules. However the program will pay for the handling charges for the CHAI donations. MJAP will procure all the adult 1st line ARV regimen formulations and obtain 2nd line from CHAI for delivery period of up to September 30th 2011. The single medicine formulations to be procured by the program include Nevirapine and Efavirenz. The fixed-dose formulations to be procured include Tenofovir/Lamivudine/Efavirenz, Tenofovir/Lamivudine, Tenofovir/Emtricitabine, Zidovudine/Lamivudine, Zidovudine/Lamivudine/Nevirapine, Stavudine/Lamivudine and Stavudine/Lamivudine/Nevirapine. Health systems strengthening and HRH Procured ARV medicines shall be received and inspected by a pharmacist of the program together with the procurement officer and stores assistant. A goods received note shall be filled on receipt as well as other inventory management records. The ARV medicines shall all be centrally procured and distributed through the pull logistics system. Stock-tacking or physical counts shall be done at monthly intervals for all centers and quarterly for the central stores n Kampala and routine reports made. MJAP will continue to further rationalise the supply management system with key approaches such as reducing buffer stock levels while improving physical distribution, strengthening of reverse logistics, shifting to fixed-dose combinations where applicable, strengthening effective medicines selection and moving to just-in-time delivery. In order to improve service delivery and build capacity MJAP will use both task-shifting and pre-service training to build capacity for HIV/AIDS management and treatment at the university teaching hospitals. MJAP will negotiate with other partners with similar mandate to conduct training of newly qualified professionals from the medical schools of Makerere and Mbarara universities, and the Mulago paramedical schools. In addition, MJAP will continue to strengthen local capacity of the health facilities to take over the provision of ART by conducting refresher trainings, support supervision, mentorship and continuing medical education on key areas of supply management. MJAP will continue to strengthen the current logistics and supply-chain management system working with facilities to strengthen reporting systems and with both MoH and the facilities to respectively avail and pull supplies from NMS. We shall continue to stock ARV formulations and distribute regimens as recommended by the Uganda national standard treatment guidelines.

1. Target populations and coverage of target population or geographic area The target population will be patients attending to; Mulago, Butabika and Mbarara Hospitals, and the satellite clinics of Mbarara municipality and Bwizibwera Health centre 2. Service delivery and other activities MJAP pioneered implementation of integrated TB/HIV services in Uganda, in 2005. Since that time an estimated 11,700 TB/HIV patients have been served by the program in Mulago, Mbarara and 5 regional referral hospitals, through the various TB/HIV clinics that were established in these hospitals. Patients co- infected with TB and HIV receive a "one stop service" for the two medical conditions in these clinics. MJAP collaborated with the National AIDS Control Programme (NACP) and the National TB program (NTLP) of the Ministry of Health (MoH), during the scale up of these services. The program actively contributed to the development of the existing MoH TB/HIV policies and guidelines such as the i) TB/HIV co-management training manuals, ii) TB infection control guidelines and iii) TB/HIV data collection tools and support supervision checklists

MJAP will support the host health facilities to develop and implement health plans which are aligned with the national framework for TB/HIV collaborative activities. Priority areas in the plan will include; i) provision of TB/HIV co-treatment, ii)TB infection control, iii) intensified TB case finding, iv)Training of health staff in TB/HIV co-management, v)MDR surveillance, vi) External quality assurance for TB microscopy, and vii) strengthening of recording and reporting of TB/HIV services using MoH tools. MJAP will continue to support the laboratory infrastructure in the host institutions to ensure that the relevant laboratory and diagnostic services for TB/HIV services are provided. 3. Integration with other health activities

MJAP will support the NTLP to improve weak aspects of CBDOTS by providing support to structures such as the DTLS and DLFPs. The specific aspects to improve will include performance smear microscopy for TB treatment monitoring and recording and reporting of the TB treatment outcomes. The program will collaborate with the NTRL, CPHL and other exiting laboratory partners to improve diagnosis of TB among HIV+ smear negative patients in order to ensure prompt TB/ART co-treatment. REDACTED 4. Health Systems Strengthening and Human Resources for Health Pre- and in-service training provided, other capacity building activities, number of healthcare workers supported MJAP support will include: recruitment and deployment of required staff in line with the MOH staffing norms and salary rates, we will negotiate with the host facilities to subsequently absorb these staff onto their payroll; support to volunteers who will not fit in the previous category. Training/ re-training with subsequent technical support supervision will be done according to needs identified.