1. Overall goals and objectives AMREF will scale up comprehensive, evidence-based HIV-prevention interventions for populations in 8 high-prevalence districts in Central and Northern Uganda, with special focus on most-at-risk populations (commercial sex workers, fishing communities, police and the military), over a five-year period.

Working with district health authorities, the Rakai Health Sciences Program (RHSP), the CDC, and other project partners, AMREF will implement several evidence-based, best practice HIV prevention activities, including: supporting training of district health workers in safe male circumcision (SMC); applying the AMREF Tanzanian Angaza Model of community mobilization and taking services close to communities to scale up HIV Counseling and Testing (HCT, including for couples); establishing Sexuality Knowledge for Youth (SKY) Clubs to promote HIV prevention among in- and out-of-school youth; and forming support groups for people living with HIV (PLHIV), HIV sero-discordant couples, and HIV-positive pregnant women and new mothers.

Targeted ABC behavior change strategies, HCT, and SMC will be promoted using community outreaches, trained peer educators, billboards, posters, leaflets and radio messages in local languages, condom distribution, and linking people at risk to sexually transmitted infection (STI) services. HIV prevention interventions will be linked to other health services to the greatest extent possible. District health systems will be strengthened by addressing: human resources; health facility equipment; training health workers and managers; providing support with annual and financial planning; and strengthening health management information systems (HMIS) by providing training in monitoring and evaluation (M&E).

The project will contribute to attaining the Uganda PEPFAR goal of preventing 165,000 new infections by 2015. The project will also contribute to attaining the PEPFAR HIV treatment and care goals by linking HIV-positive individuals through referrals to treatment and care services, and providing group support to promote positive living.

2. Target populations and geographic coverage The project will target all district residents, including MARPs, in 8 districts in the Central and Northern Regions of Uganda.

Central Districts: Kalangala, Wakiso, Mubende, Mityana, Luwero, Nakaseke, Nakasongola Northern Districts: Apac

3. Enhancing cost effectiveness and sustainability A rapid appraisal will be carried out in each project district prior to implementing interventions. Appraisals will document existing HIV prevention initiatives in the district; other HIV-related services; and agencies (including CBOs, FBOs, NGOs, and PNFPs) already providing HIV prevention interventions and services. Appraisals will be used to identify partners, opportunities for integration with existing programs, and to prioritize interventions. In districts where AMREF already has a presence (Luwero, Nakasongola) the project team will draw on existing partnerships and knowledge of the district to encourage sustainability of interventions. The project team will actively look for opportunities to integrate HIV prevention activities with other HIV prevention, treatment, care and support interventions, and with programs such as PMTCT, MCH, and SRH. Existing district structures will be accessed to ensure ownership of interventions, and a detailed project implementation plan will be drawn up in partnership with each district. Project staff will work closely with CDC, district health structures, and other implementation partners in each district to support cost-sharing of activities and collectively build capacity of local stakeholders to own and manage interventions.

4. Health Systems Strengthening

The project team will work closely with government structures from the national level to the village level to provide sustainable systems strengthening of district health services. District health systems will be strengthened by addressing: (i) Human Resources: Providing health workers with training in SMC, and HTC (ii) Infrastructure: Providing training in laboratory tests to ensure capacity for accurate HIV diagnosis; providing autoclaves, surgical instruments, and surgical kits for SMC, and extra HIV test kits if needed; (iii) Training: Providing training in management skills to members of District Health Management Committees (DHMCs) and Health Unit Management Committees (HUMCs) and project updates by means of 5-day workshops twice a year in each district; (iv) Financial Planning: Working with DHMCs and HUMCs to ensure they take over costs of project HIV prevention initiatives in a staged manner over the course of the project, and assisting them to develop budgets that incorporate these costs into strategic and annual plans; (v) Monitoring and Evaluation (M&E): Project M&E Officers will provide M&E training in order to strengthen the District Health Management Information Systems (HMIS) and Community-Based Health Management Information Systems (CB-HMIS).

5. Cross-Cutting Budget Attributions a. Human Resources for Health The project will support in-service training for counselors, laboratory assistants, Village Health Teams, peer educators, teachers, doctors, nurses, clinical officers, district staff, and selected MARPS across all relevant technical areas for their identified activities. ($174,980 in Year One)

b. Construction/Renovation REDACTED

c1. Food and Nutrition: Policy, Tools, and Service Delivery The project does not have this component.

c2. Food and Nutrition: Commodities The project does not have this component.

d. Economic Strengthening The project will support Sexuality Knowledge for Youth (SKY) Clubs with income-generating activities and provide commercial sex workers targeted under the project with alternative income-generating projects to encourage them to leave the profession. ($48,600 in Year One)

e. Education

Education will be promoted through working with district officials, health workers, peer educators, and community members to carry out HIV prevention campaigns and behavior change interventions. ($231,574 in Year One)

f. Water The project does not have this component.

g. Gender: Reducing Violence and Coercion Prevention of gender-based violence will be supported by training and peer-led outreaches in communities and among targeted MARPS populations to conduct action-oriented community education on issues of gender power relations in regard to HIV prevention and transmission. The cost for this line is incorporated under Education.

6. Key issues: a. Health-Related Wraparounds o Child Survival Activities will be supported through development of Sexuality Knowledge for Youth (SKY) Clubs for youth in and out of school, with a special focus on OVCs. SKY Clubs will conduct outreach and education activities in their communities to promote child survival and prevention of HIV transmission to vulnerable youth. o Family Planning will be integrated with existing SRH and MCH activities in target districts and prevention of HIV infection activities among positives, discordant couples, and MARPS during community HCT outreaches and at health units offering antenatal care and PMTCT programs for mothers. o Prevention of malaria in pregnancy will be integrated with existing MCH and PMTCT programs in target districts through routine delivery of goal-oriented antenatal care services. o Safe Motherhood will be integrated in PMTCT through routine delivery of goal oriented antenatal care; linkages with existing SRH and MCH campaigns in target districts will also support Safe Motherhood activities. o The project will facilitate integrated HCT outreaches in communities under Uganda's collaborative management of TB/HIV policy. Trainings for health unit staff will also focus on joint testing and treatment for TB and HIV, and funding for M&E activities will include data collection and analysis for TB/HIV services.

b. Gender Gender issues will be addressed through community mobilization, education, and outreach activities to promote positive behaviors such as: gender equity; couple dialogue; partner counseling and testing and disclosure, and support groups for people living with HIV (PLHIV), HIV sero-discordant couples, and HIV- positive pregnant women and new mothers. SKY Clubs will also promote awareness of gender issues

through community level outreaches. Female CSWs will receive income-generating support to reduce their vulnerability and provide alternatives to the CSW profession.

c. End-of-Program Evaluation An independent end-of-program evaluation will be conducted in year five to assess project achievements against set targets and objectives.

d. Mobile Population Fishing communities, migrant workers, commercial sex workers, boda boda cyclists, and long distance truck drivers will be targeted with HIV prevention, education, and testing activities and outreaches using a trainer-of-trainer and peer educator model for delivering services.

e. Military Population The project will work with the Ministry of Defense, the Ministry of Internal Affairs, Police, and army barracks commanders. Peer educators (members of the service) will be used to gain access to the target population (given that uniformed forces sometimes work in environments that are out of bounds to civilians) for HIV prevention, education, and testing activities and outreaches.

f. Workplace Programs Fishing communities, migrant workers, commercial sex workers, boda boda cyclists, and long distance truck drivers will be targeted with HIV prevention, education, and testing activities and outreaches using a trainer-of-trainer and peer educator model for delivering services in their areas of work. Health unit staff benefiting from training will also receive education on HIV in the workplace during their workshops.

1. Target populations and coverage of target population or geographic area All District Health Teams, health facility staff, and community level health workers in the 8 target districts will benefit from health systems strengthening activities.

2. Description of service delivery or other activity carried out The first activity in each district will be to make contact with the District Health Officer (DHO) and District Health Management Committee (DHMC) to describe the project and initiate a partnership. The next activity will be a rapid appraisal/needs assessment to document service availability, location of health facilities, physical health facility infrastructure, staffing levels, and staff capacity development needs. The appraisal will also identify organizations already providing HIV-related services in each district, and will identify locales where MARPs congregate. A detailed project implementation plan will be drawn up for each district. Project staff will work closely with CDC, district health structures, and other implementation partners in each district.

The project team will work closely with government structures from the national level to the village level to provide sustainable systems strengthening of district health services. District health systems will be strengthened by addressing:

(vi) Human Resources: Motivating with the Ministry of Public Service to take over HIV counselor supervisor and HIV counselor posts created by the project; providing health workers with training in SMC, HCT, and laboratory skills; (vii) Infrastructure: Providing training in laboratory tests to ensure capacity for accurate HIV diagnosis; providing autoclaves, surgical instruments, and surgical kits for SMC, and extra HIV test kits if needed; (viii) Training: Providing training in management skills to members of District Health Management Committees (DHMCs) and Health Unit Management Committees (HUMCs) and project updates by means of 5-day workshops twice a year in each district;

(ix) Financial Planning: Working with DHMCs and HUMCs to ensure they take over costs of project HIV prevention initiatives in a staged manner over the course of the project, and assisting them to develop budgets that incorporate these costs into strategic and annual plans; (x) Monitoring and Evaluation (M&E): Project M&E Officers will provide M&E training in order to strengthen the District Health Management Information Systems (HMIS) and Community-Based Health Management Information Systems (CB-HMIS).

3. Integration with other health activities Activities will be linked to existing health system strengthening activities currently undertaken at district, health sub-district, and health facility level by AMREF and other development partners.

4. Relation to the national program All health system strengthening activities will be aligned to national priorities to ensure systems are strengthened from district to community level to improve health outcomes for target populations.

5. Health Systems Strengthening and Human Resources for Health Capacity-building for critical district staff, skilled health workers, and community level health workers will be accomplished under training and review meetings implemented by the project, as indicated above.

1. Target populations and coverage of target population or geographic area All males of reproductive age in the 8 districts of focus will benefit from safe male circumcision (SMC) activities, with a special focus on MARPS (mobile populations, fishermen, military personnel, boda boda cyclists, and long distance truck drivers) and vulnerable populations (in and out-of-school youth and OVCs). The project will target 4,000 males in year one for circumcision as part of the minimum package of SMC for HIV prevention.

2. Description of service delivery or other activity carried out AMREF will work in partnership with Rakai Health Science Program (RHSP) to implement a phased roll- out of SMC in project districts. Using a training of trainer (TOT) approach, clinicians (doctors and clinical officers) from the project districts will be trained in SMC. This initial group will train additional clinicians in SMC on return to their districts. Nurses will be trained on sterilization procedures and proper waste disposal so that they are able to support clinicians during SMC operations. Outreaches to promote SMC will target specific groups most at risk such as fishing communities, uniformed services, and male youth.

Implementation will be supported through community mobilization, working with community leaders, individual and small-group sensitization by VHTs in villages and using peer education in institutional settings and among the fishing communities. SMC will be promoted as part of a comprehensive HIV prevention package (not a stand-alone intervention) with education through the mass media (radio and billboards, and IEC pamphlets) campaigns, community outreach, and providing information during pre- and post-test counseling as part of HCT.

The project team will implement SMC by partnering with RHSP to provide training to teams of clinicians and nurses from District Hospitals and HC IV facilities. The safety of circumcisions provided by district SMC teams will be monitored. Any adverse events (AEs) or Serious Adverse Events (SAEs) will be reported promptly to the AMREF SMC Technical Advisor to ensure that high levels of safety are maintained.

In accordance with national policy and WHO/UNAIDS guidelines, SMC will be promoted as part of an integrated HIV prevention package and not as a stand-alone intervention. SMC will be supported through proper community entry, working with local leaders, individual and small-group sensitization by VHTs in rural villages and peer educators in institutional settings and among the fishing communities. These will be coupled with education through the mass media (radio and billboards), IEC (pamphlets with relevant information), community campaigns.

Youth and men will be strongly encouraged to have HCT prior to undergoing circumcision and will be given risk-reduction counseling and advice about post-surgical precautions (watching for signs of infection, an initial period of abstinence, and the need for continuing use of condoms after circumcision) as a standard accompaniment to the circumcision procedure. The parents of children under the age of 14 years will be asked to assent to the procedure and will be given an explanation about the reason for it; the child will receive a simple age-appropriate explanation.

Initially, priority will be given to providing SMC to groups most at risk such as: fishing communities, uniformed services, and male students in schools, colleges and universities. As capacity to perform circumcision increases in a district, linkages will be formed with obstetric and infant health services to expand circumcision services and to encourage the circumcision of baby boys in the first month after birth.

3. Integration with other health activities Activities will be linked to existing HCT, family planning, SRH, STI, school-based ABC programs (PIACSY), and ART. The project team will actively look for opportunities to integrate HIV prevention activities with other HIV prevention, treatment, care and support interventions, and with programs such

as PMTCT, MCH, and SRH.

4. Relation to the national program All activities, key behavior change messages, IEC materials, and training workshops will be aligned to national policy, and guidelines, and strategy documents produced by the MOH and the Uganda AIDS Commission. Interventions will be carried out at several different levels, including mass media behavioral change communication (BCC), community outreaches, small groups, couple, and individual level. Interventions at different levels will be harmonized in order to convey a consistent message across all levels of intervention in accordance with government guidelines. The government's new SMC policy will be rolled out at health units in target districts to ensure application of the policy against all health unit SMC activities under the project.

5. Health Systems Strengthening and Human Resources for Health In-service training on SMC service delivery against national guidelines will be provided for nurses and doctors (number TBD). Training for 8 District Health Teams, and CSW, fishermen and military personnel TOTs (numbers TBD) will be conducted to support mobilization of men in target districts for SMC. Further capacity-building on M&E, HMIS, and operationalization of government policies on SMC will be conducted with 8 District Health Teams

1. Target populations and coverage of target population or geographic area All populations in the 8 districts of focus (Mubende, Mityana, Wakiso, Luwero, Nakaseke, Nakasongola, Kalangala, and Apac with a population of 6,823,100 people) will benefit from AB education and outreach activities to prevent sexual transmission of HIV, with a special focus on MARPS (CSWs, mobile populations, fishing communities, military personnel, boda boda cyclists, and long distance truck drivers) and vulnerable populations (in and out-of-school youth and OVCs).

2. Description of service delivery or other activity carried out HIV education and awareness-raising outreaches regarding prevention of transmission using the AB approach will be held in communities, homes, health units, and ANC clinics in target districts. Services provided include HCT, HIV education, risk-reduction counseling, addressing vulnerability, disclosure counseling, post-test clubs, peer education, and SKY Clubs. Peer Educators will be used for HIV prevention among youth, HIV-positive new mothers, CSWs, and uniformed services. These peers will be trained in behavior change communication (BCC) to promote AB strategies, and to advocate for HCT

(knowing one's HIV status) and SMC. Former CSWs will be trained to promote HIV prevention among women still active in the sex trade. HIV-positive persons, including HIV-positive mothers, will be trained to facilitate support groups. Post-test clubs for HIV-positive individuals will focus on disclosure, promoting safer sex (correct and consistent condom use), developing skills for coping with stigma and discrimination, and accessing and adhering to treatment. Groups for discordant couples and concordant HIV-positive couples will include a focus on sexual relationships and SRH issues. Groups will be established for HIV-positive mothers and pregnant women to strengthen PMTCT programs.

3. Integration with other health activities Activities focusing on sexual prevention of HIV through the AB approach will be linked to existing family planning, SRH, STI, school-based ABC programs (PIACSY), PMTCT, ANC, ART, and post-natal services. The project team will actively look for opportunities to integrate HIV prevention activities with other HIV prevention, treatment, care and support interventions, and with programs such as PMTCT, MCH, and SRH. HCT will be promoted in family planning clinics so that sexually-active women of child- bearing age will know their HIV status before becoming pregnant. At antenatal clinics, partner testing will be encouraged in addition to the HIV testing of pregnant women as part of PMTCT programs. Peer-led support groups, linked to PMTCT services, will be established for HIV positive pregnant women and new mothers.

4. Relation to the national program All activities, key behavior change messages, IEC materials, and training workshops will be aligned to national policy, guideline, and strategy documents produced by the MOH and the Uganda AIDS Commission. Interventions will be carried out at several different levels, including mass media behavioral change communication (BCC), community outreaches, small groups, couple, and individual level. Interventions at different levels will be harmonized to in order to convey a consistent message across all levels of intervention in accordance with government guidelines.

5. Health Systems Strengthening and Human Resources for Health In-service training on HIV prevention, education, and service delivery for 40 counselors, 26 laboratory assistants, 1,000 Village Health Teams, peer educators (number TBD), teachers (number TBD), SKY Clubs (number TBD), nurses and doctors (number TBD), 8 District Health Teams, and CSW, fishermen and military personnel TOTs (numbers TBD) will be conducted. Further capacity-building on M&E, public health planning, HMIS, and operationalisation of government policies on HIV will be conducted with 15 District Health Teams.

1. Target populations and coverage of target population or geographic area All populations in the 8 districts of focus (6,823,100 people) will benefit from education and outreach activities to prevent sexual transmission of HIV, with a special focus on MARPS (CSWs, mobile populations, fishing communities, military personnel, boda boda cyclists, and long distance truck drivers) and vulnerable populations (in and out-of-school youth and OVCs).

2. Description of service delivery or other activity carried out Activities include risk-reduction counseling, disclosure counseling, post-test clubs, peer education, addressing vulnerability, and SKY Clubs. Project interventions will combine promotion of Abstinence, Be faithful, use Condoms (ABC) with promoting knowledge of one's own HIV status (+) and one's partner's HIV status (++). The emphasis of ABC++ messages will be tailored to the target population. Among married and cohabiting couples the emphasis will be on being faithful and on knowing both one's own HIV status and ones partner's HIV status. Among MARPs there will be greater emphasis on condom distribution and promoting correct and consistent condom use. Among HIV-positive individuals, the emphasis will be on disclosure, encouraging partners to be tested, and using condoms. Among youth, age-appropriate ABC+ strategies will be used.

3. Integration with other health activities Activities will be linked to existing HCT, family planning, SRH, STI, school-based ABC programs (PIACSY), PMTCT, ANC, ART, and post-natal services. The project team will actively look for opportunities to integrate HIV prevention activities with other HIV prevention, treatment, care and support interventions, and with programs such as PMTCT, MCH, and SRH. HCT will be promoted in family planning clinics so that sexually-active women of child-bearing age will know their HIV status before becoming pregnant. At antenatal clinics, partner testing will be encouraged in addition to the HIV testing of pregnant women as part of PMTCT programs. Peer-led support groups, linked to PMTCT services, will be established for HIV-positive pregnant women and new mothers.

4. Relation to the national program All activities, key behavior change messages, IEC materials, and training workshops will be aligned to national policy, guideline, and strategy documents produced by the MOH and the Uganda AIDS Commission. Interventions will be carried out at several different levels, including mass media behavioral change communication (BCC), community outreaches, small groups, couple, and individual level. Interventions at different levels will be harmonized to in order to convey a consistent message across all levels of intervention in accordance with government guidelines.

5. Health Systems Strengthening and Human Resources for Health

In-service training on preventing sexual transmission of HIV and HIV service delivery for 40 counselors, 26 laboratory assistants, 1,000 Village Health Teams, peer educators (number TBD), teachers (number TBD), SKY Clubs (number TBD), nurses and doctors (number TBD), 8 District Health Teams, and CSW, fishermen and military personnel TOTs (numbers TBD) will be conducted.