The Realizing Expanded Access to Counseling and Testing for HIV in Uganda (REACH-U) project is a USAID - funded five-year cooperative agreement that was awarded to Mulago-Mbarara Teaching Hospitals' Joint AIDS Program (MJAP) on August 20th, 2009. The goal of the program is to scale up access to and coverage and utilization of quality HIV counseling and testing (HCT) services to populations at risk of HIV infection. The project has four objectives: 1) To increase the number of people accessing and utilizing HIV counseling and testing (HCT) services in Uganda; 2) improve the quality and efficiency of HCT services in Uganda by strengthening the appropriate support systems; 3) strengthen the referral network between the community and health facilities to allow expansion of HCT services and HCT linkage to HIV prevention, care, treatment and support; and 4) increase the demand for HCT services. The project is implemented in 22 districts namely, Arua, Nebbi, Maracha, Koboko, Moyo, Yumbe, Adjumani, Mbale, Soroti, Amuria, Jinja, Mukono, Wakiso, Kampala, Mbarara, Lyantonde, Rakai, Abim, Kotido, Moroto, Kaabong, Nakapiriprit, Amudat, Napak, Dokolo, Buikwe, Buvuma, and Serere which were curved out of some of the original districts cited above.

The project's strategic approaches to scale up HCT services include: a) Enhancing the capacity of the districts health services delivery system to manage HCT services; b) developing partnerships to facilitate capacity building and provision of HCT services to the private sector and community-based organizations; c) expanding a mix of approaches to increase access to HCT including VCT (facility-based and VCT outreaches), RCT for health facilities, and HBHCT (using index HIV infected individuals to test families and their surrounding communities); and d) enhancing human resource capacity for HCT service delivery through multiple approaches i.e. task shifting approaches to PLHIV, volunteers and other lay providers to alleviate the staffing constraints and creatively bridge human resource gaps.

REACH-U Project works with and through the existing structures at district, Sub -county and community levels to improve access to, coverage and utilization of HCT services at government HC IIIs, IIs and respective communities and, in the private sector facilities. The project will continue to use the same structures to increase demand and awareness to address the barriers to HIV testing and promote HIV prevention to reduce new infections. Through collaborations and partnerships with existing institutions at national, district, sub-county and community levels, REACH-U will further strengthen referral systems to ensure effective linkage of persons tested to prevention, care, treatment and support services as appropriate. Program year one focused on the start-up activities, GIS mapping of existing community structures, provision of community HTC services in 4 sub-counties and training of PITC service providers in 250 health units. FY 2011 activities will focus on five priority areas: 1) demand creation for HCT services by addressing the barriers to testing and raising awareness in 70% of the sub counties in the REACH-U districts; 2) provide HCT services to 780,000 individuals including couples; 3) provide a package of HIV prevention services to targeted populations including MARPs; 4) strengthen the national and district systems with a focus at the sub county level to improve the quality and efficiency of HCT services in all 22 districts; and 5) reinforce referrals for effective linkages for persons tested to prevention, care, support and treatment services.

REACH-U will strengthen capacity of HC IIIs to provide a package of care services that will include

provision of Cotrimoxazole, TB screening and treatment, provision of FP services, malaria diagnosis and treatment, syphilis screening and treatment, counseling on positive living and continuous clinical evaluation and HIV testing among TB patients. Other services will include; Condom promotion for HIV positive and discordant couples, partner notification, testing and disclosure will be encouraged. HIV positive clients will be encouraged to join posttest clubs for support. Individuals who test negative will be counseled about prevention, offered and/or linked to other service providers for safe medical male circumcision, enrollment into posttest clubs and encouraged to blood donation. The project will put in place mechanisms to have blood samples of children below 18 months transported and tested at regional hospitals and other centres with PCR-DNA machines and ensure that results are rapidly reported to the sites so that appropriate care can be provided. The aim is to quickly initiate referral/linkage of exposed/ infected infant to care and treatment facilities.

The REACH-U project will offer HCT services to 780,000 individuals including couples at both community and health facility levels in the 22 target districts. REACH-U will scale up PITC and CITC from 300 to 1000 health facilities out of 1700 health facilities (private and public HC IIIs and IIs) in the 22 districts. access to HCT services will be expanded through , mass campaigns, community camping, and home based CT (HBHCT) and targeted testing for MARPS and testing at national/district events e.g. World AIDS day celebrations, Philly Lutaaya Memorial celebrations, etc. The project will establish couple testing days will be introduced at designated HC IIIs and HCT couple counseling and testing campaigns. A total of 30,000 MARPs, 4,000 pregnant women and couples (12% of the total HCT target) will be tested.

REACH-U project will continue to create demand for HCT using multi-pronged approaches that will be customized to the specific barriers to testing. Health worker related barriers such as lack of appropriate knowledge and skills and the negative attitudes will be addressed through trainings (on PITC, CITC, and couple and pediatric counseling), intensive on-job support, provision of HCT guidelines and protocols, mentoring and support supervision. The project will continue to explore task shifting approaches such as use of Integrated Community Counselors, VHTs and PLWHA to perform HCT non-technical tasks in order to address the issues of staff shortages.

National level support will entail technical support in the revision of the national HCT policy, printing and dissemination, coordination of the national CT 17 and the HCT quality assurance sub-committee. District level support will be cascaded to the sub county and community levels and will encompass hands-on

training for sub-county officials in strategic planning, monitoring, reporting, support supervision, logistics management, waste management as well as other technical aspects required to succeessfully scale up quality HCT. External and Internal Quality Assurance (QA) and Quality Control (QC) for HIV testing will be implemented in collaboration with the Central Public Health Laboratory and the Uganda Virus Research Institute.

Community barriers to testing such as stigma and discrimination, low male involvement, domestic violence, negative attitudes, misconceptions and myths, low HIV risk perception, lack of awareness of availability and benefits of HCT will also be addressed through advocacy with opinion leaders, peer to peer education, sharing of testimonies, community dialogues, mass media, and drama performances. Other mobilization approaches will be through the media across the following themes: know your HIV status; circumcision; partner testing and disclosure; male involvement in HCT; couple testing and counseling; HIV associated stigma; condom use; HIV prevention; safe medical male circumcision; and the drivers of the HIV epidemic.

HIV counseling and testing services will be provided to children and adolescents as an entry point for

identification of HIV positive children to access care and treatment services. The program will target

children aged 18months and above through multiple models i.e. PICT at health centre IIIs and IIs; and

through community outreaches. Newly diagnosed HIV positive children will be referred for care and

support services.

The Abstinence and Be faithful interventions that the REACH-U project will implement are closely related

to the HIV counseling and testing services that will be provided to youths in school and couples. Age-

specific behavioral change messages on abstinence, and be faithful will be given as appropriate with the

goal of promoting positive behavior change through sexual abstinence, delayed sexual debut, and

addressing gender and its effect on HIV transmission. Disclosure, partner testing will be encouraged so

as to promote mutual knowledge of HIV status, mutual fidelity, STI prevention, and partner support.

REACH-U will provide targeted prevention services to discordant couples, CSWs and related persons,

truckers, fisher folks, persons with multiple concurrent partners, pregnant women, institutionalized

populations, PLWHAs and sexually active youth.

Newly diagnosed HIV positive individuals will receive counseling on partner testing and disclosure,

condom use, referral for PMTCT, TB assessment and referral. The project will build the capacity of HC

IIIs to be referral sites for the above services including family planning services, laboratory services, and

post-test clubs for peer support.

The prevention service package for HIV negative clients will include counseling and referral of HIV

negative males for safe medical male circumcision (MMC), age specific behavioral change messages

such as abstinence, be faithful, consistent and correct condom use will be given as appropriate.

Disclosure, partner testing will be encouraged.

Targeted HIV prevention interventions for this performance period include:

i. Discordant couples; BCC, STI screening and treatment, Couple clubs, Family planning, distribution and

promotion of consistent condom use

ii. Commercial sex workers(CSWs); HCT, BCC, distribution and promotion of consistent condom use, life

skills empowerment (for negotiation of safer sex), STI screening and treatment and family planning

iii. Mobile men with money(Truckers, cyclists, construction workers, business men); BCC, HCT,

distribution and promotion of consistent condom use, STI Screening and/or referral for treatment,

Specifically for this group we shall emphasize reduction in the number of partners during BCC message

dissemination.

iv. Persons with multiple concurrent sexual partners; HCT, distribution and promotion of consistent

condom use, STI Screening and/or referral for treatment, specifically for this group we shall also

emphasize reduction in the number of partners during BCC message dissemination.

v. Institutionalized populations (Army, Police, Prisons, returnees-Karamoja region); BCC, STI screening

and treatment, HCT, community mobilization, empowerment education on reduction of harmful practices

that increase the risk of HIV infection such as anal sex, and MSM

vi. Sexually active youth never married (15-24); Appropriate A, B and C messages, BCC, HCT, STI

screening and treatment, life skills empowerment, promotion of awareness on the relationship between

alcohol and drug use and increased HIV risk behaviors especially in urban areas of Kampala, and in west

Nile region where drug abuse is common.

vii. Pregnant women; HCT, appropriate BCC messages, STI screening and treatment, distribution and

promotion of appropriate condom use, referral for PMTCT

viii. Persons Living With HIV/AIDS (PLWHA); BCC, with the aim of reducing further transmission, TB

screening and treatment, distribution and promotion of consistent condom use community empowerment

to support PHLWA, including empowering religious, VHTs and civic leaders and other opinion leaders in

the communities through training with appropriate knowledge and skills to support PLWHA, other OIs

and referral for PMTCT and other PWP interventions

ix. Safe male medical circumcision: REACH-U project will pilot safe medical male circumcision in three

regions of West Nile, Western and Eastern at static and out reaches through mobile surgical camps.