Mildmay Uganda (MUg) supports the implementation of comprehensive HIV/AIDS services in the central region districts of Uganda. The overall goal of this project is to support the Government of Uganda provide and scale-up comprehensive HIV/AIDS care, treatment and prevention services through the integration and strengthening of the District Health Service (DHS) between 2010 and 2015. Objectives: To increase access to family-centered, comprehensive HIV and AIDS prevention, care and treatment, build human resource capacity for sustainable delivery of HIV and AIDS services and strengthen DHS planning, administration, M&E, logistics and supply chain management mechanisms. In FY 2011, MUg maintained 43,588 clients in care (59% on ART) and offered technical support to 183 HCs in 18 districts.

In FY 2012, MUg will continue to provide technical support in 16 districts in Central Region. The program plans to reach 167,194 clients with HTC; maintain 77,941 clients in care; 44,163 on ART and enroll 20,832 on HAART. In addition 77,941 clients on CTX prophylaxis; 70,156 screened for TB and reach 12,713 OVC and their families. Mug will support scale up of Option B+ to pregnant mothers and contribute to elimination of MTCT.

Programming will center on district priorities, national policies, sustainability and exit planning by districts, effective utilization of information for M&E, bi-annual project evaluation and involvement of MoH. MUg will build capacity for district administrative and health workers for HIV service delivery, leadership and governance, HMIS, HRM, M&E, logistics, finance, and laboratory and scale up Early Infant Diagnosis (EID).

PEPFAR will focus on supporting Government of Uganda (GOU) to expand access to HIV care and support with the goal to achieve universal access of 80% in care by 2015. Mildmay Uganda (MUg) program will support the provision of care and support services to 77,951 HIV positive individuals as a contribution to the overall PEPFAR target of 812,989. This target was derived using burden tables based on district HIV prevalence and treatment need. Specific attention will be given to key populations such as truck drivers, fishermen, commercial sex workers and men that have sex with men. The Continuum of Response (CoR) model was also applied to ensure improved referrals and linkages. MUg will implement approaches to promote an effective CoR model and monitor key indicators along the continuum. MUg will work in 16 districts in Central region of Uganda: Wakiso, Mpigi, Gomba, Butambala Masaka, Kalungu, Bukomansimbi, Lwengo, Mityana, Mubende, Sembabule, Lyantonde, Luweero, Nakaseke, Nakasongola, and Buikwe.

MUg will provide care and support services in line with national and PEPFAR guidance including: strengthen positive health dignity and prevention services; strengthen linkages and referrals using linkage facilitators; implement quality improvement for adherence and retention; pain and symptom management; and provide support to targeted community outreaches in high prevalence hard to reach and underserved areas.

Focus will be placed on increasing access to CD4 assessment among pre-ART clients for ART initiation in line with MoH guidance. This has been a major bottleneck to treatment scale up. Working with the Central Public Health Laboratory and other stakeholders, CD4 coverage will be improved from the current 60% to 100% over the next 12 months. MUg will support the sample referral network in line with this national CD4 expansion plan; and will monitor and report clients access to CD4 in quarterly reports. In addition, they will regularly keep track and report on client waiting lists.

MUg will liaise with PACE and UHMG for provision and distribution of basic care kits to clients. Additionally, liaise with National Medical Stores, Joint Medical Stores, Supply Chain Management Systems and Medical Access Uganda Limited for other HIV commodities (cotrimoxazole, lab reagents). MUg will build the capacity of facility staff to accurately and timely report, forecast, quantify and order commodities. MUg will work with USG partners such as PIN, SPRING, HEALTHQual, ASSIST and Hospice Africa Uganda in their related technical areas to support integration with other health and nutritional services. Collaboration with other key stakeholders at all levels for provision of required wrap around services including family planning, will occur.

The program will be aligned to the National Strategic Plan for HIV/AIDS (2011/12-2014/15); support and strengthen the national M&E systems; and work within district health plans. Mug will work under the guidance of MoH/ACP and the Quality Assurance Department for trainings, mentorship and support supervision.

In FY 2012 COP it is proposed to support recruitment of critical health workers, including laboratory cadres, in 87 districts for both public and private not for profit facilities based on the new scale up targets and current staffing level, in the particular district. A total of 195 health workers shall be recruited by MUg in 14 districts.

Mildmay Uganda (MUg) is currently offering technical assistance to develop the capacity of the District Health Services in 16 districts of the Central Region of Uganda to effectively deliver sustainable health services and scale up access to quality HIV and AIDS care and support, including OVC. The MUg OVC program aims to improve the quality of life of OVC and their households through provision of a comprehensive care package and its priority areas include the improvement of the livelihoods of the OVC, the development and strengthening of partnerships, linkages and referral systems between OVC service providers, and OVC service provider capacity. Its primary target population is the HIV positive child, their care giver, siblings and other OVC categories in the community as identified by the VHT and local CBOs. MUg currently provides HIV care to 3754 children (17% of patients in care) aged 0-17 years.

The program is in line with the NSPPI and it will train the DHS in OVC service provision, enhance the formation of circle of service providers in each sub county, and provide sub grants to districts and CBOs to enable scale up OVC services. Human resource DHT capacity for sustainable OVC service delivery and its M&E using the MGLSD OVC tools will be built starting with the DOVCC team. To understand the effectiveness of some of its programs, Mug intends to carry out program evaluation for its OVC programs.

In FY 2012, using the Circle model, MUg will reach 12,713 OVC and their families with priority OVC CPAs beyond psychosocial and child protection support. It will support DHT to functionalize existing OVC structures, strengthen linkages and networks with other public and private sector OVC service providers and with other implementing partners to increase OVC services and to strengthen the existing and create referral systems/ linkages. MUg will continue to provide direct OVC service in priority CPAs. MUg will promote and support the integration of OVC programs into other health services which include PMTCT, mental health, Integrated Management of Acute Malnutrition, Adolescent Sexual and Reproductive Health and maternal and child health. Key challenges faced include low prioritization of the OVC service in all districts, limited resources, inadequate OVC structures in some districts, and inadequate functional linkages.

Mildmay Uganda (MUg) will focus on supporting the GOU to scale up TB/HIV integration; and specifically the PEPFAR goal to achieve TB screening of 90% (731,690) of HIV positive clients in care. In addition, initiate 24,390 HIV positive clients in care on TB treatment. This target was derived using burden tables based on district HIV prevalence and treatment need. The Continuum of Response (CoR) model was also applied to ensure improved referrals and linkages.

MUg will contribute to this target by screening 70,156 HIV positive clients for TB; and 2339 will be started on TB treatment. Mug will support 16 districts: Wakiso, Mpigi, Gomba, Butambala, Masaka, Kalungu, Bukomansimbi, Lwengo, Mityana, Mubende, Sembabule, Lyantonde, Luweero, Nakaseke, Nakasongola and Buikwe.MUg will improve Intensified Case Finding (ICF) and the use of the national ICF tool, as well as, improve diagnosis of TB among HIV positive smear negative clients, extra pulmonary TB and pediatric TB through the implementation of new innovative technologies GeneXpert and fluorescent microscopy. MUg will support MDR-TB surveillance through sputum sample transportation to GeneXpert hubs and receipt of results at facilities.

In FY 2013, MUg will ensure early initiation of all HIV positive TB patients on ART through the use of linkage facilitators and/or the provision of ART in TB clinics. MUg will increase focus on adherence and completion of TB treatment, including DOTS through use of proven low cost approaches. A TB infection control focal person will be supported to enforce infection control at facilities using interventions such as: cough hygiene, cough sheds and corners, fast tracking triage by cough monitors and ensure adequate natural ventilation.

The MOH/ACP and National TB and Leprosy Program (NTLP) will be supported to roll out provision of IPT, in line with the WHO recommendations.

In addition, MUg will work with USG partners such as PIN, SPRING, HEALTHQual, ASSIST and Hospice Africa Uganda in their related technical areas to support integration with other health and nutritional services. MUg will collaborate with other key stakeholders at all levels for provision of required wrap around services.

The program will be aligned to the National Strategic Plan for HIV/AIDS and National TB Strategic Plan (2011/12-2014/15), support and strengthen the national M&E systems and work within district health plans. MUg will work under the guidance of MoH/ACP, NTLP and Quality Assurance Department in trainings, TB/HIV mentorship and support supervision. Additionally, MUg will support facilities to participate in national external quality assurance for TB laboratory diagnosis.

Mildmay Uganda (MUg) will focus on supporting the GOU to further expand pediatric HIV care and OVC with the goal to achieve universal access to care by 2015. The MUg program will contribute 7,016 children in care to the overall PEPFAR target of 812,989 HIV positive individuals in care and support services of which 73,169 are children. MUg will support 16 districts: Wakiso, Mpigi, Gomba, Butambala, Masaka, Kalungu, Bukomansimbi, Lwengo, Mityana, Mubende, Sembabule, Lyantonde, Luweero, Nakaseke, Nakasongola and Buikwe.

MUg will provide comprehensive child friendly care and support services in line with national guidelines and PEPFAR guidance, improve adolescent services, strengthen linkages and referrals using linkage facilitators, implement quality improvement for adherence and retention and provide support to targeted community outreaches in high prevalence hard to reach and underserved areas. EID services and focal points at facilities will be scaled up to ensure follow up and active search of exposed children in facilities and communities to enable early enrolment into care. A focus will be on scaling up low cost approaches, such as use of care taker support groups so as to support retention in care. MUg will implement community mobilization and targeted activities such as Know Your Childs Status campaigns to identify more children. Focus will be placed on improved assessment of pre-ART children for ART eligibility to ensure timely initiation on treatment in line with MoH guidance.MUg will support retention of adolescents in care, as well as, ensure a smooth transition into adult life using expert peers and adolescent support groups. They will be provided with positive health dignity and prevention services including, sexual and reproductive health services, and psychosocial support and life skills training. Lessons learned from the planned national adolescent service assessment will be incorporated in activities.A key priority will be to establish strong referrals between OVC and care and support programs to ensure HIV positive children are linked to OVC services, and children provided with OVC services are screened for HIV and appropriately linked to care and support. MUg will also support the integration of HIV services in routine pediatric health services, including the National Child Health Days.MUg will liaise with PACE and UHMG for provision and distribution of basic care kits to clients. In addition, MUg will work with National Medical Stores, Joint Medical Stores, Supply Chain Management Systems and Medical Access Uganda Limited for ARVs and other HIV commodities including cotrimoxazole and lab reagents. MUg will build the capacity of facility staff to accurately report, forecast, quantify and order commodities in a timely manner.MUg will work with USG partners such as SCORE, SUNRISE, PIN, SPRING, HEALTHQual, ASSIST and Hospice Africa Uganda in their related technical areas to support integration with other health, nutrition and OVC services. MUg will collaborate with UNICEF and other key stakeholders at all levels for provision of required wrap around services.The program will be aligned to the National Strategic Plan for HIV/AID (2011/12-2014/15), support and strengthen the national M&E systems and work within district health plans. Mug will work under the guidance of MoH/ACP and Quality Assurance Department in pediatric trainings, national pediatric mentorship framework and supportive supervision.

In the year 2012/2013, Mildmay Uganda (MUg) will support establishment and maintenance of eight hubs in central Uganda. In order to improve infrastructure for quality laboratory services, MUg will carrying out major renovations in five hubs which include Ngoma Health Center (HC) IVs, Mityana hospital, Kasana HC IV, and Lyantonde hospital. Minor renovations will be focused on three hubs to include Nakasongola HC IV, Maddu HC IV and Sembabule HC IV. During the same period, there will be substantial focus on increasing access to CD4+ testing, hematology and clinical chemistry. Therefore MUg will work together with Central Public Health Laboratory (CPHL) to ensure that equipment for CD4+ testing, clinical chemistry and hematology are procured and operationalized. MUg will together with the Districts support the recruitment of seven laboratory technologists (three for Mityana hospital, three for Lyantonde hospital and one for Sembabule HC IV) and 13 laboratory technicians (two for Nakasongola HC IV, three for Ngoma HC IV, one for Mityana hospital, two for Kasana HC IV, one for Kasanda HC IV, two for Maddu HC IV, one for Lyantonde hospital and one for Sembabule HC IV).

Besides, MUg in the same period will be responsible for the procurement of the 55 motorbikes in support of the specimen referral and transport network. MUg will continue to support the National Early Infant Diagnosis (EID) program lab at CPHL to perform 65,000 DNA PCR tests per year. The MUg CoE will continue to provide EID testing back-up for the National EID testing laboratory at CPHL, therefore at any one time MUg CoE would be required to have a few EID test kits. MUg Uganda will support the national HMIS data management systems and other national guidelines and policies for laboratory systems. The program will also strengthen human resource capacity for sustainable laboratory services in the 16 districts through in-service training, placements, mentoring and coaching to enhance capacity for managing testing facilities.

In FY 2012/2013, Mildmay will support CPHL to coordinate and strengthen management of laboratory services in Uganda. Specific activities for CPHL will include development of guidelines and policies for quality assurance, infrastructure development, logistics and equipment management, training of trainers, improvement of laboratory information management and support supervision. Laboratory services will be strengthened using the WHO laboratory management towards accreditation (SLMTA) approach and implementation of quality management systems starting with the lab at MUg COE in the first year; consequently all health facilities supported by Mildmay should be accredited to the desired level by 2014.

Except for Ngoma HC IV the rest of the hubs will be supported to effectively carryout CD4, clinical chemistry and hematology tests. The program will also support roll out of GeneXpert in an effort to improve diagnosis of TB and most significantly MDR strains among the HIV infected patients, or the potential risk for MDR infection to HIV infected patients.

The goal of Mildmay Uganda (MUg) Program is to scale-up comprehensive HIV/AIDS care, treatment and prevention services through the integration and strengthening of the District Health Service (DHS) between 2010 and 2015 by increasing access to family centered, comprehensive HIV and AIDS prevention, care and treatment; Building human resource capacity for sustainable delivery of HIV and AIDS services and strengthen DHS planning, administration, M&E, logistics and supply chain management mechanisms. The program will contribute to the overall HIV Testing and Counseling (HTC) goals for PEPFAR by increasing access to and use of essential counseling and testing services for the most-at-risk populations and other key populations determined by existing data on HIV prevalence in Uganda. The program will engage in scaling up Provider-Initiated Testing and Counseling (PITC) and customized interventions relevant to key populations. This program will contribute to the continuum of response by linking clients to other health services including HIV Care and Treatment and social support services in the community with the aim of increasing demand and adherence for positive clients. Linkage facilitators will facilitate active linking of HIV positives to prevention, care and treatment programs. In addition, a tracking system will be incorporated in the HTC reporting tools to enable programs to document referrals and monitor progress.Program targets reflect the prioritization of districts with high HIV/AIDS prevalence and unmet need. Partner and district level capacities were also key factors in determining the allocation of program resources.

Project coverage is 16 districts, including: Buikwe, Nakaseke, Mityana, Mubende, Nakasongola, Luwero, Mpigi, Gomba, Butambala, Masaka, Kalungu, Bukomansimbi, Lwengo, Lyantonde, Sembabule, and Wakiso. The target populations in these districts will vary depending on need, however, the following groups have been identified for priority focus for MUg HTC intervention: commercial sex workers and their clients and partners, fishing communities, uniformed forces, long distance truck drivers, and men who have sex with men.

Currently, PEPFAR contributes to more than half of the Ministry of Healths HTC targets. Of the overall PEPFAR HTC target of 1,960,054, MUg will contribute 167,194 clients provided with HTC and received results. Recognizing the important role of GOU, HTC program activities shall be conducted in partnership with district local governments under stewardship of the MoH, recognizing that the scale-up of activities will require a medium-term commitment by the USG.The project will work in collaboration with Medical access Uganda, the National Medical Stores and joint medical stores to ensure availability of HTC test kits and other required reagents so as to eliminate stock outs.

Additionally, in order to maximize program success, this program will work towards evidence gathering for the purpose of standardizing service delivery, to ensure consistency with World Health Organizations HTC Quality Assurance/Quality Improvement guidelines.

In FY 2013, Mildmay Uganda (MUg) will facilitate the implementation of PMTCT Option B+ activities in 16 districts of Central region.

Key strategic pivots for PMTCT will focus on:1) Improving access and utilization of eMTCT services to more HIV infected pregnant women early during pregnancy. To achieve this MUg will ensure provision of universal HTC services during ANC, L/D, & community mobilization.2) Decentralizing Treatment & Option B+ through accreditation of all PMTCT sites at hospital; Health Center (HC) IV and HC III levels. Activities will include site assessments; identification of training needs; procurement of equipment; printing M&E tools, job aides & Option B+ guidelines, training of service providers and sample referral system for CD4+ and EID. The transition of Option B+ will be done in accordance with MOH guidance and a total of 212 sites will be accredited by end of FY 2013.3) MUg will support Option B+ service delivery using a Family Focused model within MNCH settings. Family support groups will be formed at all sites and will meet monthly to receive adherence, Infant and Young Child Feeding (IYCF), Family Planning (FP), couples counseling; EID and psycho-social support; supported disclosure and ARV refills. Village health teams will be utilized to enhance follow-up, referral, birth registration and adherence support. Male partners will receive condoms; STI screening & management; support for sero-discordant couples; treatment for those who are eligible and linkage to Voluntary Medical Male Circumcision (VMMC). At least 31,000 partners of pregnant women will be tested within the MNCH setting.4) Supporting intensive M&E to inform Option B+ roll out through cohort tracking of mother-baby pairs and electronic data reporting. Sites will document services to the mother-baby pairs at both facility & community level. Each beneficiary will have a standard appointment schedule that will be aligned to the follow-up plan of each site. Mobile phones will be used to remind clients of appointments; EID results and ARV adherence. Home visits will be conducted to trace clients lost to follow-up. All sites will submit daily reports on key program elements electronically to support effective monitoring and timely management.

5) Facilitating joint support supervision and mentorships at all PMTCT/ART sites involving MOH, AIDS Development Partners, districts, USG and implementing partner staff. Site level support will entail cohort reviews, adherence and retention rates, data management, knowledge gaps and availability of supplies, commodities and tools.6) Integrating voluntary and informed FP services with PMTCT services. MUg will ensure FP sessions are integrated within PMTCT trainings, counseling; education and information during ANC, labor and deliver and postnatal periods, as well as, for women in care and treatment; based on respect; womens choices and fulfillment of their reproductive health rights.MUg will support the recruitment of 195 critical health staff in 14 districts including midwives, Clinical officers, lab technicians and support eight Lab hubs to facilitate EID sample collection and transportation. Mug will support linkages between GBV and HIV, including tracking linkages to services for survivors of sexual violence, provision of post-exposure prophylaxis, treatment of sexually transmitted infections, and reproductive health (RH) counseling and services.

Mildmay Uganda (MUg) will focus on supporting the National Strategic Plan 2011/12-2014/15 objective to increase access to ART from 57% to 80% by 2015. The MUg program will enroll @20,832 new clients and support 44,163 adults and kids on ART by APR 2013, contributing to overall national and PEPFAR target of 190,804 new clients and 490,028 individuals current on treatment. This target is not a ceiling, it allows for higher achievements through continued program efficiencies. Priority will be given to enrolment of HIV positive pregnant women, TB/HIV patients and key populations. MUg will support 16 districts in Central region.MUg will support MoH roll out of Option B+ for eMTCT through following: accreditation of 138 additional health facilities; training, mentorship and joint PMTCT/ART support supervision. MUg will support ART/PMTCT integration at facility level piloting feasible service delivery models.Continuum of response linkages and referrals will be strengthened using linkage facilitators across different service points. Facilitators will be utilized for TB/HIV integration to ensure early ART initiation for TB/HIV patients. MUg will support reproductive health integration including family planning and cervical cancer screening at facility level through provision of the services or referrals.Targeted community outreaches in high prevalence hard to reach and underserved areas for example islands and cattle corridor will be conducted. MUg will target key populations using innovative approaches including setting up specialized services including moonlight services. MUg will implement QI initiatives for the ART framework: early initiation of ART eligible clients on treatment; improve adherence and retention; and monitor treatment outcomes. Use of innovative, low cost approaches for adherence, retention and follow up such as: phone/SMS reminders, appointment registers and alert stickers will be supported. Special focus will be placed on adherence & retention of women enrolled under Option B+. Focus will be placed on increasing access to CD4 for routine monitoring of ART clients in line with MoH guidance. MUg will support the sample referral network in line with national CD4 expansion plan; and will monitor and report clients access to CD4 in quarterly reports.MUg will liaise with PACE and UHMG for provision and distribution of basic care kits to clients. In addition, MUg will work with National Medical Stores, Joint Medical Stores, Supply Chain Management Systems and Medical Access Uganda Limited for ARVs and other HIV commodities uncluding cotrimoxazole and lab reagents. MUg will build the capacity of facility staff in supply chain management. MUg will work with USG partners and stakeholders for provision of required wrap around services. The program will be aligned to the National HIV/AID Strategic Plan (2011/12-2014/15), support and strengthen the national M&E systems and work within district health plans. MUg will work under the guidance of MoH/ACP and the QA Department in trainings, ART/PMTCT mentorship and supportive supervision. HRH is critical for successful scale up of HIV treatment services. In the current COP it is proposed to support the new recruitment of critical health workers, including laboratory cadres, in 87 districts for both public and private not-for profit facilities based on the new scale up targets and current staffing level, in the particular district. 195 health workers shall be recruited.

Mildmay Uganda (Mug) will focus on supporting the National Strategic Plan 2011/12-2014/15 objective to increase access to ART from 57% to 80% by 2015. MUg program will enroll at least 3,958 new HIV positive children and support 5,741 children on ART by APR 2013. This will contribute to overall national and PEPFAR target of 36,252 new clients and 63,704 children current on treatment. MUg will support 16 districts: Wakiso, Mpigi, Gomba, Butambala, Masaka, Kalungu, Bukomansimbi, Lwengo, Mityana, Mubende, Sembabule, Lyantonde,Luweero, Nakaseke, Nakasongola and Buikwe.In FY 2013, MUg support the national program scale up pediatric treatment through strengthening the identification, follow up and treatment for all infants through Early Infant Diagnosis (EID) focal persons, peer mothers, SMS messages/phone calls and flagging files with initiate ART immediately stickers. Facilities will be supported to strengthen test and treat for all HIV positive under two years in line with the national treatment guidelines.

MUg will support the early initiation, adherence and retention of adolescents on treatment using expert peers and adolescent support groups. They will be provided with PWP /PHDP services including: sexual and reproductive health services, psychosocial support and life skills training.

A key priority will be to establish strong referrals between OVC and care and support programs to ensure children on treatment are linked to OVC services, and children provided with OVC services are screened for HIV and appropriately linked to treatment. MUg will support the integration of HIV services in routine pediatric health services, including the National Child Health Days.

MUg will liaise with PACE and UHMG for provision and distribution of basic care kits to clients. In addition MUg will coordinate with National Medical Stores, Joint Medical Stores, Supply Chain Management Systems and Medical Access Uganda Limited for ARVs and other HIV commodities including cotrimoxazole and lab reagents. MUg will build the capacity of facility staff to accurately report, forecast, quantify and order commodities in a timely manner.

In addition, MUg will work with USG partners such as SCORE, SUNRISE, PIN, SPRING, HEALTHQual, ASSIST and Hospice Africa Uganda in their related technical areas to support integration with other health, nutrition and OVC services. MUg will collaborate with UNICEF and other key stakeholders at all levels for provision of required wrap around services.The program will be aligned to the National Strategic Plan for HIV/AID (2011/12-2014/15), support and strengthen the national M&E systems and work within district health plans. MUg will work under the guidance of MoH/ACP and Quality Assurance Department to support pediatric trainings, implementation of the national pediatric mentorship framework and support supervision.

Human resources for health is critical for successful scale up of HIV Care and Support services. In the current COP it is proposed to support the new recruitment of critical health workers, including laboratory cadres, in 87 districts for both public and PNFP facilities based on the new scale up targets and current staffing level, in the particular district. A total of 195 health workers shall be recruited by this mechanism in 14 districts.