Strengthening Ugandas systems for Treating AIDS nationally-SUSTAINs goal is to provide quality HIV/AIDS prevention, care and treatment services at selected regional and district hospitals in Uganda and build the capacity of the public sector to provide these services.

Objectives: Ensuring provision of comprehensive HIV services within public regional referral hospitals and district hospitals; Enhancing quality of services within regional referral and district hospitals; and Increasing stewardship by the Ministry of Health (MoH) to provide sustainable quality services within the public health system.

Coverage -19 hospitals spread across all regions of Uganda are targeted: 12 Regional Referral Hospitals (Gulu, Lira, Soroti, Mbale, Jinja, Masaka, Kabale, Hoima, Fort Portal, Mubende, Moroto and Arua), and six General Hospitals (Moyo, Nebi, Kaboong, Gombe, Kawolo, and Entebbe). SUSTAIN will support delivery of clinical services to 55,500 HIV-positive individuals, including 30,527 individuals on ART. Cost effectiveness and sustainability will be enhanced by improving quality of services using modern improvement methods, joint planning and implementation with the MOH and facility leadership; integrating activities into MOH systems, and optimally leveraging other resources through coordination and partnerships all principles of GHI.

Systems strengthening activities include clinical service delivery, supply chain management, laboratory equipment, human resource support, Health Information Systems, and promoting MOH leadership. Data will be strengthened by rolling-out the MoHs Open Medical Records System. Facilities will be supported to collect, analyze and report performance data.

SUSTAIN will support the provision of care services to 50,505 HIV positive adults as a contribution to the overall PEPFAR target of 812,989 HIV positive individual receiving a minimum of one clinical care service. 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. SUSTAIN will be expected to implement approaches to promote an effective CoR model and monitor key indicators along the continuum. This program will support delivery of adult care and support services at 17 public health care facilities: 10 Regional Referral Hospitals (Gulu, Lira, Soroti, Mbale, Jinja, Kabale, Hoima, Fort Portal, Mubende, and Moroto) and seven General Hospitals (Moyo, Nebi, Kaboong, Gombe, Kawolo, Nsambya and Entebbe). It will provide comprehensive care and support services in line with national guidelines and PEPFAR guidance including: strengthening positive health dignity and prevention (PHDP); strengthening linkages and referrals using linkage facilitators; implementing quality improvement for adherence and retention; pain and symptom management; and providing 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. HIV-positive individuals will be closely and regularly monitored using clinical and laboratory methods (CD4 counts), and appropriately linked to ART when they become eligible. In addition, SUSTAIN will keep track of and periodically report on client waiting lists. Linkages between facility-based and community/home-based services will be supported and enhanced through partnerships with other community and facility based providers in respective geographical areas to ensure a continuum of care. Clients will be involved in their own care through innovative approaches, including a chronic care model. This includes self-management support, service delivery design, clinical information systems, decision support, and community support and health system changes. They will be motivated to care for their conditions, and manage their health. SUSTAIN will also make certain gender issues are integrated to ensure equitable access to care and treatment services by addressing barriers women and men may face in adhering to treatment or receiving ongoing care. Preventive care will be prioritized as a critical component of the program. SUSTAIN will liaise with PACE and UHMG for provision and distribution of basic care kits to clients. It will also access other commodities like co-trimoxazole through National Medical Stores and will build capacity of facility staff to accurately and promptly report, forecast, quantify and order commodities. Funding has been provided to support the recruitment of additional staff in the hospitals to meet the achievement of the scale-up targets.

Program Strategic Information (SI) activities will be supported to strengthen collection of data through national tools and to improve the technical quality of data through periodic DQAs. Data use at facility level will be strengthened through supporting SI focused in-service training for health workers. Key areas will be patient tracking, effective referrals and linkages across COR, while monitoring retention in care and loss to follow up.

SUSTAIN 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. SUSTAIN program will target 4,995 children with care and support services, contributing to the overall PEPFAR target of 73,169 HIV positive children receiving at least minimum one clinical care service.

Pediatric care and support services will be supported at 17 facilities: 10 Regional Referral Hospitals (Gulu, Lira, Soroti, Mbale, Jinja, Kabale, Hoima, Fort Portal, Mubende, and Moroto) and seven General Hospitals (Moyo, Nebi, Kaboong, Gombe, Kawolo, Nsambya and Entebbe). The target population includes children, infants and adolescents accessing health care services at the supported facilities and /or from the respective facility catchment areas. The RRHs are critical for national scale-up for pediatric services, as they are high-volume sites.

Services will mainly prioritize facility-based approaches for identifying HIV infected children/infants through Provider Initiated Testing and Counseling at points of entry and Early Infant Diagnosis (EID) through linkages with PMTCT services. Prevention, diagnosis and treatment of OIs will be prioritized by strengthening systems for drug logistics and leveraging resources from other health programs that support procurement and distribution of basic care commodities such as insecticide treated nets and safe water interventions.

Adolescent support activities will also be supported to address their unique needs through specialized counseling and peer group support activities. SUSTAIN will strengthen technical capacity for the regional hospitals to function as regional knowledge and training hubs for pediatric HIV services. Trainings will be conducted by a pool of existing national trainers and mentors in pediatric HIV care who are based at RRHs, including those trained by SUSTAIN in FY 12. The hospitals will be critical points for the national scale up plan for pediatric HIV services. DNA PCR and viral load test samples will continue to be referred to MOH designated centers for testing within the country.

Pediatric care services will be provided within the context of general maternal, newborn and child health services, as a component of general child health services. The program will support strengthening of the Early Infant Diagnosis referral system to ensure efficiency, specifically reducing turn-around times for test results and loss to follow-up for mother-infant pairs. Linking of those who test positive to treatment will be a top priority. Linkages between facility-based and community/home-based services will be enhanced through linkage facilitators within communities and facilities to ensure continuum of care.

Funding has been provided to support the recruitment of additional new staff in the hospitals to meet the scale-up targets. Program Strategic Information (SI) activities will be supported to strengthen collection of data through national tools and to improve the technical quality of data through periodic DQAs. Data use at facility level will be strengthened through supporting SI focused in-service training for health workers. Program evaluations for results and outcomes of interest will be supported to foster evidence-based decision-making and program improvement. Key areas will be Patient tracking, effective referrals and linkages across COR, while monitoring retention in care and loss to follow up.

TB/HIV services in HIV/AIDS clinics, TB clinics and general medical settings will be strengthened at 17 public health care facilities: 10 Regional Referral Hospitals (Gulu, Lira, Soroti, Mbale, Jinja, Kabale, Hoima, Fort Portal, Mubende, and Moroto) and seven General Hospitals (Moyo, Nebi, Kaboong, Gombe, Kawolo, Nsambya and Entebbe). The target population includes adults and children accessing health care services at the supported facilities and residents in the respective catchment areas of the facilities.

Activities will include pro-active identification of HIV infected individuals in TB settings through provider-initiated HIV testing and counseling. Screening of HIV clients for TB will be promoted as a routine clinical practice in facilities using the MOH Intensified Case Finding (ICF) form. SUSTAIN will strengthen on-site laboratory services for TB (smear microscopy and chest radiography), and monitoring and documentation of TB screening and treatment for PLHIV. Capacity of RRHs will be strengthened in terms of clinical and laboratory to function more efficiently as referral sites for lower facilities. Electronic microscopes will be procured to boost the diagnostic capacity for microscopy to ensure samples are quickly processed and results dispatched to clinicians. Strengthening National logistics system for TB diagnostics will ensure continuous availability of reagents and supplies. In collaboration with the National TB and Leprosy program, laboratory personnel will be trained to support lower level facilities in the catchment regions to quantify and requisition adequate supplies for TB.

TB/HIV activities will be routinely provided in all service delivery points at each facility, including MNCH/PMTCT settings. Other proposed activities are to include infection control measures to prevent TB transmission in clinical settings. Facilities will make specific infection control plans hinging on: administrative controls such as early identification of patients with TB symptoms, separation of coughing clients; environmental controls including improved ventilation and air flows in laboratories and selected HIV clinics through renovation works and; Personal Protective Controls including patient masks for TB patients considered infectious. Isoniazid preventive therapy will be given especially children in close contact with active TB cases. Coordination will be promoted between TB and HIV programs to ensure continuum of care for HIV-infected TB patients. Linkages between facility and community/home-based services will be enhanced through partnerships with other community based providers to ensure a continuum of care. SUSTAIN will work to improve reporting of TB/HIV activities, as well as linkages through application of quality improvement methods across clinical, laboratory and HMIS areas at each facility.

Program Strategic information (SI) activities will be supported to strengthen collection of data through national tools and to improve the technical quality of data through periodic DQAs. Data use at facility level will be strengthened through supporting SI focused in-service training for health workers. Program evaluations and outcomes of interest, will be supported to foster evidence-based decision-making and program improvement. The key areas will be patient tracking, effective referrals and linkages across COR, while monitoring retention in care and loss to follow up.

In FY 2013, SUSTAIN will assist the ministry of health (MOH), working in collaboration with the Central Public Health Laboratories (CPHL), to establish 10 hubs at the following hospitals: Nebbi, Kaabong, Kotido, Abim, Nakapiripirit, Lwala, Entebbe, and Gombe hospitals, as well as Kawolo and Hoima regional referral hospitals. This will be in addition to 12 existing functional hubs supported by SUSTAIN.

The major foci of SUSTAIN support will be 1) building CD4 capability in three sites with no high throughput CD4 machines including Kambuga, Kisoro, and Itojo (the remaining four hubs do have existing CD4 capability, 2) strengthening specimen referral and result transmission network, 3) improving laboratory infrastructure, 4) strengthening facility level quantification and reporting to reduce CD4, hematology and chemistry reagent stock out and 5) assisting the labs to implement the World Health Organization (WHO) recommended stepwise strengthening laboratory management towards accreditation (SLAMTA), with the aim to achieve a minimum of the WHO three stars by September 2014. SUSTAIN will also work with district officials and relevant stakeholders to recruit 51 lab technologists and 26 lab technicians to ensure that all the seven hubs have the necessary human resources required to run their laboratories at an optimal capacity.

SUSTAIN support is aimed at building the regional referral hospitals capacity to respond to and provide services which cannot be provided at lower Health facilities. In doing so, the national response to CD4 testing and ART monitoring services will have been increased significantly.

SUSTAIN will also facilitate the operationalization seven regional workshops aimed at reducing equipment downtime. In collaboration with the MoH Infrastructure Division and the district local authorities, SUSTAIN will support installation of service equipment, procurement of assorted tools and recruitment of biomedical engineers to support both preventive and corrective maintenance at seven identified regional laboratory equipment maintenance centers. The seven regional workshops will also be used to facilitate movement of biomedical engineers to other hubs or facilities that need urgent trouble shooting on equipment maintenance.

Over the next year, SUSTAIN will introduce Voluntary male medical circumcision (VMMC) as an additional new program in its current services, thereby increasing opportunities for its clients to access a full range of clinical services. SUSTAIN will support delivery of services while simultaneously building the capacity of partner sites to deliver this service. VMMC services supported by SUSTAIN will be delivered in 18 districts of Kabale, Kabarole, Masaka, Mubende, Jinja, Butambala, Wakiso, Buikwe, Hoima, Mbale, Arua, Nebbi, Moyo, Soroti, Lira, Moroto, Gulu and Kaabong. While using dedicated teams, SUSTAIN will deliver services largely in facilities but complementary outreaches will also be done for hinterland communities. Voluntary Medical Male Circumcision will be accessed to 42,230 eligible males across the eighteen districts. Relative emphasis will be placed on districts estimated to have high HIV prevalence, especially among women and low rates of circumcision.

SUSTAIN shall prioritize the COP 2012 VMMC strategic pivots which include: establishing dedicated teams in facilities given the critical human resource shortages currently faced in these facilities, rolling out the MOVE model in high volume sites, ensuring stable supply of VMMC kits, institutionalizing quality assurance and improvement as a routine component of service delivery and most importantly increasing community knowledge and raising demand for VMMC. SUSTAIN will support the national plan for rolling out voluntary medical male circumcision and activities will be delivered in line with the national policy, guidelines and tools.

VMMC will be promoted as part of conventional good health behavior and practice. Messages will include: the benefits it offers on general STI prevention/transmission (some of which may reduce risk of cancer and problems with fertility especially in females), improved hygiene, and reduction in risk of on HIV transmission to men (which benefits both men and women subsequently). VMMC messages will also be included in the MOH routine health education guidelines/curriculum for health care facilities. Within health care facilities, routine health education sessions shall be given to clients in various service areas both in wards and outpatients departments. Carefully crafted VMMC promotion messages will be disseminated to health care service providers to avoid conflicting messaging by health and community workers.

Messages about benefits of VMMC will also be integrated into other USG supported programs for example SUSTAIN will collaborate with existing family planning and reproductive health USAID partners (Maries topes Uganda; STRIDES and Uganda Health Marketing Group) to increase awareness of the benefits of circumcision, safe sex, family planning, birth spacing, active linkage of adolescents, women and men to various reproductive health services and cervical cancer screening.

SUSTAIN will support key HCT pivots by increasing the availability of Provider Initiated Testing and counseling (PITC) services at 17 public hospitals supported for delivery of comprehensive HIV services. Of these, the program will support 10 Regional Referral Hospitals in Gulu, Lira, Soroti, Mbale, Jinja, Kabale, Hoima, Fort Portal, Mubende, and Moroto, and seven General Hospitals in Moyo, Nebi, Kaboong, Gombe, Kawolo, Nsambya and Entebbe. The target population will include adults and children accessing general health care services at these facilities, including those specifically seeking HIV testing services on their own (client-initiated). In the past 12 months, 115,744 individuals received HCT services at these facilities; in FY 2013, up to 60,000 individuals will be targeted. The slump in targets is a result of the need to target services at most at risk individuals and PITC as opposed to the general population. Efforts will be made to ensure that patients needing HTC shall access it.

Provider-initiated HIV Testing and Counseling will be the approach for offering HIV tests to all patients/clients as an integrated component of routine health care services. PITC will be offered in maternal, newborn and child health clinics (including antenatal and family planning), TB and STI clinics, as well as in-patient wards and outpatient service areas for adults and children. Testing within PMTCT and TB service areas will require about 40% of level of effort for all HTC activities, with the rest (care and support, treatment, prevention with positives) taking 60%. Linking HIV-infected clients, and family members and partners into care within the facilities and other facilities will be ensured.

SUSTAIN will ensure that there is training, mentoring of staff and appropriate continuing medical education activities; and equip all service providers in different disciplines with skills for delivering quality HTC services (training, coaching and support supervision). 305 service providers will be equipped with these skills. Support will also be provided to ensure availability of testing commodities, through efficient commodity management training and support supervision for pharmacy, laboratory and stores staff. All activities for HTC will follow the national guidelines for HTC in health care facilities, including the national HIV testing algorithms for adults and children, thus ensuring the provision of WHO and Government of Uganda approved services.

HCT services will be an integral component of all health care service packages in the various service delivery points in each facility. The deliberate linking of clients, through dedicated Linkage Facilitators, will connect those who test positive, to care and treatment services (both within and outside the facilities) and for those in need of other health and social services the program will increase its partnerships with community-based support services, including health worker networks.

Program Strategic Information (SI) activities will be supported to strengthen collection of data through national tools and to improve the technical quality of data through periodic DQAs. Data use at facility level will be strengthened through supporting SI focused in-service training for health workers. Program evaluations on results and outcomes of interest will be supported to foster evidence-based decision-making and program improvement. The key areas will be measurable linkages to care, treatment, PMTCT, VMMC.

SUSTAIN will receive $650,000 under the PMTCT acceleration plan funds and this will go towards support of eMTCT services across 10 Regional Referral Hospitals (Gulu, Lira, Soroti, Mbale, Jinja, Kabale, Hoima, Fort Portal, Mubende, and Moroto) and six General Hospitals (Moyo, Nebi, Kaboong, Gombe, Kawolo, and Entebbe). HIV counseling and testing services will be provided to 95,900 pregnant and lactating women, hence identifying 7,960 HIV positive pregnant women, of whom 6,766 will be initiated on HAART for life and 1,194 will be provided with ARV prophylaxis. Early Infant Diagnosis will be provided to 7,960 exposed babies.

SUSTAIN will focus on all eMTCT prongs in line with the goals of virtual elimination of MTCT and keeping mothers alive. SUSTAIN will:

1) Improve utilization of eMTCT services to reach more HIV infected pregnant women as early as possible during ANC, labour/Delivery, and post-partum periods;

2) Transition by the end of September 2013, all 17 sites to Option B+ through: site assessments to identify training needs, procurement of equipment, printing of M&E tools, job aides, and Option B+ guidelines; training of service providers; and provision of CD4 and EID test at the on-site laboratory hubs. Retention will be enhanced through the family- focused service delivery model within the PMTCT/MNCH settings coupled with the formation of family support groups (FSGs) at all eMTCT sites led by peer mothers and midwives. FSGs will meet monthly to receive adherence counseling and psycho-social support; supported disclosure; infant and young child feeding counseling; EID; family planning counseling; couple HTC; repeat-testing; ARV refills; and link negative male partners to VMMC if required.

3) Intensify M&E at facility and community levels in supported sites through cohort tracking of mother-baby pairs and electronic data reporting for effective Option B+ monitoring and program management. Mobile phone technology will be used to remind mothers and their partners on appointments; EID results; and ARV adherence. Home visits will be conducted to trace those lost to follow-up. Strategic Information (SI) activities will be supported to strengthen collection of data through national tools and to improve the technical quality of data through periodic DQAs. Data use at facility level will be strengthened through supporting SI focused in-service training for health workers. Key areas will be tracking the implementation of Option B+ and process evaluation of phase-one Option B+ implementation.

4) Enhance the quality of eMTCT services through quarterly joint support- supervision and mentorships at all eMTCT/ART sites. Site level support will entail cohort reviews; adherence rates; retention rates; data management; availability of supplies (commodities, HIV test kits, tools, job aides & ARVs); and addressing existing knowledge gaps on Option B+.

5) Integrate voluntary and informed family planning services based on respect for womens choices and fulfillment of their reproductive health rights. FP sessions will be integrated within eMTCT trainings for all service providers. FP counseling; education, and information will be provided to all women during antenatal care, labor and delivery, and postnatal periods; and in care and treatment settings. SUSTAIN will collaborate with existing FP partners to increase awareness of the benefits of FP.

SUSTAIN program will enroll at least 11,523 new HIV positive adults and support 26,558 adults currently on ART by September 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, allowing for higher achievements with continued program efficiencies. Priority will be given to enrollment of HIV positive pregnant women, TB/HIV patients, and key populations. Adult treatment services will be supported across 10 Regional Referral Hospitals (Gulu, Lira, Soroti, Mbale, Jinja, Kabale, Hoima, Fort Portal, Mubende, and Moroto) and seven General Hospitals (Moyo, Nebbi, Kaboong, Gombe, Kawolo, Nsambya and Entebbe).

ART services will be delivered in accordance with the Ugandan national treatment guidelines and protocols. Continuous Quality improvement will be implemented through facility-specific quality improvement teams that cut across all HIV service areas and are therefore able to foster intra-facility linkages. The improvement teams will have their skills strengthened through support supervision and mentoring.

Through staff training and provision of appropriate HMIS tools, facilities will be further supported to ensure capacity for adequately managing data collection, documentation and reporting results, using the newly introduced MOH HMIS tools including Open MRS software.

Adherence to ART will be supported through various methods: counseling and psychological support to individual clients; client peer support group activities at facilities and communities; targeted follow-up for at-risk clients. Close linkages with other health care delivery points within each facility will be promoted to facilitate bi-directional intra-facility referrals and enhanced by linkages facilitators. Prevention with Positives activities will be integrated into all care and treatment clinics. All the 17 facilities provide ART and antenatal services, including PMTCT.

SUSTAIN will ensure gender issues are integrated in programs to ensure equitable access to care and treatment services by identifying and addressing barriers influencing adherence to care & treatment. Preventive care will also be prioritized as a critical component of the program. SUSTAIN will liaise with PACE and UHMG for provision and distribution of basic care kits to clients, and will access other commodities like co-trimoxazole through National Medical Stores. SUSTAIN will additionally build the capacity of facility staff to accurately and timely report, forecast, quantify and order commodities.

Funding has been provided to support the recruitment of additional staff in the districts to meet the achievement of the scale-up treatment targets.

Program Strategic Information (SI) activities will be supported to strengthen collection of data through national tools and to improve the technical quality of data through periodic DQAs. Data use at facility level will be strengthened through supporting SI focused in-service training for health workers. Program evaluations on results and outcomes of interest will be supported to foster evidence-based decision-making and program improvement. Key areas of focus will be patient tracking, effective referrals and linkages across COR while monitoring retention in care and loss to follow up.

SUSTAIN will enroll at least 2,281 new HIV positive children on treatment and support 3,969 children current on ART by September 2013. This will contribute to overall national and PEPFAR target of 39,799 new pediatric enrollments and a total of 64,072 children current on treatment. Pediatric treatment services will be supported at 17 facilities spread across the country, including 10 Regional Referral Hospitals (Gulu, Lira, Soroti, Mbale, Jinja, Kabale, Hoima, Fort Portal, Mubende, Moroto) and seven General Hospitals (Moyo, Nebbi, Kaboong, Gombe, Kawolo, Nsambya, Entebbe).

Service delivery activities include: early initiation of ART for HIV-infected children as per the newly revised national guidelines. This involves monitoring response to treatment and identifying treatment failure using clinical and laboratory methods (CD4 counts at regular intervals and viral load where absolutely necessary).

SUSTAIN will strengthen laboratory capacity to support pediatric ART by improving efficiency of Dried Blood Sample (DBS) testing systems. Quality Assurance systems for early infant diagnosis (EID) specimen collection and ensured through practical mentoring sessions at facilities. Service provider skills for evaluating children for ART, initialing and monitoring children on ART, and providing psychological care and support to children and their families will be strengthened through facility-based training, coaching and quality improvement approaches.

Pediatric treatment services will be integrated by: using the modified child health card to identify HIV-exposure status and PMTCT services received; provision of EID services and cotrimoxazole prophylaxis at child health clinics (immunization, well-baby and out-patient) and inpatient wards; institutionalization of PITC, preventive care, and OI treatment into routine MNCH services; collaborative planning and communication among pediatric, PMTCT and MNCH programs to ensure integration of HIV services at all levels of the health care system; screening, diagnosis and treatment of children and families with TB; and coordination with home-based care and OVC programs to foster identification of HIV infected or exposed children, care and treatment adherence support and follow-up, educational, psychological and nutritional support.

Preventive care will be prioritized as a critical component of the program. For provision and distribution of basic care kits to clients SUSTAIN will liaise with the CDC and USAID supported partners PACE and UHMG respectively. SUSTAIN will also build the capacity of facility staff to accurately and timely report, forecast, quantify and order commodities.

In this FY, funding has been provided to support the recruitment of additional new staff in the districts to meet the achievement of scale-up treatment and option+ targets. This will be done in collaboration with the Health Systems Strengthening technical working group.

Program Strategic Information (SI) activities will be supported to strengthen collection of data through national tools and to improve the technical quality of data through periodic DQAs. Data use at facility level will be strengthened through supporting SI focused in-service training for health workers. Key areas of focus will be patient tracking, effective referrals and linkages across COR while monitoring retention in care and loss to follow up.