This new mechanism builds on current PEPFAR-support and continue providing comprehensive HIV care and treatment services to an existing 6,500 clients in Mulago hospital, and another 34,000 in Rwenzori region including Kabarore, Kasese, Kamwenge, Ntoroko, Bundibugyo, Kyegegwa and Kyenjojo districts, with one of the highest HIV prevalence in the country at 8%. The grantee in collaboration with other USG funded IPs will support MOH build its capacity to strengthen National Pediatric HIV/AIDS care and treatment in collaboration with Regional Referral Hospitals (RRH) to supervise, train and mentor health facility staff in comprehensive pediatric HIV/AIDS care and treatment in a sustainable manner. As part of this project, the grantee will expand delivery of comprehensive HIV/AIDS prevention; care and treatment services to HIV infected children, adolescents and adults in 8 districts of Rwenzori region and other districts in western Uganda, while integrating with GHI principles which are infused into all program elements women, girls and gender equality; country owned and country led; strategic coordination and integration; metrics, monitoring and evaluation. This initiative represents a new and innovative way of doing business for the U.S. Government and will strengthen integration between USG-funded programs. The objectives of the project are Scale up access to comprehensive pediatric and adolescent HIV/AIDS/TB care and treatment services to existing and new clients at the COE, in Mulago Hospital, 8 districts in Rwenzori region, support MOH Strengthen National Pediatric/adolescent HIV/AIDS Care and treatment as well as Strengthening implementation of district based programming approach while integrating GHI principles. Not able to determine vehicle purchase/lease plans.

The adult care and support services that should be offered include both facility-based and community or home-based activities for HIV-infected adults aimed at improving and maintaining quality of life from the time of diagnosis throughout the continuum of care during sickness. The targeted populations will include adults, MARPs, adolescents, women including PMTCT mothers.

The project will provide Care and support services in 8 districts in the region. Some of the services will include clinical, psychological, social, spiritual, and prevention services to improve quality of life of clients. Uganda aims at providing care to over 900,000 HIV+ clients in 2013 and this project is intended to contribute by providing care and support to over 57,000 individuals.

The project is expected to provide 100% adults in care with cotrimoxazole in addition to other care and support services. This number of clients in care is expected to progressively increase at an annual rate of 20-30% over the project period.

Positive Health Dignity and Prevention will be implemented both at the facility and community levels, while strengthening referrals in between. Health facility staff will be oriented in the delivery of PHDP services to ensure key messages are passed on to clients at every clinic or home visit.

The project will provide comprehensive reproductive health services to clients and caretakers in all supported health facilities. Health facility staff training in cervical cancer screening and STD management and quality improvement will be conducted.

The project will support health facilities in data capture, management and reporting through hands on capacity building and training for staff, as well as supporting commodity quantifications and requisitions from NMS and JMS. A monitoring frame work will be developed to monitor progress of activity implementation.

Linkages will be created or strengthened to ensure retention in care, minimize patient loss to flow up by working in collaboration with VHTs and other community support groups with health facilities. Clients will be linked or referred to other programs for other services including nutrition care and support but routine assessment of clients will be emphasized and monitored. The project will also work in collaboration with other USG partners to avoid duplication and service overlap.

The grantee will build on existing collaborations between District Health Offices (DHO), Community Development Offices (CDO), to strengthen CBO and Faith Based Organizations (FBO) for coordinated provision of services (child protection, education, health, food security and economic strengthening) to OVC and their families. The grantee is expected to;

Support training of health care workers, probation/community development officers/assistants and community workers and CSF organizations in OVC care targeting improving the range and quality of OVC services provided to vulnerable children.

Support community based organizations and facilities provide OVC services in 3 or more core program areas (CPAs). At the minimum, 3+ services must include health, food security and nutrition, and economic strengthening. And about 7,000 OVCs are expected to be provided with 3+ services while about 14,000 OVCs provided with 1 or 2 CPAs.

To support promotion of multi-sectoral approach in programming through integration of OVC activities in other district programs, including education, health and agriculture among others for coordinated unduplicated service delivery.

Support districts to institutionalize OVC Vulnerability Index for OVC identification and programming as well as strengthen reporting and coordination of OVC activities at lower levels parish, sub county and district.

The grantee is also expected to support linkage of services through referrals to other service providers to achieve comprehensive programming including schools, health facilities, CBOs.

The grantee will work with DHOs and CDOs to jointly define schemes for livelihood and IGA that may be funded by the project. The grantee will support caretakers of the OVCs form groups that could be funded through the district system.

TB/HIV activities will be implemented according to MOH TB/HIV policy through the structures of the National TB and Leprosy control Program. Priority MOH activities aimed at decreasing the burden of TB among PLHA (Intensified TB case finding-ICF, Isoniazid prevention therapy, and Infection control) and HIV among TB patients (PITC, CPT and ART for TB/HIV co-infected patients) will be supported. This project will support TB screening which will be integrated at all service delivery health facilities. The project will also support procurement of supplies for TB commodities like tuberculin skin tests and X-ray services will be supported for some facilities. In new facilities health care workers will be trained in TB screening and TB/HIV management and a refresher for other facilities to update on new approaches to improve the quality of services provided. The number of TB patients recorded in the TB register and the same number of TB patients with an HIV test result recorded in the TB register during the reporting period will be measured as an important outcomes. The project will target 100% TB patients recorded in TB registers and 100% TB patients with an HIV test result recorded in TB register. Another important output indicator will be targeting 80% HIV+ incident TB patients receiving both TB treatment and ART.

Surveillance for MDR TB through sputum cultures will be supported and identified patients referred to the national referral centre that is being planned for at Mulago National referral hospital. In addition the following activities will be carried out by the grantee;

The project will support screening of all HIV positive individuals for TB and conduct TB diagnosis and initiate TB treatment -in all HIV care and treatment settings and provide ART to co-infected TB patients. Facilities will be supported to provide Isoniazid Preventive Therapy to eligible clients in HIV care and treatment settings.

The project will also support HIV Prevention, care and support targeting co infected TB patients and facilitate facilities offer HIV counseling and testing of TB patients and record the results in the TB register.

To support and improve linkages between facilities and communities the project will facilitate Sub-county Health Workers (SCHW) and Facility TB Focal Persons to conduct TB contact and defaulter tracing at community level. DTLS will be supported to conduct support supervision of TB/leprosy/HIV services in the district.

The grantee will work with MOH to procure and distribute patient cards, registers, job aides and IEC materials on TB to district health facilities.

The project will build on the ending mechanism and support districts and health facilities to provide quality pediatric/adolescent HIV/AIDS care. Health workers will be trained and re-oriented and supported to maintain patients in including lifelong co-trimoxazole prophylaxis. Health facilities will be supported to offer ongoing counseling, and ensure patient follow up and strengthen community linkages.

The project will provide care and support services in at least 8 districts. Currently the number of clients in care is about 44,000 with children contributing about 20% in both the COE in mulago clinic and Rwenzori region. The proportion of children in care at the COE is 80% compared to the Rwenzori region which is about 10%. This project will focus on increasing the number of children in care in the Rwenzori region as well as supporting MOH scale up National Pediatric and adolescent HIV care and treatment nationwide to achieve a nationwide target of 15%-25%.

The grantee will support districts and health facilities to forecast, procure and provide OI drugs for children and adults in all supported health facilities. The grantee will facilitate all supported districts to conduct integrated MCH/HIV care outreaches in all facilities to improve care linkages for all clients in supported facilities in line with the GHI principles.

The grantee will provide both existing and new children with comprehensive HIV care and support services to improve their quality of life through supporting client peer support activities; provide psychosocial, social and spiritual services.

The grantee will build the capacity and mentor lower level health workers in all supported facilities to improve care for children through capacity building and skills development as well as providing educational materials, procure and distribute job aides on pediatric HIV prevention, care and support and nutrition. The project will also support training of VHTs to help improve linkages to care between PMTCT and EID testing points. This will help reduce loss to follow up, improve retention in care and improving the general health services in line with the GHI principles.

This mechanism will support Positive Health Dignity and Prevention (PHDP) activities for adolescents including counseling, OI management, palliative care needs, pain management, STI management, nutritional care and support. It will also support capacity building for nutritional assessment for facility and community health workers for early identification and management of malnourished individuals both HIV+ and HIV-.

This project will support creation of strong peer support groups to help support each other through Adolescent -Adult transition process. The project will also strengthen participation of adult care takers in the transition process and integrate MCH/FP and other reproductive health services as part of the adolescent package.

The project will collaborate with PACE to procure and distribute safe water systems, cotrimoxazole for prophylaxis, malaria prevention, Condom distribution, family planning information and commodities. This project will work in the context and policies of the MOH and support the use of MOH monitoring and evaluation systems.

During FY 2013, changes will be made in PEPFAR support for the laboratory program in Uganda in line with the identified pivots. The pivots will focus on a change from facility based to lab network strengthening. Building on the success of Early Infant Diagnosis hubs there will be an increase in the number of hubs from 19 to 72 thus increasing the geographical coverage and access for specimen transportation, testing and result transmission. This is focused on the ART population to improve CD4+ testing coverage from 60% to 100%. There will be an overall effort to improv the quality of laboratory services, reducing stock out of reagents, laboratory supplies and commodities, reducing equipment downtime and improving data collection, results transmission, analysis and utilization. To achieve this, laboratory technical staff will need to be hired and retained and where possible task shift non-technical activities to appropriately trained lay health workers.

Implementation of the WHO Strengthening Laboratory Management Towards Accreditation (SLMTA) will be the mainstay for quality improvement in addition to other quality assurance activities.

The hubs are strategically located health facilities identified by the MoH to serve as coordination centers for specimen referral, testing and result transmission for a catchment area of 30km to 40km radius serving 20 to 50 facilities.

Baylor-Uganda will establish four new hubs which include Kyegegwa and Kyenjonjo in Health Center (HC) IVs, as well as, Bundibugyo and Kilembe Hospitals on top of Kagando Hospital which is already a functional hub. All these hubs are within the Ruwenzori Region in Western Uganda. In order to improve infrastructure for service delivery, Baylor-Uganda will carry out major renovations on Kyegegwa HC IV and Kyenjojo, Bundibugyo and Kilembe will receive minor renovations of their laboratory facilities. In collaboration with the districts seven laboratory technologists (three for Bundibugyo hospital, two for Kilembe hospital and two for Kagando hospital) and five laboratory technicians (one for Kyegegwa HC IV, one for Bundibugyo hospital and three for Kilembe hospital) will be recruited to address HR health gaps. Baylor-Uganda will work with Central Public Health Laboratory and MoH to ensure capacity for all the hubs to carry out CD4+, Clinical chemistry and hematology testing are installed and operationalized.

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The grantee will build on existing efforts in strengthening organizational and technical capacities of districts to plan and manage comprehensive HIV/AIDS services by:

Supporting MOH to facilitate planning processes by level; clearly defining various roles and responsibilities with MOH in the drivers seat.

Strengthening coordination for planning/budgeting and resource allocation.

Supporting management structures and harmonize district-IPs planning cycle.

Advocating for an integrated system of service delivery at all levels; leveraging the broader Health system and PHC to address all HIV issues at various H/Fs, bringing on board the community and its structures to strengthen linkages, referral and disease surveillance.

Supporting and strengthening effective referral linkages among prevention, care and treatment services; support public-private partnership to improve access, coverage and utilization for PMTCT, MNCH services. Strengthen integration of service delivery between PMTCT and MCNH and scale up evidence based prevention services like SMMC, PWP and PMTCT.

Linking clients through trained VHTs to the existing H/Fs for PMTCT, EID, Point of care, ART, and CB DOTs among services.

Supporting recruitment of Key cadres in the target districts to support provision of comprehensive HIV comprehensive services and train health facility staff in HIV/AIDS services provision (PMTCT/EID, RCT, Pediatric HIV Care) in supported districts.

The grantee will support mentorships and technical support visits to health facilities to build skills and ensure sustainability of provision of comprehensive HIV/AIDS prevention, care and treatment services. The grantee will support MOH build capacity of regional and district mentors in HIV/AIDS technical support supervision to ensure continuity of services in supported health facilities at district level.

The project will support SMMC services as one of the very new services in a region whose HIV prevalence is about 8%. The SMMC service will provide a minimum package of prevention services which include routine counseling and testing for all men and, where possible, their partners attending MC services; age-appropriate sexual risk reduction counseling; and counseling on the need for abstinence from sexual activity during wound healing; and promotion of correct and consistent use of condoms. SMMC will be implemented in accordance with national standards and international guidance with active linkages with other HIV prevention, treatment, and care and support services as needed. SMMC encompasses a focus on policy, training (task-shifting/sharing), outreach, development of tools for communications, efficient and accessible service delivery, quality assurance, and equipment /commodities related to male circumcision.

10,000 males have been targeted for male circumcisions, in the 8 districts where the project will be implemented. Sensitization will be key element in this program; testing and counseling will be provided as part of the package. Awareness campaign and SMMC outreaches will be supported to create demand for the service.

The grantee will do an assessment of health facilities for SMMC and support health facilities to conduct health education sessions about SMMC. Health workers will be trained in SMMC and the grantee will also support procurement and supply of surgical equipment to facilitate SMMC service.

To have a rapid scale up, health sub districts will be supported to conduct mobile clinics for SMMC as well as support the conduct of mini-district surgical camps for SMMC.

In the focus districts of Rwenzori region and Kampalas COE, Mulago in 2011 the population that accessed counseling and testing services increased by about 46% i.e. from 57,613 who tested between Oct 2009 and Sept 2010 to 84,331 people who tested for HIV between October 2010 and June 2011 and an average HIV prevalence was 8% for the region. The project will scale up coverage of PITC utilization by contributing to MOHs target of 1,500,000 people to provide HTC to about 190,000 in the first year from 90 facilities.

This project shall increase coverage and utilization of PITC services within health facilities as well as HBHCT through community out reaches in the districts. Adults, couples, pregnant women, adolescents and MARPs will be particularly targeted. With project technical and logistical support, health facilities will be supported to integrate PITC including EID in all service delivery points. To achieve the scale up Health worker capacity will be built through in-service training in HIV Counseling and Testing and EID.

The project will support all initiatives aimed at providing access to HIV testing for those who need it. The grantee will support health facilities to offer HIV testing at various points in the health facilities as well as in the communities through working in collaboration with community groups and VHTs. The project will employ approaches ranging from client-initiated/ provider-initiated to HIV testing and counseling. This project will support delivery of this service in health facilities in ANC settings, TB clinics, Outpatient departments, in-patient departments (wards) and home-based HTC; outreaches, voluntary counseling and testing (VCT); special events or campaigns. Consenting HIV+ clients tested in communities will be linked with VHTs to facilitate referral, reduce loss to follow up and increase retention of clients in care. The index HIV+ client in a family will be offered a chance for home based or family based HCT in their homes.

The project will support health facilities to conduct know your child HIV status campaigns, targeting children of HIV + clients in the project. KYCS is an approach that has been found to be very effective in identifying children from mothers who did not go through PMTCT and hence a gate way to early and timely access of care and treatment services.

The project will employ the use of the standard MOH algorithm for HIV testing and will use the MOH HMIS to strengthen the M&E function of health facilities. Provision of HIV testing materials will come from NMS/JMS and the project will only support facilities to quantify and make timely reporting and orders.

Uganda has adopted Option B+ for all HIV positive pregnant women, hence these services will be offered: Training of health care workers to provide Option B+ as opposed to previous Options A and B; Follow up of women to ensure adherence; Partner involvement; Ensuring Facility delivery; Laboratory monitoring and Post natal services including Infant feeding issues. The project will expand coverage and utilization of PMTCT services to contribute to virtual elimination of MTCT efforts in the country and achieve district targets and a four-pronged strategic approach to PMTCT will be employed. The grantee will expand PMTCT services from 90 to 120 health facilities in the first year thus increasing the number of clients accessing PMTCT services from about 119,400 in 2012 to 120,000.

Prong 1: Primary Prevention Of HIV

The project will support radio talk shows in the region focusing on prevention; train VHTs to carry out household sensitization for prevention of HIV. The project will train additional 60 health workers and volunteers in PICT and also support HCT outreaches by facilities through sub granting. Supporting ANC and HIV testing for pregnant women as an entry point into PMTCT service provision for 100% clients attending ANC.

Prong 2: Prevention of unintended pregnancies in HIV infected women

The project will support health facilities to provide counseling to HIV infected women and family planning services. Modern long term methods of family planning will be availed in supported health facilities. We shall provide cervical cancer screening services to HIV infected women. Family planning will be provided to all women accessing services at these facilities.

Prong 3: Prevention of mother-to-child HIV transmission

Selected trainings will be conducted for health workers in supported districts. These will include; PMTCT-EID, TOT, HCT, VHT and Logistics management. Technical support supervision through mentorship will be supported. To scale-up quality PMTCT interventions the project will implement Option B+ and will continue to use strategies as PITC and support access to CD4 testing to all HIV+ mothers. The use of community support groups including VHTs will improve retention and adherence of mother-infant pair to their ART regimens as well as strengthening linkages and referral to treatment, care and support services. Peer mothers will be facilitated to follow up mother baby pairs and support initiation on ART for all HIV+ women for life and exposed babies on NVP for 6weeks from birth. To improve uptake through family support model, focus will be on promoting couple counseling and counseling and testing male partners in PMTCT settings.

Prong 4: Provision of care and support for HIV-infected women, their children, and their families

The project will establish effective referral systems for HIV infected mothers and HIV exposed/Infected babies for enrollment into HIV care and treatment. To promote timely care and support for children born to HIV+ women, HIV testing (PCR) will be done within 6 weeks. The project will support health facilities to use the national transport system for DBS to and from CPHL where testing will be done. Ongoing care and support services including counseling, cotrimoxazole prophylaxis and STI management will be provided at all care and treatment sites for clients to improve retention and quality of care. Setting up of more chronic care HIV clinics in lower HFs and ART accreditation will be supported.

About 17,000 patients are on ART in the COE in Mulago hospital and in the 7 district based programs in the Rwenzori region. The grantee will support patients at the COE in Kampala, and patients served in PNFPS with ARVs. About 8% of the patients on ART are expected to be on second line treatment.

The grantee will provide ARV for facilities at COE and PNFPs in the supported districts, train health facility staff in HIV/AIDS logistics and supplies management to minimize stock out of drugs and improve forecasting. The grantee will also support district based programs with training in logistics and supplies management and integrate this activity into other health related commodities procured from NMS/JMS. Procurement of ARVs for PMTCT (Option B) will be done. Overall the grantee will work with Medical Access Uganda Limited (MAUL), the drug and logistics mechanism to procure ARVs for PMTCT, PEP and ART for the COE, PNFP and PFP facilities.

The grantee will support capacity building, training of clinicians and other services providers, clinical examination of adult patients, clinical monitoring, and community-adherence activities and management of opportunistic infections will be a main focus. Using district based teams the grantee will support district quality improvement and provide support supervision and mentorship to lower level facilities. Of the 17,000 patients on ART about 80% of them are adults which the grantee will support in addition to new clients that will become eligible for ART. However, the adult treatment services will be provided to all clients who are both in Pre-ART and on ART.

Under Adult treatment the grantee will carry out activities such as community based home care, training of district teams in support supervision and leadership for HIV/AIDS services. Districts will be supported to conduct support supervision of district HIV/AIDS care and treatment services as an integrated activity in MNCH/RH, and other health related services to foster ownership and sustainability of activities and programs.

The grantee will support annual health planning workshops of supported districts, regional program review and facilitate districts to support VHTs conduct CBHC activities to ensure clients are liked to care and there is sustained care at community level. The grantee will have activities that promote follow up and client retention at all levels of care to reduce loss to follow up especially of community based HIV testing and counseling programs.

The grantee will work with other partners in the regions to avoid duplication and overlap in services provided. The grantee is expected to support storage, transportation and distribution of ARV drugs for PNFP and PFP facilities in the regions. The grantee will also support training of clinical service providers in Adult HIV/AIDS treatment and monitor patient adherence to treatment and performance of other clinical outcomes aiming at improving quality of care, reducing loss to follow up, reducing mortality rates, timely initiation of ART and improving retention in care and on treatment. The grantee will develop a patient monitoring system to track treatment services and patient outcomes for progress in service delivery.

The new grantee will support districts and facilities provide quality HIV related care and treatment services. To provide focused attention to pediatric and adolescent services health workers in new facilities will be trained and others re-oriented and supported to assess patients for ART eligibility and initiate patients on ART. Overall there are existing 20% of children in HIV care although in the district based programs the proportion is much smaller at 10%. There are 17,000 patients the grantee will support in addition to an estimated new of 7,000 through 60 ART sites.

The project will support health workers to ensure quality patient monitoring and management of complications of ART according to 2011 MoH ART treatment guidelines. Ongoing patient counseling will be supported to ensure patient follow up and community linkages.

This project will scale up pediatric/adolescent HIV/AIDS care through providing technical support supervision to all supported health facilities that will have completed training and mentorship.

In improving quality of care for existing and new patients on ART, the facilities will be supported to monitor ARV toxicity through performing hematology, blood Chemistries and viral Loads. In district laboratories bi-annual CD4 monitoring for patients will be done for all patients. CD4 testing will be provided for both adults and children and for clients in pre-HAART and ART for eligibility and monitoring treatment progress.

The project will support strengthening of MOH to carry out technical support supervision of RRHs and lower level district facilities in collaboration with other USG partners.

The project will support maintenance of laboratory testing equipments in health facilities. The grantee will support facilities develop M&E capacities in data capture, management and analysis and use of information generated to inform decisions on pediatric/adolescent HIV/AIDS care and treatment.