Since 2005, The Henry M. Jackson Foundation has officially received funds and transferred them to The Makerere University Walter Reed Project (MUWRP) in Uganda to implement HIV care, treatment and prevention activities. The MUWRP goals are to build the capacity and systems of local public and private partners in Uganda to ensure sustainable, quality HIV services. Since 2005, MUWRP has supported HIV programs including: expansion of HIV clinical sites, provision of laboratory capacity, district-level data system strengthening, supply-chain management strengthening, human capacity development, youth-focused programs, short-term technical staffing, comprehensive home-based OVC services, and a variety of counseling and testing and prevention programs, including medical male circumcision and house-to-house testing. MUWRP manages only data-driven programs from ongoing program monitoring and evaluation. MUWRPs strong emphasis on efficiency has achieved improved economies in procurement, highly coordinated service delivery, and expanded coverage of programs with low marginal costs. In 2011, a USG-Uganda rationalization effort resulted in the directive of MUWRP greatly expanding its service area coverage. Therefore, beginning October 1, 2011, MUWRP became the only PEPFAR implementer for all PEPFAR Program Areas for the three Uganda districts of Kayunga, Mukono and Buvuma. Cooperative agreements will be entered into with each district to transition many activities to local governments. The demographics of these districts include large MARP populations with a total target population > 1.2 million persons. Since 2005, MUWRP has purchased five vehicles and plans to purchase one vehicle (approximate cost $40,000) in 2012 to transport its mobile circumcision camp.

Through FY 2011, the MUWRP Adult Care and Support program has supported comprehensive and compassionate HIV care services for all HIV clinics in Kayunga district (including one specifically for youth < 25 years), and three HIV clinics in Mukono district. M&E data show that the rate at which adults have sought HIV care through MUWRP-supported clinics continues to rise as a result of: (1) RCT, (2) renovated clinics, (3) ART availability, (4) MUWRP expansion, and (5) referrals from MUWRPs house-to-house HCT program. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. As a result of this, the number of HIV+ patients within the MUWRP catchment area will more than double. MUWRPs care and support for these health units will continue as described below through carefully monitored district-based programming cooperative agreements. The locations of the clinics serve large transient fishing communities along the River Nile and Lake Victoria islands. The program links to other program areas, especially SI, CT, lab, and drugs. MUWRPs care package includes prevention and treatment of OIs and other HIV-related complications, including malaria. A cervical cancer screening program will be implemented at Kayunga and Nagalama Hospitals in FY 2012. The program also provides drugs, ITNs, water vessels, lab tests, social services, and pain relief; and for those patients with very low BMI, a food-by-prescription program. Each year, MUWRP sends all clinicians at its supported HIV facilities and NGOs (95 per year on average) to attend an MOH-directed refresher course on comprehensive HIV services. MUWRP has supported 81 clinicians to attend family planning training, and in FY 2011, sent 40 clinicians to CQI training. Each week, MUWRPs mobile clinical team (four clinicians, one data manager) visit all supported HIV clinics to provide support supervision. Most importantly, since OI supplies are not reliably available in Uganda, MUWRP serves as a buffer to ensure zero OI or family planning commodity stock outs. MUWRPs model includes the training of patients to deliver (with compensation) the most basic of ARV clinic services. These roles and services include: receptionists, peer adherence counselors, simple record keepers, following up lost-to-follow-up (LTFU) patients to their homes, distributing basic care packages equitably, and coordinating monthly treatment club and prevention-for-positives meetings. Their work is carefully monitored each week by clinic supervisors. For example, data from the LTFU program shows that the LTFU rate in 8out of 9 MUWRP-supported clinics is extremely low. Also as a result of patient capacity building, patients have developed 27 farm groups (> 100 acres total, > 1,000 patients actively participating). The goal of the farms is to supplement patient income and diet. Initial support to the patient farms may include: farm animals, farm/bee keeping equipment, plowing, and training on accounts, bee keeping, poultry, and permaculture. Data show that all patients who have participated in the farms have benefited (on average) by earning $47 per harvest. This work is supervised and evaluated by two farm monitors, including a Peace Corps Volunteer. The monitors provide agriculture extension, ensure that cooperatives follow established rules, ensure that member patients get an equal share, and vigilantly wean off farms from MUWRP support.

Through FY 2011, MUWRP has supported an OVC home-based counseling and follow-up program that provides community-based outreach, counseling, and education for OVCs residing in Kayunga district, and utilizes three HIV clinics in Mukono district. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. MUWRPs support for these OVCs will continue as described below through CBO partnerships and district-based programming. Home-based visits and school fees for 200 OVCs will be supported by MUWRP. The programs target population is children up to age 18 who have lost a parent to HIV/AIDS; who are otherwise directly affected by the disease; or who live in areas of high HIV prevalence and may be vulnerable to the disease or its socioeconomic effects. As a result of the expansion described above, the numbers of OVCs within the MUWRP catchment area in FY 2012 will more than double, and will incorporate many isolated fishing villages along the River Nile and islands on Lake Victoria. MUWRPs OVC program is part of a comprehensive HIV/AIDS program and has strong links to other program areas, especially Pediatric Care & Treatment, PMTCT, Lab, HTC, Prevention, and Strategic Information. Specifically, the OVC programs priorities lie in improving families/households, service delivery, community support and coordination, and provision of education to MARP OVCs. For the OVCs themselves, the program activities include home visits for monitoring treatment adherence and well-being, and ensuring that they are provided with the minimum package for OVCs as defined by PEPFAR, including play rooms at HIV clinics. For the families of OVCs, the program activities include home-based services which incorporate HIV education, counseling, psychosocial/emotional support, and nutritional evaluation/counseling; and for the most needy, scholastic materials, clothes, blankets, mattresses, and supplemental food. Specifically for the OVC caregivers, MUWRP will continue to provide technical assistance on caring for pediatric ART/HIV+ patients, symptom control, and linkages to other caregivers of OVCs for group/peer counseling and psychosocial support. These meetings are held once per month at each MUWRP-supported HIV clinic. The OVC program is data-driven by means of routine monitoring and evaluation (M&E). For example, MUWRP allows caregivers of OVCs to participate in MUWRP-supported patient farms, a large scale income generating program. M&E data show that all caregivers of OVCs who have participated in the farms have benefited (on average) by earning $47 per harvest. Further, M&E data reveal that > 80% of MUWRP-supported OVCs were deemed adherent as per Uganda MOH standards. In FY 2012, MUWRP will continue to support the Kayunga District Youth Recreational Center, which was founded in 2006 by the Kayunga District Government and MUWRP. The goals of this facility are to build district capacity in identifying and providing HIV services to youth and especially OVC. The Center currently provides counseling, care, and recreational space specifically geared toward youth between the ages of 12 and 18 who are HIV+ or defined as OVCs. HIV+ youth are strongly referred for evaluation for ART. To date, 26 OVCs volunteering at the Center have been awarded contracts with MUWRP to work in areas such as VMMC, SI or HIV Care, and others were given scholarships to start a business or attend university.

MUWRP 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.

MUWRP will contribute to this target by screening 17546 HIV positive clients for TB; and 858 will be started on TB treatment. MUWRP will support three districts: Kayunga, Mukono and Buvuma (an island in lake victoria)

MUWRP will improve 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 at Kayunga Hospital Laboratory hub. MUWRP will support MDR-TB surveillance through sputum sample transportation to the Gene Xpert hub and receipt of results at facilities.

In FY13, MUWRP 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. MUWRP 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; ensure adequate natural ventilation; etc.

The MOH/ACP and NTLP will be supported to roll out provision of IPT, in line with the WHO recommendations.

In addition, MUWRP will work with USG partners such as PIN, SPRING, HEALTHQual, ASSIST, Hospice Africa Uganda in their related technical areas to support integration with other health and nutritional services. MUWRP 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. MUWRP will work under the guidance of MoH AIDS Control Program, National TB and Leprosy Program and Quality Assurance Department in trainings, TB/HIV mentorship and support supervision. Additionally, MUWRP will support facilities to participate in national external quality assurance for TB laboratory diagnosis.

he MUWRP Pediatric Care and Support program has supported facility-based HIV pediatric care services for all HIV clinics in Kayunga district (including one specifically for youth < 25 years old) and three HIV clinics in Mukono district. M&E data show that the rate at which pediatric patients have sought HIV care through MUWRP-supported clinics continues to rise as a result of: (1) referrals from MUWRPs community-based programs (specifically OVC and house-to-house HCT), (2) renovated clinics, (3) ART availability, and (4) MUWRP expansion. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. As a result of this, the numbers of HIV+ pediatric patients within the MUWRP catchment area will more than double. MUWRPs support for these districts and health units will continue as described below through carefully monitored district-based programming cooperative agreements. The programs target population is HIV-exposed infants, as well as HIV-infected children and adolescents residing within Kayunga, Mukono or Buvuuma districts. Services to this target population are linked to other program areas, especially SI, CT, lab, and drugs, and include early infant diagnosis, and prevention and treatment of OIs and other HIV-related complications, including malaria and diarrhea. The program includes the provision of drugs, ITNs, water vessels, lab tests, social services, pain relief, and for pediatrics with low BMI, a food-by-prescription program. Each year, MUWRP sends all clinicians at its supported HIV facilities (95 per year on average) to attend an MOH-directed refresher course on the delivery of comprehensive (including pediatric) HIV services. In FY 2011, MUWRP sent 40 clinicians to attend Continuous Quality Improvement training. Each week, MUWRPs mobile clinical team (which includes one clinical officer and one nurse specifically designated for pediatric patients) visits all supported HIV facilities to provide supportive supervision. All MUWRP-supported facilities sponsor a monthly PLWHA/PWP club meeting, with a separate meeting held specifically for HIV+ pediatrics and their caregivers. Most importantly, since OI supplies are not reliably available in Uganda, MUWRP serves as a buffer to ensure zero OI commodity stock outs. MUWRP also allows parents of pediatric HIV patients to participate in MUWRP-supported patient farms, an income generating program. The program has supported the development of 27 farm groups (> 100 acres total, > 50 parents of pediatric HIV+ patients are actively participating). The goal of the farms is to supplement the income and diet of HIV+ persons. Initial support to the farms may include: farm animals, farm/bee keeping equipment, plowing, and training on accounts, bee keeping, poultry, and permaculture. Data show that all caregivers of HIV+ pediatrics who have participated in the farms have benefited (on average) by earning $47 per harvest. Additionally in FY 2012, MUWRP intends to develop the capacity of its reference laboratory at Ntengeru to include early infant diagnosis using dried blood spots.

In order to promote self-sufficiency for the Kayunga and Mukono districts in terms of HIV laboratory monitoring, MUWRP renovated and equipped the Kayunga District Hospital laboratory. MUWRP also provided a rural energy solution, training and task shifting for lab techs, and a full-time QA/QC staff support supervisor. Starting in FY 2007, this laboratory began processing and providing results for all HIV samples from MUWRP-supported HIV clinics, including haematology, chemistry, CD4, and syphilis tests. Except for the cost of reagents and the QA/QC staff, this laboratory is largely self-sufficient. As CD4s are not considered to be the best indicator of treatment failure, MUWRP began to support routine viral load testing in FY 2009 for all ART patients who had been on ART for more than six months. During FY 2010, MUWRP converted an underused research laboratory into a regional QA reference laboratory with the capacity to test viral loads. This additional service has led to policy changes and patients being switched to second line drugs. In FY 2011, MUWRP began routine resistance testing for any ART patient who is under consideration for second line treatment. The QA reference laboratory conforms to all principles of GLP. Furthermore, monthly comparability runs are conducted between the field laboratories and MUWRPs research laboratory in Kampala. Both the hospital and reference laboratories are enrolled with the UK NEQAS Program, which sends bimonthly EQA samples to the UK for chemistry, haematology, and flow. All panels have been passed as satisfactory by both labs. All of the services listed above will continue in FY 2012. MUWRP will continue to buffer laboratory reagents/consumables, maintain and repair laboratory equipment, and provide in-service trainings for GCLP, Flow cytometry, malaria microscopy, and TB diagnosis. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. As a result of this, the number of HIV+ patient samples will double and MUWRP will support two additional HIV processing laboratories at (1) the Nagalama Hospital and (2) the Mukono Health Center IV. Quality management systems will be strengthened in these new laboratories, staff will be trained, appropriate systems will be put into place, and QA/QC services will be introduced, including enrolment into EQA programs. A FACS Calibur CD4 machine and a Cobas integra 400 plus machine will be needed to accommodate the increase in patient samples. To further basic laboratory strengthening, MUWRP plans to develop the capacity of the laboratories. Firstly, TB and MDR TB diagnosis will be improved by acquiring a TB GeneXpert machine, and a fluorescent TB microscope, and creating a designated TB testing area at the Kayunga District Hospital. Secondly, in FY 2012, the capacity of its reference laboratory at Ntengeru will be expanded to include ELISA confirmatory testing and QC for chemistry testing. The capacity of all the other MUWRP supported laboratories will be improved to include: Hep B and Hep C rapid tests, the Serum cryptococcal antigen test, the Toxoplasma gondii latex agglutination test, malaria rapid diagnostic tests, and pregnancy tests for MUWRPs new PMTCT program. MUWRP is now starting to work towards accreditation of the laboratories in the program, following ISO 15189 standards, and will continue to improve laboratory quality standards.

Since FY 2006, MUWRP has supported the development and acquisition of tools for its district partners to enable them to collect data from patient clinics, and to report required PEPFAR indicators. MUWRP has provided computers, training, and internet access to six district health officials and to the Kayunga District Hospital. This has allowed for easy electronic communication between stakeholders; the electronic reporting of required health indicators from the district HMIS focal person to the Uganda Ministry of Health; and the electronic filing of drug and commodity reports/requests within the National Medical Stores by logistic managers. In 2008, MUWRP supported the implementation of a District Health Information System (DHIS) with the Kayunga district health authorities. This system has served as a model for other districts in Uganda. In order to facilitate the DHIS, MUWRP supported computer engineers to come to Uganda and customize a district-based HMIS program/database. As a result, the district HMIS focal persons can capture all district health indicators and transfer them electronically into Ministry of Health. Also beginning in FY 2008, MUWRP has offered continuous data QA/QC services and HMIS technical support to all of its supported health units. In FY 2009, the MUWRP SI team collaborated with the Safe Male Circumcision program to design and implement a circumcision ledger tool, which greatly reduced the paperwork burden for clinicians, but still captured all of the WHO-recommended circumcision indicators. This tool is now used effectively at all MUWRP circumcision sites. In FY 2011, MUWRP customized and implemented an electronic medical records (EMR) system at the Kayunga District Hospital. The EMR is now fully operational and links all patient data (including clinical, laboratory, pharmacy, radiology, appointments, visits, and other departments) into one electronic record. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. As a result of this, the number of HIV+ patients within the MUWRP catchment area will double. MUWRPs SI support for these districts/health units will continue as described above (provision of computers, internet, weekly SI QA/QC supervision etc.) and as per the established MUWRP M&E plan. This plan includes rolling out routine M&E to district-based programs, and also contains a provision for training selected data managers in SQL database development and analysis. MUWRP will continue to work throughout each of the districts in FY 2012 to offer assessment, HMIS-related trainings, essential HMIS tools, quarterly off-site supportive supervision, and quarterly review meetings to monitor the submission of reports and encourage data usage. Furthermore, MUWRP will assist Kayunga, Mukono and Buvuma districts to roll out the recently revised HMIS tools and to adopt the DHIS. In an effort to reach out to MARP/stigmatized populations on Lake Victoria, MUWRP will conduct mapping of the Kome and Buvuma Islands in FY 2012. Finally, in FY 2012, MUWRP will implement an EMR system at the Nagalama Hospital. This EMR will be similar in scope to the program that has been successfully established at the Kayunga District Hospital.

In FY 2009, MUWRP implemented Uganda's first non-research VMMC program at the Kayunga District Hospital. The program launch included a remodeling of a minor surgical theatre for performing VMMC surgeries. MUWRP developed program policies, procedures and quality assurance guidelines, all in accordance with WHO guidance. Data from the first 315 service recipients was analyzed as part of a basic program evaluation (BPE). The data showed levels of patients very satisfied at > 85%, minor adverse events at < 1%, and zero HIV sero-conversion after one year. After the BPE, MUWRP developed a VMMC ledger tool, which greatly reduced the paperwork burden for clinicians, but still captured all of the WHO-recommended VMMC indicators. In FY 2010, MUWRP launched a second VMMC program at the Kojja Health Center IV, and was mandated to establish a second National VMMC Training Center. Since its establishment, more than 250 clinicians have completed the comprehensive two-week training. Through the training center, MUWRP teaches the implementation of VMMC methods such as the forceps-guided surgical technique, electro-cautery, and the MOVE Model. During FY 2011, in an effort to provide VMMC services to MARP fishing populations along the shores of the Nile River and Lake Victoria, MUWRP designed and implemented a VMMC mobile clinic. MUWRP also launched a third VMMC fixed site at the Mukono Health Center IV in FY 2011. After the launch, MUWRP conducted a VMMC camp which provided safe, comprehensive services to over 1,200 males in two weeks. In FY 2012, the MUWRP VMMC program will continue to safely reach more service recipients, and through its Training Center, will teach innovative staffing and surgical techniques to VMMC service providers. Before and after clinicians are trained, MUWRP staff visit them to confirm that they are an appropriate investment, and that training goals have been realized. To ensure the continued scale up and roll out of VMMC in Uganda, MUWRP will continue to provide VMMC technical support to the MOH and to VMMC technical working groups. Additionally, the MUWRP VMMC training center has drafted a curriculum that will shorten the two-week VMMC training to just one week. Plans are underway to incorporate MUWRPs mobile clinic into a mobile surgical camp setting, using customized tents and collapsible equipment. Using this infrastructure, MUWRP plans to increase mobile services to MARP populations on island communities, as well as to begin conducting satellite and mobile trainings for service providers. MUWRP will continue to provide safe, comprehensive VMMC services, which always include: (1) HIV testing and counseling, (2) pre- and post-operative sexual risk reduction counseling, (3) assessment and/or treatment of STIs, (4) family planning/condom use counseling, (5) counseling pertaining to the need for abstinence from sexual activity during wound healing, (6) wound care instructions, and (7) post-operative clinical assessments and care. Of paramount importance to MUWRP is an efficient program that yields low marginal costs. This is made possible by securing strong buy-in from district and national health officials, as well as religious/opinion/political leaders; and strong messaging, mobilization, and community education components within the program.

As part of an expanded MUWRP PEPFAR program in FY 2007, a HIV prevention program was inaugurated, which has coordinated Sexual Prevention Abstinence/Be Faithful (AB) activities in Kayunga district. Since that time, district residents have been routinely exposed to HIV prevention messages promoting abstinence, including the delay of sexual activity or secondary abstinence; fidelity; reducing multiple partners and concurrent partners; and related social and community norms that influence these behaviors. These messages are disseminated through radio, marketplace loudspeakers, standardized IEC materials, posters, eight billboards, weekly drama presentations (including competitions), health fairs, and sporting events. Services have been especially tailored to reach underserved/at-risk youth populations, both those in- and out-of-school, as well as those living in high risk fishing villages along the river Nile and at the inlet to Lake Kioga. MUWRPs (AB) program has trained and supported volunteers and district lay workers, including 1,200 treatment club members, and 70+ dedicated youth volunteers to carry out the AB prevention activities described above. In addition to AB messages, these lay workers concentrate on male norms/behaviors, increasing gender equity, cross generational sex, and increasing womens legal rights and access to income -including life skills as they are related to HIV prevention. MUWRPs AB program additionally supports the infrastructure and activities of a vibrant and well-attended youth center, the Kayunga District Youth Recreation Center (YC). In partnership with the US Peace Corps and the Kayunga Town Council, MUWRP supports the YC to be a place of recreation and education for young people, ensuring that they are provided with an array of health related and life-skill services. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. As a result of this, the target population for MUWRPs AB services will dramatically increase and include many more isolated MARP populations on Lake Victoria islands. MUWRPs AB programs for these districts will continue as described above (use of various media, IEC materials, etc.). MUWRP will continue to target in- and out-of-school youth through community and school outreach programs and via the YC (focusing on abstinence-only for those under age 15, and abstinence and faithfulness for age 15-17) . MUWRP plans to utilize the newly built basketball court at the YC to teach AB health promotion through supporting a multi-district basketball league. Human resources for MUWRPs AB program relies on the annual training of peer educators, who start as volunteers at the YC and train to become full-time community outreach workers, under the strict supervision of MUWRPs HIV Prevention QA/QC Coordinator. Under his supervision, all of MUWRP prevention programs are monitored, analyzed, and evaluated to determine if the program has realized its designated goals. Finally, MUWRPs AB program will partner with the ARTIVISTS group in FY 2012. ARTIVISTS are a newly formed group of dynamic young artists from Makerere University who will conduct bi-weekly dance, drama and art sessions with youth throughout the three MUWRP districts. The ARTIVISTS focus on AB messaging, creating different media forms (especially mural messages on buildings), and the reduction of HIV transmission among youth caused by traditional male norms.

During FY 2011, MUWRP supported comprehensive HTC services for more than 25,000 persons. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. As a result of this, the number of persons requiring MUWRP-supported HTC services will double. The program supports the following HTC programs: provider-initiated (routine at all MUWRP supported clinics, including X-ray, dental, and in- and outpatient wards), client-initiated, couples testing, VMMC, PMTCT, and special events/HTC campaigns throughout 40 health units. Special target populations in MUWRPs HTC program include: fishing villages along the River Nile and island communities on Lake Victoria, youth, alcohol users, and CSWs and their partners. The proportional allocation of MUWRP HTC funding to each target area are as follows: VMMC 12%, MARPs 22%, PWP 4%, and Youth 13%, HIV prevalence in the MUWRP catchment area is 6-7%; however, among MARPs it is as high as 27%. Due to sporadic availability of commodities in Uganda, MUWRP always provides supply chain management technical assistance (TA) and back-up commodity supplies to all of the HTC sites/programs. Funds are also used for training, staffing, transportation, supportive supervision, sub-contracts, and ongoing TA in the areas of service delivery. The Uganda MOH HIV testing algorithm (Determine, Stat Pak, and Uni Gold-as a tie-breaker) is employed for all HIV tests. For those few individuals whose results are still inconclusive after undergoing the MOH algorithm, a blood sample is sent to the MUWRP research laboratory in Kampala for an both an ELISA and a Western blot test. This program heavily focuses on strengthening the linkages to HIV clinics, especially for mothers who test HIV+ through PMTCT programs, for TB patients, and for those who tested HIV+ through the recently ended house-to-house HTC program. Program staff routinely return to the homes of individuals who test HIV+ to ensure that they follow up with facility-based care and treatment. MUWRP supports expert patients who trace LTFU patients to their homes, and also supports an active discordant couples group, which meets quarterly, with an emphasis on prevention with positives. For the purposes of quality control, two processes take place monthly within the program: (1) DBS from all clients who test HIV+ as well as from 2% of the HIV- clients are collected and sent to a reference lab for retesting, the results of which are compared with the field results; and (2) quarterly testing of quality control samples prepared in the lab are distributed to the HTC staff and their results are compared with the known results; thus, staff competency is routinely ascertained. Routine monitoring and evaluation of all data from the HTC program have informed program policy at the district level and driven MUWRP program policy to expand program services to clearly identified MARPs, especially fishing communities and youth. Promotional activities to reach all of the HTC target populations include billboard advertising, marketplace announcements, posters, drama presentations, and sporting events. All HTC services, despite the program, are provided by either trained/tested/monitored para-professionals or clinical staff. During FY 2011, MUWRP supported the re-training of 70 HTC staff and eight new staff. Ongoing supportive supervision is provided by a full-time MUWRP HTC technical specialist.

As part of an expanded MUWRP PEPFAR program in FY 2007, a formal HIV prevention program was inaugurated, which has provided Kayunga district Other Prevention (OP) activities and coordination. The most important focus of this program has been to ensure 100% condom availability to residents, through coordinated and omnipresent distribution coupled with condom demonstration outreaches. Also since FY 2007, district residents have been routinely exposed to HIV prevention messages and interventions including: sexual and non-sexual HIV transmission, post-exposure prophylaxis (PEP), positive living, reproductive health services, stigma and discrimination, HIV violence and gender issues, traditional male norm issues, and the availability/locations of ART. These messages are disseminated through radio, marketplace loudspeakers, standardized IEC materials, print, posters, eight billboards, weekly drama presentations (including drama competitions), health fairs, and sporting events. Services have been especially tailored to reach underserved/at-risk communities, such as out of school youth and high-risk fishing village youth populations along the river Nile and at the inlet to Lake Kioga. MUWRPs OP program has trained and supported volunteers and lay workers, including 70+ dedicated youth volunteers to carry out the OP prevention activities described above. In addition to OP messages and counseling (one-on-one, or groups < 25), these lay workers concentrate on gender equity, cross generational sex, and increasing womens legal rights and access to income and productive resources as they are related to HIV prevention. In FY 2009, MUWRPs OP program began evening outreach to the specific MARP populations of alcoholics, commercial sex workers and their clients, and bar maids. These outreaches include condom demonstration and distribution. Also beginning in FY 2009, MUWRPs OP program supported the purchase and implementation of incinerators for four health centers. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. As a result of this, the target population for MUWRPs OP services will dramatically increase and include many more isolated MARP and transient populations on Lake Victoria islands. MUWRPs OP programs for these districts will continue as described above. As MUWRP expands, efforts will specifically focus on strengthening condom dissemination to ensure that condoms are available at each new health center (levels II, III, and IV), hospital, hotel, bar, police installation, and fishing community. PEP trainings and initiating a PEP referral system for youth and all health centers in the new MUWRP districts will occur in FY 2012. Human resources for MUWRPs OP program relies on the annual training of peer educators, who start as volunteers at the Kayunga District Youth Recreation Center and train to become full-time community outreach workers, under the strict supervision of MUWRPs HIV Prevention QA/QC Coordinator. Under the Coordinators supervision, all MUWRP prevention programs are monitored, analyzed, and evaluated to determine if the program is realizing its designated goals. Finally, MUWRPs OP program will partner with the ARTIVISTS group in FY 2012. ARTIVISTS are a newly formed group of dynamic young artists from Makerere University who will conduct bi-weekly dance, drama and art (three in one) sessions with youth throughout the three MUWRP districts.

FY 2012 will be the first year that MUWRP implements a PMTCT program as part of its HIV/AIDS portfolio. MUWRP employs a PMTCT coordinator/mentor, who is already working with PMTCT implementers and partners. The MUWRP PMTCT program will be decentralized and supported at hospitals and health centers (levels II through IV) throughout the Kayunga, Mukono and Buvuuma districts. The locations of clinics serve large MARP fishing communities along the River Nile and Lake Victoria islands. Since MUWRP implements a comprehensive HIV program in all three districts, the PMTCT program will be easily integrated among other MUWRP program areas, especially: RH, SI, HTC, lab, care and treatment, food/nutrition, and HIV prevention among women of reproductive age. In order to transition to local ownership, some of the PMTCT services will be maintained through carefully monitored district-based cooperative agreements. The goal of MUWRPs PMTCT program is to ensure HIV-free survival of infants and AIDS-free survival for mothers. This will be accomplished by enhancing the following services: primary prevention, PITC, prevention of unwanted pregnancies among HIV-infected women, ARVs for HIV-infected pregnant women, and full support services for HIV+ mother-infant pairs. The program will also support tracking mothers to their homes, and dried blood spots for exposed infants with a result turnaround time of less than 11 days. For HIV+ mothers, the program will include mother kits and the establishment of a referral system for those who reside far from where they were tested or delivered. HIV+ mother-infant pairs will be provided the most effective ARV regimens (Plan B), and access to Hb/syphilis/ CD4/viral load laboratory testing. This support will also be extended to their non-infected children and partners as needed. To increase PMTCT uptake, the program will include components of male involvement, gender-based violence trainings with police, provision of job aides, couples CT, community mobilizations, advocacy among political and religious leaders, and the availability of lights, beds, and trained clinicians at each MUWRP-supported PMTCT site. In order to build PMTCT capacity, MUWRP will ensure that PMTCT training is facilitated for all relevant clinicians, as well as trainings in EID, data, and logistics management. An integral part of MUWRPs package will involve nutrition and feeding activities, in both clinical and outreach PMTCT settings. Specifically it will support the provision of plum peanuts, and a staff nutritionist position. The nutritionist will assess mothers and guide them on infant and child feeding, as well as demonstrate essentials such as breastfeeding and the termination of weaning. MUWRPs community approach will link not only the static centers, but also the village health teams for the purposes of training them to: (1) identify pregnant women, (2) refer pregnant women to static sites, and (3) inform MUWRP when the mother has delivered for follow-up purposes. All of MUWRPs programs are data-driven, as expressed in MUWRPs overall M&E plan. Provision of M&E tools will be supported and PMTCT data will be analyzed and monitored for data quality, service quality, and effectiveness. These assessments will instruct the Program on when adjustments are needed at any of the PMTCT sites.

Through FY 2011, the MUWRP Adult Treatment program has supported HIV treatment services for all HIV clinics in Kayunga district (including one specifically for youth between 18-25 years) and three HIV clinics in Mukono district. M&E data show that the rate at which adults have sought HIV treatment through MUWRP-supported clinics continues to rise as a result of: (1) RCT, (2) renovated clinics, (3) ART availability, (4) MUWRP expansion, and (5) referrals from MUWRPs house-to-house HCT program. In FY 2012, MUWRPs coverage area will significantly expand to include all of Kayunga, Mukono and Buvuma districts. As a result of this, the number of HIV+ patients within the MUWRP catchment area will more than double. MUWRPs treatment program in FY 2012 for these districts/health units will continue as described below. In order to transition to local ownership of ART service delivery, programming will be accomplished through carefully monitored district-based programming cooperative agreements. The locations of the clinics serve large transient fishing communities along the River Nile and Lake Victoria islands. The program links to other program areas, especially SI, CT, lab, and care. MUWRPs treatment package includes ART provision, cotrimoxazole prophylaxis, and 100% TB screening. MUWRP has already taken steps to implement a pilot cervical cancer screening program at Kayunga and Nagalama Hospitals. Since 2005, MUWRP has remodeled five HIV clinics to allow for better patient flow, open-air waiting spaces, and confidentiality. In FY 2012, MUWRP will be remodeling two additional HIV clinics, the Busana Health Center III and the Kome Island Health Center III. Each year, MUWRP sends all clinicians at supported HIV facilities and NGOs (95 per year on average) to attend an MOH directed refresher course on comprehensive (pre-service and in-service) HIV services. In FY 2011, MUWRP sent 40 clinicians to continuous quality improvement training. Each week, MUWRPs mobile clinical team (four clinicians, one data manager) visit all supported HIV clinics to provide mentorship and support supervision. Due to expansion, MUWRP will support two additional HIV processing laboratories in FY 2012, the Nagalama Hospital and the Mukono Health Center IV. To improve TB/ MDR TB diagnosis, MUWRP plans to acquire a TB GeneXpert machine and a fluorescent TB microscope; and to create a designated TB testing area at the Kayunga District Hospital. Additionally in FY 2012, MUWRP intends to develop the OI diagnostic capacity at supported laboratories to include: serum cryptococcal antigen test, the Toxoplasma gondii latex agglutination test, malaria rapid diagnostic tests and pregnancy tests for MUWRPs new PMTCT program. In FY 2011, MUWRP implemented an electronic medical records (EMR) system at the Kayunga District Hospital which links all patient data, including clinical, laboratory, pharmacy, radiology, appointments, visits and other departments. In FY 2012, MUWRP will implement the same EMR system at the Nagalama Hospital. MUWRPs model includes the training of patients to deliver (with compensation) following-up of lost-to-follow-up (LTFU) patients to their homes. Data from the LTFU program shows that the LTFU rate in 8out of 9 MUWRP supported clinics is extremely low. Routine monitoring and evaluation data from this successful LTFU cohort has been presented at three international conferences.

In FY 2011, the MUWRP pediatric treatment program supported HIV treatment services for 240 pediatrics aged 0-15 years (46 new patients in 2011 and 357 ever enrolled). Services are offered at nine HIV clinics, including one specifically for youth. In FY 2012, MUWRPs coverage area will significantly expand, and as a result, the number of HIV+ pediatric patients within the MUWRP catchment area will more than double. MUWRPs pediatric treatment program will continue as described below throughout FY 2012. In order to transition to local ownership and sustainability of ART service delivery, programming will be maintained through district-based cooperative agreements that will be carefully monitored by MUWRP. As they become mandated, MUWRP will support the local government in rolling out updated pediatric treatment guidelines. The program targets HIV exposed infants, and HIV infected children and adolescents residing within Kayunga, Mukono or Buvuuma districts. Services to this target population are very strongly linked to other program areas within MUWRPs comprehensive HIV program, especially: PICT, OVC, SI, lab, and pediatric care. Through these linkages, MUWRP ensures that pediatric HIV+ clients receive a wide range of services, including early infant diagnosis, prevention and treatment of OIs (including malaria and diarrhea), ITNs, water vessels, lab tests, social services (including ARV counseling for adolescents and support in transitioning to adult services), and pain relief; and for pediatrics with low BMI, a food by prescription program. Since 2005, MUWRP has remodeled five HIV clinics to allow for better patient flow, open-air waiting spaces, and confidentiality. In FY 2012, MUWRP will be remodeling two additional HIV clinics: the Busana Health Center III and the Kome Island Health Center III. Each year, MUWRP sends all clinicians at its supported HIV facilities and NGOs (95 per year on average) to attend an MOH-directed refresher course on the delivery of comprehensive (pre-service and in-service) HIV services. In FY 2011, MUWRP sent 40 clinicians to attend Continuous Quality Improvement training. Each week, MUWRPs mobile clinical team (which includes a clinical officer and a nurse specifically designated for pediatric patients) visits all supported HIV clinics to provide mentorship and supportive supervision. To improve TB/ MDR diagnosis in FY 2012, MUWRP plans to acquire a TB GeneXpert machine and a fluorescent TB microscope; and to create a designated TB testing area at the Kayunga District Hospital. Additionally in FY 2012, MUWRP intends to develop the OI diagnostic capacity at supported laboratories, to include malaria rapid diagnostic tests, and pregnancy tests for MUWRPs new PMTCT program. CD4 laboratory results for pediatric HIV+ patients are always reported as a percentage. All HIV+ pediatrics are monitored for treatment failure/regimen switching by routine viral load testing, and on a case-by-case basis, resistance tests. In FY 2011, in collaboration with the USG-Uganda national program, MUWRP implemented an electronic medical records (EMR) system at the Kayunga District Hospital, which links all pediatric patient data, including clinical, laboratory, pharmacy, radiology, appointments, visits and other departments. In FY 2012, MUWRP will implement the same EMR system at the Nagalama Hospital. M&E data from MUWRPs lost-to-follow-up program shows that adherence among pediatrics is > 95%.