Research Triangle Institute (RTI Intl) is an international,independent not-for-profit organization dedicated to improving the human condition through multidisciplinary technical assistance,training and research services that meet the highest standards of professional performance.RTI was awarded this project in November 2008 to support the Uganda Peoples Defense Forces to improve access to and utilization of quality HIV-related services by the military and their families.The primary objectives of the project include:Improving knowledge of HIV sero-status among soldiers and their families;Strengthening prevention of mother-to-child transmission(PMTCT) of HIV among military families;Strengthen basic and specialized care and treatment of HIV infected soldiers and dependants; Improve diagnosis and management of TB-HIV co-infection among military families;and Support mitigation of HIV impact for orphans and vulnerable children(OVC) in military families. For the past three years,RTI has provided comprehensive support in various aspects of HIV programming to 10 core and other military health facilities across the country.In FY2012,RTI will additionally support the scale up of safe male circumcision as part of the comprehensive HIV prevention package.Our support will focus on activities that strengthen systems to further build the institutional capacity for sustainability.We will promote quality service delivery by emphasizing capacity building through in-service training and technical support to the different HIV program areas to improve providers knowledge and skills;strengthening commodities supply chain management,and close monitoring of performance of the supported facilities.The target population and numbers to be reached in FY2012 are listed under each budget area code.

In FY2011, RTI expanded its support from 6 to 10 UPDF health facilities from Northern, Eastern, Western and Central Uganda, increasing access to comprehensive HIV care and support services by HIV-positive patients of all age groups in the supported facilities. The support provided include remodeling of ART clinic space, supply of furniture and basic equipment for patient management, supporting baseline CD4 testing collection, transportation of blood samples to the reference laboratory, Septrin supplementation to minimize stock-outs, and instituting quality improvement measures in service delivery. Four ART clinics were remodeled and equipped with furniture for patients and clinicians and all ART clinics for the 10 supported facilities received basic equipment for patient care. By August 31st, 2011, 316 new HIV+ clients had been enrolled at the 10 supported facilities and a total of 4,214 patients were enrolled on HAART.

In FY2012, the project will continue to provide support to the 10 military facilities across the country focusing on institutional capacity building and systems strengthening in order to consolidate achievements made in FY2011. Remarkable improvement has been made in the past year in increasing both access to comprehensive HIV care and support services, and in the quality of patient management. However, routine performance assessments done during technical support visits showed gaps in linkages between diagnosis and chronic care and patient retention into care and adherence to treatment. In view of this, our support in FY2012 will focus on: i) strengthening linkages between diagnosis and chronic care through improved patient referral from HCT, PMTCT, TB, OVC and other Health service delivery points within and outside the facilities 1620 new patients will be enrolled in chronic care, and 648 adults and children with advanced HIV will be enrolled on HAART; ii) strengthen adherence monitoring and counseling by the health care workers in the ART clinics of all the 10 supported facilities health care providers will be re-oriented on adherence monitoring and counseling, and routine supportive supervision. The project will also support the establishment and running of two satellites ART clinics for troops in hard to reach areas that are currently receiving their treatment from Mubende and Moroto. iii) Scale up number of clinician and nurses teams who take short courses in HIV chronic care, with special focus on pediatric HIV care. 60 health workers will be trained to bridge the knowledge gap resulting from transfer and recruitment of new health workers. To further bridge the existing human resource gaps in the facilities, we will continue to support the use of a minimum of 4 volunteer health workers and/or PHAs per target facility to provide counseling, psychosocial support and helping patients to develop sexual behavior, care and treatment plans in order to prevent HIV transmission and improve adherence

One of our project objectives is to support the mitigation of HIV impact for orphans and vulnerable children (OVC) in military families. In FY2011, OVC support focused on building the Institutional (UPDF) capacity to provide care and support to OVCs living within the military bases. Activities undertaken by the RTI team include the establishment of OVC implementation committees and focal persons in two facilities (Kakiri and Mubende), and training 27 committee members on OVC programming, care and support. Through OVC implementation committees, the project identified and enrolled 264 OVC households for support. All enrolled households received support in at least 3 core program areas (health, nutrition and food security, education, and social economic security) as well as receiving psychosocial support for both caregivers and enrolled children. In FY2011, RTI supported the training of OVC caregivers from all 264 supported households on parenting, caring and supporting OVCs. Caregivers were also trained on vegetable and cereal growing to improve on their crop yield.

In FY2012, RTI will consolidate achievements made FY2011 in the two currently supported military facilities, while scaling up to two more facilities in Northern and Eastern Uganda. The two new facilities will be selected based on the number of OVCs living within the bases, and on their level of vulnerability. The 264 OVC households supported in FY2011 will be maintained with an additional 86 households enrolled from the two new facilities, to make a total of 350 OVC households receiving project supported. Activities will focus on further building the capacity of OVC caregivers to effectively provide care and support for OVCs, as well as building the skills of the UPDF staff/facility OVC implementation committees for improved implementation of OVC programming. For example, to further build OVC caregivers capacity to support OVCs, RTI will conduct 3 day training for the 86 newly identified caregivers. Training will focus on building caregivers knowledge and skills on; child development and needs, good parenting and guardianship, how to communicate with children, Child Rights and Abuse, and child support systems. Lessons will focus on increasing caregivers understanding of their roles in supporting the different categories of vulnerable children and the role of the government, local leaders and at of implementing partners in providing additional support. The project will work with the UPDF administrative and social welfare structures to reach new OVC households, building institutional capacity to run and monitor OVC support activities by empowering the units OVC implementation committees and the social workers (OVC focal) persons. RTI will continue to provide core support to OVC households, emphasizing activities that encourage self reliance and sustainability. The project will continue to determine the program areas and actual support package based on individual OVC household current needs, and work to establish linkages and collaborations with other OVC implementing partners and related national programs in communities around the barracks to increase synergy and to leverage additional resources.

In FY 2011, RTI supported TB/HIV co-infection service in 10 military health facilities. The support activities mainly aimed at promoting early TB detection and treatment among HIV infected patients. By August 31, 2011, close to 4214 HIV- positive patients had been screened for TB and 228 new TB patients started on TB treatment. To further build capacity of health workers to effectively manage TB/HIV co-infected patients, RTI targeted and trained 45 lower cadre health care workers (clinical officers and nurses) on TB/HIV collaborative activities..

During FY 2012, RTI will continue to support efforts that provide cross-referral and integrate diagnosis, treatment and support services for TB and HIV in 10target military facilities across the country. HIV-positive individuals will be actively screened at initial diagnosis and during follow up at chronic care clinics and the TB positives treated. The program will also promote provision of HIV counseling and testing to all patients in the TB clinics. RTI will further build the capacity of health care workers from the 10 military facilities to better understand policies and guidelines for integrating TB/HIV interventions - 100 health workers will be reached with in-service training on TB/HIV co-infection. This will lead to better management of TB/HIV co-infected patients, to maximize TB case detection, increase treatment completion rates and ART literacy. In addition the project will continue to support the implementation of the national Intensified Case Finding strategy within the target military health facilities. TB Infection control measures in HIV care settings will be enhanced through literacy campaigns for patients and health workers, triage of symptomatic patients and enhanced TB case-finding. RTI will collaborate with MOH/NTLP to ensure a constant supply of TB drugs, and ARVs to TB/HIV co-infected patients. Furthermore, the project will collaborate with NTLP to roll out the revised national TB/HIV treatment guidelines, infection control and MDR-TB guidelines to all support UPDF facilities.

The goal of the pediatric HIV care and support program is to extend and optimize quality life for HIV infected children of military families and surrounding communities, through the continuum of illness by provision of clinical, psychological, spiritual, social and prevention services. The services are provided using mainly the facility based approach, in 12 ART accredited centres. RTI continued to build the capacity of UPDF health workers in pediatric care management through trainings. A total of 20 health workers were trained in specialized pediatric HIV care and treatment from 10 clinics. This enhanced health workers skills and knowledge in providing pediatric care. RTI staff conducted follow ups on trained health workers to assess the progress made on pediatric HIV care integration and providing on site mentorship and technical support. RTI will continue to provide supplemental pediatric septrin formulation buffer stock in all supported clinics.

In FY 2012, RTI will continue its support to provision of comprehensive pediatric HIV care services to all facilities among the Ministry of Health accredited ART centres. The program will support referral of blood samples for HIV positive children for CD4 testing and timely return of results. Short courses for clinical officers and nurses in pediatric care and treatment will be conducted and be given special emphasis. RTI will work in collaboration with the MOH-ACP to distribute the pediatric HIV care and treatment guidelines and job aids to all health workers involved in pediatric HIV care and treatment.

All new health care workers in the supported health facilities and in the two new facilities will be trained to provide facility-based palliative care and /or referral for further assessment and specialized care for HIV+ children. Refresher training and technical support supervision will be provided as needed to ensure quality delivery of Palliative Care services for children. In order to minimize stock-outs, RTI will support health unit staff in forecasting and requisition for the right amounts of drugs and other basic care supplies.

In FY 2011, NAMERU was involved in the development of human capacity in the HIV clinic data collection, management and reporting. A total of 28 data managers were trained , and all required data capturing and reporting tools were provided to all supported health facilities. They aimed at setting up a functional paper based HIMS that can accurately and timely report relevant data according to national and PEPFAR reporting needs. Computer based data management with internet reporting was introduced in all supported health facilities. A data base has been introduced and they are testing out an electronic data based system.

In FY 2012, NAMERU will aim at transforming all the paper based medical records into an electronic form. A core support team will be trained in electronic data base management so that these can offer on-job training of the UPDF data clerks and health workers. They aim at launching a functional integrated internet based HIMS where data from all clinic sites can be accessed by the data managers at the center.

In FY2011, UPDF provided MC services at 4 static sites namely- Bombo, Gulu, Mbarara, and Katabi, circumcising about 700 men. Male circumcisions is highly acceptable among uniformed men however service delivery is limited by human resources, commodities availability, and administrative and other structural issues that influence uptake of MC.

In FY2012, RTI will provide technical support to the UPDF team to scale up MC services. UPDF MC implementation strategy will been redesigned with the aim to: 1) Increase uptake of MC up to 80% of all eligible males in the UPDF, by utilizing static and mobile MC service delivery teams; 2) Provide MC as part of comprehensive HIV prevention package that includesrisk reduction, increased condom use, reduction in the number of sexual partners, early identification and treatment of sexually transmitted infections, and prevention for positives and; 3) Provide linkages to care and treatment for PLHWAs identified during the MC campaigns.

The program will primarily target men aged 15 49 years, to include UPDF staff, their dependents and civilians. MC will be provided for only eligible males who voluntary consent for the surgical procedure. MC service delivery will be expanded to two more static facilities and three mobile teams that will cover military personnel in underserved hard to reach areas across the country.

In order to increase demand, RTI will work hand-in-hand with the UPDF Medical Directorate, MOH and DOD/PEPFAR MC members to sensitize and solicit support from UPDF leadership to take a lead in the communication and mobilization of the uniformed men for MC services. There will be a high level of planning and coordination for MC activities so that uniformed personnel are available at the time when the services are offered, and are given time-off after surgery, including some days of light duty, 1-2 weeks after surgery. The MC site coordinators, UPDF health care providers and peer educators will reach the target population with MC messages during ongoing routine HIV prevention education activities, and through MC specific mobilization activities.

In order to ensure quality, MC clinical protocols and guidelines will be provided to ensure that teams offer services based on the recommended national and international standards; standard surgical approach that is simple, safe and effective, requiring minimal specialized skills will be adapted to reduce the probability of complications and to allow appropriate task-shifting to health-care cadres with lower qualifications and; team will be support supervised once every three months during which the providers performance will be assessed based on a standard quality checklist and onsite feedback and mentorship will provided. Through this effort a total of 24,840 men will be circumcised in FY2012.

In FY 2011, NAMERU implemented an injection safety program in all the 14 UPDF supported health facilities and will seek to build on this for sustainability and consolidation.

The program has so far trained a total of 740 UPDF health works and medical waste handlers in 14 UPDF health facilities. NAMERU has ensured a consistent supply of injection safety materials such as single use syringes, personal protective equipment, safety boxes, medical waste bins and waste paper bags. They have reprinted and distributed National Policy and Guidelines to all health workers and facilities. Also provided are Information, Education and Communication materials to reinforce behavior change.

During FY 2012, NAMERU will continue to support injection safety program in the following area;

Trainings- Refresher trainings will be arranged for all the health workers and medical waste handlers at the 14 UPDF health facilities. Trainings will focus on safe blood drawing procedures, proper handling of medical waste and the general principles of minimizing medical transmission of HIV/AIDS in particular and blood-borne diseases in general.

Promotion for behavior change will be emphasized and all necessary IEC materials will be printed and displayed in all supported facilities. In addition, Ministry of Health Guidelines and standards for injection safety and proper medical waste management will be provided.

Supply of injection safety materials will be maintained in all the supported health facilities. In addition every supported health facility shall offer Post Exposure Prophylaxis services and that a log of all occupational and other exposure occurrences is kept. Every supported health facility will have a designated PEP focal person who will offer a comprehensive PEP package including counseling, testing and drugs.

During FY2011, RTI supported behavior change activities in 10 target military facilities in the different parts of the country. The activities targeted in-school male and female youth between the age of 10 -14 years mainly pupils in the upper primary school; in-school and out-of school youth between the ages of 15- 24 years, and; Adults 25+ years mainly uniformed personnel and their partners. Behavioral change message were disseminated through small dialogue meetings of 20-25 people. A total of 7,798 individuals were reached with ABC messages and 5,781 with A only messages during FY2011.

In FY 2012, RTI will continue to support sexual prevention activities for behavior change in all the 10 target military facilities and the Mobile MC unit. The project will target adolescents in and out of school in the age groups 10 -14 years and 15- 24 years, and adults 25+ years mainly the uniformed personnel and their partners. School going youths from upper primary level through secondary schools will be reached at school by health care providers from the military health facilities in collaboration with school teachers who received training in abstinence and being faithful (AB) information dissemination approaches. Out of school youths and adults will be reached through small group community dialogue meetings and health education sessions organized in collaboration unit commanders and welfare officers. Similar to those organized in schools, participation in each meeting will range between 20-25members. Each of the 10 health facilities will conduct at least 1 outreach per week, each one of the categories will be targeted every month. The facilitators involved in the dissemination of information will receive orientation to update their knowledge on AB information dissemination and will receive a package of materials to use in the dialogue meetings in order to standardize the information to be disseminated. Project staff will conduct regular monitoring activities including sit-in sessions, exit interviews to participants and program review of field activity reports to ensure the program is implemented effectively. This activity proposes to reach 10,000 individuals with AB messages while A only will reach 3300.

The projects primary target population is soldiers and their families, however civilians in the catchment area of the supported military health facilities are also served. Using both provider-initiated and client initiated approaches, close to 24,000 individuals (both military and civilians) have been counseled and tested, receiving their results at one of the 10 military service outlets supported by the project in the past 12 months. The project staffs have provided technical support supervision to health workers in all 10 project health facilities as well as through Mobile HCT. Health workers performance has been assessed, and gaps addressed through onsite mentorship, Continuing Medical Education sessions, and technical support. In the last 12 months the project has conducted 5 days of training on RCT/BC for 240 health workers from 14 military health facilities across the country. To minimize periods of stock out, RTI regularly supplemented HIV testing commodities.

In FY2011, RTI will support provision of HCT services to uniformed personnel and their families at static sites using provider-initiate approach and outreach sites through client initiated counseling. The project will provide support for CT services in the 10 static military health facilities where we have presence, and conduct CT outreaches to field troops in underserved and hard to reach areas across the country through the General Military Mobile HCT unit. . Facilities are expected to reach 30,000 individuals with CT services by the end of September 2012. The project will support activities that build and strengthen linkages between CT clients and care, treatment, support, and other HIV preventive services within and outside the supported facilities. To further build capacity for sustainability and to ensure quality of CT, in-service training and technical support supervision will be provided to health workers in the 10 project facilities by the project staff. In addition, UPDF senior counselors who underwent both the counselor supervisor and the counselor training of trainers training will be supported to further develop their supervision and trainers knowledge and skills through practical implementation to build institutional capacity. This activity proposes to train 180 healthcare workers in RCT/BC from 14 military facilities focusing on new recruits and transfers from lower/field facilities. An institutional (UPDF) team of trainers and counselor supervisors will be built to oversee this new cadre. To further enhance quality of counseling and testing, the project will continue to support external quality control for HIV testing, focusing on tests conducted during Mobile HCT. Proficiency testing for health care workers involved in HIV rapid testing will be conducted every six months and blood samples from field tests will be re-tested at a reference laboratory at least once every quarter. The project will facilitate the collection and transportation of blood samples for re-testing from the static facilities to the reference laboratory. In order to avoid interruption of CT services resulting from prolonged periods of stock-out, the project will strengthen institutional supply chain management by supporting activities that would improve the coordination between the UPDF Directorate of HIV, the MOH-National Medical Stores (NMS), and the US-DOD.

In FY 2011, UPDF piloted Commander Peer lead training in the second division that was successfully implemented. In this strategy, commanders at each level were selected and trained as peer educators for their respective peers. A total of 250 Commander Peer educators were trained and passed out. These peer educators unlike the previously peer educators will be able to reach their respective peers with ease. In addition, Senior Commanders from UPDF medical services and HIV Directorate carried out a sensitization campaign on Alcohol and drug abuse with in all 5 divisions of UPDF.

During FY 2012, the other sexual prevention program will focus on increasing access to condoms by the military community. This will be achieved through by placing condoms in all health facilities in places with easy accessibility. In addition peer educators and counselors will be given condoms for distribution whenever they are conducting health education talks. Condoms will primarily be obtained from the national Ministry of Health procurement system.

DOD will continue to support current activities that include health education/film shows/drama show outreaches integrated with HIV Counseling and Testing outreaches, health talks at military parades and training institutions to further build the capacity of UPDF personnel for sustainability purposes. Peer educators will be engaged in quarterly review meetings to keep track of their performance and where possible refresher trainings be organized to equip them with new information and skills in HIV prevention. UPDF HIV Directorate will continue to take advantage of every social event like football shows, army week, world AIDS day to show case for HIV prevention, like supporting a popular commander to address the participants, facilitating PHAs to give testimonies and others.

During FY2011, RTI supported PMTCT activities in ten military hospitals (Kakiri, Katabi, Mubende, Rubongi, Nakasongola, Mbarara, Bombo, Gulu, Acholi Pii and Moroto) across the country targeting a minimum of 80% of pregnant women and 25% of partners of pregnant women attending ANC in these facilities. We supported routine counseling and testing of pregnant mothers and their spouses in ANC; linkage to care and support services; assessment of HIV-positive mothers for ART; enrollment into chronic care; provision of HAART and prophylactic ARVs to the mothers and babies; and training health workers on PMTCT service delivery to enable them to effectively provide PMTCT services. In FY2011, a total of 1,254women were counseled tested and received results, and 254 mothers and babies received ARV prophylaxis. In addition, 60 health workers were trained on PMTCT-EID strengthening strategy.

In FY2012, RTI will continue providing support to the 10 health facilities to consolidate achievements made and to further strengthen systems for implementation of the PMTCT-EID cascade. The project will promote the integration of PMTCT activities within the routine maternal and child health services at the target facilities. Our support will also focus on activities that empower facilities to provide a continuum of PMTCT services, strengthening linkages between PMTCT and other HIV program areas within and outside the supported facilities. The project will support facilities to provide routine counseling and testing of pregnant women and partners; assess HIV-positive women for ART eligibility; enroll patients into care and support; provide prophylactic ARVs to pregnant women and their babies; perform HIV testing for exposed infants; promote good infant feeding practices; and provide FP services and screening for sexually transmitted diseases. We will also continue to support activities that enhance links between community and facility services so that they will complement and reinforce each other for maximum impact on PMTCT; on the health of mothers; and on the preventive, mobilizing effect of the program on the community at large. The project will promote the use of pregnant women as index contacts to support the involvement of partners in the PMTCT program by promoting HIV testing for family members; couples counseling; disclosure of sero-status; and support for discordant couples. We will continue to build the capacity of health workers to provide quality PMTCT services through technical support and on site mentorship, continuing medical education, and short course in-service trainings. Through this effort we propose to test 3500 mothers and reach 189 pregnant women with known HIV status. The same number will be assessed for ART eligibility while 250 women will receive antiretroviral drugs for MTCT risk reduction.

The goal of the adult treatment program area is to extend and optimize quality life for HIV infected clients and their families, through management of common illnesses, improving clinical infrastructure and provision of monitoring laboratory tests.

During FY2011, RTI a DoD-UPDF implementing partner focused on promotion of quality management of patients in all supported health facilities with the ART clinics. In addition 1 ART satellite clinic was established in Ntungamo army detach in Mubende for easy accessibility of services by the clients. A team of health workers from Mubende army hospital was supported with logistics to conduct monthly satellite clinic at Ntungamo. In Mubende, RTI emphasized on improving knowledge of health workers on pediatric HIV Care, mentorship to health workers in ART clinics ,HIV patient CD4 monitoring and supplementation of prophylaxis drugs. RTI supported Moroto health facility to organize the clinic space previously remodeled, and also supported ART clinic staff to come up with modalities to strengthen linkages between PMTCT mothers and babies and the ART clinic.

Following the supply and installation of Point Care CD4 machines in Acholi Pii, Mbarara, Moroto and Nakasongola, access to CD4 testing has significantly improved. Other sites like Kakiri, Mubende, Katabi, and Rubongi were supported to refer their samples to reference laboratory for CD4 testing. In FY 2012, RTI laboratory specialist will continue to provide monthly technical support for the UPDF health facility laboratory staff to perfect their skills on use of PC and for troubleshooting. UPDF laboratory staff that was oriented on Point Care assessment tools compiled the data that and is being assessed for future use.

Although remarkable achievements were made in organizing the clinics and supporting health workers to improve patient management, the growing number of patients versus the static or even reducing number of clinicians continues to present major challenges to the quality patient management. As a way to minimize this effect, RTI will continue to support expert clients to participate in the running of ART clinics as previously has been done.

DoD-UPDF will continue to tap the services of trained counselors by the University of Connecticut to sensitize clients on adherence and other risky behaviors. Counselors will use developed IEC materials by University of Connecticut to support the Prevention with Positives (PwP) Program in Bombo and Nakasongola and where possible scale it up.

The goal of the pediatric HIV care and support program is to extend and optimize quality life for HIV infected children of military families and surrounding communities, through the continuum of illness by provision of clinical, psychological, spiritual, social and prevention services. The services are provided using mainly the facility based approach, in 12 ART accredited centres. RTI continued to build the capacity of UPDF health workers in pediatric care management through trainings. A total of 20 health workers were trained in specialized pediatric HIV care and treatment from 10 clinics. This enhanced health workers skills and knowledge in providing pediatric care. RTI staff conducted follow-ups on trained health workers to assess the progress made on pediatric HIV care integration and providing on site mentorship and technical support. RTI will continue to provide supplemental pediatric septrin formulation buffer stock in all supported clinics.

In FY 2012, RTI will continue its support to provision of comprehensive pediatric HIV care services to all facilities among the Ministry of Health accredited ART centres. The program will support referral of blood samples for HIV positive children for CD4 testing and timely return of results. Short courses for clinical officers and nurses in pediatric care and treatment will be conducted and be given special emphasis. RTI will work in collaboration with the MOH-ACP to distribute the pediatric HIV care and treatment guidelines and job aids to all health workers involved in pediatric HIV care and treatment.

All new health care workers in the supported health facilities and in the two new facilities will be trained to provide facility-based palliative care and /or referral for further assessment and specialized care for HIV+ children. Refresher training and technical support supervision will be provided as needed to ensure quality delivery of Palliative Care services for children. In order to minimize stock-outs, RTI will support health unit staff in forecasting and requisition for the right amounts of drugs and other basic care supplies.