The response of Government of Uganda to HIV has involved integrating HIV interventions into the workplaces to increase access to services for civil their employees. World Vision International supports a five-year project named Supporting Public Sector Workplaces to Expand Action and Responses against HIV/AIDS (SPEAR) to scale-up and enhance HIV-related interventions in three government departments of Education and Sports, Local Government and Internal Affairs. The aims to enhance HIV/AIDS prevention, care and treatment for public sector workers in selected workplaces in Uganda. Although the impact of AIDS is manifest in all public sector workplaces, ministries and departments with occupational migrant workers and uniformed services, such as teachers, Police, Immigration and Prisons are at a higher than average risk of HIV infection. SPEAR is designed to achieve three key results : Supporting public sectors to have policies, plans and activities that assure availability, integration and utilization of sustainable HIV services for their employees; increasing access to and utilization of quality HIV prevention, care and treatment services, with a focus on identifying HIV-positive individuals and facilitating access to networked care and treatment services; and improving access and use of wrap-around services by PLHIV and their families through effective partnerships with other programs. Where applicable, SPEAR equips health units with selected supplies as well as building the capacity of the health workers. SPEAR uses various approaches to reach out to the target population.

In FY2013, SPEAR project will build upon activities funded under SPEAR project and expand technical support to selected accredited ART health facilities to provide quality HIV/AIDS care and support services. SPEAR will support the provision of care services to 546 HIV positive adults as a contribution to the overall PEPFAR target of 812,989 HIV positive individual receiving a minimum of one clinical care service. This is a subset of overall care target. SPEAR will be expected to implement approaches to promote an effective Continuum of Response (CoR) model and monitor key indicators along the continuum. The project will provide on-site mentorship and training of private health providers in HIV care and support, in line with Ministry of Health guidelines and policies.

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

SPEAR will liaise with PACE and UHMG for provision and distribution of basic care kits to clients. Additionally, liaise with National Medical Stores, Joint Medical Stores and Supply Chain Management Systems for other HIV commodities (cotrimoxazole, lab reagents). SPEAR will build the capacity of facility staff to accurately and timely report, forecast, quantify and order commodities.

In addition, SPEAR 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. Collaboration with other key stakeholders at all levels for provision of required wrap around services including, family planning.

SPEAR will ensure gender awareness and issues are integrated in programs to ensure equitable access to care and treatment services such as identifying and addressing barriers that women and men may face in adhering to treatment or receiving ongoing care.

SPEAR 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 and 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. SPEAR will contribute to this target by screening 540 HIV positive clients for TB and staring 18 individuals on TB treatment.

SPEAR will improve Intensified Case Finding (ICF) and the use of the national ICF tools to improve case detection. SPEAR will refer suspected TB cases for diagnosis and ensure support for retention and adherence. SPEAR will increase focus on adherence and completion of TB treatment, including DOTS through use of proven low cost approaches.

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. SPEAR will work under the guidance of MoH AIDS Control Program, National TB and Leprosy Program and Quality Assurance Department in training, TB/HIV mentorship and support supervision.

The revised COP 2012 strategic pivots for VMMC in SPEAR will focus on increasing coverage from 3 districts where SPEAR has previously trained VMMC teams to 16 districts. These are districts where SPEAR has large barracks for both Prisons and Police forces. Some of the districts that SPEAR will be focusing on have high HIV prevalence in the general population; high HIV prevalence among women; and low circumcision prevalence. The primary target populations for SPEAR will be the uniformed personnel and members of the general population that surround the barracks. A total of 29,496 men will be circumcised by the SPEAR project. In addition to these targets of circumcised uniformed men, SPEAR will work with existing health facilities in the 7 Karamoja districts to circumcise over 9,198 men from the general population. Therefore, in this FY 2013, SPEAR will circumcise approximately 38,694 men. To attain the above target, SPEAR project will use multiple approaches to scale up VMMC that include: training eight dedicated teams; integrating VMMC services within twelve Police and Prisons health facilities ( stand-alone sites ) and holding outreaches and camps including the hard to reaches areas. SPEAR will use the Model for Optimizing the Volume for Efficiency (MOVE) as a means to optimize the efficiencies and increase the volume safely in all VMMC service outlets. A total of 36 service providers will be trained from Rakai Health Center, Walter Reed Project or Infectious Disease Institute /IHK (public-private partnership). Quality improvement and assurance will be integrated as part of the minimum package of VMMC services through the implementation of national & international quality standards; and external quality assurance (EQA). The SPEAR project will build the capacity of providers to use the Non-surgical VMMC devices (Perplex) in the supported sites. Working closely with the USG community partner, the SPEAR project will implement community campaigns to create acceptance and demand for VMMC through a mix of approaches including: 1) peer-to-peer strategy for interpersonal communication; 2) use of linkage facilitators to mobilize men; 3) community mobilization; and 4) use appropriate channels of communication including print and electronic mass media. Emphasis will be placed on increasing linkages of HIV+ clients from VMMC to care and treatment services as part of the Continuum of Response (COR).SPEAR will enhance monitoring & reporting through the MOH VMMC Operational Centre and HMIS tools and periodic data quality assessments (DQA). Data use at facility level will be strengthened through supporting M&E focused in-service training for health workers to foster evidence-based decision-making and program improvement. VMMC will be offered as part of SPEARs comprehensive HIV prevention package, which includes: promoting delay of sexual debut; abstinence and reduction in the number of sexual partners and being faithful; providing and promoting correct and consistent use of male condoms; providing HTC services ;treatment of sexually transmitted infections and referring HIV+ men to appropriate care and treatment services. Where VMMC client are young people and not yet sexually active , they will be supported with appropriate risk reduction strategies. SPEAR will integrate VMMC services as part of the continuum of response (COR), contributing to access to reproductive health care for men; better engagement of men in care.

As part of SPEAR routine community activities, they will offer age appropriate risk reduction messages to the young people leaving in and around the uniformed personnel barracks.

SPEAR will help to contribute to HCT goals by increasing demand and utilization of HCT services by public sector employees, occupational migrant workers, teachers in both pre- and in- service, and the uniformed services, such as police, prisons, immigration officers and private security guards, and their family members as well as youth. These populations will be addressed throughout the 56 districts where the program is implemented with particular attention paid to high prevalence communities.

SPEAR has the benefit of being located in the same districts as the USAID-supported, comprehensive STAR programs. This arrangement provides the client the benefit of being referred to a quality health provider for HIV Care and Treatment or other needed health services. Most importantly, it allows the program to best address HTC pivots namely PITC scale-up. To this end, SPEAR will also work with district hospitals, Health Center IVs and other USG-supported HCT outlets and implementing partners to scale up HCT services and ensure they are of quality and are accessible. These partnerships will also increase the provision of referral information and support for increased early diagnosis, and initiation of treatment and follow-up care for HIV positive individuals. At the individual-level, the program will target public sector employees and their partners for counseling and testing. Specific community-activities will take place in police barracks and prisons. For men in these settings, VMMC will serve as the foundation for increased HCT; referrals from other partners will also facilitate increased HTC in the community. SPEAR will address institution-level needs by strengthening the systems and capacity of workstations and communities to integrate successful HIV/AIDS and health network models. Activities will largely feature work place support for HTC through media campaigns and testing events, as well as development of work place policies. The program will also support partner organizations and institutions to facilitate Behavior Change campaigns to address negative perceptions surrounding HCT and increase HCT uptake to reach 70,583 individuals including couples.

Other non-biomedical activities will involve advocacy, formal community-facility linkages, transport, fee waivers/subsidies, and staff training to ensure continuum of HIV services in key catchment areas. Special attention will be directed towards workplaces outside urban settings through outreach camps to meet the unmet demand for HCT among public sector employees deployed in hard to reach rural and peripheral areas. In all interventions, efforts will be made to bring VCT services as close to the workplace or community as possible.

Health workers for the uniformed services will be trained on approved national HCT protocols and approaches including child counseling and testing, home-based counseling, and nutritional counseling, so as to increase opportunities and coverage among target groups. For Quality Assurance re-testing with the use of panels will be done quarterly.

In the revised COP 12 the key pivots for other prevention aim to ensure a balanced portfolio that will address prevention needs for the older population, Most At Risk Populations (MARPS) as well as the youth as the primary target groups and support high impact interventions. SPEAR key target populations are public sector employees, uniformed personnel ( Police, Prisons and private guards ) teachers in pre-service and in-service and their families including the youth. SPEAR will focus on addressing the key bottlenecks to increasing condom use: accessibility, availability and acceptability of condoms among the target populations. SPEAR will ensure that the targeted population has access to condoms and other prevention services as needed. SPEAR will support condom distribution and promotion by increasing the number of distribution outlets at facilities, community level, hard to reach areas from 26 to 232. Additionally, SPEAR will also engage with social marketing partners to increase distribution and promotion of condoms, with the hospitality industry, particularly bars and hotels within the vicinity of the prisons and police barracks, teacher training institutions and identified hot spots to ensure that condoms are readily available. SPEAR will implement community campaigns to create acceptance of and demand for condoms through:

1) Peer-to-peer strategy for interpersonal communication; 2) use of linkage facilitators to mobilize men; 3) community mobilization; and 4) use appropriate channels of communication including print and electronic mass media. SPEAR will work with the communication partner to contribute to an advocacy strategy aimed at de-stigmatizing condoms at all levels. SPEAR will engage the leadership of the three target ministries to establish norms that promote faithfulness, condom use at high risk sex and denounce forced sexual activity especially among the uniformed forces.

In order to ensure age appropriate messaging , SPEAR will adopt various approaches to target the out of school youth who are leaving in and around the targeted barracks with comprehensive risk reduction programs. Amongst the MARPS, the interventions will focus on increasing perception of HIV risk associated with sex work, having multiple concurrent partners , strengthening PwP among infected MARPs at facility and community levels, promotion of condom use and scale up of evidence based behavioral interventions. SPEAR will target 1350 PHLAs with PHDP interventions. The PHDP interventions will aim at increasing knowledge of HIV status among PHLA and their partners, reducing the risk of HIV transmission and reducing HIV acquisition among person at high risk for infection. SPEAR will ensure that 52,753 people and 35, 125 uniformed personnel are reached with comprehensive HIV prevention services.

Program monitoring and evaluation activities will be supported within this budget to strengthen the collection of data through national HMIS tools and to improve the technical quality of data through periodic data quality assessments. Data use at facility level will be strengthened through supporting M&E/SI focused in-service training for 20 health workers.

The SPEAR project will roll out the implementation of Option B+ in ten health units in Uganda that are owned by the Uganda Police and Prisons departments, targeting the uniformed forces, their families and surrounding communities. Activities will be supported by a combination of FY12 and PMTCT acceleration funds, $38,485 and $200,000, respectively. HIV counseling and testing services will be provided to 22,655 pregnant & lactating women, hence identifying 1,880 HIV positive pregnant women, of which 1,598 be initiated on HAART for life and 282 will be provided with ARV prophylaxis. Infant ARV prophylaxis and EID will be provided to 1,880 exposed babies. All the four eMTCT prongs will be supported in line with the goals of virtual elimination of MTCT and keeping mothers alive. To achieve the above, the SPEAR project will implement the following COP 2012 strategic pivots: 1) Improving utilization of eMTCT services to reach more HIV infected pregnant women as early as possible during ANC, L/D, and post-partum periods; 2) Decentralize treatment and Option B+ through the accreditation of all supported sites. Activities will include site assessments for accreditation; identification of training needs; procurement of equipment; printing of M&E tools, job aides, & Option B+ guidelines; training of 70 service providers; and sample referrals for CD4+ and EID. The transition of Option B+ will start initially in the two ART sites followed by accreditation of the remaining eight Non-ART PMTCT site. Retention will be enhanced through the family- focused service delivery model within the PMTCT settings coupled with the formation of Family Support Groups (FSGs) at all eMTCT sites led by peer mothers and midwives. The FSGs will meet monthly to receive adherence counseling and psycho-social support; supported disclosure; IYCF counseling; EID; FP counseling; Couple HTC; repeat-testing; ARV refills; and link negative male partners to VMMC if required. Village health teams will utilize to enhance follow-ups; facility referrals; and adherence support. 3) Intensive M&E at facility & community levels in the SPEAR-supported sites through cohort tracking of mother-baby pairs & electronic data reporting for effective Option B+ monitoring and program management. Mobile phone technology will be used to remind mothers & their partners on appointments; EID results; and ARV adherence. Home visits will be conducted to trace those who are lost to follow-up. 4) The SPEAR project will enhance the quality of eMTCT services through quarterly joint support supervision & mentorships at all eMTCT/ART sites. Site level support will entail cohort reviews; adherence rates; retention rates; data management; availability of supplies (commodities, HIV test kits, tools, job aides & ARVs); and addressing of existing knowledge gaps on Option B+. 5) The SPEAR project will integrate voluntary and informed family planning (FP) services based on respect; womens choices; and fulfillment of their reproductive health rights. FP sessions will be integrated within eMTCT trainings for all service providers. FP counseling; education, and information will be provided to all women during ANC, Labor & Delivery, and postnatal periods; and in Care and treatment settings. Dual protection will be promoted among women living with HIV and their partners to help them avoid unintended pregnancies, HIV transmission and/or re-infection. The project will collaborate with existing FP partners.

SPEAR will support all selected public sector ART accredited sites. The program will enroll at least 240 new HIV positive adults on treatment and support 261 HIV positive adults on ART by September 2013; contributing to overall national and PEPFAR target of 190,804 new clients and 490,028 individuals current on treatment. This target is not a ceiling, allowing for higher achievements with continued program efficiencies. Priority will be given to enrolment of HIV positive pregnant women, TB/HIV patients, and key populations.

SPEAR will support the MoH roll out of Option B+ for eMTCT in selected public sector sites through the following activities: accreditation of health facilities in line with MoH accreditation scale-up plan; training, mentorship and joint PMTCT/ART support supervision. SPEAR will also support ART/PMTCT integration at facility level piloting feasible service delivery models, such as same day integrated HIV clinics.Continuum of response linkages and referrals will be strengthened using linkage facilitators across different service points in facilities and communities.

SPEAR will implement quality improvement initiatives for the ART framework: early initiation of ART eligible clients on treatment; improve adherence and retention; and monitor treatment outcomes. Use of innovative, low cost approaches for adherence, retention and follow up such as: phone/SMS reminders, appointment registers, alert stickers will be supported. Special focus will be placed on adherence and retention of women enrolled under Option B+. Focus will be placed on increasing access to CD4 for routine monitoring of ART clients in line with MoH guidance. SPEAR will support the sample referral network in line with the national CD4 expansion plan; and will monitor and report clients access to CD4 in quarterly reports. SPEAR will liaise with PACE and UHMG for provision and distribution of basic care kits to clients. Additionally, liaise with National Medical Stores, Joint Medical Stores and Supply Chain Management Systems for ARVs and other HIV commodities (cotrimoxazole, lab reagents). SPEAR will build the capacity of facility staff to accurately and timely report, forecast, quantify and order commodities. In addition, SPEAR will work with USG partners and other key stakeholders for provision of required wrap around services, particularly, family planning and malaria prevention.

SPEAR will work under the guidance of MoH AIDS Control Program and Quality Assurance Department in trainings, ART/PMTCT mentorship and support supervision.

SPEAR will ensure gender awareness and issues are integrated in programs to ensure equitable access to care and treatment services such as identifying and addressing barriers that women and men may face in adhering to treatment or receiving ongoing care.