PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY UNCHANGED FROM FY 2008.
Makerere University Faculty of Medicine was awarded a cooperative agreement titled "Provision of routine
HIV testing, counseling, basic care and antiretroviral therapy at teaching hospitals in the Republic of
Uganda" in 2004. The program named Mulago-Mbarara Teaching Hospitals' Joint AIDS Program (MJAP)
implements HIV/AIDS services in Uganda's two major teaching hospitals (Mulago and Mbarara) and their
catchment areas in close collaboration with the national programs run by the Ministry of Health (MOH).
MJAP also collaborates with the national tuberculosis and leprosy program (NTLP), and leverages
resources from the Global fund. MJAP provides comprehensive HIV/AIDS services including: 1) hospital-
based routine HIV testing and counseling (RTC), 2) palliative HIV/AIDS basic care, 3) integrated TB-HIV
diagnosis with treatment of TB-HIV co-infected patients, 4) antiretroviral treatment, and HIV post- exposure
prophylaxis, 5) family based care (FBC) which includes services for orphans and vulnerable children (OVC),
in addition to home-based HIV testing and prevention activities (HBHCT), and 6) capacity building for HIV
prevention and care through training of health care providers, laboratory strengthening, and establishment
of satellite HIV clinics. Mulago and Mbarara hospitals are public referral institutions with a mandate of
training, service-provision and research. Annually 3,000 health care providers are trained and about one
million patients seen in the two hospitals (500,000 outpatients and 130,000 inpatients for Mulago, and
300,000 in and outpatients for Mbarara). Approximately 60% of medical admissions in both hospitals are
because of HIV infection and related complications. Within Mulago, MJAP works closely with the Infectious
Diseases Institute (IDI). IDI is an independent institute within the Faculty of Medicine of Makerere University
with a mission to build capacity for delivering sustainable, high-quality HIV/AIDS care, treatment and
prevention in Africa through training and research. At IDI health care providers from all over sub-Saharan
Africa receive training on HIV care and antiretroviral therapy (ART); people living with HIV receive free
clinical care including ART at the Adult Infectious Diseases Clinic (AIDC) - the clinic is integral with Mulago
teaching hospital. The main HIV clinics in Mbarara and Mulago teaching hospitals are the Mbarara ISS
(HIV) clinic, Mulago ISS, and AIDC respectively; MJAP supports HIV care and treatment in all the three
clinics. Since 2005, MJAP has established 12 satellite clinics due to the rapidly increasing number of HIV
positive patients; increasing the total number of treatment sites to 15. The twelve satellite clinics include
Kawempe, Naguru, Kiswa, Kiruddu, Kisenyi, Kawaala, Kitebi and Komamboga (under Kampala City Council
- KCC), Mbarara municipality clinic (under the Mbarara municipal council), Bwizibwera health centre IV
(under MOH and Mbarara local government), Mbarara TB/HIV clinic, Mulago TB/HIV clinic, which provides
care for TB-HIV co-infected patients. The satellite clinic activities are done in collaboration with several
partners including KCC, Mbarara Municipal Council, IDI, Baylor-Paediatric Infectious Disease Clinic (PIDC),
Protection of Families against AIDS (PREFA), MOH, and other partners.
MJAP has been providing prevention counseling including Abstain "A" and Be faithful "B" counseling
through the HIV testing programs. Prevention counseling has also been integrated into the care and
treatment programs and OVC interventions (counseling and life skills training). In the Routine HIV testing
and Counseling (RTC) program, couple testing is encouraged thus promoting HIV status disclosure and
strengthening the B messages for couples. ‘A' messages are encouraged for single youth below 18 years,
among other interventions. Family members who are tested through the HBHCT program also receive
prevention counseling. Since November 2004, more than 5,000 children and youth have been served
through the MJAP Counseling and testing, care and treatment programs. We have provided HIV testing to
over 3,000 couples, 19% of who were sero-discordant and 60% concordant negative. Since 2007, MJAP
has been supporting the STD Unit of Mulago hospital to carry out facility based RTC and prevention
counseling with a community component of targeted interventions towards Commercial Sex Workers (CSW)
in selected communities around Kampala City whose HIV prevalence is as high as 40%, according to
sentinel STI surveillance data. These interventions include HIV testing, STI screening and treatment,
partner/contact tracing, community sensitization, training of CSWs peer leaders, and establishing condom
outlets within these high-risk communities. In February 2008, MARPI (Most At Risk Population Initiative)
project was started with an aim of I) providing HCT services to MARPs especially Commercial Sex Workers
(CSWs), ii) increasing the level of comprehensive HIV/STD knowledge among MARPs, iii) providing
effective STD services to CSWs and iv) promoting safer sexual practices and early STD care seeking
behavior among the MARPs. A number of areas in Kampala district with high risk populations including
Kisenyi, Kinawataka/Mbuya, Bwaise, Kagoma, Ndeeba, Kasubi and Ntinda were identified. A total of 9
additional staff was recruited. A total of 161 individuals were trained. Of these, 43 are peer leaders of CSWs
while 118 are from the different sub-categories identified to be clients to CSWs. A total of 2,334 individuals
have been tested for HIV. Of these, 637 individuals were tested through community VCT, 672 through
facility based VCT, 975 through facility based RTC and 50 individuals through Sex workers clinic. Sero-
prevalence among individuals tested through community VCT was 8.5% whereas that among individuals
tested through the facility was 18.9%. Sero-prevalence among individuals tested through the sex workers
clinic was 32%. Laboratory investigations were also carried out. These included 526 RPR tests for syphilis,
62 wet preparations and gram stains for STIs and 16 blood slide tests for malaria. In addition to the above
services, MARPI promotes 100% condom use among sex workers and their clients through education and
sensitization and also ensures that condoms are available and accessible through establishment of
acceptable condom outlets. The Ministry of Health supplies the condoms. A total of 23 condom outlets have
been established by far and 424,800 condoms have been distributed.
In FY 2009, MJAP will strengthen the integration of AB activities into the existing programs. Through FBC,
the community outreach program that promotes HIV/AIDS though abstinence and/or being faithful, we will
provide home based counseling and testing to family members of 2,500 households of index patients in
care. Within these households we plan to reach 10,000 youth both male and female with interventions that
emphasize health education, counseling support and life skills training to enable them make informed
choices. The "A" activities will primarily target children and single youth below 18 years and the adults who
are sexually active and/or married will also receive "B" messages and other prevention support including
condom use, as appropriate. The "B" activities will also be integrated with couples counseling (in RTC and
HBHCT) to encourage couples' HIV testing, disclosure of results and mutual faithfulness. We will also
integrate the entire spectrum of prevention activities within the care and treatment sites through the positive
prevention and family planning interventions. Through collaboration with the Mulago STD clinic, we will
provide STI diagnosis and treatment to 4000 individuals referred from the community. Within the community
Activity Narrative: we will provide outreach voluntary HIV counseling and testing (VCT). The high-risk and commercial sex
worker (CSW) communities have organized networks with peer leaders (queen mothers). We will train 400
such peer leaders whom we will use to distribute coupons for facility based VCT for individuals who do not
wish to test within the community. These coupons will be numbered and tracked to evaluate the response
rate of these referrals. HIV infected individuals identified through the community-based and facility-based
HIV testing activities will be referred to the MJAP supported clinics and others facilities within Kampala.
Education within the community will address STI and HIV prevention, and will address the entire spectrum
of prevention (AB and condom use) as appropriate. We will identify and train peer leaders to mobilize the
high-risk communities, provide education and support for distribution of condoms. We will also work with bar
owners and attendants to distribute condoms through the 30 established outlets for high-risk groups.
Through these activities we will reach over 5,500 individuals in the high-risk communities. Overall, 60,000
individuals will be supported in FY 2009 (includes HIV positive patients in the clinics, discordant couples,
and high-risk groups in the selected communities in Kampala). We will provide condoms through 101
condom distribution outlets (all the 16 HIV clinics, 30 community outlets for high-risk groups, Mulago and
Mbarara, and seven regional referral hospitals). The ‘other sexual prevention' budget will cover training, IEC
materials, health education and support for the PHAs who will be involved in the prevention interventions.
We will strengthen the prevention with positives and family planning activities in all clinics, and will involve
People living with HIV/AIDS (PHA) in prevention education and Counseling for patients. We will also
strengthen the support for discordant couples identified through the HIV testing programs. All HIV testing
facilities and care and treatment sites will provide condoms to support the discordant couples, in addition to
the prevention Counseling. We will also improve on the data management, reporting and M&E for ‘other
prevention' programs. The capacity of the STD laboratory will be reinforced through purchase of additional
laboratory supplies. We will also procure some additional drugs for treatment of STIs in order to supplement
the MOH drugs, and support additional staff to improve the clinical management at the unit.
MJAP will support Post Sexual Exposure Prophylaxis beginning with the Mulago Hospital 5A Annex which is
the reception ward for patients presenting with sexual assault among other obstetrics and gynecological
emergencies. In this centrally initiated pilot program, MJAP intends to offer a comprehensive package of
medical services for survivors of Sexual Gender based Violence (SGBV). This package will include
emergency contraception, HCT, ART for the infected (post sexual exposure prophylaxis (PSEP); STI
diagnosis and treatment, psychosocial support. Funding will go towards training in PEP for Health care
providers, production and distribution of IEC materials, establishing linkages to Police and organizations
offering psychosocial support through referrals and networking, recruitment of additional staff (counselors,
social workers ), training of all the staff (midwives, laboratory staff, interns, medical officers, senior doctors)
in PEP, RTC, and SGBV; procurement and infrastructure refurbishments ( Drugs, laboratory reagents and
testing kits) treatment of STIs and soft tissue injuries. The results of this pilot will be used for a nation wide
scale up of provision of PSEP services for survivors of SGBV with the ultimate aim of reducing HIV
transmission and improving care and support as well as early linkage of those infected by HIV/AIDS virus to
care.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
* Increasing women's legal rights
* Reducing violence and coercion
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $202,731
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Estimated amount of funding that is planned for Education $16,000
Water
Table 3.3.02:
New/Continuing Activity: Continuing Activity
Continuing Activity: 13272
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13272 8513.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $560,000
Disease Control & University Faculty Teaching
Prevention of Medicine Hospitals -
MJAP
8513 8513.07 HHS/Centers for Makerere 4805 1107.07 Mulago-Mbarara $390,000
Table 3.3.03:
prevention in Africa through training and research. At IDI, health care providers from all over sub-Saharan
Africa receive training on HIV care and antiretroviral therapy (ART), and people living with HIV receive free
clinical care including ART. The main HIV clinics in Mbarara and Mulago teaching hospitals are the
Mbarara ISS (HIV) clinic, Mulago ISS, and AIDC respectively; MJAP supports HIV care and treatment in all
the three clinics. Since 2005, MJAP has established 12 satellite clinics due to the rapidly increasing number
of HIV positive patients; increasing the total number of treatment sites to 15. The twelve satellite clinics
include Kawempe, Naguru, Kiswa, Kiruddu, Kisenyi, Kawaala, Kitebi and Komamboga (under Kampala City
Council - KCC), Mbarara municipality clinic (under the Mbarara municipal council), Bwizibwera health
centre IV (under MOH and Mbarara local government), Mbarara TB/HIV clinic, Mulago TB/HIV clinic, which
provides care for TB-HIV co-infected patients. The satellite clinic activities are implemented in collaboration
with several partners including KCC, Mbarara Municipal Council, IDI, Baylor-Paediatric Infectious Disease
Clinic (PIDC), Protection of Families against AIDS (PREFA), MOH, and other partners.
Currently, the MJAP Adult Care and Treatment activities are implemented at 15 outlets as listed above. By
June 2008, the 15 service outlets had served over 45,000 patients cumulatively of which 37,365 were still in
active care and 8,154 (48.58%) were receiving antiretroviral therapy. Of the patients on ART, 7,404 patients
receive their ARV drugs from Global Fund for AIDS, TB and Malaria, and the Clinton Foundation HIV/AIDS
Initiative (CHAI). The number of HIV patients in all the clinics continues to increase with the expansion of
Routine HIV Testing and Counselling (RTC) in the hospitals: over 25,000 HIV infected persons were
identified through RTC in FY 2008 and a good proportion were linked to care at MJAP supported sites.
MJAP provides mainly adult care and treatment while pediatric patients are handled through collaborative
partnerships with other providers namely e.g. PIDC, KCC, and MOH. KCC provides clinic space and drugs
for management of OIs. NTLP provides TB medications and support supervision. VCT is provided by AIDS
Information Centre, PMTCT under PREFA, ART under MOH-Global Fund Program, and OVC support
through Ministry of Gender, Labour and Social Development. These programs are working together to
ensure comprehensive care for families affected by HIV/AIDS while avoiding duplication of service.
The demand for HIV basic care and ART services is very high in all the care and treatment sites compared
to the available staffing and space. The basic care and ART programs are integrated: all patients on ART
receive basic care, and all patients receiving basic care are regularly evaluated for ART eligibility. The
palliative basic care programs include provision of a basic care package comprising of daily cotrimoxazole
for prophylaxis, insecticide treated mosquito nets, safe water vessels for safe water provision, diagnosis and
treatment of opportunistic infections (OI) treatment and prophylaxis. Newly diagnosed HIV positive patients
from the RTC program also receive a month's supply of cotrimoxazole prophylaxis and are provided with
referrals for follow-up care in the HIV clinics. Up to 70% of HIV positive patients identified through the RTC
program are ART eligible. Before patients get initiated on ART, they undergo counseling to prepare them for
ART including basic facts on ART, issues of adherence, side effects, duration of treatment, among others.
Patients who fulfill the eligibility criteria receive a second orientation meeting with their treatment supporter.
ARVs are initiated on the third visit if the medical officer is satisfied that the patient is ready to begin
therapy. Patients are seen by the adherence nurse counselor on day 0, day 15, 1 month and then monthly
for counseling and ARV refills. Adherence to ARVs is monitored by self report using a visual analogue
scale, ART patient cards and pill counts (patients return the bottles with any remaining pills). The program
also carries out routine ART monitoring tests that include CD4+ cell count, haematology, serology and
routine TB screening. Currently, the clinics get support for follow-up of patients from the home visitors and
the family based care team of MJAP In both Mulago and Mbarara ISS clinics, we estimate that about 80%
of clinically eligible patients are receiving ART.
In addition to the support for ART, the program provides special attention to discordant couples at all the
treatment centres with currently over 100 couples attending the special clinics. The couples are provided
with psychosocial support, prevention and treatment of OIs, positive living package and disclosure support.
MJAP has trained over 800 health care providers in the provision of antiretroviral therapy and strengthened
systems for ART delivery including staffing, laboratory support, and logistics and data management. By the
end of FY 2008, the program expects to provide adult care and treatment services to over 70,000
individuals. Over 10,000 patients shall be supported to initiate ART at the supported sites.
In FY 2009, MJAP will consolidate existing services; scale up to 4 new service outlets, bringing the total to
19. The location of the new clinics shall be determined based on the current demand for care and treatment
services. Funds will go towards additional staffing and training of new and existing staff. A limited number of
staffs shall be hired with emphasis being placed on transferring the management of the current existing
clinics/ services to the local government systems.
Activity Narrative: MJAP will provide care and treatment services to 85,000 HIV-infected persons with at least 38,000 being on
ART (15,000 of whom will receive their ARVs from GFTAM and CHAI sources). Thirty thousand (30,000)
newly- identified HIV infected persons (through the RTC program) will receive a month's supply of
cotrimoxazole at the time of diagnosis before referral into care. At least 10,000 patients will be supported to
initiate antiretroviral therapy. The program will reinforce adherence counseling and support, and follow-up of
ART patients through modifications in the current adherence support mechanisms at all clinics. As a quality
improvement strategy, patients that are stable on ART shall be moved from routine clinician visit to the
pharmacy-only and nurse-only visit programs to reduce both the waiting time and need for staffing. In this
arrangement, patients shall only see a clinician/doctor only once in three months while in all the other visits
they are either picking their drugs from the pharmacy directly or are seen by a nurse. The program will
continue to carry out routine ART monitoring tests that shall include CD4+ cell count, haematology, serology
TB screening.
MJAP will strengthen prevention with positives counseling and support including HIV testing for spouses
and other family members of index patients attending the HIV clinics. Many more Family clinic days will be
held in order to reach out to many more patients. In all the clinics MJAP will provide comprehensive
HIV/AIDS care and treatment for families including children in partnership with other programs where
applicable. Pregnant mothers registered in the clinic shall be evaluated for ART eligibility and provided with
ARVs in accordance with the national PMTCT guidelines. Patients with opportunistic infections shall be
offered treatment and where necessary referred for further specialised care. MJAP will provide
cotrimoxazole prophylaxis and other OI care, malaria diagnosis and treatment, and Population Services
International (PSI) will provide safe water supplies and insecticide treated mosquito nets. The clinic based
activities will be further supported by the Family-based Care team and health visitors who will conduct follow
up visits to support disclosure, trace treatment defaulters, provide support on home care for HIV positive
persons, test other family members and refer the HIV positive ones to the clinics for further care.
MJAP will support efforts to identify and provide care and treatment services to new HIV infected persons
by extending RTC services to HC IVs in the catchment areas of the already supported regional referral
hospitals. In order to achieve the above objectives, MJAP will enhance the human resource capacity in
various ways. MJAP will hire and train additional and existing staff: - up to 500 health care providers will
receive training in ART delivery. In collaboration with Makerere and Mbarara universities, the program will
provide pre-service training to students (offering courses of bachelor of medicine and surgery, dental
surgery, pharmacy degree, nursing degree and post-graduate studies) in provision of HIV care and
treatment services. A total of 400 students will receive training through both lectures and practical
attachment to the MJAP supported centres. To ensure sustainability, MJAP will continue to support the
improvement of existing infrastructure and systems. This will include the improvement of data management
and reporting to all stakeholders within the districts to MOH; strengthening of logistics management
information system and internal technical support supervision by health managers in the supported facilities.
In order to further mitigate the human resource gaps in the facilities, MJAP has recently developed and is
already implementing a strategy for involvement of people living with HIV/ AIDS (PHAs) in aspects of patient
care following appropriate training.
Continuing Activity: 13273
13273 4032.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $1,460,000
8315 4032.07 HHS/Centers for Makerere 4805 1107.07 Mulago-Mbarara $1,400,000
4032 4032.06 HHS/Centers for Makerere 3182 1107.06 Mulago-Mbarara $935,587
Health-related Wraparound Programs
* TB
Estimated amount of funding that is planned for Water $20,000
Table 3.3.08:
FY09 activities
Activity Narrative: staffs shall be hired with emphasis being placed on transferring the management of the current existing
MJAP will provide care and treatment services to 85,000 HIV-infected persons with at least 38,000 being on
Continuing Activity: 13279
13279 4036.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $2,525,400
8319 4036.07 HHS/Centers for Makerere 4805 1107.07 Mulago-Mbarara $2,025,400
4036 4036.06 HHS/Centers for Makerere 3182 1107.06 Mulago-Mbarara $1,725,400
Estimated amount of funding that is planned for Human Capacity Development $1,782,040
Table 3.3.09:
HIV testing, counselling, basic care and antiretroviral therapy at teaching hospitals in the Republic of
based routine HIV testing and counselling (RTC), 2) palliative HIV/AIDS basic care, 3) integrated TB-HIV
MJAP currently offers pediatric clinical HIV care and treatment at only the Mbarara satellite clinics of
Bwizibwera health centre-IV and Mbarara Municipal Council Clinic. The other 12 operational MJAP
supported clinics have on-site pediatric care and treatment services provided in partnership with the Joint
Clinical Research centre-JCRC (Mbarara ISS Clinic); Baylor College of Medicine Children's Foundation -
Uganda/PIDC for Mulago Hospital and all the satellite KCC sites. In these clinics, MJAP conducts Routine
HIV Testing and Counseling (RCT) in pediatric wards and refers these kids for care and treatment in
existing clinics after initiating cotrimoxazole. In Mulago, MJAP is also supporting pediatric care with
laboratory support for ART delivery (CD4, counts, CD4 percentages, CBC and chemistry tests.. This
partnership is expected to continue in FY 2009. The MJAP pediatric care and treatment program is
currently offering HIV care for HIV infected children and babies born to HIV positive mothers (exposed
babies) until their HIV status is established. There are functional PMTCT programs within the MJAP
affiliated satellite clinics that work in line with the MoH PMTCT guidelines.
HIV diagnosis is carried out using DNA PCR for infants below 18 months and using the normal HIV antibody
testing algorithm for all the children above 18 months of age. A family- based approach to care is used
whereby a mother or parent is seen together with their child/children on the same clinic day by the same
clinician. Under basic HIV care, all children attending HIV care receive an Insecticide Treated Mosquito Net
(ITN), Cotrimoxazole for prophylaxis, multivitamin supplementation, diagnosis and management/treatment
of all major HIV opportunistic infections (OIs), childhood vaccinations, provision of anti-helminthes (for de-
worming), counseling and psychosocial support, growth and development monitoring, and age specific
health education. Adolescents are given health education about prevention of HIV transmission i.e.
‘prevention with positives'. Children enrolled in care are also offered routine HIV monitoring tests to include
CD4+ cells count/percentage monitoring, hematology, serology and other related tests at regular intervals
that are detailed in the National Care and Treatment standard operating procedures/ guidelines. Children in
the clinic are offered basic nutritional support consisting of a pint of milk as they wait for their clinical review.
Follow-up of the children is carried out with the support of the MJAP family based care (FBC) team and
home visitors that regularly track these clients at home. In addition, the FBC team provides linkages to the
clinics through testing of family members (including children) of index clients identified in the clinics and
linking those found to be HIV infected to care and treatment. The home visitors are routinely involved in the
tracking of patients lost to follow-up and those defaulting on treatment. Routine pregnancy testing using
HCG tests is recommended/ offered for all women of child bearing age and with suspected pregnancy in the
clinics to facilitate early prevention of vertical transmission. Among the sexually active females with
amenorrhea and/or a high index of suspicion for pregnancy attending the HIV care services the HCG
positive rates range between 40 to 50% of those taking the test. The ARV drugs for the pediatric care are
obtained from the Uganda Ministry of health/Global fund for treatment of AIDS, Tuberculosis and Malaria;
Clinton foundation HIV/AIDS initiative. MJAP supplements supplies in case of stock-outs. MJAP also
collaborates with other existing HIV programs that include the AIDS Information Centre, EGPAF for PMTCT,
ART under MOH-Global Fund Program, and OVC support through Ministry of Gender, Labour and Social
Development. Treatment for tuberculosis is provided through the National TB and leprosy control program
(NTLP) which provides the drugs and support supervision to the sites. MJAP is supporting paediatric TB
diagnosis through provision of purified protein derivative (PPD) and administration needles. The different
programs are working together to ensure comprehensive care for families affected by HIV/AIDS while
avoiding duplication of services. MJAP trains various cadres of staff in paediatric HIV care and treatment in
order to enhance their knowledge and skills in provision of quality paediatric care and treatment, In order to
address the huge human resource needs and gaps for paediatric ART, MJAP in FY-2008 embarked on task
-shifting and allowed lower clinic staff and persons living with HIV/AIDS (PHA) to be trained and later
involved in the routine care and treatment for the patients. The PHAs are involved in the counselling, health
education, peer support and other non-technical roles. Qualified PHAs have been continuously involved in
Activity Narrative: the routine technical activities of the clinic. To date, MJAP has trained over 60% of the health workers
offering HIV care in pediatric HIV care; supported 128 children (110 in active care) to initiate and stay on
antiretroviral therapy; provided basic and palliative HIV care to 234 children; provided the basic care
package to 306 children and followed up 270 babies born to HIV positive mothers identified through the
clinics.
In FY 09, the program will intensify efforts for early identification of HIV and early initiation of quality care
and treatment for those found to be HIV positive, while also supporting activities to reduce vertical HIV
transmission. Greater emphasis will be put on capacity building (human, infrastructure, and systems) for
sustainable provision of quality pediatric care and treatment services. The program will continue to offer
HCT for children and HIV DNA PCR tests for exposed babies as described above. Early infant diagnosis
shall continue to follow the algorithm set out by the national PMTCT and Early Infant Diagnosis guidelines
for Uganda. The programs in collaboration with the different partners will link all pregnant HIV positive
mothers to available PMTCT services and ensure that these are followed up together with their babies. At
all 18 proposed sites, MJAP shall continue to offer routine HCG/pregnancy tests to women of child-bearing
age. Furthermore, the program shall further strengthen the early identification of children through counseling
existing clients to have their children tested and increased campaigns for family treatment days in the
clinics. In the satellite clinics, more HIV positive children and infants will be identified by extending RTC to
cover vaccination points and young child clinics. The FBC team will also identify and refer more children
(including OVC) who need HIV care and treatment during visits to homes of consenting index clients but
also from the community based HCT component. The pediatric care and treatment services will be offered
at Bwizibwera and Mbarara municipal council satellite clinics. These two clinics will be provided with
additional equipments for routine monitoring. Such equipment includes those meant for monitoring growth,
nutrition and other routine HIV monitoring test Using the revised WHO guidelines, all children eligible and
ready to start ART will be offered ART. All children under care will be provided with all the appropriate
components of pediatric and adolescent HIV care following the ten point management plan for pediatric HIV
care. The program will continue to offer routine screening and treatment of all major opportunistic infections
in children with emphasis on the special treatment needs. The current OI treatment drugs range will be
expanded to include medicines specific for the needs of pediatric patients. In particular, cancer
chemotherapy; and treatment and prophylaxis for Cryptococcal meningitis and Pneumocystis carinii
pneumonia shall be strengthened. The pediatric patients in the clinic will be given Cotrimoxazole
prophylaxis or Dapsone for cases unable take the former. Tuberculosis diagnosis and treatment shall be
carried out in close collaboration with the NTLP as described above. In order to step up pediatric HIV care,
pediatric counselors shall be recruited to address the specific needs of these patients. The clinical care
team will work closely with the FBC team and identified OVC programs to address other OVC related
needs. As mentioned earlier, MJAP will put greater emphasis on local capacity building for sustainable
delivery of quality pediatric care and treatment services by the health facilities and community structures by
2010. In collaboration with the Faculty of Medicine of Mbarara University of Science and Technology, MJAP
will train 200 students to offer home-based support to family members in the clinics. In addition, a further
200 students of both Makerere University faculty of Medicine and Mbarara university faculty of medicine
shall be offered pre-service training in HIV/AIDS pediatric care as a sustainability measure. The task-shifting
of provision of care and treatment will be further enhanced through the involvement and close supervision of
more PHAs. Over 100 health workers and PHAs will be trained in all or parts of comprehensive pediatric
HIV care. Children requiring nutritional rehabilitation will be attached to nutritional rehabilitation centers.
Reproductive health services will be offered as part of PMTCT services and adolescent care. All HIV
positive mothers will be trained in infant feeding. The pediatric care and treatment program of MJAP shall
target the under-served populations in rural and peri-urban areas of Mbarara. Bwizibwera offers a typical
rural ART clinic in a facility with limited resources and a poor population unable to afford basic health care.
The program targets to provide care and treatment to 600 HIV infected children at the two clinics with at
least 350 being on ART. In addition, at least 400 babies born to HIV infected mothers (HIV exposed babies)
shall be followed up until a diagnostic test of sero-status is possible. All children seen in the clinics will be
given milk as they wait to be seen by the clinicians.
Estimated amount of funding that is planned for Human Capacity Development $50,000
Table 3.3.10:
Table 3.3.11:
Makerere University Faculty of Medicine (FOM) was awarded a cooperative agreement titled "Provision of
Routine HIV Testing, Counseling, Basic Care and Antiretroviral Therapy at Teaching Hospitals in the
Republic of Uganda" in 2004. The program named "Mulago-Mbarara Teaching Hospitals' Joint AIDS
Program (MJAP) implements HIV programs in Uganda's two major teaching hospitals (Mulago and
Mbarara) and their catchment areas. MJAP collaborates with the National Tuberculosis and Leprosy
program (NTLP), and leverages resources from the Global fund (GFATM). MJAP provides a range of
HIV/AIDS services including: 1) Hospital-based routine HIV testing and counseling (RTC), 2) provision of
palliative HIV/AIDS basic care, 3) provision of integrated TB-HIV diagnosis with treatment of TB-HIV co-
infected patients, 4) antiretroviral treatment, and provision of HIV post- exposure prophylaxis, 5) Family
Based Care (FBC) which includes services for orphans and vulnerable children (OVC), in addition to home-
based HIV testing and prevention activities, and 6) capacity building for HIV prevention and care through
training of health care providers, laboratory strengthening, and establishment of satellite HIV clinics. MJAP
currently supports HIV services in 23 facilities (Mulago and Mbarara national teaching hospitals, seven
regional referral hospitals, and 14 satellite health centers). In August 2006, the program was awarded
another grant titled "Expanding Tuberculosis/HIV Integration Activities in the Republic of Uganda, 2006"
under cooperative agreement U2G/PS000591-01 with the Faculty of Medicine. The funding was awarded to
support the Uganda Ministry of health to expand integrated RTC and TB screening and care to regional
referral hospitals. This was in line with the Ministry's plans of improving access to HIV testing in clinical
settings and integrating TB/HIV diagnosis and care. The TB/HIV integrated services model includes I)
Concurrent diagnosis of TB and HIV infection among in- and out-patients in general wards and clinics ii)
Routine HIV testing for TB patients iii) enhanced TB screening for HIV positive patients in care including
those on ART and iv) Integrated care and treatment for patients with TB/HIV co-infection. TB screening is
conducted at several levels beginning with clinical evaluation through history taking and examination, to
other investigations such as sputum smear microscopy which is the main diagnostic tool, Chest X-rays,
biopsies and cultures.
Using the TB/HIV grant (cooperative agreement No.U2G/PS000591, MJAP directly supports TB /HIV
services in three regional referral hospitals: Jinja, Hoima and Mbale using the model described above.
MJAP has provided key equipment (Microscopes, CD4 Facs count machines, chemistry, and hematology
machines) for TB diagnosis, HIV care and monitoring to these hospitals. Recording and reporting systems
have been strengthened through the provision of computers and accessories, training in electronic data
processing, refining and updating of ministry's data tools and, establishment of electronic data bases and
linkages to the national Health Management Information Systems (HMIS). Testing supplies for HIV and TB
screening have been provided and staff trained and supported on job to forecast, track and monitor
supplies. Between April 1st 2007 and March 31st 2008, 19,630 persons were tested for HIV and provided
with results. Out of these, 2290 were found HIV positive (12% prevalence). Among those tested, 313 were
TB patients on treatment and out of these, 175 (56%) were HIV positive. TB screening is a process that
involves history taking, clinical examination and investigations routinely performed by all health workers.
During the period, 2807 patients were screened for TB using sputum smear microscopy in all the 3 sites. Of
these, 302 were HIV patients in care of which 174 (58%) were found with smear positive TB. Overall, 349
patients were identified with TB/HIV co-infection and initiated on TB treatment. The program has set up
infection control committees in the 3 hospitals, developed infection control protocols and materials to
facilitate patient education and prevention of TB transmission in the facilities. The program developed
training materials in partnership with MoH and conducted training for staff in the three hospitals in various
aspects of TB/HIV care. 225 were trained in RTC, 240 trained in TB/HIV co-infection management, and 30
in logistics management. The program has embarked on expansion of the services to an additional 2
regional referral hospitals (Masaka and Soroti) as well as strengthening referral systems for TB and HIV
care for patients with either of the two infections in partnership with the National TB program and other
partners. Through the activities of the sub partners-the National TB reference laboratory (NTRL) and the
Central Public health laboratories (CPHL) the program continues to strengthen the performance of regional
hospital laboratories in the use of Acid-fast direct-smear microscopy through training and on job support as
well as establishment of a National External Quality Assurance System (NEQAS) to increase accuracy and
reproducibility in TB smear-microscopy.
In FY2009 MJAP plans to strengthen diagnosis for TB among HIV+ smear negative patients through the
use of liquid cultures. This technique will be scaled up, based on experiences from a pilot service in the
Mulago TB/HIV clinic and selected program sites around Kampala. Following the pilot, services will then be
rolled out to all the regional hospitals. Subsequently, we envisage providing a cold chain system and also
disseminating culture facilities to enable diagnosis of other difficult cases. We will to continue with rapid
MDR-TB screening and introduce second line drug susceptibility testing to support the DOTS-plus program
in collaboration with the NTRL. Surveillance of MDR will continue through a specimen referral system and
expansion of TB culture facilities to 2 other laboratories. NTRL will also improve processing of samples,
biosafety at work place and storage of isolates through purchase of refrigerated centrifuges, Biosafety
cabinets and freezers as well as creation of a freezer space. We will also continue to strengthen the weak
aspects of CB-DOTS namely sputum smear microscopy, recording and reporting in all the regional
hospitals. We will do this in collaboration with the national TB program, CPHL and other partners. As part of
this process, NTRL we will strengthen the EQA System by increased problem-oriented supervision, and,
provision of ongoing training to laboratory personnel to address the poorly performed areas of EQA. To
sustain the EQA system, we will strengthen the district and regional laboratories by training 100 laboratory
staff from the district and regional laboratories and facilitate them to carry out support supervision and
problem-oriented supervision.
We will pay special focus to the quality of TB/HIV care by incorporating quality improvement plans and
targets in the overall program plans. We will monitor and document TB/HIV treatment outcomes in all the
program sites. The program will continue to support the improvement of existing structures and systems
within the hospitals. We will hire additional staff in the regional hospitals to support integrated TB-HIV
services, provide refresher training for new and existing staff, support quality assurance and support
supervision, and enhance the existing referral systems between the regional referral hospitals and the lower
level health facilities, and linkage to care for newly diagnosed TB-HIV patients. NTRL will hire an
administrative assistant who will help in running the non technical aspects of the project such as assisting in
Activity Narrative: procurements and logistics, preparing accountabilities, tracking of expenditures and monitoring of stocks.
This will release time from the technical staff to concentrate on their work. We will continue offering RTC
and TB screening to in -and out-patients in all the 5 hospitals and care for the co-infected patients. The care
will include; HIV testing and counseling of TB clients and referral or management of those found HIV
positive, provision of ARVs and cotrimoxazole prophylaxis, TB screening of patients with HIV/AIDS,
provision of TB treatment using DOTS management strategy for HIV infected patients with TB and
implementation of infection control activities to prevent TB transmission in all our HIV care settings.45, 000
individuals are targeted for RTC during the period, and 80% of HIV positive patients receiving HIV services
in the hospitals will receive routine screening for TB disease at least once a month, by either clinical
evaluation through history taking and examination, or performing investigations such as sputum smear
microscopy which is the main diagnostic tool, Chest X-rays, biopsies and cultures. Data for this indicator will
be retrieved from patient ART chronic care cards. 75% of patients diagnosed with TB will receive HIV
counseling and testing services over the period of their treatment for TB. Data for this indicator will be
retrieved from the TB treatment registers. The program will strengthen the capacity of the facilities to
provide the relevant laboratory and diagnostic capacity for the TB/HIV services. We will roll out IPT
prophylaxis to two Regional hospitals following the year's planned pilot in the Mulago TB/HIV clinic. The
benefits of all these activities will be improved patient care.
Continuing Activity: 13274
13274 4034.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $500,000
8317 4034.07 HHS/Centers for Makerere 4805 1107.07 Mulago-Mbarara $500,000
4034 4034.06 HHS/Centers for Makerere 3182 1107.06 Mulago-Mbarara $361,409
Estimated amount of funding that is planned for Human Capacity Development $450,000
Table 3.3.12:
and Protection of Families against AIDS (PREFA), MOH, and other partners.
MJAP has continued to support TB/HIV integration activities in Mulago and Mbarara teaching hospitals, in
the regional referral hospitals of Soroti, Fort Portal and Masaka, as well as in 14 specialized HIV/AIDS
clinics. These activities are being initiated in Kabale regional referral hospital and will be fully established
by the end of FY 2008. TB and HIV service integration happens at several levels: 1) integration of TB
screening and Routine HIV testing (RTC) on the in-patient wards and out-patient clinics where patients are
offered both HIV testing and screening for TB, 2) provision of RTC in the TB wards and clinics, 3)
enhanced TB screening in the HIV clinics, and 4 ) provision of both TB and HIV care and treatment for
patients who are co-infected with TB and HIV. MJAP pioneered the integration of TB and HIV management
in Uganda by opening up a TB/HIV clinic at Mulago hospital in 2005. In this TB-HIV clinic, TB/HIV patients
receive TB treatment, HIV palliative and basic care, and initiation of ART if eligible. After completion of TB
treatment, these patients are referred for follow-up HIV care in the other established clinics. The program
also completed the setting-up of an integrated TB-HIV clinic in Mbarara hospital as an extension of the
Mbarara ISS clinic. TB treatment has been integrated into all the care and treatment sites, with a dedicated
day for treatment of co-infected patients in each site. Key equipment (Microscopes, CD4 measuring
machines, chemistry, hematology machines) for TB diagnosis, HIV care and monitoring are available at the
hospitals either directly managed by MJAP or in collaboration with other PEPFAR funded partners.
Recording and reporting systems have been strengthened through the provision of computers and
accessories, training in electronic data processing, refining and updating of ministry's data tools and,
establishment of electronic data bases and linkages to the national Health Management Information
Systems (HMIS). Testing supplies for HIV and TB screening have been provided and staff trained and
supported on job to forecast, track and monitor supplies. Implementation of the TB screening and treatment
services is done in collaboration with MOH-NTLP. The MOH-NTLP provides TB medications free to
patients; and the HIV clinics dispense TB medications supplied by MOH-NTLP. The program developed
training materials in partnership with MoH and conducted training for staff in the implementing sites in
various aspects of TB/HIV care. TB screening is covered in the existing RTC training curriculum.
Since February 2005, over 35,000 individuals have been screened for TB and more than 3,000 sputum
positive patients identified and linked to care. More than 2,500 patients have received TB and HIV
treatment in the HIV care centers. Between April 1st 2007 and March 31st 2008, a total of 26,412 patients
were screened for TB in all the implementing sites. A total of 2,263 co-infected patients received treatment
and care in the TB/ HIV clinics. A total of 225 health service providers were trained in TB screening as part
of the basic RTC training and 240 staff was trained in TB/HIV co-infection management.
In FY 2009, four new satellite care and treatment sites will be opened to decongest the current care and
treatment sites; with the Mbarara TB/HIV clinic becoming an independent site from the Mbarara ISS clinic.
The integrated RTC-TB screening program will also be expanded to four additional wards in Mulago and
Mbarara hospitals and four health centre IVs within the catchment areas of the regional referral hospitals.
This funding will support TB screening in 28 sites ( four Mulago and Mbarara hospital wards, four regional
referral hospitals, four health centre IVs and all the 18 MJAP supported HIV clinics); 18 sites will provide
integrated care and treatment while ten will provide integrated diagnosis with referral to existing care and
treatment facilities. The aim is to screen 100, 000 patients for TB and provide TB-HIV care to 3,000 TB-HIV
co-infected patients in the coming year. MJAP will strengthen diagnosis for TB among HIV+ smear negative
patients through the use of liquid cultures in collaboration with the National TB reference laboratory. This
technique will start in selected hospitals and be rolled out to all the regional sites by the end of Oct 2010.
MJAP will implement infection control activities to prevent TB transmission in all our HIV care settings.
To ensure sustainability, MJAP will continue to support the improvement of existing structures and systems
Activity Narrative: within the facilities. The program will hire additional staff to support the TB-HIV integration efforts, provide
training for new and existing staff in the clinics (200 health care providers will be trained in the coming year),
support logistics management and supplies, quality assurance and support supervision, and enhance the
existing referral systems between the diagnosis and the care and treatment sites. The program will also
support the improvement of data management/ M&E and reporting to all stakeholders within the districts,
zonal supervision offices and MOH-NTLP. Although implementation will happen in the regional and national
referral hospitals, health providers in the lower level health centers (including CB-DOTS providers) will also
be trained, to enhance TB-HIV care, infection control and CB-DOTS. The laboratory personnel at the
regional referral hospitals will be trained and supported to provide support supervision for the lower level
laboratories (an area within their mandate but currently not fully implemented). We will do this in
collaboration with the national TB program and other partners. Special focus will be paid to the quality of
TB/HIV care by incorporating quality improvement plans and targets in the overall program plans. Through
the activities of sub partners, the program will focus on culture and drug susceptibility testing of samples
from previously treated patients. We will monitor and document TB/HIV treatment outcomes in all the
program sites. The program will target both adults and children in all the clinics and hospitals.
Continuing Activity: 13275
13275 9757.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $1,400,000
Estimated amount of funding that is planned for Human Capacity Development $214,286
MJAP also collaborates with the National Tuberculosis and Leprosy Program (NTLP), and leverages
resources from the Global fund. MJAP provides comprehensive HIV/AIDS services including; 1) hospital-
based routine HIV testing and counseling (RTC); 2) palliative HIV/AIDS basic care; 3) integrated TB-HIV
diagnosis with treatment of TB-HIV co-infected patients; 4) antiretroviral treatment, and HIV post-exposure
prophylaxis; 5) family based care (FBC) which includes services for orphans and vulnerable children (OVC),
in addition to home-based HIV testing and prevention activities (HBHCT); and 6) capacity building for HIV
Activities for Orphans and Vulnerable Children (OVC) are integrated in all MJAP activities but more so in the
Family Based Care (FBC)/Community HIV Counseling and Testing (HCT) program. Other OVCs are
accessed through the hospital based MJAP HIV testing and counseling program. The integrated OVC
services are run by social workers, field nurse counselors and community based people living with
HIV/AIDS. The team serves OVCs and caregivers in households of index HIV patients attending MJAP care
clinics. Through the FBC/community HCT program, OVCs and caregivers in households of index HIV are
offered Home-based HIV counseling and Testing (HBHCT) and health education about HIV/AIDS. The
OVCs identified in the homes are given Insecticide Treated mosquito Nets (ITNs) for prevention of malaria,
safe water vessels, anti-helminthes, and multivitamins. Adolescents aged 12-17 are counseled about HIV
prevention. In case of bereavement, this target group is encouraged and given reassurance so that they
accept their situation, learn how to cope and remain positive about life. Psychosocial support is also offered
to OVCs to whom parents/guardians have disclosed sero-status.
The FBC team works closely with the Mulago ISS clinical care team and other satellite HIV clinics in Naguru
and Kawempe (Kampala) and Bwizibwera and Mbarara Municipality Council (Mbarara) to offer clinic based
OVC services. Services offered include providing a snack at the clinic site as the children wait for care,
psycho-social reassurance and information giving. OVCs that require other services that MJAP does not
provide such as legal support, shelter, education, security are given referral forms to other OVC service
provider organizations for further support. how do you do the linking?. In 2007/8, the FBC program reached
a total of 2,113 index client households. Within these households, XXX OVCs were identified, 804 were
tested and 4.5% (35) were HIV positive. In Mbarara, 1928 OVCs were identified and tested, 5% (98) were
HIV positive. The positive ones were incorporated into care while all the OVCs (infected and uninfected)
received 10,000 ITNs, 100 safe water vessels distributed by the FBC team in their homes. 350 OVCs were
offered snacks during clinic visits and 1,000 OVC care takers received health education talks to improve
knowledge and skills in OVC care.
In FY 2009, MJAP will further enrich the package of services provided to OVC. The package will include
health, psychosocial support, education, nutrition and socio-economic security. The target group will be all
children of index adult patients receiving care in Mulago ISS clinic, Mbarara Pediatric clinic (Toto Clinic),
Mbarara Municipality (MMC) and Bwizibwera clinics as these are all considered to be vulnerable, and some
may be orphans, in case they have lost one or both of the parents. Adult patients will be encouraged to
bring their children with them to the clinics. As per the RCT program HCT for these children will be offered
in the clinics according to MOH guidelines and those found to be HIV positive in Mulago ISS clinic will be
referred to Baylor Uganda for further care. MJAP will however continue providing family based OVC
services for those found to be HIV negative in these clinics. Through the family based home visiting
program to the homes of consenting index patients, additional children will be identified, cared for as above.
Through the clinics and the home visits, MJAP hopes to identify and support a total of 4,000 OVCs with food
support. The FBC team will through the index case that agrees to disclose to the community, reach more
households and thus identify more OVCs. All these OVCs will be given health care and psychosocial
support as needed. The basic health package will consist of de-worming, insecticide treated nets, safe
water vessels, up-date immunizations and health education. We shall distribute 6,000 mosquito nets (2000
to OVCs identified through Index HIV patients households and 4000 to other OVC households identified
through community FBC) and 1000 water vessels to the respective OVCs families. Since the OVCs needs
are many, MJAP will assess the specific needs and identify the most needy OVCs and target these ones.
Educational support will be given to about 1,000 OVCs in form of scholastic materials which will include
pens, pencils, uniforms and books targeting all OVCs in a household. In the households visited, identified
OVCs will be offered nutritional supplements such as soya flour, maize flour, rice, and sugar as needed.
Activity Narrative: Families will also be given some advice on how to improve their nutrition and household income. In
Bwizibwera, Mbarara Pediatric clinic and MMC, the HIV positive children who come for care and the HIV
negative ones who come with their HIV positive parents/guardians because they are too young to be left at
home will all receive snacks as they wait to receive care. A snack will also be provided for OVCs who come
with parents/guardians at the Mulago adult ISS clinic while in waiting. Through this approach, all the
targeted 4,000 OVCs will be accessed with food support. Socio-economic security for OVC will be
addressed during this year. This activity will target out of school OVC aged 16-17 years. These will be
identified as above and will be supported to receive skills apprenticeship training. MJAP will hold
discussions with these OVCs and their caregivers to identify suitable short course apprenticeship trainings
that range from 2 to 12 months. Such trainings will include hair dressing, cookery, mechanics, carpentry,
brick laying, metal works and tailoring. A total of 100 OVCs will benefit from this activity.
OVCs will be given psychosocial support in various ways. Quarterly adolescent/peer support group
meetings intended to strengthen coping mechanisms against HIV and mitigating the impact of HIV among
them will be initiated by the FBC teams at the two clinics. All OVC caregivers from the 2000 households
which will be visited will be equipped with information on OVC care, including effective ways of disclosing
HIV status to them, linking them to schools and other CBOs in the area who offer OVC services. In order to
enhance the capacity of communities to handle OVCs including assisting the HIV negative to remain so and
disclosure of HIV status to OVCs, MJAP will train 100 community based PHAs caregiversin income
generating activities, during which sessions, HIV prevention messages will be passed on. For other services
not provided by MJAP like secondary education, child protection and legal support, efforts will be made to
identify other OVC support and care Institutions for referrals.
Through this capacity building among OVC care givers and adolescents we hope to improve coping
mechanisms towards HIV/AIDS as well as mitigating its effects on families and communities.
Continuing Activity: 13276
13276 4372.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $200,000
8321 4372.07 HHS/Centers for Makerere 4805 1107.07 Mulago-Mbarara $175,000
4372 4372.06 HHS/Centers for Makerere 3182 1107.06 Mulago-Mbarara $49,241
* Child Survival Activities
Estimated amount of funding that is planned for Human Capacity Development $90,000
Table 3.3.13:
MJAP started implementing Routine HIV Testing and Counseling (RTC) in November 2004, in Mulago and
Mbarara University teaching hospitals. Since that time, the RTC program has expanded from six to 49
hospital wards and clinics (30 in Mulago and 19 in Mbarara). The current unit coverage represents over
95% in Mbarara and about 75% at Mulago although over 95% of the high prevalence units provide RTC. In
line with Uganda's HIV/AIDS National Strategic Plan 2007/2008-2011/12, MJAP has expanded RTC to
seven regional referral hospitals: Jinja, Mbale, Hoima, Soroti, Masaka, Fort Portal and Kabale as well as to
the satellite clinics listed above. In RTC, HIV testing is routinely offered to all patients seeking care in the
wards/clinics where the program is operational but those who decide not to test receive other hospital
services without discrimination. The RTC program is implemented in line with the three C's - confidentiality,
informed consent (opt out) and counseling/information, as recommended by WHO, and the MOH HIV
testing policy. Care for identified HIV positive patients is initiated at the time of diagnosis; all HIV positive
patients receive cotrimoxazole prophylaxis. In 2006 MJAP integrated TB screening and treatment within its
existing routine HIV testing and care program. In this regard TB screening is provided for all patients with
history of cough for more than 3 weeks irrespective of the HIV status. HIV positive patients are also
referred for follow-up care in the HIV clinics where they receive basic HIV care, psychosocial support and
ART when eligible. For patients found to be HIV negative, HIV prevention messages are emphasized to
reduce risk of infection. The program also offers HIV testing to family members of patients in the hospital
and has found a high HIV prevalence (24%) among these. In order to strengthen prevention with positives,
MJAP provides home-based HIV counseling and testing (HBHCT) for household members of index HIV
positive patients attending Mulago, Mbarara and the satellite clinics who consent to be visited which has led
to identification of more HIV positive persons and early referral to care. Initial efforts have already been
made to extend this service to communities, other than only the household members. HIV testing for family
members of HIV positive patients identifies other HIV infected individuals in their households, facilitates
partner disclosure and testing, and identifies many discordant couples. Additionally, testing of family
members encourages early entry into care and support for the HIV infected individuals. To date, the
program has trained over 1,200 health care providers in the implementing sites in the provision of RTC.
Cumulatively, more than 170,000 in- and outpatients have received HIV testing and over 56,000 HIV
infected individuals identified and linked to care and treatment.
In FY 2009, (October 2008-september 2009), MJAP will extend RTC services to an additional six units in
Mulago, four lower level Health Center IV in the catchment areas of regional referral hospitals, 2 units and
one satellite clinic in Mbarara. In Mbarara we will achieve 100% coverage of all wards and clinics and
increase coverage in Mulago to 85%. We will achieve 100% coverage for all units with a high HIV
prevalence. MJAP will continue providing RTC in the seven regional referral hospitals and in the satellite
clinics. We intend to provide HIV testing to a minimum of 170,000 individuals in FY 2009. In the RTC units,
all patients with undocumented HIV status will be routinely offered HIV testing but this will not preclude the
right to opt-out of testing. The program will target all categories of patients and family members including
adults, infants, children, health care workers. Through the revised HBHCT program, MJAP will provide HIV
counseling and testing to 2,000 households (10,000 individuals) in FY 2009. By the end of FY 2010, the
program will have offered its services to 15,000 individuals in 2,500 homes. Newly diagnosed HIV positive
patients will receive a month's supply of cotrimoxazole before referral for follow-up palliative care and
treatment. The program will endeavor to improve linkages to care and treatment services providers as well
as strengthen linkages with clinical services for better performance. The HIV testing through the MJAP
integrated TB-HIV services will be consolidated in all MJAP sites. It will endeavor to offer TB screening to
80% of all its patients and clients who benefit from RTC services. We will strengthen prevention with
positives (PWP) and offer counseling and support including HIV testing for spouses of patients in the HIV
clinics and RTC wards. Discordant couples will be referred to the ‘Discordant couples' clubs which are
Activity Narrative: currently being piloted at two sites (one in Mulago and another in Mbarara). In those clubs, the couples will
be supported to enable them understand and cope with HIV, ensure reduction of sexual transmission by
using condoms, and other means and share experiences with similar couples. For the concordant negative
couples and other HIV negative patients, MJAP will re-emphasize the HIV preventive messages. To ensure
sustainability, MJAP will support the improvement of existing structures and systems within the facilities.
The program will support the engagement of people living with HIV/AIDS to supplement personnel for HIV
counseling and testing. A total of 1,000 new and existing health care providers will be trained in RTC/TB
service provision. MJAP will support the existing logistics management system, procure HCT items to cover
gaps, strengthen quality assurance and support supervision, and enhance the existing referral systems to
improve linkage to care for newly diagnosed HIV patients. The program will also support the improvement of
data management/ M&E and reporting to all stakeholders within the districts and MOH. In addition, targeted
evaluations will be conducted to provide the program with lessons learnt and plans for the future.
Continuing Activity: 13277
13277 4033.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $1,400,000
8316 4033.07 HHS/Centers for Makerere 4805 1107.07 Mulago-Mbarara $1,400,000
4033 4033.06 HHS/Centers for Makerere 3182 1107.06 Mulago-Mbarara $984,058
Estimated amount of funding that is planned for Human Capacity Development $729,501
Table 3.3.14:
Currently, MJAP procures and distributes ARV drugs for 15 service outlets as listed above through Medical
Access - (provide some description of Med Access). The 15 outlets serve over 27, 000 patients in care,
9,365 of whom have their ARV drugs procured through MJAP funding. The current (July 2008) distribution
of these patients who receive the MJAP directly procured ARVs are 1400 at AIDC, 1620 in Mbarara ISS
clinic, 2,645 in Mulago ISS clinic, 730 in Mbarara municipality clinic, 598 in Kawempe KCC, 482 in
Bwizibwera HC IV, 239 at Mulago TB/HIV clinic, 379 in Naguru, 332 at Kiruddu, 167 Kiswa, 145 at Kawala,
and 650 at the centres of Kisenyi, Komamboga and Kitebi. The target is to procure ARVs for at least 10,000
patients by March 2009. In addition, the program targets at least a further direct leverage of ARV drugs from
the Clinton Foundation HIV/AIDS Initiative drug donation program. The program in FY 2008 achieved a
150% recruitment target by getting 7510 patients on to the directly procured ARVs. This was achieved as a
result of the timely switch from branded to generic FDA approved ARVs medicines that are cheaper and
became increasingly available locally. The program has continued to utilize the available opportunity of
global price reductions to allow many more patients onto treatment in FY 2008. In addition to the switch to
generic medicines, the program will continue to promote the increased use of fixed-dose combination
medicines in order to improve patients' adherence to therapy. The demand for ART in the clinics continues
to increase with the expansion and strengthening of RTC (provider-initiated testing) in the hospitals. The
Mbarara ISS and AIDC are now at maximum carrying capacity yet the trend of identification of newly
identified HIV-infected persons remains the same. Majority of HIV positive patients identified through the
RTC program (55%) need ARVs (WHO Stages 3 and 4 and/or CD4+ cells count of =250). Currently, we
estimate that only about 70% of clinically eligible patients are receiving ART at the clinic sites despite
increased efforts to have them on treatment. MJAP has trained over 800 health care providers in the
provision of antiretroviral therapy and strengthened systems for ART delivery including staffing, laboratory
support, logistics and data management. As a result of the capacity building of lower level clinics within the
catchment's areas of Mulago and Mbarara for HIV care by MJAP, an additional >8,500 patients are able to
access ARV drugs from MOH/ GFATM and Clinton Foundation HIV/AIDS Initiative at the MJAP supported
sites. The program as well was able and will continue to support over 100 children on ART at the Mbarara
municipal council clinic and Bwizibwera health centre in Mbarara districts. In the past year, due to ART drug
procurement interruptions for global fund, MJAP supported the procurement of 2-3 months' buffer stock for
up to 5,000 of these patients on both first and second line art regimens. In addition, MJAP continued to
increase access to treatment for pregnant mothers and patients with hepatitis co-infection at all the sites.
Over 200 health care workers received post-exposure prophylaxis for HIV infection at all the sites offering
antiretroviral therapy.
In FY 2009, MJAP plans to procure and distribute ARVs for a total of 20,000 patients attending 19 different
treatment service outlets. Four new centres shall be opened in Kampala and Mbarara to decongest the
current centres that are overcrowded. The distribution of the treatment slots shall be based on capacity,
demand for art and available space. In FY 2009, MJAP will strengthen the uptake of children on to
antiretroviral therapy at all the centres where no other partner provides paediatric care namely Mbarara
municipal council clinic and Bwizibwera health centre in Mbarara. The program expects to have at least
10% of all the patients on ART at these two sites to be paediatric. The ART drugs for provision of prevention
of mother to child HIV transmission shall be obtained from the GFTAM- MOH PMTCT program available at
all the centres. MJAP will continue to carry out task-shifting for the management of the ART drugs supply
chain with more emphasis being put on using the lower level staff in the quantification and distribution of the
products. Over 300 health care workers and 500 women of sexual and gender based violence shall be
provided with post-exposure prophylaxis based on the current recommended regimens. MJAP will continue
to procure FDA approved generic ART medicines at competitive prices through Medical Access Uganda
limited. In addition, the program will continuously monitor the current global pricing mechanisms report to
Activity Narrative: ensure value for the commodity procurement and to increase access through increasing treatment slots for
every significant price reduction. In order to improve service delivery and build capacity, MJAP will use both
task-shifting and pre-service training to build capacity for uptake of ARV drugs at the treatment facilities.
MJAP will train newly qualified students from the medical schools of Makerere and Mbarara Universities,
and the Mulago paramedical schools. Procured ART medicines shall be received and inspected by a
pharmacist of the program together with the procurement officer and stores assistant. The drugs are then
entered into a ‘goods received' note and other inventory management records. The ART medicines shall all
be centrally procured and distributed through the pull logistics system. Stock-taking or physical counts shall
be done at monthly intervals for all centres and stores and routine reports made. In addition, MJAP will
provide a buffer stock of up to three months for all patients receiving their ART stocks from the Ministry of
Health/ Global Fund for Tuberculosis, AIDS and Malaria program during stock-out. In addition, MJAP will
continue to strengthen local capacity of the health facilities to take over the provision of ART through
training and on-site support. MJAP will upgrade the current logistics and supply-chain management
software to be able to handle the increased activities and number of sites. In addition to the ART resources
from the GFTAM-MOH program, MJAP will continue to obtain additional ARV drugs for paediatric and adult
second line treatment from the Clinton foundation HIV/aids initiative (CHAI) donation program. The CHAI
donation program will continue for up to December 2009. The savings that shall be realised from the CHAI
donation and shall be used to provide additional treatment options or slots for eligible patients.
Continuing Activity: 13278
13278 4035.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $4,242,541
8318 4035.07 HHS/Centers for Makerere 4805 1107.07 Mulago-Mbarara $3,742,541
4035 4035.06 HHS/Centers for Makerere 3182 1107.06 Mulago-Mbarara $2,725,400
Estimated amount of funding that is planned for Human Capacity Development $100,000
Table 3.3.15:
MJAP currently supports 19 laboratories. The main areas of support include training of staff, improving of
laboratory space, procurement and maintenance of equipment and reagents, support for infection control
and quality assurance. All the program supported sites are now able to provide HIV testing, TB sputum
microscopy, syphilis and malaria diagnosis. Five laboratories (Mulago Hospital, Mulago IDC, Kiswa, Kiruddu
and Mbarara Municipal Council) have capacity to provide ART laboratory monitoring tests. Mulago, which
supports CD4 tests for all the Kampala based sites, has two Facs Calibur machines. CD4 tests for patients
from the Mbarara ISS clinic are performed by the Mbarara referral hospital laboratory, supported by JCRC.
In FY 2007 and FY 2008, all the regional referral hospital laboratories Jinja, Soroti, Hoima, Masaka and Fort
Portal were equipped with hematology and chemistry analyzers, biosafety hoods and calorimeters in order
to support TB/HIV integration activities. The program shares costs with the hospitals for reagents and
maintenance of the equipment. The program also conducts CD4 tests for other programs such as PIDC.
External quality control (QC) for HIV testing is done at the MU-JHU laboratory. The Quality Control for
sputum microscopy is done at the NTLP laboratory. For CD4 testing, selected samples are sent to the CDC
laboratory in Entebbe. MJAP Laboratory also participates in the proficiency testing scheme that is
implemented by the HIV reference laboratory at Uganda Virus Research Institute (UVRI). In order to
improve on space, the program put up two prefabricated structures to house the laboratory in Mbarara
satellite clinics; these have adequate space for equipments installation and performing routine work. The
introduction of RTC services has contributed to the increase in the quantity of waste being generated
therefore; appropriate biohazard disposal mechanisms have been put in place in order to strengthen
existing infection control systems. Laboratory staff has received the relevant training in infection control. In
this regard, bins with pedals and liners were provided in the entire program supported sites, and Bio-safety
hoods were installed at all the TB screening units. In order to improve the performance of the lab staff,
MJAP conducted several training using standard MOH guidelines. The laboratory and data staff was also
trained eDOTS, a soft ware for tracking laboratory and clinical information for patients under treatment for
tuberculosis. In order to strengthen capacity for internal support supervision, MJAP recruited two
supervisors, one for each arm of the program. In spite of the above achievements, the available equipment
and personnel are inadequate to meet the ever- increasing program needs. Another major challenge
experienced is the delay in receiving infant DNA PCR results from partners where samples are processed.
The current turn around time for DNA PCR results is one month for Mbarara and four months for regional
referral hospitals. This means that in case of HIV positive infants, there is a delay in initiation of the
appropriate care and treatment. The absence of an interface information management system makes
retrieval of results and specimen storage difficult. There is therefore need to introduce a laboratory
electronic information system. Finally, the increasing number of samples has impacted negatively on the
only 5-parts differential Coulter machine in Mulago and leads to frequent breakdowns due to overload.
In FY 2009 four new satellite care (HC1V) and treatment sites will be opened (increasing the number of
treatment sites to 19). MJAP will provide ART laboratory screening and monitoring support to over 70,000
patients (this includes patients accessing Global Fund ARV drugs). In the new treatment sites, MJAP will
provide support in terms of space modification, staff training, provision of equipment and reagents, quality
assurance and infection control according to identified gaps. To ensure sustainability, MJAP will continue to
support the improvement of existing infrastructure and systems within the facilities. Funds will go towards
training and support for laboratory monitoring including CD4 counts. MJAP ART laboratory infrastructure will
support all ART patients within health units in which MJAP is operating thereby leveraging resources. The
program will maintain the baseline tests, additional tests for improvement in diagnosis of opportunistic
infections will be added basing on costs evaluation and significance as may be required by the clinical team.
Additional equipment will be procured for the two new health centres of Kitebi and Komamboga. This will
reduce costs and improve the turn around time for results. The program will provide supplies and
Activity Narrative: maintenance for all the equipment. Due to the expansion and setting up of several centres, a quality
monitoring section with two staff will be set up to monitor the quality of laboratory performance, regional
referral hospitals inclusive. The internal and external quality procedures that are in place will be
strengthened. The two main central laboratories in Mulago and Mbarara will be listed for International
Standards Organisation accreditation (ISO) by reputable bodies. The primary target is to come up with
workable and sustainable laboratory quality standards and implement good laboratory practice, in delivery
of reliable, accurate and timely HIV related laboratory services.Safety practices and infection control will be
strengthened. Basic disposal materials like waste bins and waste liners will be replenished and staff will be
trained in infection control as needed. The program will upgrade tuberculosis (TB) screening from ZN
sputum smear to Fluorescent microscopy technique to improve case detection across all regional referral
hospitals. Periodic monitoring, supervision and training will be done in order to maintain the desired quality.
In order to improve on the turn around time for infant DNA PCR results, MJAP will hold discussions with the
supporting partners in order to address the obstacles encountered. A laboratory training curriculum
targeting laboratory technicians and laboratory managers that is under development will be implemented. In
order to improve service delivery and build capacity, MJAP will use both task shifting and pre-service
training to build capacity in expansion of laboratory services at the University teaching hospitals. Support
supervision will be strengthened, this will be in-line with the national health structure, which is: National
referral to regional referral then to lower level laboratories, and this will improve follow up of TB patients.
Laboratory personnel involved in HIV screening will be constantly supported, through capacity building and
exchange visits to partner laboratories.
Continuing Activity: 13280
13280 4037.08 HHS/Centers for Makerere 6431 1107.08 Mulago-Mbarara $900,000
8320 4037.07 HHS/Centers for Makerere 4805 1107.07 Mulago-Mbarara $900,000
4037 4037.06 HHS/Centers for Makerere 3182 1107.06 Mulago-Mbarara $439,270
Estimated amount of funding that is planned for Human Capacity Development $496,447
Table 3.3.16:
