The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF) is a transfer mechanism to local organizations. HJF officially receives funds and transfers them to The Makerere University Walter Reed Project (MUWRP) in Uganda to implement HIV program activities. MUWRP thus falls under the auspices of the US Military HIV Research Program and has a Memorandum of Understanding with Makerere University of Uganda. MUWRP has been working in Uganda since 1998 in the area of HIV research and more recently in the provision of HIV care, treatment, and prevention services. Among the goals of MUWRP is to build the infrastructure, capacity, and systems of local public and private partners in central Uganda to ensure sustainable, quality, comprehensive HIV services for communities that have participated or could participate in research studies. Since 2005, MUWRP has increased its PEPFAR support to the Kayunga and Mukono Districts by supporting cross-cutting HIV programs including: expanding the number of HIV clinical sites, provision of efficient laboratory capacity, infrastructure remodeling, District-level data system strengthening, supply-chain management strengthening, human capacity development, innovative task shifting, youth-focused programs, short-term technical staffing, comprehensive home-based OVC services, and a variety of counseling and testing and prevention programs including medical male circumcision and house-to-house testing. MUWRP manages only data-driven programs from on-going program monitoring and evaluation. Finally, MUWRPs strong emphasis on efficiency have achieved improved economies in procurement, highly coordinated service delivery, and expanded coverage of programs with low marginal costs.

The Adult Care and support program described below continues to be part of a comprehensive HIV program and activities do link to other program areas. Specific program activities that are linked to adult care and support include: OP, SI, CT, laboratory, ARV drugs, Adult treatment, male circumcision, and OVC services. During FY2008 and FY2009, MUWRP greatly expanded facility-based adult care and support services to cover all of Kayunga District (older than 18 years (now including the north of Kayunga District specifically the rural, underserved, fishing communities of Galilyra via the facility; Galilyra Health Center III). The rate at which adults sought HIV care and treatment rose during FY 2009, largely as a result of: (1) provider initiated HIV testing and (2) HIV+ referrals from a house-to-house CT program which started in July 2008. To address this, MUWRP partnered with the remote Busana Health Center III in FY 2009 in eastern Kayunga and this clinic began providing the MUWRP model of comprehensive HIV services, including adult care and support. Finally during FY2009 MUWRP also expanded adult care and support services to support one additional clinic in the neighboring District of Mukono, specifically to the Kojja Health Center IV in Mukono South sub-district. Expansions to these facilities were carefully targeted by MUWRP and fit nicely into the overall Uganda PEPFAR specific country strategy of regionalization. Each year, MUWRP sends all of the clinicians at each of its supported HIV facilities and NGO's (nurses, medical officers, clinical officers, record keepers, etc) to attend a two-week course on the delivery of comprehensive HIV services. The course is delivered by a team of trainers from the Uganda MOH and strictly follows MOH HIV guidelines and policy. Also pertaining to QAQC, MUWRP continues to provide supportive supervision (expanded now to all seven HIV MUWRP supported facilities). More specifically, this includes HIV clinic day supervision from MUWRP's mobile clinical team comprising of two nurses, two clinical officers, one pharmacist, and one medical officer. A primary strength of MUWRPs model of providing adult care and support includes the routine training of district lay workers, treatment club members, and members of PLWHA groups to deliver the most basic of ARV services. As a result of this capacity building, volunteers have now developed 5 rural treatment club nutrition farms (23 acres total) to supplement the diet of adult care and support patients each of the farms has had several successful harvests and all patients have benefited regardless of the percent time they have spent working on the farms. Most recently, MUWRP supported the distribution of cows, chickens and pigs to these farms who collectively use the Send a Cow model as a successful IGA. Through a MUWRP partnership with PACE, treatment club volunteers also distributed over 2300 basic care packages to HIV+ persons on care and probably most notably, the treatment club members themselves spearhead a follow-up program that traces patients deemed lost-to-follow-up to their homes. Data from this lost-to-follow-up program was presented at the International AIDS Conference in Mexico City. As a result, lost-to-follow-up issues in Kayunga are (relatively) very low. Also recently, MUWRP supported the implementation of Post Exposure Prophylaxis Programs at each of the 7 HIV clinics in Kayunga and Mukono for victims of rape, defilement, or any other person who has had immediate exposure to HIV and also supported 30 District clinicians to attend a two-week training on reproductive health. Finally, and possibly most importantly under this program area, because OI supplies are not stable in Uganda; MUWRP has always served as a back-up source to ensure that neither PEPFAR nor GOU MOH patients in Kayunga experience OI drug stock outs.

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During FY2009, and in collaboration with Child Advocacy International (CAI), MUWRP supported CAI activities which center around a home-based counseling/ follow-up program that provides community based outreach, support, counseling, and education for Kayunga District OVC's, their families, and the community. CAI priorities lay in improving families and households, improving quality service delivery and improving community support and coordination. Last year, CAI expanded their coverage of Kayunga District and consequently expanded the number of OVC's they provide primary direct support through scheduled monthly home visits. CAI will continue to offer OVC families a comprehensive list of home-based services which include HIV education, counseling, psycho-social activities, emotional backing, scholastic materials, clothes, nutritional evaluation and counseling, supplemental food based on need, and school fees for 100 OVC's in FY2010. CAI will also continue their on-going home-based education through monthly home visits to include technical assistance to caregivers and families on how to care for pediatric ART/HIV+ patients as well as the direct provision of some basic palliative needs such as symptom control for the patients themselves. Support for the caregivers includes linking families of pediatric ART patients together for group/peer counseling and psychosocial support. Most recently, and as a result of routine monitoring and evaluation, home-based services were expanded to the fishing villages and the remote northern and southern most regions of Kayunga District. CAI continued to refine their quality of services at each of the existing OVC points of service during FY09. This was accomplished by provision of quality trainings, technical advisors, focus groups, institution of best practices, and standard operating procedures. A recent success was the result of a consultation with 120 caregivers of OVC, in which nearly 500 mattresses, blankets and mackintoshes were supplied to the caretakers during FY09. One notable challenge during FY2009 is that CAI has acted as a referral mechanism for MUWRP's house-to-house CT program. Consequently, CAI has increased the number of OVC families it must support and its staff and budget have been stretched. MUWRP funding levels to CAI currently support the cost of staffing, training of volunteers in HIV service provision (home-based care), and community-based activities including monthly home visits/follow-up visits/fuel to OVC, care-giver counseling, tools for home monitoring of OVC and household evaluation, psycho-social activities, and bi-monthly community sensitizations. During FY2010, CAI will continue to provide high quality OVC services that link with other District services such as PMTCT, care and support, ART, HCT as well as other NGO services in Kayunga (listed below) to strengthen the capacity of the family unit (caregiver) to care for OVC.

Also during FY2009, MUWRP continued its support of the highly successful Kayunga District Youth Recreational Center. This center was founded in 2006 as a joint effort between the Kayunga District Hospital, the Kayunga District Government and MUWRP as an organization/facility to build district capacity in identifying and providing HIV prevention services to Kayunga Districts' youth population, and especially their orphans and vulnerable children. The Center priorities lay in improving families and households, improving quality service delivery and improving community support and coordination. The Center currently provides youth with counseling and care in a manner which is specifically geared toward persons between the ages of 12-18 who are HIV positive or defined as OVC's. Any youth found to be HIV+ are successfully referred for evaluation for ART by clinical staff of the District Hospital. The Center continues to provide community based counseling to youth, emotional support, and meets psycho-social needs through recreational games, sports, music, big competitions, and drama. Community focused activities include district-wide youth outreach, education and psycho-social activities at schools and in communities with emphasis on identifying orphaned children or vulnerable adolescents. Special emphasis is put on vulnerable children, especially those made vulnerable due to: unemployment, disability, early child labor, gender or those living outside of family care. This Center also works closely with community structures which protect and promote healthy child development, such as schools, churches, clinics, and the Kayunga District police force. During FY09 three of the volunteer youth staff at the Center, all of whom were out-of-school and living outside of family care, were supported with school fees with the goal of accessing higher paying careers. Two other volunteer staff were awarded competitive Youth Center scholarships, one for university and one for starting a business. Finally five of the volunteer staff have been given advanced contracts with MUWRP to work in other MUWRP program areas such as male circumcision, SI, and as program coordinators.

CAI and the Kayunga Youth Recreational Center and MUWRP have collaborated and/or partnered with the following civil society groups in Kayunga in order to build local capacity: (1) Boy brigades, (2) Kayunga town youth council, (3) Kayunga District youth council, (4) Community and Response to AIDS, (5) Busaana Women Community HIV/AIDS Positive Living and Orphanage Care, (6) Girl guides, (7) Uganda scouts association of Kayunga, (8) Nazigo youth health and development association, (9) Disabled school of Bukoloto and (10) Fare Ministries, (11) Human Rights and Civic Education Forum, (12) the Rubaga Youth Development Association, and (13) Youth in Action of Kayunga.

Specific program activities that are linked to Adult Treatment include: OP, SI, CT, laboratory, ARV drugs, Adult care and support, male circumcision, and OVC services. The MUWRP model of comprehensive care and treatment is delivered at each of its seven supported facilities, including ART, cotrimoxazole prophylaxis and routine TB screening at each patient visit. Each year, MUWRP sends all of the clinicians at each of its supported HIV facilities and NGO's (nurses, medical officers, and clinical officers) to attend a two-week course on the delivery of comprehensive HIV services including adult treatment. The course is delivered by a team of trainers from the Uganda MOH and strictly follows MOH HIV guidelines and policy. Also pertaining to QAQC, MUWRP continues to provide supportive supervision (expanded now to all seven HIV MUWRP supported facilities). More specifically, this includes HIV clinic day supervision from MUWRP's mobile clinical team comprising of two nurses, two clinical officers, one pharmacist, and one medical officer. A primary strength of MUWRPs model of providing adult treatment includes the routine training of district lay workers, treatment club members, and members of PLWHA groups to deliver the most basic of ARV services. Very large treatment club meetings are supported each month by MUWRP at each of the 7 supported HIV clinics. MUWRP and clinic facilitators ensure that at each meeting, adherence and nutrition issues are fully addressed as are: treatment club IGA issues and particular clinician concerns from each facility. Linking this program area to MUWRPs laboratory program area, routine viral load tests are performed on every patient on ART as per WHO guidelines. Clinical patients outcomes are tracked by (1) CD4's, (2) viral loads, (3) routine patient screening for OI's, especially TB, (3) patient presentation, (4) other diagnostic tests. Data from viral load testing and individual patient counseling indicate that although adherence is routinely addressed at each clinic visit and each treatment club meeting, IGA meeting, home visit, etc,. adherence is still an issue for between 8-13% of ART patients. As a result of the capacity building at the patient level, volunteers have now developed 5 rural treatment club nutrition farms (23 acres total) to supplement the diet of adult care and support patients each of the farms has had several successful harvests and all patients have benefited regardless of the percent time they have spent working on the farms. Most recently, MUWRP supported the distribution of cows, chickens and pigs to these farms who collectively use the -Send a Cow- model successfully. Through a MUWRP partnership with PACE, treatment club volunteers also distributed over 2300 basic care packages to HIV+ persons on care and probably most notably, the treatment club members themselves spearhead a follow-up/adherence program that traces patients deemed lost-to-follow-up to their homes. Data from this lost-to-follow-up program was presented at the most recent International AIDS Conference in Mexico City. MUWRP has greatly expanded facility-based adult treatment services to cover all of Kayunga District, persons older than 18 years (now including the north of Kayunga District specifically the rural, underserved, fishing communities of Galilyra via Galilyra Health Center III facility). The rate at which adults sought HIV treatment rose during FY 2009, largely as a result of: (1) provider initiated HIV testing and (2) HIV+ referrals from a house-to-house CT program which started in July 2008. To address this, MUWRP partnered with the remote Busana Health Center III in FY 2009 in eastern Kayunga and this clinic began providing the MUWRP model of comprehensive HIV services. Finally during FY2009 MUWRP also expanded adult treatment services to support one additional clinic in the neighboring District of Mukono, specifically to the Kojja Health Center IV in Mukono South sub-district. Expansions to these facilities were carefully targeted by MUWRP and fit nicely into the overall Uganda PEPFAR specific country strategy of regionalization.

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MUWRP's HIV counseling and testing (CT) program occurs throughout Kayunga District and in FY09 was expanded to the Kojja Health Center IV in Mukono District. The program provides provider-initiated (routine at all MUWRP supported clinics), client initiated, couples testing, medical male circumcision, and special events/CT campaigns through 9 health units in Kayunga including the Kayunga District Youth Recreation Center Clinic and the Kojja Health Center IV. Note that CT testing at PMTCT sites is done through another implementer. Further, the program initiated a house-to-house (H2H) CT program in August 2008 (only in Kayunga District). The H2H program is on-going and as a result, more than 35000 Kayunga residents have been tested, counseled, received their results in their homes and strongly referred (with persistent follow-up) for PMTCT, TB, OVC, ART or care services if appropriate. The Uganda MOH HIV testing algorithm (Determine, Stat Pak, and Uni Gold-as a tie-breaker) is employed for all HIV tests. For those few individuals whose results are still inconclusive after undergoing the MOH algorithm, a red top tube of blood is drawn and sent to the MUWRP research laboratory in Kampala for an both an Eliza and a Western blot test.

MUWRP has provided strong follow-up to those who test HIV positive, especially those who tested through the H2H program. H2H program staff routinely return to the homes of individuals who tested HIV+ to gage and ensure that no harm was introduced by informing persons of their HIV+ status in their homes. As of this writing, no harms have been reported. Further, MUWRP has formed and supported an active discordant couples group with an emphasis on prevention with positives. Promotional activities to reach the target populations (couples counseling and the H2H program) have included billboard advertising, market place announcements, posters, drama presentations and sporting events. All CT services, despite the program, are provided by either highly trained/tested/monitored para-professionals or clinical staff. Ongoing support supervision at all of the health centers, the sporting events, the youth center clinic, the H2H program, post-test clubs, or the drop-in centers is provided by a full time MUWRP CT technical specialist operating in strict accordance with Uganda MOH CT guidelines. For the purposes of quality control, two process take place monthly within the program; (1) dried blood spots (DBS) from all clients who test HIV+ (following the MOH algorithm) as well as DBS from 2% of the HIV- clients are collected and sent to a reference lab for retesting, using the DNA PCR technique - the results from the retesting are compared with the field results to determine the proportion of true positives and false positives; and (2) quarterly testing of quality control samples prepared in the lab are randomly distributed to the HCT staff and their results are compared with the known results - thus staff competency is routinely ascertained and remedial action taken whenever necessary.

Routine monitoring and evaluation of all data from the HCT program have informed program policy at the District level and driven MUWRP program policy to expand program services to clearly identified MARPS, including fishing villages and youth.

Due to the fact that availability of commodities remains sporadic, MUWRP has always provided technical support in supply chain management as well as back-up commodity supplies to all of the CT sites/programs to ensure that there will be no stock outs. Funds are also used for training, staffing, transportation, supportive supervision, sub-contracts, and on-going technical assistance in the areas of service delivery. The increase in demand for CT has been met through training of additional counselors and medical staff to provide this service not only at the HIV clinic and VCT centers, but as part of inpatient and out patient services, including the TB clinic, where a majority of treatment eligible patients are found. MUWRP also works alongside other health agencies in Kayunga and Mukono, such as Doctors with Africa (CUAMM) and the National TB and Leprosy Programme (NTLP), so that capacity was developed to ensure that individuals being screened for TB at NTLP sites were concurrently tested for HIV and referred to HIV services if HIV-positive.

The Pediatric care and support program described below continues to be part of a comprehensive program with activities linked to other program areas. Specific program activities in this comprehensive program include pediatric treatment, prevention, SI, CT, laboratory, ARV drugs, and OVC services. In partnership with Child Health Advocacy International - Uganda (CHAI), MUWRP has expanded activities of its mobile clinical/counseling follow-up program which provides home-based care and support to HIV+ pediatrics. CHAI's coverage now includes all of Kayunga District (all HIV+ persons between 0-18 years old) and consequently expanded the number of HIV+ pediatrics they provide direct support through scheduled monthly home visits. This included expansion to the fishing villages and the remote northern and southern most regions of Kayunga District. Most recently, MUWRP expanded their pediatric care and support program to the neighboring District of Mukono to provide care and support services through the Kojja Health Center IV in Mukono South Sub-district (again, all HIV+ persons between 1-18 years old). CHAI offers HIV+ pediatrics a comprehensive list of home-based services which include care, treatment, HIV education, counseling, psycho-social activities, emotional backing and (when appropriate) school fees, scholastic materials, clothes, mattresses, blankets, mackintoshes, and supplemental food. MUWRPs laboratory support ensures that all pediatrics on care routinely get chemistry, hematology, and CD4's. During FY2008, CHAI continued their on-going home-based care and treatment through these visits to include technical assistance to caregivers and families on how to care for pediatric ART/HIV+ patients as well as the direct provision of some basic palliative needs such as symptom control for the patients themselves. Support for the caregivers also includes linking families of pediatric ART patients together for group/peer counseling and psychosocial support. CHAI also has refined their quality of services at each of the existing points of service. This was accomplished by provision of quality trainings, technical advisors, focus groups, institution of best practices, and standard operating procedures. The Kayunga District Youth Recreational Center was founded in 2005 as a joint effort between the Kayunga District Hospital, the Kayunga District Government and MUWRP as an organization/facility to build district capacity in identifying and providing HIV services to Kayunga Districts' youth population, and especially HIV+ pediatrics. The Center currently provides youth with care and clinical services in a manner which is specifically geared toward persons between the ages of 12-18 who are HIV positive. The Youth Clinic at the Center counsels and tests youth and successfully retains 100%of those testing positive for care and treatment. Finally, because an array of OI supplies is not stable in Uganda, MUWRP has always served as a back-up source to ensure that Kayunga District HIV+ pediatrics never experience OI drug/commodity stock outs.

The Pediatric Treatment program described below continues to be part of a comprehensive program with activities linked to other program areas. Specific program activities in this comprehensive program include pediatric care and services, prevention, SI, CT, laboratory, ARV drugs, and OVC services. MUWRP, in partnership with Child Health Advocacy International - Uganda (CHAI), MUWRP has expanded activities of its mobile clinical/counseling follow-up program which provides home-based care and treatment to HIV+ pediatrics. CHAI's coverage now includes all of Kayunga District (all HIV+ persons between 0-18 years old) and consequently expanded the number of HIV+ pediatrics they provide direct support through scheduled monthly home visits. This included expansion to the fishing villages and the remote northern and southern most regions of Kayunga District. Most recently, MUWRP expanded their pediatric treatment program to the neighboring District of Mukono to provide treatment services through the Kojja Health Center IV in Mukono South Sub-district (again, all HIV+ persons between 1-18 years old). CHAI offers HIV+ pediatrics a comprehensive list of home-based services which include treatment, HIV education, and counseling, and when appropriate supplemental food. MUWRPs laboratory support ensures that all pediatrics on treatment routinely get chemistry, hematology, and CD4's. Beginning in FY 2009, all patients on ART, including pediatrics, were routinely given viral load tests. CHAI has continued their on-going home-based care and treatment through these visits to include technical assistance to caregivers and families on how to care for pediatric ART/HIV+ patients as well as the direct provision of some basic palliative needs such as symptom control for the patients themselves. Support for the caregivers also includes linking families of pediatric ART patients together for group/peer counseling and psychosocial support. CHAI also has refined their quality of services at each of the existing points of service. This was accomplished by provision of quality trainings, technical advisors, focus groups, institution of best practices, and standard operating procedures. The Kayunga District Youth Recreational Center was founded in 2005 as a joint effort between the Kayunga District Hospital, the Kayunga District Government and MUWRP as an organization/facility to build district capacity in identifying and providing HIV services to Kayunga Districts' youth population, and especially HIV+ pediatrics. The Center currently provides youth with clinical services in a manner which is specifically geared toward persons between the ages of 12-18 who are HIV positive. The Youth Clinic at the Center counsels and tests youth and successfully retains 100%of those testing positive for treatment. Finally, because ART supplies are not stable in Uganda, MUWRP has always served as a back-up source to ensure that Kayunga District HIV+ pediatrics never experience ART or OI drug/commodity stock outs. MUWRP funding to CHAI currently supports the cost of ART/OI drugs and commodities, some staffing, training, mobile activity overhead, monthly home visits/follow-up visits to HIV+ pediatrics, care-giver counseling, tools for home monitoring of HIV+ pediatrics, household evaluation, evaluation of nutritional status, nutritional counseling and provision of supplemental food based on needs. Currently, pediatric care and treatment patient enrollment rates are rising in Kayunga due to HIV+ referrals from a house-to-house counseling and testing program which started in July 2008. This trend is expected to continue.

Program activities that are included in MUWRP's comprehensive approaches, such as care, treatment, laboratory, and CT services, are budgeted under their respective program areas. However, in order for these programs to operate successfully, MUWRP leverages SI funding to cover required expansion of staffing, increased materials and data management and training of local implementing partners. The focus of MUWRP's SI program during FY2009 was to strengthen the HMIS capacity of Kayunga District Hospital and six health centers for accurate and timely reporting on required indicators to GOU MOH. Technical assistance was provided to continue collection, management and analysis of data not only across PEPFAR Program areas but for all District health data collection and analysis. MUWRP provided technical and infrastructural support to the District, including computer and email access to seven key District HIV staff personnel operating in remote areas. A MUWRP data officer has partnered with District HMIS staff (both at the District level and at 6 health facilities) to ensure they receive adequate training in data collection, management and analysis. Monthly supportive supervision by District level HMIS staff to the lower level facilities was also supported by MUWRP. SI funding supported salary of 4 SI staff, training, maintenance, six computers, supplies, technical expertise and internet service provision. Finally during 2009, MUWRP staff continued to conduct analysis of data that are collected as a part of routine patient/client visits. Some of the analysis includes exploring and describing change among treatment cohorts, factors associated with lost-to-follow-up, youth, CT trends etc., in order to inform program implementers and policy makers. Because of these analyses, MUWRP and Kayunga District officials have presented abstracts and posters at local and international AIDS conferences. Also during FY2009, MUWRP began partnering with the CDC to pilot test an electronic tracking system for HIV/AIDS patients at the Kayunga District Hospital. This system is not yet complete, but in FY2010 the goal will be to expand the pilot to include electronic laboratory data. The current system being used is paper-based and with the staff and facility now operating at a higher level of capacity with increased patient loads, the time is right for an automated system. This system will provide more efficient means of managing files and tracking patients. This will involve providing material and technical support to the District Hospital clinic and laboratory which has the largest patient load of all the HIV clinics in Kayunga District. During the past year, other program areas within the MUWRP comprehensive model experienced great success in task-shifting to treatment club members. During FY2010, MUWRP intends to task shift to the patient level and build capacity among treatment club members for services such as data entry and data verification. Also during FY2010 MUWRP intends to build on past success by continuing to support an SI innovative. The goal is to develop capacity, infrastructure, and provide technical training to enable the Kayunga District Health authorities to export all health indicator data from their locally maintained database directly to the Uganda Ministry of Health databases. Support includes material support as well as technical assistance. Efforts so far have been successful in completely customizing a specialized soft wear (the DHIS) for the Uganda HMIS system, with over 2000 indicators added to the software and all of the Uganda HMIS forms entered into the database back to the year 1995. Further, MUWRP has supported a two-week training by DHIS engineers which was offered to technicians from Uganda MOH, USG agencies, as well as technicians from MUWRP and Kayunga District. After months of trial and error, Kayunga health data was successfully exported for the first time into the Uganda MOH HMIS system in June 2009.

During FY09 MUWRP implemented Uganda's first non-research medical male circumcision (MMC) program at the Kayunga District Hospital. The program was officially launched in July 2009 when a renovated surgical theatre was handed-over to the District. Implementation of this service included: (1) training support for 15 doctors, clinical officers, nurses and counselors through the Rakai Health Services Program; (2) generation of MUWRP MMC program policy, procedures (in accordance with international guidance), quality assurance guidelines (including safety/support supervision) and clinical tools; (3) provision of equipment and commodities; (4) establishment of a target population-specific messaging program that included billboards, radio talk-shows, posters, market-place announcements, drama groups (specifically trained in MMC messaging for both males and females), and weekly community outreach and sensitization; (5) the implementation of an MMC basic program evaluation of the first 300 service participants and a community survey to gage pre-post MMC sensitization knowledge attitudes and behaviors; and finally (6) the complete remodeling of a minor surgical theatre for performing MMC surgeries. HIV testing and counseling was provided for every service recipient as well as; pre and post-operative sexual risk reduction counseling, assessment and/or treatment of STIs, strong promotion of consistent use of condoms, counseling on the need for abstinence from sexual activity during wound healing, wound care instructions, and post-operative clinical assessments and care. Of paramount importance to MUWRP was to roll out a safe program that was efficient with low marginal costs. This was made possible by securing strong buy in from District and National health officials, community/religious/opinion/political leaders, and by primarily utilizing District hospital clinicians in the provision of service. During FY10, in an attempt to reach more service recipients, plans are already underway to expand the exact MMC program described above to neonates and through two additional sites; the Kojja Health Center IV in Mukono District and the Kangulumira Health Center IV in Kayunga District. Training for neonatal circumcision will be done by pediatric surgeons based at Mulago Hospital. Also, using data from the basic program evaluation that was conducted and, with continued strong emphasis on cost savings and safety (out of 330 males circumcised during FY09 - only 3 experienced very small adverse events such as bleeding) MUWRP intends to pilot a clinical ledger tool. The aim of this tool is to greatly reduce paperwork for clinicians by allowing them to record all (WHO recommended) surgical, pre and post clinical information in one book. With this expansion plan, it is expected the Program can perform 3000 circumcisions during FY10. The Henry Jackson Foundation seeks to establish a Medical Male Circumcision (MMC) training center in Kayunga that will facilitate expansion of MMC services and best practices for Uganda. The medical cadres that will be trained through this center are comprised of: surgeons, doctors, clinical officers, theater assistants, and councilors. Training will focus on service provision to sexually active men and adolescents as well as neonate surgery. This application requests funding for infrastructure remodeling, supplies, equipment, staff, trainee facilitation, mobilization; an M&E component; and other direct costs.

In 2009, MUWRP launched the first non-research MMC site in Uganda at the Kayunga District Hospital. The Kayunga event was endorsed by the MOH and was attended by representatives from the Uganda ACP, AIDS Commission, and the US Embassy. Most recently, MUWRP expanded MMC service delivery to another fixed site in Mukono District, and has served as a pilot site to implement Uganda's recently developed MMC counseling curriculum. Of strategic importance in the implementation of MMC services is the availability of MMC training for health workers. While MMC training is available in Uganda through Rakai Health Sciences Program (RHSP), due to RHSP's funding and large number of international applicants, the wait to receive MMC training at Rakai is nearly 6 months. In October 2009, recognizing that the wait for training was causing a bottleneck to a more rapid MMC scale up, RHSP representatives requested that MUWRP establish a satellite MMC training center in Kayunga. On March 5, 2010, 15 Mukono and Kayunga health workers completed the first 2-week MMC training in Kayunga. This was done using MUWRP and District staff whom RSHP had already trained-as-trainers, and with technical oversight from RHSP. The course was funded with non-obligated limited MUWRP funds. During exit evaluations the 15 trained health workers were asked if the Kayunga training course had provided them with sufficient technical skills/knowledge to implement MMC; 53% strongly agreed, 40% agreed, and 6% had no opinion. MUWRP has already hired an architect and a quantity surveyor management consultant to assist in the remodeling of 4 areas at the Kayunga District Hospital that have been allocated to MUWRP. These include a large MMC training classroom, 3 breakout session rooms, a MMC resource center with internet capacity, a lunch area, a laundry room, and most critically; the expansion of the present surgical center into a 6-surgical table training facility.

Based on the MUWRP experience, there is a need to avoid provision of MMC training to inappropriate medical staff or to medical staff who will not be appropriately supported. For that reason, before any training is offered to an individual or to a team of individuals, as part of MUWRPs training curriculum, a MUWRP team will first need to conduct a pre-training site assessment visit. The conditions and issues to be assessed at every site include: (1) MMC infrastructure, (2) MMC supplies/equipment/materials, (3) willingness and availability of medical staff to implement MMC, and (4) MMC program commitment from the District Health Officer. Furthermore, the MUWRP team will need to meet with the Director and managers of the MMC program of the implementing partner. The purpose of this meeting is to assess the supply chain management plan for all MMC sites.

Post training supportive supervision will be carried out by the MUWRP supportive supervision team as per the following schedule: *Month 1 post MMC training - 1 supportive supervision visit every two weeks *Months 2, 3, 4, and 5 post MMC training 1 supportive supervision visit per month MUWRP supervisors may determine that some subsequent visits should be canceled. Reasons for canceling a supportive supervision visit could include perfect performance at a MMC site as deemed by the supervisors, or that the site has never operationalized MMC provision. Finally, the supportive supervision team will always be available by telephone.

Supportive supervision for the MUWRP MMC training center will continue to be supplied by RHSP in a collaborative and on a contractual basis. More specifically supervision will be supported from RHSP surgeon Daniel Namuguz and RHSP gynecologist Steven Watya. MUWRP will now endeavor to have the training center accredited by the Ugandan Ministry of Health, again collaborating with colleagues from RHSP who have already provided MUWRP with templates for most of their training materials and training curriculum.

In addition, the Henry Jackson Foundation will establish two pilot sites providing a comprehensive Medical Male Circumcision (MMC) package in Mukono and Kayunga utilizing the "Broken Chair Room" (BCR) Model recently accepted by the Uganda USG HIV Transmission Prevention Task Force. This application requests funding to establish two much reduced cost sites, including; 5 staff per site, supplies, equipment, mobilization, BCC counseling, site identification, cleaning and other direct costs. Staff training will be provided by the Kayunga District MUWRP MMC Training Center.

According to all mathematical models on the number of infections averted due to MMC, if Uganda is to attempt to prevent a sizeable number of HIV transmissions using MMC, a much larger number of circumcision surgeries must be performed. The BCR model of rolling out MMC in Uganda was carefully developed by the MUWRP and DOD USG agencies in an effort to provide a realistic solution to this problem with the main goals of providing a large number of MMC surgeries at a reduced cost without sacrificing safety. The costing data for this model was based on successful MMC program data and budget set for just one BCR site is meant to include everything except training. If administered carefully and medically, the goal for each of these BCR MMC sites is to perform 2250 circumcisions per year, with less than five adverse events reported.

Last year, MUWRP's Abstinence and Be Faithful program trained and supported volunteers and District lay workers, including 46 dedicated youth volunteers, to carry out AB prevention activities. During FY 2010, AB activities are aimed at all of Kayunga District, rural and semi-rural areas, males and females. However, MUWRP's HCT data reveal that the vast preponderance of HIV infections in Kayunga occur from age 21 through age 32. Thus; MUWRP has thus tailored its AB program so that persons falling within this age group are pinpointed for the highest number of interventions. This is made possible due to the strong mobile prevention presence, which includes CT and OP activities, that MUWRP has supported since its inception in 2005, However, abstinence activities are primarily aimed at those under the age of 18 who are both in-school and out-of-school and include counseling on the delay of sexual activity. Supportive supervision for counselors is given by MUWRP's full-time prevention coordinator, who monitors program counselors and provides regular feedback. Last year as a further measure of quality, MUWRP coordinated and supported the standardization and all AB IEC materials and training curricula in Kayunga District. Faithfulness messages and trainings have also been standardized and focus on those older than 15 years of age (District-wide) and include messaging campaigns, prevention with positive activities, male norms and behaviors, increasing gender equity, cross generational sex, increasing women's legal rights and access to income and productive resources including life skills as they are related to HIV prevention. Although other target populations get faithfulness messages, MUWRP's faithfulness programs target men and women age 21-32 in concurrent partnerships. MUWRP's program will continue to support the infrastructure and activities of a vibrant and well-attended youth center, the Kayunga District Youth Recreation Center. In partnership with the US Peace Corps and the Kayunga Town Council, MUWRP supports this center to be a place of recreation and education for young people, especially at-risk out-of-school youth, ensuring that they are active, engaged, and provided with an array of health related services, including HIV education, testing and counseling. Specific community activities include bi-weekly mobile HIV education outreaches, youth outreaches to schools and communities, AB messages delivered during a District house-to-house HIV testing program, outreach to boda boda (motorcycle taxi) drivers, and at least 4 District-wide sports competitions with strong HIV education, messaging, counseling and testing components. During FY 2009, these programs reached more than 10,000 individuals who were provided with abstinence and be faithful services and 10 new individuals were trained. During FY 2010, these programs will continue and, if appropriate, client services will be strongly linked/integrated to MUWRP's OP activities, which include: prevention with condoms, male circumcision, prevention with positives, and domestic violence community sensitizations and messaging campaigns. AB data is monitored routinely and reported to the Kayunga District health authority so as to assist them (and MUWRP) in prevention programming and plans, especially pertaining to identifying geographical gaps.

During FY 2010, OP activities will continue to be aimed at all of Kayunga District, rural and semi-rural areas, males and females. However, MUWRP's HCT data reveal that the vast preponderance of HIV infections in Kayunga occur from age 21 through age 32. Thus; MUWRP has thus tailored its OP program so that persons falling within this age group are pinpointed for the highest number of interventions, especially condom distribution. This is made possible due to the strong mobile prevention presence, which includes CT and AB activities that MUWRP has supported since its inception in 2005. Another big MUWRP focus during FY2010 will be to continue to push for reducing violence and coercion throughout Kayunga District, in all 9 sub-counties. Several reinforcing approaches will be used in this respect, including re-training the entire Kayunga District police force, District clinicians, and lay workers - as well as a billboard campaign utilizing the local police force in the photos. MUWRP will partner with technical experts from the SHARE project and Raising Voices, both local NGOs with expertise in gender based violence to ensure quality trainings, billboard messages, and consistent (WHO standards), effective IEC messages are disseminated to the District communities through a variety fixed and mobile venues. Moreover, MUWRP will support a District-wide HIV drama competition that focuses on domestic violence and the winning group will tour all 9 sub-counties performing their play deep in the communities. As a result of MUWRP's house-to-house testing program that began in 2008, a large number of discordant couples throughout the District have been identified. Under this program area, MUWRP supports these couples (District-wide) with follow-up visits to the home and with quarterly meetings which include re-testing. Also under this program area, MUWRP will continue to train and support expert clients at each of the 8 MUWRP supported HIV clinics to conduct education sessions while patients wait to see a clinician. The topics covered by these lay workers include: prevention with positive, condom use, reproductive health measures, and pre-exposure prophylaxis. Supportive supervision for counselors is given by MUWRP's full-time prevention coordinator, who monitors all program counselors and provides regular feedback. Last year as a further measure of quality, MUWRP coordinated and supported the standardization of all OP IEC materials and training curricula in Kayunga District. Further, messages and trainings pertaining to condom use, cross-generational sex, male norms, reproductive health, and prevention with positives were standardized. All of these programs focus on those older than 15 years of age. Dissemination of messages under this program area will be District wide, utilizing: face-to-face counseling, group counseling, radio, marketplace loud speakers, roadside billboards and (coordination of District) state-of-the-art IEC materials. Also during FY2010, MUWRP will retrain District clinicians on the standard operating procedures of a post-exposure prophylaxis program that was implemented at each HIV clinic site in Kayunga for victims of rape, defilement, or any other person who has had immediate exposure to HIV. MUWRP will also continue its revolving billboard messages in FY2010, these messages currently focus on testing for HIV, medical male circumcision, couples counseling, the benefits of disclosing ones' HIV status, condom use, and as mentioned above, an entire billboard series on preventing domestic violence. Finally, MUWRP will support age-appropriate reproductive health training to 30 youth counselors from the Kayunga District Youth Recreation Center as well as in-depth training (including surgical techniques) to an additional 30 District clinicians.

The MUWRP supported laboratory program for Kayunga and Mukono Districts described below continues to be part of a comprehensive HIV program and activities do link to Counseling and Testing, Strategic Information, Adult and Pediatric Care and Treatment, ARV drugs, and OVC services. During FY2009, MUWRP supported the Kayunga District Hospital laboratory which operates at full capacity. This capacity has been built over-time and this laboratory is now processing and reporting CD4 enumeration, chemistry, and hematology for all HIV samples originating in Kayunga District and from the Kojja Health Center IV in Mukono District. Further, MUWRP supports routine viral load testing for those patients on ART at each of the 8 MUWRP supported HIV clinics. The addition of this test during FY 2009 has led to significant policy changes and patients being switched to second line drugs. Presently, testing of viral loads (and routine early infant PCR testing) is done through MUWRP's research laboratory in Kampala. The lessons learned by MUWRP in the achievement of their laboratory goals were presented at the 2009 International AIDS Conference in Mexico City. During FY 2010, MUWRP will continue to support laboratory services in Kayunga and Mukono Districts with; supply chain management supervision, strong daily supportive supervision, staffing support, task shifting programs to lab assistants, power solutions, perishables, trainings, and maintenance contracts for all equipment. The laboratory follows SOPs for all the testing they perform and strictly run controls on machines before testing any patient samples. Furthermore monthly comparability runs are done monthly between the hospital laboratory and MUWRP's research laboratory. Moreover on issues pertaining to Quality Control the laboratory is enrolled with the United Kingdom External Quality Assessment Service (UK NEQAS), which sends US samples bimonthly for EQA. Most recently the laboratory started receiving External QC flow cytometry samples from Synex life sciences, South Africa called Lymphosure. MUWRP intends to continue provision of these services, especially on their successful model of task shifting and building local capacity in FY2010. MUWRP intends to convert an underused research field laboratory in to a regional QA laboratory with the capacity to test viral loads and perform Elisa confirmatory tests. Access to this second laboratory operating at capacity will improve planning, forecasting and budgeting for laboratory support activities. Finally, plans are underway for MUWRP to partner with CDC in launching an electronic data system at the Kayunga District Hospital which will link patient clinical data to their laboratory data.