AIDS Information centre-Uganda (AIC) is a Non-Governmental Organization established in 1990 to provide HIV information to the general public including letting people know their status through Voluntary Counseling and Testing (VCT) for Human Immune Deficiency Virus (HIV). The Organization was founded by individuals in Kampala with support from United States of Agency for International Development (USAID) and Centre for Disease Control (CDC) as a response to growing demand from people who wanted to know their HIV status. It has since grown into a national organization with its offices in all regions of Uganda and nearly 170 staff. The objectives of AIC include to: Scale up initiatives for counseling and testing for 3.5 million people in 5 years; Scale up approaches for care and support to 3.5 million people in 5 years; Promote disclosure, anti stigma and non discrimination through post test clubs, couple clubs, and ongoing counseling to cover 250,000 people in the next 5 years; and Refer 25 percent of all HIV positive clients who are eligible for chronic care and other services in 5 years.

AIC is providing a number of HIV prevention, care and support services. The main focus is on HIV counseling and testing, Palliative Care and treatment of opportunistic infections. Services are offered through its 8 stand-alone branches that cover all regions of Uganda. These include Arua Lira ; Soroti ; Mbale ; Jinja; Kampala ; Mbarara and Kabale . AIC through the 8 branches, works closely with all hospitals, Health Center IVs and Health Center IIIs (also referred to as indirect sites or supported sites) to provide quality routine counseling and testing services. Coordination of these activities is done through the office of District health services in line with the national Health Sector Strategic Plan. The specific services targeted include: Clinical services like, diagnosis and Management of sexually transmitted diseases (STDs), Tuberculosis, family planning, prevention of mother to child transmission of HIV (PMTCT) and management of opportunistic infections (including contrimoxazole and Isoniazid prophylaxis). To date, AIC has reached more than 120,000 people with medical care and support.

HIV prevention is promoted through Post Test Club (PTC)/Philly Lutaaya Initiative services, which provide a range of services including: psychosocial support for people living with HIV/AIDS and conduct drama performances through which people are mobilized and sensitized on the different aspects of HIV. Post test clubs in AIC consist of more than 10,000 members. Monitoring the progress of the HIV/AIDS disease is done through CD4/8 tests that are readily available at all the branches. Furthermore, AIC conducts outreaches to reach the Most at Risk Persons (MARPS), with HIV counseling and testing (HCT). These HCT services are provided as an integrated package of comprehensive management of HIV/AIDS. These services are often preceded by drama sessions from Post test clubs (PTC) on a variety of topics including: Abstinence, Be-faithful and Condom use, discordance, other prevention services, public speaking and disclosure.

Since 1990 AIC has offered HCT services reaching a cumulative total of over 2,200,000 clients who had received HCT as of December 31st 2008. In 2008 alone more than 300,000 clients were counseled, tested and received their results. In-spite of its achievements, AIC noted that it has not been able to reach all its potential clientele through traditional approaches (facility based and outreaches). Secondly, the number of clients seeking VCT services has increased over the years; hence AIC realized the need to scale up services both geographically and in scope so as to ensure a wider coverage of services at community level.

AIC has received funding from a number of donors since its inception in 1990 to date. The Civil Society Fund (July 2007-June 2009) has supported AIC to scale up HCT services, in the three branches of Arua, Kabale and Mbale. USAID first funded AIC in 1990 this funding has continued to increase over time through PEPFAR. USAID through John Snow Inc (JSI) to scale up HCT services in Northern Uganda under the Northern Uganda Malaria, HIV/AIDS and TB Program (NUMAT). From CDC, AIC received a 5 year cooperative agreement to implement TB/HIV integration activities. Department for International Development (DFID), United Kingdom was instrumental in provision of bridge funding and budget support to AIC.

Implementing Partners: The Ministry of Health has a well established and decentralized health delivery system in the country through national and regional hospitals, and health centers at different levels. At District level, the Local governments through their structures have also been part of the support to implementation. To ensure ownership and sustainability, AIC works closely with the District Health Officer's (DHO) office and heads of Health sub-districts (HSDs). At sub-county level, AIC provides HCT services on an outreach basis. The communities are mobilized on pre-set dates and HCT is provided by trained service providers. Furthermore, AIC builds capacity of service providers through regular trainings at AIC facilities. In FY 2009/10 AIC will support 45 government health units, through the 8 AIC branches. AIC will also scale up collaboration with the private sector to support HCT in privately owned health units including work place settings. AIC has been implementing programs together with other partners like the Alliance of Mayors and Municipal Leaders Initiative in HIV/AIDS in Lower Local government (AMICALL), Health Communication Partnership (HCP) and Program for Accessible Health, Communication and Education (PACE). The partner organizations facilitate mobilization of clients while AIC provides the actual service of HCT. The private sector like the stanbic bank have supported AIC to carry out some activities. These include health education of the population they serve and HCT services including other services like provision of condoms. Other government sectors like the UAC, the police force, the Army, the Uganda prison services have all approached AIC to provide health education on prevention and care and HCT services.

Activities under this program will contribute to the implementation of the Uganda National policy on Tuberculosis (TB)/HIV integration, and will help to reduce morbidity and mortality related to TB among people with HIV.

The project will seek to achieve the following objectives:

i. To promote HIV diagnostic counseling and testing among persons with TB disease;

ii. Strengthen and expand screening, diagnosis and treatment for Active and Latent TB among HIV infected persons for one year;

iii. Strengthen prevention, care and support to active and latent TB clients for one year;

iv. To ensure effective TB infection Control among service providers and clients at AIC facilities.

TB-HIV Care Statistics

According to the WHO (2009), it is estimated that 9.27 million new cases of TB occurred in 2007 (139 per 100,000 population). Of the 9.27 million new cases, an estimated 4.1 million (44%) were new smear positive cases. Furthermore, among the 9.27 million incident cases in 2007, an estimated 1.37 million (14.8%) were HIV positive. A total of 456,000 deaths occurred from TB among HIV positive people (equivalent to 26% of deaths from TB in HIV positive and HIV negative people, and 23% of an estimated 2 million HIV-related deaths). Uganda is one of the world's 22 TB high-burden countries, with an incidence of 136 smear positive TB cases per 100,000 people per year [WHO, 2009]. TB is one of the most common causes of morbidity and the leading cause of mortality in people living with HIV/AIDS. HIV is the biggest risk factor for the development of active TB and at present an estimated 39% of TB patients are also co-infected with HIV [WHO, 2009]. The treatment success rate remains low because of the high proportion of patients who die, default from treatment or the treatment outcome is not evaluated (WHO, 2009).

TB/HIV Collaborative activities in AIDS Information Center

The AIDS Information Center started TB/HIV collaborative activities in 2001, with support from the CDC and the National TB and Leprosy Control Program (NTLP). Over 44,861 HIV positive clients have been screened for TB under this collaboration. Of those screened, 1,072 (2.4%) clients were found with active TB and were started on treatment. Furthermore, AIC has provided HCT services to over 2,500,000 clients since its inception. Approximately, 150,000 clients are counseled tested and provided with results in the AIC system every quarter. This has strategically positioned AIC, with an opportunity to screen all HIV positive clients under the TB/HIV collaboration.

During the third year of the cooperative agreement with CDC, AIC continued to counsel and test for HIV among TB patients. Over 3,221 TB clients were tested for HIV; because of AIC's major objective is to provide HCT to the general population, with support from CDC over 3,457 HIV positive clients were screened for TB during the 3rd year of funding; and a total of 955 clients were started on anti TB drugs. Other services provided during the year included: Isoniazid preventive therapy (IPT) for people living with HIV and a total of 82 clients accessed this service; Septrin prophylaxis was provided to over 2,035 HIV positive clients; and a total of 1,562 HIV positive clients accessed the CD4 count tests during the year. Of those with a CD4 less than 250 were referred for treatment in centers like MOH hospitals, TASO and JCRC. Well as those with CD4 above 250 were enrolled into chronic care at AIC and received septrin, management of OIs and psychosocial care through our post test clubs.

Capacity building in TB/HIV collaborative activities for the supported sites has greatly improved outputs in terms of quality TB/HIV activities under this collaborative agreement. To-date, AIC has built capacity of over 58 facilities to counsel and test all TB patients. Further more capacity has also been built in these facilities to screen all HIV positive clients for TB. Hence AIC is strategically positioned to expand coverage of TB/HIV collaborative activities in Uganda.

Human resource capacity and sustainability: The program has continued to recruit medical doctors, clinical officers and laboratory technicians. These have undergone training in the provision of HIV/TB integrated Services.

A number of training activities took place during the 3rd Year of the project. These include:

Trainer of Trainers (TOT) in TB infection control and TB-HIV co-infection conducted by TB-CAP. It involved 5 health workers from AIC.

Eight laboratory supervisors were trained by Becton Dickson in use of CD4% soft ware to be able to carry out and report on pediatric immunological profiles.

75 health workers from Wakiso, Mbarara, Kabale, Arua, Moyo and Koboko underwent a training TB-HIV co-infection. These health workers are now able to understand TB-HIV co infection and are carrying out TB-HIV co infection activities in their respective facilities.

Challenges for the TB/HIV Collaborative activities in AIDS Information Center

AIC experienced a number of challenges during implementation of the TB/HIV collaborative activities. These were both system and programmatic challenges and they included:

1. The low levels of knowledge on TB/HIV collaborative activities among staff at the supported sites. This has greatly affected outputs from this collaboration.

2. Stock out of anti-TB drugs from the District TB and Leprosy Office, especially streptomycin. This was a country wide problem, which affected most of the AIC branches. This compromised treatment of clients.

3. Lack of skilled health workers in most of the supported sites. The most affected cadre was that of laboratory technicians.

4. Transport for clients on anti-TB drugs especially those on facility DOTs. The difficulties in transport have greatly contributed to the loss to follow-up of clients.

5. Lack of basic equipment including: electric beam balance and measuring cylinders for measure minute amount of raw materials used to prepare and X-Ray services, especially in the rural facilities.

6. Follow-up of clients on active and latent TB treatment is increasingly becoming difficult. Volunteerism is no more and most TB patients have depended on volunteers to bring them drugs. AIC has also supported these volunteers with a lunch and small transport refund. However because of the ever escalating costs of food and transport it's becoming expensive to maintain these volunteers hence affecting the program. The program has noted losses to follow-up.

Targets for year 4 (FY 2009-2010): During FY 2009-2010, AIC will continue to address the challenges identified on top of continuing to implement. AIC provide IPT to 150 clients; active TB treatment to 350 individuals; HCT for 3,000 TB clients; TB screening for 24,000 HIV positive clients; CD4 testing for 2,000 TB/HIV co-infected clients; cotrimoxazole prophylaxis for 24,000 HIV positive clients; referral of 400 clients for ART. To improve drug adherence, AIC will continue to implement the DOTS program in all its branches covering 400 clients including follow-up in the community. These clients will also receive treatment for OIs and will be referred for ART where applicable.

AIC will continue to build capacity of 50 health workers in public and private facilities in TB-HIV Co infection and TB infection control.

In collaboration with selected Health centers IIIs, AIC will provide diagnostic HCT for the TB clients through provider initiated testing and counseling (PITC). Those found to be infected with HIV will be provided with CD4 cell counts and referral for ART if eligible.

All planned activities will be closely monitored through a comprehensive monitoring and evaluation plan in collaboration with the respective District Health Management Teams.

Monitoring and Evaluation

AIC branch teams consisting of the manager, Medical, Laboratory and data supervisors have held 34 meetings with the District Health officer (DHO), and the District TB and Leprosy supervisor (DTLS)/focal person. The joint teams conducted 10 support supervision visits to the supported health facilities and submitted 30 monthly and 14 quarterly reports in year 3. At least two support supervision visit by headquarter staff were carried out in all the 7 branches. AIC data collection tools were harmonized with those of MOH with assistance from CDC. The national TB register is in use and the program is in close collaboration with the National TB and Leprosy program and Uganda AIDS Commission. This has made it simple for AIC to report on the national indicators according to the national M&E framework.