Makerere University School of Public Health (MUSPH) is located within the Mulago National Teaching and Referral Hospital in Uganda. The mission of MUSPH is to improve the attainment of better health for people of Uganda through public health training, research and community service. In December 2007, Makerere University School of Public Health (MUSPH) and the Centers for Disease Control and Prevention (CDC) renewed their commitment to develop human resource capacity for management of HIV/AIDS programs in Uganda, and continue to collaborate with Rakai Health Sciences Project (RHSP) to deliver comprehensive community based HIV/AIDS prevention, care and treatment services to over 5000 HIV infected persons and their family members in Rakai and surrounding districts. This is a five year grants that carries forward lessons learnt in phase1. The grant has four major programming components that are addressed in this narrative.

1) The comprehensive community based HIV prevention, care and treatment implemented by RHSP. The focus is this program is to provide comprehensive HIV/AIDS prevention, care and treatment to over 5000 HIV positive clients in Rakai and neighboring districts. RHSP implements programs under 12 budget codes including: i) Prevention of mother to child HIV transmission (PMTCT), ii) HIV prevention AB (Abstinence and being faithful), iii) Other sexual prevention, iv) Biomedical prevention male circumcision, v) HIV testing and counseling, vi) Adult care and support, vii)Adult treatment, viii) Pediatric care and support, ix) Pediatric treatment, x)ARV drugs, xi) Laboratory infrastructure, and xii) TB-HIV care. Details of the activities under RHSP are described under the respective budget code narratives.

2) The SPH-CDC HIV/AIDS Fellowship Program is a capacity building and training program implemented by Makerere School of Public Health to strengthen the leadership and management of HIV/AIDS programs in Uganda. The Program aims at building competencies of professionals and health care workers in HIV/AIDS program leadership, management, and comprehensive HIV prevention, care and treatment through hands-on apprenticeships, technical placements, and offsite training. The overall aim of the Program is to build capacity for high quality HIV/AIDS prevention, care, and treatment and support services in Uganda.

3) The internet based distance learning program to support the training of PEPFAR partners is implemented by Johns Hopkins University Center for Clinical Global Health Education (CCGHE). This is a public-private partnership that has the following goals:

- Establish a Project Coordinating Center in Kampala, which will train and employ Ugandan nationals to lead and sustain this initiative over the long term.

- Establish free connectivity for Ugandan PEPFAR partners to a new national high-band internet network supported by RENU, UTL and a large multinational business consortium that will link the Ugandan network to a submarine cable landing site in Mombasa, Kenya.

- Develop a web-based "portal for this initiative, located in Uganda, to support multiple distance learning tools/functionality for the PEPFAR program

- Develop initial priority distance learning programs, defined by key PEPFAR partners

- Initiate an ongoing program evaluation to document the impact of this initiative

- Initiate discussions with local and international business interests, in order to develop a long-term sustainable business plan for this initiative.

The progress, approach of implementation and targets of each area are described under each of the 13 budget code narratives

4) The Crane Survey is a Public Health Evaluation (PHE) among Most at-risk population (MARP). The survey employs surveillance methods for high-risk groups including men having sex with men, female sex workers, non-paying partners of sex workers, paying clients of sex workers, non-paying partners of clients of sex workers, university students, and transport workers in Kampala, Uganda. These surveys will be conducted annually among various groups deemed to be at higher risk for HIV and other STI acquisition

ADULT CARE AND SUPPORT (HBHC)

The Rakai Health Sciences Program provides HIV care and support services to HIV positive adults residing in Rakai, Lyantonde and a few from the surrounding districts of Masaka, Mbarara and Sembabule. Services provided include both clinical and non-clinical care and support services. Non clinical services include health education and prevention of domestic violence while clinical care services include post-test counseling and linkage to care, treatment and prophylaxis for opportunistic infections especially cotrimoxazole prophylaxis for prevention of respiratory and gastro-intestinal infections, provision of basic care package for prevention of malaria and diarrheal diseases, tuberculosis screening and treatment, general health education, nutritional counseling, prevention of mother to child transmission, reproductive health services like provision of contraception, prevention, screening and treatment of sexually transmitted infections and on-going HIV counseling and support. Condom use is encouraged as a method of contraception and as a method for prevention of STI spread and acquisition. Condoms are distributed by peer educators and clinicians during all clinic days.

To address patient nutrition issues, the program has introduced food preparation demonstration sessions to accompany the nutrition education sessions. In these sessions, patients are practically educated on how to use locally available foods to prepare nutritious meals. This is a sustainable and affordable way to empower patients and prevent malnutrition. This intervention will be evaluated in due course, to assess its impact on the nutritional status of our clients.

Clinical services are provided and will continue to be provided to patients both at home and at facilities. The program operates a total of 17 clinics located at already existing government health centers within Rakai and Lyantonde districts. Locating the clinics at government health units has facilitated integration into the district health system. The clinics are run on a bi-monthly basis where patients are given drug refill appointments but are free to walk-in on any of the clinic days, if they require care for any illness.

Health education is provided through both community meetings like village meetings and at the clinics. Community health education jointly targets both HIV positive and non-infected individuals. In this, health talks, video shows, drama are used. The clinic health education sessions focus on the HIV positive patient health needs, and cover a variety of topics including; positive prevention, use of condoms, nutrition, PMTCT, emphasis on testing children, adherence to care, use of clean water, etc.

Patient monitoring: The program will continuously assess the well-being of patients enrolled on the program through scheduled clinical and laboratory patient assessments. Patients not yet on ART will receive two monthly cotrimoxazole refills and have their CD4 cell counts re-assessed at least once every six months. Diagnosis and treatment for opportunistic infections will be offered as provided.

Reduction of HIV transmission: In addition to the general health education and distribution of condoms for prevention of HIV transmission, particularly attention will be paid to discordant couple through establishment of discordant couple clubs. This group will receive special education and support to prevent transmission of HIV to uninfected spouses. Couples will be encouraged to share their challenges during the quarterly meetings and access counseling. Uninfected spouses will also be offered repeat HIV testing every three months.

Patient retention: Patients who receive a positive HIV diagnosis through the counseling and testing (CT) program are linked to care through referral chits given by the counselors. Patient who miss their clinic appointments are traced by the resident counselors in their communities and reminded to attend the clinic.

In the past 5 years of HIV care provision, the program has experienced some challenges in the provision of care and support to HIV positive patients. These have included timely enrolment of patients referred from the Counseling and Testing (CT) program, adherence to both ART and non-ART care. Various interventions have been designed to address the issue of early entry into care, adherence to and retention in care. These have included use of the community resident HIV counselor home visits to clients who have received HIV positive results to ensure entry into care. Among patients already enrolled into HIV clinics, adherence to care has been greatly improved by use of the home visiting team that consists of nurses who make impromptu home visits to both patients on ART and those not yet eligible for ART to check on adherence to treatment as well as follow up patients who have missed their clinic visits. The program has also trained patient peers to follow up fellow patients, reminding them of clinic visits, and this has greatly improved patient clinic attendance. One of the main reasons for falling out of care has been identified as patient feeling unwell. We have provided a pre-paid telephone line which patients call to notify the clinicians of their ill health. These patients are then actively followed up by the home visiting teams. All patient deaths are documented through administration of verbal autopsy. This has helped us keep track of the death rate on the program.

Patient referral: Patients in need of specialist services like chemotherapy or in need of hospitalization are referred to places with the available resources. With separate funding (Suubi fund), the very needy patients receive financial assistance to cater for their upkeep while in hospital.

Quality control and assurance: The program is closely monitored to ensure all clinicians provide quality care. All HIV care providers have been trained in comprehensive delivery of care services. In addition, we provide continuing medical education to further equip the health care providers with skills to provide care. Staff trained in health quality control and assurance provide support to the program by identifying areas where the clinicians need to perform better and recommend any required training to bridge the gap. Editors review all patient files to ensure completeness and correctness of clinic records.

Monitoring and evaluation: The adult care and support program is monitored through MOH, PEPFAR and Rakai program generated indicators. These are derived from the data collected and reports are routinely generated to inform the program performance.

As of the 30 June 2009, approximately 4,906 patients over 14 years of age were receiving care. In FY 2010, the program targets to provide care to 6,500 HIV positive patients and 7200 patients in FY2011. This will greatly contribute to the PEPFAR target of providing care for 12 million people living with or affected by HIV/AIDS.

ADULT TREATMENT (HTXS)

The RHSP provides antiretroviral therapy (ART) to patients whose CD4 counts are 250 cells/ul or with WHO stage is IV. For HIV-infected pregnant women and patient co-infected with TB and HIV, ART is initiated at CD4 below 350. ART is provided via 17 outreach clinics, 16 of which are located in the communities at already existing government centers. Patients are screened for eligibility for ART through clinical evaluation and laboratory evaluation. Through the clinical evaluation, all morbidities are identified and patient WHO staging noted. Blood is drawn for CD4 cell, liver and renal function tests. These are carried out, to evaluate eligibility for ART as well as establish the capability of the liver and kidneys to handle antiretroviral drugs.

Once identified as eligible for ART, a patient is assessed for readiness to initiate ART, both medically and socially. Medically, the status of the liver and kidney are assessed based on the chemistry results, as well as assessment for any co-morbidity like tuberculosis that may prevent immediate initiation of ART. Prior to ART, the patient's social situation is also assessed so as to prepare adequate support once started on treatment. For some, a home visit may be arranged. A patient is requested to bring along a treatment buddy who will also be educated on ARV drug use. The primary role of this buddy is to remind the patient to take his ARV drugs properly. This extra step taken in assessing the patient social circumstances has greatly helped us identify patients in need of extra help to facilitate adherence to treatment. Quite often, socially challenged patients initiating ART are linked to a resident HIV counselor and peer educator located within their geographical region, who subsequently offer additional adherence support.

Once initiated on treatment, the patient is monitored both clinically and through laboratory indicators to assess improvement. Clinically, a patient is assessed every two weeks for the first three months on ART, then monthly until one year. After one year on treatment, if the patient is fully adherent to his treatment, he/she starts receiving 2 monthly drug refills. Patients' CD4 cell counts and viral loads are monitored every six months. (NB. Viral load monitoring is supported by the National Institutes of Health).

Adherence monitoring and support: Patients on ART receive comprehensive adherence support at the clinics through focused adherence counseling sessions and at home through impromptu adherence checks. Adherence is assessed by self report and by spot check pill counts. Currently, at least 95% of the total ART patient population have 100% adherence.

Role of peer educators: Peer educators are experienced ART patients who have been trained to offer adherence support to fellow patients on ART. They conduct home visits at least 2 weekly and document adherence by pill count. They also take note of the patients' general state of health and inform the clinicians via a pre-paid telephone line, if there is need to urgently review the patient. The peer educator adherence records are filed on the patient records folder to supplement the self report adherence.

Monitoring clinical outcomes: Patient routine data is analyzed to assess the clinical, immunological and virological outcomes of individual patients. Most importantly, we use viral load monitoring to guide decisions to switch patients from first to second line regimens

Patient failure discussions: Lists of patients with have virological failure are periodically generated from the database and discussed during the patient failure discussions held weekly. Each patient is carefully assessed and the reasons for failure documented. When poor adherence is suspected, a spot adherence check is conducted by an adherence nurse and counseling given. In the past year, approximately 50% of patients with virological failure who received additional adherence counseling were able to attain an undetectable viral load within the subsequent six months, therefore delaying switch to the more expensive second line ART regimens.

Training of health care providers in provision of ART care and monitoring.

Adult treatment is provided by personnel trained in comprehensive HIV care and treatment. Also, personnel involved in patient support and monitoring for example the HIV and adherence counselors, laboratory personnel, peer educators, data managers, monitoring and evaluation personnel, are trained to offer quality services. In an effort to strengthen the capacity of the district health workers to provide care to patients on ART, even when the Rakai program clinics are not in session, we have previously supported the training of district health care providers in provision of comprehensive HIV care.

The program targets to provide a comprehensive care and treatment package, including ART to 2500 patients in FY2010 and 2700 in FY2011.

HIV CONSELING AND TESTING

The Rakai Health Sciences Program provides testing and counseling to clients residing in Rakai and Lyantonde districts. This service will build on the existing HIV testing program where HIV testing is provided through three main avenues:

1. Community HIV testing and counseling. All year round, health education and mobilization will be provided to the Rakai and Lyantonde communities in preparation for community testing and counseling. Different households will be notified by community educators about their respective testing days. Community HIV testing targets people in the 15-49 year age group. At the testing and counseling venues, individuals will be counseled and blood drawn for HIV testing. The blood will be transported for testing at central laboratory in Kalisizo using ELISA therefore results will not be provided at the same sitting, as would be the case with Rapid HIV testing. The program will maintain HIV counselors in the communities, who will return HIV results to clients tested at community level.

2. Testing and counseling through the male circumcision service: Clients seeking medical male circumcision will be offered voluntary counseling and testing during the pre-surgery counseling.

3. Testing and counseling at the HIV clinics: At each clinic, VCT will be offered especially for the spouse and children of the index client. The HIV negative partners will be followed up for re-testing and referred to discordant couple clubs for continued support and HIV prevention initiatives.

The number of children tested for HIV has been observed to be low in the program. The program plans to work hand in hand with the district health units, to target HIV positive mothers bringing their babies for post-natal clinics like immunization days. These mothers will be counseled to have their babies tested for HIV. This will provide us with the opportunity to identify HIV positive infants and link them into care early. The early infant diagnosis will be implemented in collaboration with the MOH nation-wide program. Infants confirmed to be HIV-infected will initiated on ART as per national HIV treatment guidelines.

Because the Rakai program does not provide rapid HIV testing, there will be no counseling and testing provided at campaigns or special events, where clients need to receive their results immediately. Failure to return results immediately may seem like a missed opportunity, however, the program has used HIV rapid tests before at the beginning of one of RHSP's trials and found that rapid tests generated inaccurate results with an unacceptable number of false positives (see publication: BMJ published online June 1, 2007, doi:10.1136/bmj.39210.582801.BE). Based on this information, RHSP decided to drop rapid testing and continue using double EIAs and Western blot confirmation for discordant EIAs as had previously been done for all research studies and services provided.

Supportive supervision, quality assurance, and M&E: Delivery of quality services will be assured through provision of support supervision for all testing and counseling teams, and resident HIV counselors. Support supervision and quality assurance and control will be provided by staff trained in counseling, testing and HIV quality control. Like all other program areas, the outputs of the testing and counseling program will be closely monitored by a monitoring and evaluation team that captures data on various indicators. Regular progress and scientific reports will be generated on a monthly basis and quarterly reports submitted to CDC, PEPFAR, and MOH.

Referral and linkage to care, treatment, and prevention services: Clients who test HIV positive will be referred to any of the 17 HIV clinics of their choice but will preferably be referred to the clinic nearest to their home. Periodically (approximately monthly), referral data will be examined to determine numbers linked to care.

The program targets to provide testing and counseling to approximately 13,000 individuals in FY2010 and about 14,000 in FY2011.

PEDIATRIC CARE, SUPPORT AND TREATMENT

Pediatric care is provided for all HIV positive children ages 0-14 years, who reside in the districts of Rakai, Lyantonde and the surrounding districts of Mbarara and Masaka. Entry into pediatric care starts with HIV testing. This may be through the PMTCT program, the Early Infant Diagnosis Program, or HIV testing and counseling at the facilities for in and out patients. At the community meetings, participants are educated about the advantages of having the children under their care tested for HIV.

At the HIV clinics, HIV positive children are provided with a wide range of services including clinical and non-clinical services like health education for the older children, on-going counseling, cotrimoxazole prophylaxis, treatment of opportunistic infections, provision of basic care package for prevention of malaria and diarrheal diseases tuberculosis screening and treatment, general health education, nutritional counseling for child care takers,.

To address patient nutrition issues, we have introduced food preparation demonstration sessions to accompany the nutrition education sessions given to the children's caretakers. In these, caretakers of HIV positive children are educated on how to use locally available foods to prepare nutritious meals, so as to prevent malnutrition among the HIV positive children under their care.

Clinical services are provided to patients both at home and at facilities. The program operates a total of 17 clinics located at already existing government health centers within Rakai and Lyantonde districts. The clinics are run on a bi-monthly basis and although patients are given drug refill appointments, they are free to walk-in on any of the clinic days, if they need care for any illness.

Patient monitoring: The program continuously assesses the wellbeing of these children enrolled on the program through scheduled clinical and laboratory assessments. Children not on ART are seen monthly for cotrimoxazole refills and have their CD4 cell counts re-assessed at least once every three months.

Scaling up pediatric care: Poor uptake of pediatric services still remains a challenge in the program. Strategies to increase awareness about the availability of these services will be implemented like community health education and sensitization meetings and clients will be urged to bring children for HIV testing so that those that are HIV positive receive care. The program will also incorporate HIV testing services for infants into childhood immunization days. It's hoped that this strategy will help identify HIV infected infants early.

Supervision, improved quality of care and strengthening of health services: The program is closely monitored to ensure all clinicians provide quality care. All providers receive support supervision from well trained medical officers. All HIV care providers have been trained in comprehensive delivery of care services. In addition, the program will provide continuing medical education to further equip the health care providers with skills to provide pediatric care. Editors will continue to review all patient files to ensure completeness and correctness of clinic records. In order to strengthen health services, the program will continue to provide training to staff offering pediatric care services in all relevant HIV pediatric care.

Integration with routine pediatric care, nutrition services and maternal health services: The program currently provides nutritional education and food demonstrations to address the children's nutritional needs. In FY 2010 the program will partner with organizations like Uganda Women's Efforts to Save Orphans, to provide skills in sustainable food security to caretakers of HIV positive children, and also link with programs like Nulife, that are already providing nutritional interventions especially to malnourished children.

Activities to strengthen laboratory support and diagnostics for pediatric clients:

The RHSP has partnered with the Uganda Ministry of Health to provide reliable HIV testing for pediatric patients. Samples are collected and transported to the Joint Clinical Research Center laboratory. The program will continue working with the Ministry of Health to ensure provision of diagnosis for pediatric patients. The Rakai program laboratory will also continue to support patient monitoring and diagnosis for opportunistic infections.

In FY2010, the program targets to provide pediatric care to 400 children and 500 in FY2011.

PEDIATRIC TREATMENT

Pediatric treatment is provided to children residing in the districts of Lyantonde, Rakai and the surrounding districts of Masaka and Mbarara. Antiretroviral therapy (ART) is provided to all HIV positive children <2yrs irrespective of CD4.

ART for pediatrics is provided via 17 outreach clinics, 16 of which are located in the communities at already existing government centers. Children are screened for eligibility for ART through clinical evaluation and laboratory evaluation. Once identified as eligible for ART, a child is assessed for readiness to initiate ART, both medically and socially. Medically, the status of the liver and kidney are assessed based on the chemistry results, as well as assessment for any co-morbidity like tuberculosis that may prevent immediate initiation of ART. Prior to ART, the child's caretaker's ability to support the child on treatment is assessed and any special needs identified addressed prior to ART initiation. A home visit may be arranged if thought necessary. It is greatly encouraged that both parents of the child participate in the support of a child on ART. The caretaker is thoroughly educated about ARV drugs and all questions arising are answered.

Once initiated on treatment, the patient is monitored both clinically and through laboratory indicators to assess improvement. Clinically, a patient is assessed every two weeks for the first three months on ART, then monthly. Patients' CD4 cell counts and viral loads are monitoring is done every six months (NB. Viral load monitoring is supported by the National Institutes of Health).

Adherence monitoring and support:

Children on ART receive comprehensive adherence support at the clinics through focused adherence counseling sessions and at home through impromptu adherence checks. Adherence is assessed by caretaker report.

Role of peer educators:

Peer educators are experienced ART patients who have been trained to offer adherence support to fellow patients on ART. They conduct home visits at least 2 weekly and document patient adherence to treatment. They also take note of the patients' general state of health and inform the clinicians via a pre-paid warm line, if there is need to urgently review the patient. The peer educator adherence records are filed on the patient records folder to supplement the self report adherence.

Monitoring clinical outcomes:

Patient routine data is analyzed to assess the clinical, immunological and virological outcomes of individual patients. Most importantly, we use viral load monitoring to guide decisions to switch patients from first to second line regimens

Patient failure discussions

Lists of patients with have virological failure are periodically generated from the database and discussed during the patient failure discussions held weekly. Each patient is carefully assessed and the reasons for failure documented. When poor adherence is suspected, a spot adherence check is conducted by an adherence nurse and counseling given.

Supervision, improved quality of care and strengthening of health services: The program is closely monitored to ensure all clinicians provide quality pediatric treatment. All providers receive support supervision from well trained medical officers. All HIV care providers have been trained in comprehensive delivery of care services. In addition, the program provides continuing medical education to further equip the health care providers with skills to provide pediatric treatment. Staff trained in health quality control and assurance provide support to the program by identifying areas where the clinicians need to perform better and recommend any required training to bridge the gap. Editors review all patient files to ensure completeness and correctness of clinic records. In order to strengthen health services, the program provides training to staff offering pediatric treatment services in all relevant HIV pediatric care.

Monitoring and evaluation: The pediatric care and support program will be monitored through PEPFAR and Rakai program generated indicators. These will be derived from the data collected and reports will be routinely generated to inform program performance.

Integration with routine pediatric care, nutrition services and maternal health services: The program currently provides nutritional education and food demonstrations to address the children's nutritional needs. In FY 2010 the program plans to partner with organizations like Uganda Women's Efforts to Save Orphans, to provide skills in sustainable food security to caretakers of HIV positive children on the program, and also link with programs like Nulife, that are already providing nutritional interventions especially to malnourished children.

In FY2010 the program, we shall provide treatment to 150 children and 200 in FY2011.

MARPS study: This is an ongoing surveillance activity (dubbed "Crane Survey"). The survey's 1st phase was successfully completed in 2009 (sampling female sex workers and their male partners, men having sex with men, university students, and motorcycle taxi drivers), enrolling more than 3,000 survey participants. SPH staff (~20) included data and coupon managers, administrative assistants, counselors and laboratory technicians. Current activities include data cleaning and analysis as well as preparing for the next phase that will survey school students, drug users and high risk heterosexuals. Field activities are currently paused due to ongoing IRB review of the protocol amendment, unexpected cost increases, and the necessity of finding a new survey office in downtown Kampala. This 2nd phase of field activities will commence in the 1st half of 2010. We anticipate training for approximately 15 staff on protocol adherence, IT training (ACASI), possible also on VCT. This collaborative activity between CDC, MOH, and Makerere University (School of Public Health, SPH) mostly involves SPH staff, thereby greatly expanding SPH's technical capacity and skills and will inform Uganda's HIV/AIDS stakeholders about high risk populations and their needs.

The SPH-CDC Fellowship program currently has four major training activities: 1) the two-year: i) the two-year (long-term) fellowship which has been implemented for the last six-seven years, ii) the eight month (medium-term) fellowship, iii) off-site short courses, and iv) the technical placements which started at the end of FY 2008.

A) Long-term (two year) Fellowships This is a 2-year, fulltime, non-degree training program, open to Ugandan nationals with a postgraduate degree in a health-related discipline such as: Medicine, Nursing, Social Sciences, Statistics, and Journalism. Enrolled Fellows are attached to host institutions involved in HIV/AIDS activities, and placed under the supervision of host institution and academic mentors. Fellows spend 75% of their apprenticeship at the host institution while the remaining 25% is dedicated to short courses conducted at the MUSPH. Currently, the program has 19 long-term Fellows; 9 enrolled in FY 2008 and 10 enrolled in FY 2009. The Fellows who were enrolled in FY 2008 are scheduled to complete their training in March 2010, and in April 2010 the program will enroll 10 new Fellows. A total of 45 long-term Fellows have so far graduated from the program and are occupying leadership positions in leading HIV/AIDS organizations in Uganda and the region. Host institutions have benefitted through staff training, development and implementation of innovative pilot programs as well as through operations research conducted by Fellows at their institutions.

B) Medium-term Fellowships Medium-term Fellowships are offered for a period of eight months to middle- and senior-level managers who may not be able to leave their employment for the long-term Fellowships. The purpose of medium-term Fellowships is to improve identified systemic gaps within institutions. Trainees undergo six weeks didactic modular training course spread over duration of eight months. Fellows undertake three distinct but inter-related modules, and after each module, they return to their institutions. This training approach allows them to take the course while continuing with their employment. Two medium-term Fellowships have been implemented since 2008, one in Continuous Quality Improvement (CQI) and the other in Monitoring and Evaluation (M&E) of HIV/AIDS programs. To date, 30 medium-term Fellows from 17 institutions have completed the course while 37 individuals from 21 institutions are still undergoing training. Fellows implemented a broad range of CQI activities including improvement of efficiency of clinic systems and reduction in waiting time for patients, increasing enrollment of patients on ART and patient retention, and improvement of logistics management systems at their institutions. Fellows also developed and enhanced M&E systems within their organizations. A number of the institutions have started scaling up these activities to other sites with the programs and districts.

C) Offsite short courses Offsite short courses are provided to individuals and institutions to enhance their capacity to lead and manage HIV/AIDS programs. Over 2,000 individuals have been trained to date; 519 of these in the past one year. About half of the individuals trained in the past year were from upcountry programs.

D) Technical Placements Technical placements are offered to individuals working with HIV/AIDS programs. Under these placements, selected individuals are assisted to visit other HIV/AIDS organizations to learn and document best practices for replication within their respective institutions. This is the most recent addition to the Program activities, with the first three trainees completing their placement in April 2009.

FY 2010 plans for MUSPH-CDC Fellowship In FY 2009, MUSPH fellowship program will support a total of 580 individuals. We will support 20 long-term fellows (10 fellows continuing and 10 new fellows admitted in FY 2010). Two medium term-fellowships will be conducted, each with 24 fellows; a total of 48 medium-term fellows from 24 institutions in the year. In addition to these, short courses will be provided for 500 individuals and technical placements for 12 individuals. Through the medium-term fellowships the program will support the individuals and institutions to improve on identified systemic gaps within their organizations. Within the medium-term fellowships, the short courses at MUSPH will be delivered in three modules, in a staggered manner, for a period of 4 weeks. Through the Fellows apprenticeship attachments 44 organizations will be supported (20 through long-term and 24 through medium-term fellowships). More institutions will be reached through the short courses. These will include public and private organizations (CBOs, FBOs, NGOs etc). The institutions will cut across several districts within the country. Deliberate efforts will be made to reach the rural districts; the program has started regional sensitization meetings to ensure that eligible institutions and individuals throughout the country are aware of the capacity building opportunities available at MUSPH. Varied range of beneficiaries and stakeholders associated with organizations that will be hosting the fellows and receiving short courses will therefore be reached indirectly. These may include people affected by HIV/AIDS as well as special populations such military and refugees.

2. Progress of the JHU-CCGHE initiative The CCGHE Distance Learning initiative has established a local in-country Project office and Management Team (PMT); Project Manager, Technical Assistant, and Project Administrator. Equipment and software has been installed and IT specifications and setup of the server are complete. The PMT have received extensive training in video capture, editing, lighting, and filming of live conferences/lectures. The IT assessment (network topographies) defining partner IT infrastructure equipment and connectivity requirements continue for the PEPFAR partners; a total of 18 partners have been contacted. Fifteen implementing partners including; (MUWRP, IAVI, TASO, IKI, NIH, MUFOM, MUSPH, PIDC, MUJHU, RO, TMC, UVRI, MJAP) have undertaken the assessment exercise and 5 (CDC, JCRC, MOH/ACP, AID & CPHL) are still to provide the required information. Geographical maps have been generated showing physical location of sites/buildings in Mulago, as well as connections to the backbone and/or MU fiber, and where fiber or copper wiring to connect is currently missing. In June, the first Infectious Disease Grand Rounds event took place between IDI and Johns Hopkins. IDI presented 3 cases for discussion. Archived recordings were created. A GPS-enabled Patient Tracking Tool and an Educational Training System have been designed, developed and programmed for smart phone deployment. A working demo was created which transfers data via the UTL mobile network to a database on a local server. These tools will allow providers of our PEPFAR partners in remote settings to capture patient information and to receive educational training from our educational portal via a mobile device. A Circumcision Procedural training video (online/DVD) script has been completed and videotaping of the procedure was done in June. Initial meetings were held in June to discuss evaluation of the final training video. The Infectious Diseases Summit 2009 conference, co-sponsored with the Accordia Foundation and held in Kampala April 20-22 was digitally captured and recordings made available to sponsors and for network distribution. A two-day training course held in January by the NIH was digitally captured for network distribution when available and produced on DVD for immediate distribution. The course provided participants with the knowledge and skills on Good Clinical Practice (GCP) regulatory requirements in order to carry out their research within a well structured framework.

FY 2010 plans for CCGHE initiative Prepare IT Departments of "Second Phase" PEPFAR partners for connectivity to the new network (Kampala-Entebbe-Rakai). The Ugandan PMT will work with key PEPFAR partners on purchasing equipment required for network connectivity based on IT infrastructure needs discerned from network topographies. Connectivity to the new GMRE/RENU national network in Uganda will be complete. A plan for wireless connectivity for remote clinics of key PEPFAR partners will be completed. Assistance with connectivity from the Ugandan PMT will be available. A web-based platform ("portal") to support multiple distance learning tools/functionality will be completed and intranet access available. Webcasting, digital recording and archiving of key PEPFAR training programs conducted by PEPFAR partners in Kampala, Entebbe and possibly Rakai for distribution to PEPFAR partners will be available. The video training program for male circumcision will be available and evaluation will begin. Population of a digital library of key educational resources by PEPFAR partners will be available. Initiate an ongoing program evaluation plan, which could include data collected on an ongoing basis, by the Project Management Team on the impact of the program, including numbers of trainees, numbers and types of training content provided, knowledge and skill assessments and feedback from the participating PEPFAR partners. Grand Rounds will take place on a regular basis and archived for access from the portal. All programs captured in FY2009 will be available within the portal to all connected PEPFAR partners. Mobile technology platform will be finalized and a pilot project will be initiated for testing and feedback of the device. Both data capture of patient assessments will be 'pulled' from the phone as well as relevant provider training will be 'pushed' to the phone.

The RHSP will continue to promote and provide Medical Male Circumcision as part of a comprehensive prevention package. The program will continue promoting the ABC strategy at all mobilization meetings in the community, in schools and out of school to cover both school going and out of school adolescents and adults. ABC will also be emphasized as part of the package at group and individual counseling sessions, during operation, recovery and at follow up visits.

The program will also continue providing MC skills training to teams of providers; a total of 105 MC providers will be trained in FY 2010 and these will include 35 MC counselors, 35 theater assistants and 35 surgeons (including Medical and clinical officers).

We plan to implement the following strategies in order to make the MC skills training program even more user friendly: Making practice in skills more beneficial by providing video guides for all short procedures, Availing more clinical rooms for pre operative assessment, post operative assessment, and follow ups, Implementing a timely evaluation of the on-line didactic phase of the circumcision skills course, Making monitoring and support supervision visits to trainees. In order to support service providers at government health units, District officials including district medical directors, Nursing officers and health educators will be invited to attend a circumcision awareness course at the program.

Current status: The program had conducted 1200 surgeries by the end of August 2009 (40% of FY 09 target). The program has been able to provide post operative follow up to ~90% of the men we circumcised during this period. Adverse event rates continued to be low during this period (< 2%). Consenting for minors before surgery continues to be a challenge given the fact that parents/guardians are not readily available. The influx of clients from far locations has increasingly delayed surgery as this is not done immediately thereby increasing the cost per circumcision done. The Rakai MC program will set up at least 2 satellite MC provision centers one in Lyantonde district and another one in Masaka district to overcome this problem. These centers will be routinely supervised by staff from the Rakai MC program.

Post training follow up for trainees: The program will continue to conduct post training follow-up and support supervision to Kalisizo hospital, Kakuuto Hospital, Kayunga Hospital and Kiruhura. This will ensure that supervised units are conducting their MMC activities in accordance with the WHO guidelines and are satisfactorily providing MC services.

IN FY 2010, up to 3300 men will be offered MC services through surgeries at the RHSP center and 2 satellite MC centers, the program will target males 13 years or older in Rakai and neighboring districts of Lyantonde, Sembabule, Kiruhura and Masaka. It will also cover rural communities and high risk communities such as landing sites of Malembo, Kasensero and Kacheera and higher institutions of learning, police and military barracks. All men who report for surgery at the RHSP centre will be offered HIV counseling and testing. Those who test HIV positive and are ready to continue with circumcision will have a sample drawn for CD4 testing to help them accesses ART care and support will be provided to all identified HIV positive clients

To ensure good quality of circumcision services, the program plans to set up constant supervisory strategies at various stages of service provision. These measures will be aimed at ensuring that the health workers offer standard quality of care as well as ensuring that the recipients of these services follow guidelines as prescribed. The Rakai MC program is the only program providing training to MC providers in Uganda. RHSP will follow up a sub sample of trainees to monitor their performance and productivity following receipt of the MC training. This activity will inform programs on issues that need to be addressed to enable easy and smooth integration of MC services into existing private and public health units. Finances allowing, we will do monitoring and evaluation (and support supervision) to at least 10 units in Rakia and neighboring districts.

Communications activities for male circumcision as they relate to males and females will be delivered to the population through a number of channels; namely community health education sessions for ABC that include male circumcision, in schools where teachers, students, school counselors, student leaders and school heads will be equipped with information about MC; drama and film shows addressing circumcision messages, Mass media including news papers and radios; MC brochures to clients and household members.

Male Circumcision service - FY2010

Number of male circumcisions to be performed.

We plan to offer service circumcision to 3300 men during FY 2010 and 3300 in 2011. This is estimated to be achieved by conducting surgeries at the RHSP center and 2 satellite MC centers.

Coverage either in the geographic area or among the target population

We will target males 13 years or older in Rakai and neighboring districts of Lyantonde, Sembabule, Kiruhura and Masaka.. We plan to cover rural communities and high risk communities such as landing sites of Malembo, Kasensero and Kacheera. We also plan to target higher institutions of learning, police and military barracks.

Activities for supportive supervision and quality assurance

To ensure good quality of circumcision services, we plan to setup constant supervisory strategies at various stages of service provision. These measures are aimed at both ensuring that the health workers offer standard quality of care as well as ensuring that the recipients of these services follow guidelines as prescribed.

The Rakai MC program is providing training to MC providers in Uganda. RHSP will follow up a sub sample of trainees to monitor their performance and productivity following receipt of the MC training. This activity will inform programs on issues that need to be addressed to enable easy and smooth integration of MC services into existing private and public health units. Finances allowing, we will do monitoring and evaluation (and support supervision) to at least 10 units in Rakia and neighboring districts.

The Rakai MC program is hoping to set up at least 2 satellite MC provision centers one in Lyantonde district and another one in Masaka district. These centers will need routine support supervision which will be provided by staff from the Rakai MC program.

Routine training, re-training and refresher training sessions for counselors, theater assistants, surgeons and MC trainers will be organized when ever necessary. During these sessions, issues that will have been identified through interaction with providers, clients and trainers will be addressed.

Over the shoulder observation and review of service records will be done to assess provider and trainer competency. Any gaps identified will be addressed through individual and/or group re-training seminars.

Communications activities for male circumcision as they relate to males and females

Information will be delivered to the population through a number of channels;

Community health education sessions will be conducted in groups of about twenty men and women. Issues including ABC, male circumcision and family health will be addressed.

In schools, we plan to equip teachers, students, school counselors, student leaders and school heads with information about MC through targeted school meetings.

Drama and film shows addressing circumcision messages will also be conducted.

Mass media including news papers and radio will be used to disseminate MC messages.

Brochures carrying information about male circumcision will be given to clients together with post operative wound care instructions. This will act as an easy means of providing MC information to the rest of the members in the household.

Provision of Testing and Counseling onsite

All men who report for surgery at the RHSP centre will be given chance to receive VCT. The following procedure will be followed;

Men will be given proper pretest counseling at first contact.

A blood draw will be done for all men who accept to have an HIV test.

Testing will be done at the Kalisizo lab or hospital lab if available

HIV results will be provided to all men who are willing to receive them.

All HIV positive men who receive results and are ready to continue with circumcision will have a sample drawn for CD4 testing to help them accesses ART care.

Support will be given to all HIV positive clients through discordant couple clubs. Men who are willing to disclose their HIV status to their partners will be provided with counselor facilitate disclosure.

HIV positive clients will be referred for ART care.

Inclusion of Medical Male Circumcision as part of a comprehensive prevention package

The program will continue to promote and provide MC as part of a comprehensive prevention package. We shall continue promoting ABC at all mobilization meetings in the community, in schools and out of school to cover both school going and out of school adolescents and adults. ABC will also be emphasized at group and individual counseling sessions, during operation, recovery and at follow up visits.

Training programs and materials being used

We will continue providing MC skills training to teams of providers. We will provide training to 105 MC providers. These will include 35 MC counselors, 35 theater assistants and 35 surgeons (including Medical and clinical officers).

We plan to implement the following strategies in order to make the MC skills training program even more user friendly.

Making practice in skills lab more beneficial by providing video guides for all short procedures

Availing more clinical rooms for pre operative assessment, post operative assessment, and follow ups

Implement and make timely evaluation of the on-line didactic phase of the circumcision skills course.

Make monitoring and support supervision visits to trainees.

In order to support service providers at government health units, District officials including district medical directors, Nursing officers and health educators will be invited to attend a circumcision awareness course at the program.

A recently concluded in-country review of PEPFAR prevention portfolio recommended the need to scale-up Medical Male Circumcision. Rakai Health science Project ( RHSP) is a WHO accredited site for training trainers and service providers in safe medical male circumcision for Uganda and other countries in the region. In FY 2009, Rakai trained over 120 service providers (including Medical officers, clinical officers, Nurses and counselors) from various programs in the public and private sector. Wiith PEPFAR support Rakai HSP provided MMC services to over 3000 men in Rakai and the surrounding districts. To increase capacity for training and service delivery, Rakai has expanded services to Lyantonde District Hospital and Kakuuto Health Center IV. Through this expansion, Rakai has not only brought services closer to rural communities but also demonstrated models for integration of MMC services in public health facilities.

Initially MUSPH- Rakai received $535,200 in COP 2010 in MMC technical area to continue implementing training and service delivery at Rakai HSP and for supporting the two satellite site at Kakuuto and Lyantonde. With additional $400,000, Rakai HSP will increase the number service provider s trained from 15 per month to 30. The Training Center has position itself to double its training out in order to meeting the increasing demand for trained service providers and trainers. In addition, Rakai will expand services to an additional two new health facilities in the surrounding districts, most likely Masaka and Isingiro. Selection of health facilities will be done after conducting a needs assessment and discussions with the local authorities. REDACTED.

ABSTINENCE/BE FAITHFUL

Abstinence:

The Abstinence education program will target school-age children and youth below 18 years; a group which is considered not yet prepared to make responsible, healthy decisions about sex; to promote abstinence from sexual activity until marriage. The program shall provide abstinence messages to youth both in and out of school, male and female ages 10-24 years. Youth will be supported and encouraged to avoid risky behaviors. Young people will be reached with messages about abstinence and fidelity. They will be urged to choose abstinence before marriage and faithfulness in marriage as the best prevention against HIV and other sexually transmitted diseases.

Abstinence will be promoted particularly among young adolescents who are not yet sexually active. We shall also help "influencers" of youth such as parents, guardians, pastors, teachers, and youth leaders to guide youth to make and sustain wise life choices about their sexual behavior. We shall encourage unmarried youth under the age of 24 to commit to sexual abstinence until marriage. Some young people who may be sexually active shall be convinced to return to abstinence ("secondary abstinence,") but realistic options will be provided for the majority who will not, including information on and access to condoms. Young people will be equipped with life skills to cope with negative peer pressure These will include skills for building self esteem and skills for being assertive, for example to be able to say 'NO' when one means 'NO'. Education on gender norms, concurrent sexual partnerships, transaction sex, and cross generational sex will also be emphasized.

Messages will be delivered through talks, videos, role plays and group discussions. IEC materials with the relevant messages will also be distributed. At community level and through meetings with opinion leaders like religious leaders, we shall encourage integration of abstinence support programs and HIV/AIDS awareness into their ongoing youth programs

Be Faithful:

Messages to promote perfect fidelity (that is, mutual fidelity with a non-infected partner) as another highly effective method, especially for stable and married couples will be delivered. It shall be emphasized that this strategy works only if both partners are faithful and uninfected. 'Be faithful' messages will be delivered to married persons during their special prevention meetings. Fidelity and reduction of number of sexual partners will be encouraged among both HIV positive and negative persons. The discordant couples will be encouraged to remain faithful to their partners as well as use condoms. Where possible, abstinence will be supported for discordant couples. The younger age groups will be prepared to be faithful when they choose to marry.

Quality assurance and promotion: The Rakai program will ensure quality services are provided to the clients served. Health educator supervisors will directly oversee preparation and delivery of health education sessions and will provide support to staff providing the service. Messages to be discussed will be discussed prior to delivery and will be pre-tested within a representative sample of the targeted population. In addition, the Rakai program's quality control and assurance team will regularly sit in the sessions to provide support supervision, hence ensuring that quality messages are given.

Linkage of Sexual prevention activities to other services/platforms: All sexual prevention activities have been integrated into all services offered in the program, including testing and counseling, where individuals or couples are counseled and educated on the ABC message, the HIV care clinics and sexually transmitted Infection clinics. Sexual prevention activities have also been incorporated in the male circumcision services and the Rakai program research activities like the annual HIV surveillance.

Evaluation and monitoring plan: The sexual prevention program will be monitored through PEPFAR and Rakai program generated indicators. Data on these indicators will be systematically collected by the health educators using data collection tools designed for this purpose. Forms will be entered in electronic databases and periodic reports generated to track program performance as well as meet reporting requirements.

OTHER PREVENTION

Other prevention activities will be conducted in the districts of Rakai and Lyantonde, covering the population of potentially sexually active males and females. Activities will include health education conducted at the general community meetings and through the HIV clinics, condom distribution at the clinics, at community HIV counselor offices and through condom sale agents spread out in the communities.

Health education: The program will conduct 17 Health education clinics on a bi-monthly rotational basis in the HIV clinics. Each clinic session will start with a health education session which lasts about 30 minutes and then a maximum of 30 minutes will be given to questions in small group sessions. In the past, structured community sexual prevention health education messages have been offered through avenues like general village meetings, drama shows, large community meetings, and other crowd pulling events. Different age groups have been targeted including youth in and out of school, married men and women, single parents; these will continue to be used for mobilization of people for the smaller group sessions

Safe Homes and Respect for everyone: The Safe Homes and Respect for Everyone "SHARE" aims at prevention of HIV spread through prevention of domestic violence in the communities. The activities aim at encouraging different groups to focus on prevention of Domestic Violence (DV). The SHARE activities include: village meetings, film shows, drama shows, impromptu discussions, poster exhibitions, booklet clubs, capacity building workshops/ seminars; specialized meetings for youths in and out of school, married adolescents; counseling and referrals., The SHARE project uses volunteers like community volunteers, police officers, health care workers etc to carry out its activities.

Condom distribution: The program receives free condoms from the Population Services International (PSI). These are distributed during clinic sessions by counselors as well as peer educators in the HIV clinic and refills provided as required. In the community, 10 RHSP resident counselors provide points for easy reach. These conduct home visits community members can access free condoms from them. Condom distribution is accompanied by condom use education, addressing issues like proper use, safe storage and disposal after use.

Condom sale agents will also continue to play a key role in distribution of condoms to the Rakai population. These agents will be supplied with both free and branded condoms for sale. The Rakai program will provide the commercial condoms at a subsidized price, so the agents are able to sell at a subsidized fee to clients who prefer the non-free condom brands. Currently, the program supports 120 condom sale agents.

Special groups: For a long time, the program has continued to recognize the discordant couples as a special group that needs continued support to prevent HIV transmission and marital dissolution. The program sustains discordant couple clubs, through which clients who have been identified as being discordant are enrolled and receive on-going support from counselors and fellow couples. Through this arrangement, couples who are coping well encourage others.

In these clubs, structured health education and condom distribution are also availed. However, the clubs currently have no developed resource materials but hope to adopt already existing discordant couple IEC materials, to avail to these clients. Re-testing for the HIV negative partner in the discordant relationship is also emphasized. The program will provide quarterly HIV re-testing for HIV negative sexual partners of HIV+ persons and a card on which re-test dates are entered will be provided.

In FY2010, the program will continue to provide "other prevention" interventions including health education messages addressing ABC, as well as condom distribution and condom use demonstrations to the population in the Rakai and Lyantonde districts. In addition to the general community health education sessions, the program will provide focused small group (25-30) health education sessions youth, married, discordant couples, and the general population, with messages specially designed to address that group's needs. We hypothesize that in the small group education sessions, the targeted population will be able to clearly understand the information given, ask for any clarifications, and subsequently change behavior. High risk groups like the motor-cyclists and fishermen will specially be targeted. The participants will be invited to the respective meetings at a selected venue, where the sessions will be held. Refreshments will be provided during the meetings.

Intervention(s) for each specific target population will include the following. Discordant couples: These will be educated through health talks from Rakai staff and external facilitators, video shows, facilitated group discussions and client testimonies. The program will ensure use of interventions that maintain the confidentiality of clients. Discordant couple club activities will be held every six months, but on-going counseling and support will be provided by the community resident counselors all year round.

MARPS: Most at risk populations (MARPS) like the motor-cyclists, fishing communities and commercial sex workers will specially be targeted.

These will be educated through health talks from Rakai staff and external facilitators, video shows and facilitated group discussions. The program will ensure use of interventions that maintain the confidentiality of clients. Special education packages will be identified and used to provide preventive strategies like abstinence, being faithful and consistent and proper condom use, so as to reduce HIV acquisition and transmission within these groups. Education will be delivered through health education talks, drama, video shows and facilitated group discussions. Condom use demonstrations will also be conducted during one on one session, to ensure proper use.

General population: There will be sexual prevention packages particularly delivering messages on abstinence, being faithful to one's sexual partner and consistent use of condoms. These messages will be delivered through workshops of varying durations tailored to the needs of the specific group. Health talks, drama and video shows and small group discussions.

The Rakai program has in place a mechanism to ensure that quality services are provided to the clients. The health education department has supervisors directly responsible for supervising and providing support to staff delivering the "other prevention services to the clients. Messages to be delivered will be discussed prior to delivery and pre-tested within a representative sample of the targeted population. In addition, the Rakai program's quality control and assurance team regularly will sit from time to time in the sessions to provide support supervision, hence ensuring that quality messages are given.

PMTCT

The Rakai Health Sciences Program (RHSP) provides Prevention of Mother to Child Transmission (PMTCT) of HIV to mothers attending the 17 HIV clinics, which cover the geographical regions of Rakai, Lyantonde districts and a few areas in the surrounding districts of Masaka and Mbarara. PMTCT services are provided by the program through the out-patient HIV clinics but this program does not run routine antenatal clinics. PMTCT interventions are aimed at preventing acquisition of HIV by the baby from their HIV infected mother. Activities include antiretroviral prophylaxis for mother and baby, infant feeding education to encourage safe feeding options as well as reproductive health (family planning) services.

Women attending the HIV clinics and are identified as pregnant, receive education on PMTCT, with the aim of ensuring that they deliver an HIV-free baby. These are uniquely identified and flagged to ensure easy identification at the subsequent visits. All pregnant mothers are encouraged to attend antenatal care clinics (from other health care providers) and their antenatal records are reviewed by RHSP clinicians at all visits.

Newly diagnosed pregnant HIV positive mothers are offered PMTCT prophylaxis in accordance to the National guidelines: All mothers are given Nevirapine and Zidovudine syrup with instructions on safe storage and administration of the drug to the infant after delivery. This is given as early as 28 weeks to cater for any premature deliveries, since a relatively large proportion of mothers may deliver at home, where the babies may miss out on PMTCT interventions. On-going health education to all pregnant HIV positive mothers is given during pregnancy emphasizing the importance of delivery in a health center, post-partum hygiene, infant feeding and adherence to ARV prophylaxis for the mother and baby. All the HIV-infected pregnant women are also assessed for ART eligibility and initiated on ART as per national guidelines (i.e. with CD4< 350) if eligible. Mothers that aren't eligible for ART receive combined ARV regimens (commonly AZT/3TC) for prophylaxis. For infected mothers that report very late in pregnancy or in early labor, single dose Nevirapine (SDNVP) is given. The RHSP is working in close collaboration with the district facilities MCH clinics to improve referrals and follow-up and avoid double counting of the clients served.

Infant feeding: The infant feeding option chosen by an HIV infected mother is very critical in further prevention of maternal transmission of HIV to the baby. The RHSP does not provide infant formula to mothers but emphasizes safe feeding practices during the pre-natal health education sessions to ensure that the mothers are adequately prepared for the arrival of the baby. Mothers are educated on all the available methods of infant feeding (exclusive breastfeeding, use of infant formula or alternative feeds, mixed feeding) and the risks involved in each mode. Alternative feeding is only encouraged if it is Affordable, Feasible, Acceptable, Safe and Sustainable (AFASS). Currently, mothers are encouraged to exclusively breastfeed for 6 months post-delivery and wean gradually. Mixed feeding is greatly discouraged as it increases risk of MTCT through breast feeding.

In the FY 2010, in addition to health education, food demonstration sessions will be offered especially to mothers with babies. During these sessions, they will learn to prepare nutritious foods, using foods readily available in their communities.

Reproductive health services: Prevention of pregnancy is the surest way to prevent mother to child transmission of HIV. Therefore, as part of the PMTCT package, RHSP offers reproductive health education and services. Readily available in the clinics are condoms, oral contraceptive pills and Depo-Provera and Intrauterine devices (IUD). The program also plans to explore the possibility of making available long term methods of contraception like Norplant. Patients in need of surgical reproductive health interventions will be referred to the district hospitals.

Patients will be offered family planning counseling and have their knowledge and understanding assessed before selection of a method. Education on possible side effects will be provided and women will be supported to discuss family planning options with their sexual partners and couple family planning counseling will be encouraged.

PMTCT program evaluation: The impact of the use of extended (14 week) Nevirapine prophylaxis to babies born to HIV positive mothers, a practice adopted from the PEPI Malawi PMTCT trial will be evaluated using external funds. Linkage of babies born to HIV+ mothers into care and treatment will also be evaluated with the aim of improving service quality and program outcomes. All babies born to HIV positive mothers enrolled onto the PMTCT program will be tested for HIV using HIV-1 PCR at 4-6 weeks for both breast-feeding and non-breastfeeding mothers with the aim of early HIV diagnosis among the exposed infants.

All HIV exposed infants will be started on co-trimoxazole at 6 weeks of age and those whose results are positive on DNA PCR will be enrolled for regular HIV care and initiated on HAART. Exposed babies who initially test negative will be followed up for repeat testing until HIV infection is definitely excluded.

Progress: During the first quarter of FY09, 28 pregnant mothers were enrolled into the PMTCT program, bringing the total number of pregnant women active in PMTCT care to 36. Twelve (33.3%) of them were started onto HAART and 24 (66.7%) women were started on a course ARV prophylaxis. There were 14 reported live births, 12 (85.7%) of whom tested for HIV and all these tested HIV negative. There were no reported deaths, stillbirths nor abortions.

In FY2010 and 201, the program targets to provide PMTCT services to at least 150 women. The program will ensure that the HIV infected pregnant women receive the highest level of care.

LABORATORY INFRASTRUCTURE

The Rakai Health Sciences Program laboratory supports all HIV testing and monitoring for biological samples collected from the 17 HIV clinics and counseling and testing centers within Rakai and Lyantonde districts. The only exception is the qualitative PCR for infant diagnosis, which is provided by the Joint Clinical Research center laboratory. The laboratory provides services not only to the Rakai program clinics but also district health centers like Kalisizo hospital and Kitovu mobile, which are supported with CD4 count testing.

Overall, the Rakai program laboratory provides a wide range of testing including: HIV testing, serology like syphilis testing, microbiology testing like TB diagnosis, viral load testing, CD4 count testing, chemistry tests like renal and liver function tests, etc. In FY2009, with PEPFAR funding, RHSP procured a Chemistry machine, therefore increasing the efficiency of running chemistry tests

In FY2010 and FY2011, the program plans to continue providing laboratory support to the district health units in need of testing services and extend support to two other health centers, Rakai hospital and Kakuuto health center IV.

In order to provide quality laboratory services, training of staff has been identified as critical. The laboratory employs well qualified laboratory staffs but these will be provided with additional training to suit the laboratory-specific needs.

The program plans to support training in all laboratory sections of molecular biology, microbiology, chemistry, serology etc. RHSP targets to provide training to at least one staff in each of the laboratory sections; a total of at least 5 laboratory staff will be trained. The laboratory employs two quality control and assurance staff who will continue to move through all the sections to provide support supervision and quality assurance, ensuring accurate performance

In line with the transition process for PEPFAR Track 1.0 implementing partners, the program will transition laboratory services to local in-country partners. In particular, plans and activities that will result in sustainable accredited laboratory programs.

The program plans to build capacity in laboratories in the district health centers so as to build their ability to diagnose opportunistic infections. It will also support the training of laboratory assistants at these health centers through laboratory rotations at the Rakai program laboratory, assist in design of standard operating procedures, training in laboratory safety measures and facilitation with basic laboratory equipment including microscopes and microscope slides.

ARV DRUGS

Rakai program will procure antiretroviral drugs to cover patients on first and second line regimens, for both adult and children in line with recommendations of the National treatment guidelines. Drugs will include zidovudine, lamivudine, nevirapine, efavirenz, alluvia, tenofovir, truvada, and smaller quantities of stavudine for patients who cannot tolerate zidovudine, didanosine and abacavir. Both syrup and tablet formulations will be procured

Prevention of Stock outs:

The program did not experience stock outs in FY 09. To ensure that there are no stock outs in FY2010, the program will continue to submit timely quarterly drug forecasts to our drug suppliers, so as to assist them predict our consumption. In order to prevent stock outs arising from unpredicted drug delivery lead time, we shall include within our drug stock a two months buffer stock.

In FY2010, the program plans to purchase ARV drugs for a total of 2500 patients and for 2700 patients in FY2011.

TB/HIV

Rakai Health Sciences Program provides TB/HIV care to all clients enrolled in the HIV clinics. All patients are routinely screened for TB and those with signs and symptoms of TB have further testing like sputum examination, Chest x-ray done to make a diagnosis. The program provides tuberculosis care under the guidance of the ministry of health through the Rakai district. We use the district TB registers to capture Ministry of health indicators. Our program works close with the district TB focal person, to whom monthly TB reports and drug forecasts are forwarded. Since the Rakai program was recommended for accreditation as a TB center, the district has provided all the required first line TB treatment. The program receives support supervision from the district focal person and ministry of health TB/leprosy section.

We provide TB/HIV care within the framework of the district set-up, for example referral of patients initiated on TB to the community TB Directly Observed Therapy (DOTS) program, in areas where there are no Rakai program peer educators to reinforce adherence to TB therapy. The Rakai program has continued to support the Rakai district in the diagnosis of TB. Until recently, when the district hospital x-ray machine broke down, we assisted with supply of both adult and pediatric x-ray films, as well as fixer chemicals. We currently have an agreement to accept referrals from district health units for x-ray at the Rakai program x-ray facilities.

Human Resource Capacity and Sustainability:

The clinical section conducts on-going medical education sessions, covering various topics of which TB management in HIV patients is included. In addition, all the staff currently engaged in TB/HIV care have received training in comprehensive HIV care which covers TB management as well. The TB focal clinicians have received specific training in TB management of HIV positive patients.

Monitoring and Evaluation:

RHSP program gathers data on various indicators. Some of the information is captured in the structured Ministry of Health TB registries while additional PEPFAR program indicator data is collected within the other regular patient clinic forms. TB/HIV is one of the regular program areas on which we report. Data collected is verified by clinically trained editors, who ensure that high data quality is reported. In addition, the quality control and assurance team provides support supervision to the clinicians.

Accomplishments: We have successfully redesigned data collection tools to capture all the required TB/HIV indicator data, including the recent PEPFAR-revised TB indicators. In addition, all staffs have received in-house training on management of TB, in accordance to the ministry of health guidelines. The program has successfully solved the problem of failure of patients to provide all three sputum samples for diagnosis of TB by collecting a spot sample on the first patient visit and leaving the patient with one sputum container to return with an early morning sputum sample on the following clinic day on which a 3rd spot sputum sample is taken, to complete the 3 required samples. This was a compromise between having no follow up sputum samples to complete TB diagnosis since many patients were too poor to bring the subsequent samples to the central laboratory. Reinforcing routine TB screening has seen our program treat more patients than in the previous years, indicating that we might have missed out some infected patients if we screened only patients with suspicious symptoms.

Lessons learnt: We have learnt that it is critical to emphasize routine screening of all HIV positive patients for TB. It is imperative to ensure complete adherence to TB drug therapy so as to prevent development of multi-drug resistant TB, whose treatment is very costly.