NUMAT is a cooperative agreement implemented by John Snow Research and Training Institute, Inc. (JSI) and its partner organizations (AIC and World Vision). It was awarded in August 2006 as a program - Expanding HIV/AIDS, Tuberculosis, and Malaria Services to Northern Central Uganda which later came to be known as Northern Uganda Malaria AIDS and TB Program (or "NUMAT"). NUMAT works in 3 broad areas: HIV/AIDS, Tuberculosis and Malaria with an overall goal of expanding access to and utilization of HIV, TB and malaria prevention, treatment, care and support activities in the nine districts of North Central Uganda region (Lira, Apac, Dokolo, Amolatar, Gulu, Amuru, Kitgum and Pader). NUMAT places emphasis on strengthening capacity and utilization of HIV/AIDS/TB and malaria services at all the different levels of service delivery with special focus on HC IV and III which are close to where the formerly displaced population has returned. The objectives of the project are:

1. Improved coordination of HIV/AIDS and TB responses. NUMAT's emphasis is on strengthening decentralized coordination at lower local government levels at districts, sub-counties, parishes and villages. NUMAT also recognizes that local government support must be complemented with national technical support and working in partnership with others. Thus NUMAT works with Uganda AIDS Commission and members of Decentralized Response Self Coordinating Entity (DR-SCE) including UNAIDS. NUMAT also works with other NGOs, UN agencies and donors that are supporting coordination of MAT response in the nine NUMAT supported districts.

2. Increased access to and utilization of quality HIV/AIDS, tuberculosis and malaria prevention, care and treatment services.This objective strives to ensure that communities and individuals in the Program area can access and utilize quality services in an integrated manner, both in their communities and from the health facilities. It includes all the three key program areas of HIV, TB and Malaria. As for HIV the purpose is to ensure that the supported services focus on identifying HIV-positive individuals and facilitating access to networked care and treatment services.

The key HIV services include: HIV counselling and testing (HCT), Prevention of Mother to Child transmission of HIV (PMTCT), palliative care for HIV including but not limited to facility-based chronic care and ART provision both for treatment and prevention where indicated. As for Tuberculosis, the key program components included scaling up and strengthening TB CB-DOTS services and making sure that TB and HIV services are integrated through support to TB/HIV collaborative activities. For all the three program areas to be supported it was important to have a functional laboratory system in order to improve access to the other services. Human resources for health is another key area that NUMAT has put in resources to achieve this objective.

3. Decreased vulnerabilities for specific groups to HIV/AIDS and other infectious diseases.The NUMAT Program prevention strategy primarily targets the following groups for HIV prevention: girls and women at risk of survival sex, Discordant couples,Uniformed service members/mobile male populations, PHA (for positive prevention), young married women, orphans and other vulnerable children, youth aged 10-24 years, men including fishing communities, long distance truck drivers farmers groups, boda boda and commercial sex workers. NUMAT uses the ABC strategy and is working closely with other partners to roll out key elements of a comprehensive strategy for balanced and targeted prevention. The key elements of the NUMAT strategy are: to strengthen district capacity and linkages to coordinate prevention activities; to plan and implement message dissemination; to improve prevention component of clinical services; and to establish and strengthen community-based groups to reinforce messages and provide ongoing support to most-at-risk populations.

4. Increased access of PHAs and their families to wrap-around services (care and support).NUMAT seeks to strengthen systems and mechanisms to increase access of PHAs to care and support services not provided directly by the NUMAT programme. These wrap around services include: access to nutrition and food support, family planning, water and sanitation, orphans and vulnerable children (OVC) support, spiritual and psychosocial support, counseling, non-food item distribution, income generating activities, legal assistance, and human rights protections. The programme works with partners to build and strengthen collaboration with USAID and non- USAID implementing partners, local government, FBO/CSOs, other NGOs, PHA networks and the private sector operating in the region to create effective linkages to these essential wrap around services. The NUMAT approach has also involved capacity building of PHA networks/groups to ensure active participation in and promotion of access to wrap around services through advocacy. PHA volunteers are supported to serve as service navigators, connecting fellow PHAs and their families to wrap around services support. The third approach has involved strengthening of referral networks in the region.

5. Improved use of Strategic Information.NUMAT has been building its own monitoring and evaluation system in partnership with the district focal persons for HMIS, in order to compare the raw data and disseminate analysed information. Additionally, the program's main approach is to support districts to provide timely and quality information for their planning and decision making.

NUMAT's Guiding Principles:

? Scaling up service provision within existing framework and policies. NUMAT works with the local governments and existing service providers to improve and expand service delivery through providing a variety of inputs. Al this is done within existing national guidelines and policies.

? Ensuring District involvement and ownership of the supported services. All NUMAT's support is aimed at complementing what the Government is doing. And all activities are supported with the involvement and blessing of the districts l under a partnership agreement between NUMAT and each of the nine District local governments.

? Strengthening services in peripheral areas beyond towns and municipalities. Emphasis is put to strengthen services at lower level facilities HC IVs and HC IIIs with specific emphasis on those sites which are beyond municipalities and towns.

Overall strategies

? Strengthening existing service provision sites to increase on coverage and quality of services offered;

? Supporting new sites in peripheral areas to offer comprehensive services;

? Strengthening integrated outreach and service delivery;

? Strengthening existing local structures to coordinate and integrate services;

? Addressing critical human resource needs; and

? Involving beneficiaries in planning and delivering of services (including PHAs).

Overall Inputs

? Training: in-service and pre-service TOTs and direct service providers (mainly by the districts);

? Direct Technical assistance through support supervision and mentoring (central, district or NUMAT); Districts are always involved;

? Infrastructure development mainly in lab sector (targeting 27 labs);

? Equipment support (labs, PTCs, ANC, FSGs);

? Supplies and reagents test kits and other lab consumables;

? IEC/BCC materials (print, audio & video);

? Medicines ARVs; and

? Direct funding to districts/sites and community groups through grants & other mechanisms.

NUMAT contributes to the health system strengthening through several programme components namely:

Infrastructural development - The programme has supported districts to renovate laboratories and counseling rooms at HCIII level. In 2010 laboratories and counseling will be refurbished and equipped with basic lab equipment to improve the diagnostic capacities of the units.

Capacity building - NUMAT works closely with local governmemet to build their capacity in planning, management and delivery of HIV/AIDS, TB and malaria services. Four NUMAT supported districts have been supported to develop and put in place HIV/AIDS strategic plans. An additional four districts will be supported to develop their plans which would help them strengthen coordination of HIV activities and also help the districts rationalize allocation of resources to HIV/AIDS acivities.

NUMAT supports in service training for health workers. Given the high attrition rate of health workers, NUMAT will train more health workers in different program areas. Support supervision will continue being strengthened through providing logistical and financial support to the District health offices, supporting MoH technical staff to conduct supervision visits and through NUMAT staff conducting their own independent support supervision visits to the service delivery sites.

NUMAT will continue helping districts to address the critical Human Resource constraints facing them by providing resources and technical assistance to districts to conduct exhaustive staffing needs assessments, putting in place functional Human Resources information systems, advertising vacant positions and supporting district health service commissions to shortlist and interview candidates. Support will also be provided to districts for orientation of newly recruited staff as well as training district human resource managers in support supervision and performance management.

NUMAT has partnered with Baylor College of Medicine to leverage resources for pediatric HIV Care. Through this partnership ART sites jointly supported by NUMAT and Baylor have benefitted from ARV pediatric formulations, Capacity building initiatives including didactic training of health workers in pediatric care, establishment of ART databases, recruitment of additional support and technical staff in ART clinics and increased HIV lab monitoring tests. This partnership will continue in FY2010 and will be expanded to another 20 sites.

In the last two years NUMAT has continued to support free CD4 and CBC outreach testing through a partnership with two organizations - JCRC and CNAPSIS for a fixed quota of samples per month. In FY2010 the number of CD4 and CBC tests performed will increase at no direct cost to NUMAT as other partners like Baylor College and AIC start conducting tests at no cost for NUMAT. There are also plans by the MoH to procure CD4 machines for several sites in the nine districts this will go a long way in increasing coverage of this vital activity at a low marginal cost for NUMAT.

As mentioned above, NUMAT will train more health workers in FY2010, but more focus will placed on skills and confidence building through a mentorship of health workers at their work places by experienced and more senior collegues from the cntre or within the region. District based trainers will facilitate the bulk of the trainings in FY 2010 to ensure relevance, sustainability and local support of the trainings conducted.

NUMAT supports health facilities and community-based service providers to increase access and utilization of care and support services for HIV infected adult individuals and their families. NUMAT addresses support and care by strengthening psychosocial support, establishment of referral networks to link PHA to HIV/AIDS and other wrap-around services. These services include: home-based care services and the provision of essential drugs for OI prophylaxis and ART, pain and symptom management and psychosocial support. The NUMAT support also includes technical capacity building of health workers, community-based providers, PHA groups and community volunteers to offer quality care and support for PHAs and their families.

Psychosocial support in the region was promoted when NUMAT trained 140 counselors from 40 health facilities in Northern Uganda to provide counseling on disclosure to spouses and significant others, ongoing counseling, therapeutic counseling and bereavement counseling.

In FY2010 an additional 120 counselors will be trained; these will mainly be drawn from health centre III's and IV's in the Acholi sub region. Majority of those previously trained hailed from the Lango sub region. The counselors will be followed up on a quarterly basis by MoH mentors to ensure adherence to set standards.

In FY2009, NUMAT supported 28,000 PHAs with basic chronic care services including Cotrimoxazole for primary prophylaxis and screening for tuberculosis. An adequate supply of Cotrimoxazole for patients assessing care at the supported sites has been made possible through the auspices of the NMS/JMS/MoH/CDC Laboratory supplies project, leaving NUMAT to concentrate on providing new ART clinics with antiretroviral drugs. Co-trimoxazole has been availed to all clients at all NUMAT supported ART sites which include two hospitals, 12 health centre IVs and 14 health centre III's. In PY2010 five more sites will be added, bringing the total of NUMAT-supported sites to 33. This will contribute to bringing comprehensive care to an additional 5000 PHA in the nine districts, as they are targeted for various forms of treatment. In addition to supporting the provision of cotrimoxazole, NUMAT will also support the mechanisms to ensure the supply of oral morphine and other pain relieving drugs to support pain and symptom management at the supported sites. This however will require working with MoH, Palliative Care Association of Uganda and Hospice Uganda to support training of Palliative care specialists and nurse prescribers for oral morphine for the sites.

People living with HIV/AIDS in the sub-region are provided home-based care services by a team of 1,100 home visitors trained by NUMAT. These are volunteers, often PHA peers, drawn from within the community. The home visitors visit clients in their home environments, providing basic nursing care, psychosocial support, on going counseling, prevention care services and referrals for other services. In FY 2010 therefore, there will be additional 80 home visitors trained as replacements of drop outs. This will bring the number of home visitors trained to 1,180. CBOs, FBOs, NGOs and PHA networks will be strengthened through mentorship and support supervision of home visitors to provide quality home-based care services. Home-based care implementation guidelines and policies shall be given to the home visitors to use and guide the activities implemented. Replenishment of supplies such as soap, ORS, monitoring notebooks and referral forms will continually be provided as required.

The program engages individuals openly living with HIV/AIDS as service providers. These are referred to as Network Support Agents (NSAs). The Network Support Agents are a link between communities, health facilities and the direct service providers. To date, there are 140 Network Support Agents working as navigators of HIV/AIDS/TB services including provision of clear information on ART treatment, making it more understandable by not only those living with HIV/AIDS, but also their immediate families and communities. In FY2010, the role of NSAs will further be strengthened.

The wrap around services needed by PHA and their families are many and diverse. However, NUMAT program does not directly provide these services but it coordinates with providers of these services to ensure linkages. In this context, NUMAT collaborates with of these services to increase their access by PHAs and their families. Such collaboration with Population Services International (PSI) has enabled 5500 PHA households to access basic care commodities (BCP).

In FY2010 NUMAT will continue partnering with Program for Accessible Health Communication and Education (PACE) to enable an additional 5,000 PHA access the BCP commodities. NUMAT will also develop a working relationship with ACDI VOCA Project to ensure that the registered PHA access food nutrition and security support. The National Agricultural advisory services (NAADS) programme will also be engaged to empower PHA households to grow their own food. NUMAT will continue to strengthen collaboration and partnerships with various implementing partners and services providers to expand access to wrap around services by PHA and their families. New partners will be identified and brought on board to provide wrap around services. Where possible, small grants will be provided to some selected CBOs and NGOs providing critical wrap around services to scale up these services. A key strategy is for NUMAT to continue supporting the active participation and capacity building of PHA networks to serve as service navigators, connecting PHA between direct HIV services and wrap around support. The program will continue strengthening the roles of PHA networks and groups in increasing access and utilization of these services. Evaluating NUMAT's activities will include an evaluation of the referral mechanisms and access to wrap around services.

Quarterly referral coordination meetings to improve referrals mechanism between service providers (facility and community-based) from health sub district and or sub county level will be held in all the nine districts. Referral forms and tracking tools will be developed, printed and distributed to community-based HIV/AIDS service providers to track and record clients for services. A key strategy is for NUMAT to continue supporting the active participation and capacity building of PHA networks to serve as service navigators, connecting PHA between direct HIV services and wrap around support. CBOs providing services will be brought together at the health sub district or sub county level to support referrals between community and clinical services. NUMAT will continue to strengthen PHA Networks to perform referral and linkage functions.

Involvement of the PHA networks in patient care and support will continually be enhanced. At the health facility, PHA as network support agents will be engaged in supporting menial tasks at the clinic and in maintaining PHA registers. At the community, the role of the sub county PHA groups will be expanded to include providing patient follow up and defaulter tracing. These activities will support retention of patients in the ART programs run in the region. Data captured in the PHA registers, defaulters traced and loss to follow-up verified through the PHA activities will enrich the monitoring and evaluation processes that the NUMAT program has to undertake.

NUMAT supports capacity building for health workers at the supported sites in the nine supported districts of Northern Uganda. In FY2009, through collaboration with the World Health Organization (WHO), the AIDS Control Programme and the MoH, NUMAT supported the training of 160 health workers in Adult Comprehensive HIV care. This course also called the Integrated Management of Adult Infectious Diseases (IMAI) has been offered to health workers constituting ART teams in 28 supported health facilities in the nine districts of Northern Uganda. Training has also been provided in various aspects of palliative care. In collaboration with the Palliative Care Association of Uganda (PCAU), NUMAT trained and mentored 55 health workers from 17 NUMAT-supported ART sites. Other trainings held include one in opportunistic infectious diseases. Held in collaboration with the AIDS control program, it trained 35 health workers in advanced management of HIV and AIDS-related diseases. In FY2010, NUMAT is to facilitate two more IMAI trainings for ART teams from five new ART sites. Additional didactic training will be required in pain and symptom management. This will be made possible by teaming up with PCAU and Mildmay Uganda. This will address critical gaps in pain and symptom management and terminal care recognized in some of the more rural districts of the region. This includes Apac, Pader, Oyam, Amolatar and Dokolo districts.

In FY2009, 72 health workers from ten newly-accredited ART sites were mentored and provided guidance in adult HIV management, ARV drug logistics, data management and nursing care. Mentorship will be a prominent feature of capacity building for health workers supporting the ART clinics in FY2010. Mentors will include clinicians, nurse specialists and pharmacists. Curricula to guide and standardize the different mentorship areas will be developed with the support of HIV training experts.

NUMAT has endeavored to monitor clinical outcomes of therapy. Through a contract arrangement with Joint Clinical Research Center (JCRC) and CNAPSIS, a CD4 lymphocyte outreach testing project is supporting treatment at the ART sites. In FY2009, 11,880 CD4 and 2,378 full hemogram tests were provided to PHA at the supported sites. Average CD4 level for patients increased by 91.8%, from 158.8 cells/ul at initiation to 304.7 cells/ul after six months of follow up. This evaluation was undertaken during an HIV adherence and retention survey completed in FY2009. The Survey also established that there was a nominal increase in weight gain of 6.2%. In regard to health facilities supported by the project, had two year retention of patients on ART of 51.1% at baseline when support had just commenced. In additional to CD4 monitoring, HIV surveillance testing will commence in FY2010 so that the efficacy of ART drugs provided through the NUMAT program, in accordance with the National ART guidelines remain appropriate.

NUMAT supports adherence activities at the health facility through technical supervision and mentoring for health facility staff, enhancing recording of patient self report, pill counting and the use of appointment registers to detect default and loss to follow up. NUMAT also strengthens adherence activities at community level by utilizing PHA peers and volunteer home visitors. The stakeholders supporting HIV treatment at the NUMAT sites are facilitated to have monthly meetings were default, loss to follow up, transfer and death amongst the clients is discussed. The review meetings enabled health workers and community workers to improve the continuum of care. In FY2010 the meetings will continue and will expand their scope to address linkages for TB/HIV collaboration and PMTCT.

With a prevalence of 8.2%, about 220,000 adults in this project area are HIV positive and in need of various forms of treatment. In FY2009 NUMAT supported 28,000 PHAs with basic chronic care services including cotrimoxazole for primary prophylaxis and screening for tuberculosis. In FY2010 by adding 5 more sites, NUMAT will be supporting 33 ART clinics. This will contribute to bringing comprehensive care to an additional 5,000 PHA in the nine districts, as they are targeted for various forms treatment. Specifically, an additional 878 persons will be initiated onto antiretroviral treatment.

In FY 2009, NUMAT, like in the previous year, collaborated with various partners to support HCT services in the nine Northern Uganda districts. The partners include the nine districts: AIDS Information Centre (AIC), the NUMAT sub-partner; Straight Talk Foundation through Gulu Youth Centre (GYC) and Kitgum Youth Center (KYC). These partners helped to roll out HCT services using the voluntary Counseling and Testing model.

Through partnership with AIC, NUMAT was able to conduct HCT outreaches to the most at risk population (MARPS), namely internally-displaced persons in camps, youth, prison inmates, uniformed personnel, and fishing communities and over 2,500 MARPS were reached with HCT services

In addition to the outreaches, NUMAT supported a total of 100 health facilities including hospitals, health center IVs, health center IIIs and selected health centrer IIs supported to provide HCT. This support was in the form of technical support supervision; capacity building/ training; and the provision of logistics tools, registers, cards and HIV test kits to facilities without these commodities. In FY2009, NUMAT, in partnership with MOH and AIC, trained 150 health workers as VCT counselors drawn from 40 lower level health facilities and 399 health workers from the district hospitals of Kitgum and St Josephs were trained in provider-initiated testing and counseling (PITC), in addition to the 404 health workers from Gulu and Lira regional referral hospitals trained in PITC in FY2008. As a result of the above mentioned support, over 180,000 clients were counseled, tested and received results with an HIV prevalence of 11%. These were linked to preventive and treatment services including wrap-around services

In FY2009, ten Post-Test Clubs (PTC) were enabled to conduct activities for positive living. These were in the districts of Amuru, Amolatar, Apac, Dokolo and Oyam .With this support, over 5,000 HIV positive and negative individuals have benefited from PTC activities including psycho-social support meetings; educational talks; and music, dance and drama activities. Working with PTCs and through strengthening referral mechanisms, those who test positive at the HCT sites will be supported and linked to a wide range of palliative care, ART and other wrap-around services.

During FY2010, NUMAT will consolidate and build on the achievements made in the past two years, while working closely with the districts, AIC and other partners to continue provision of HCT outreached to the communities and MARPS. The HCT outreach will mainly be focused on the far/hard-to-reach and the returning communities.

NUMAT will also consolidate and strengthen existing facilities, where HCT services are provided and support the establishment of new HCT service delivery points. Furthermore, health facilities will be supported to conduct HCT outreach. This will be done in order to increase geographical and population coverage.

In order to increase demand for testing, targeted HCT promotion and community mobilization as well as distribution of IEC materials in all communities will be given due attention. Targeted populations will include groups at most risk like discordant couples and those engaged in transactional sex. Where appropriate materials do not exist for certain populations or language groups, either existing materials will be translated and/or adapted or new materials will be developed using a participatory process.

Also in FY2010, support to PTC activities will be strengthened and in addition, NUMAT will support discordant couple clubs so that discordant clubs are able to meet monthly and offer each other psycho-social support and can benefit from counselor-led health education session.

To ensure the smooth flow of supplies for uninterrupted service delivery, NUMAT will invest in logistics training of the concerned health workers with support from MOH. The project will also support the District health managers of HCT access to supplies and test kits from National Medical Stores. The project will continue to support procurement of US and Ugandan government-approved buffer test kits and work with the existing distribution systems to ensure their constant availability at all supported sites.

NUMAT will yet again enhance capacity building by training 120 health workers as VCT counselors. These will be drawn from lower health facilities from the Acholi sub-region districts where populations have just returned.

In FY009, NUMAT supported a team from MOH to conduct second-round (bi-annual) support supervision to the HCT implementing health facilities. The MOH team patterned with other HCT stakeholders in the region to conduct this exercise. Emphasis was put on logistical management, data management, infection control and adherence of the service providers to the nationally recommended testing algorithms.

NUMAT supported sites using the nationally-recommended testing algorithms i.e. serial algorithm for rapid HIV testing and in partnership with MOH reproduced the standard operating procedures (SOPs) for testing and these were distributed during the supervision. The health workers were trained in the use of SOPs

For purposes of quality control and quality assurance, at least 3% of the tested blood samples from health facilities and the outreaches were sent to a reference laboratory at Uganda Virus Research Institute for re-testing.

These activities will again be supported in FY2010. In addition, NUMAT will facilitate the MOH team to mentor the district and health sub-district (HSD) teams, which will be supported to conduct quarterly support supervision to the sites. Quality assurance and quality control will again be conducted to promote provision of quality services.

In the previous two years, NUMAT main approach of HCT provision was the voluntary counseling and testing (VCT) which was offered at the NUMAT HCT supported sites and through the outreaches. In FY2009, health workers from the two regional hospitals of Gulu and Lira were trained in PITC and implementation began. NUMAT, in partnership with AIC and MOH, trained 400 health workers from the district hospitals of Kitgum government hospital and St Josephs Hospital in PITC and implementation has began

In 2010, NUMAT will strengthen the PITC approach in the implementing health facilities. All hospitals will be supported to conduct PITC. In addition, two HCIVs from the districts without hospitals will be trained and supported in implementation of PITC

NUMAT will in 2010 partner with more sub-grantees in HCT services delivery in the districts of Amuru, Gulu, Kitgum and pader. In Kilak County (Amuru district), the approach will be through home-based HCT so as to reach majority of the returning population. The program will continue to hold integrated outreaches as work camps with HCT as one of the service areas among others. This outreach activity, which started in FY2009 brings together a "cocktail" of NUMAT services (HCT, PMTCT, ART, Malaria, T.B, Palliative, Prevention a services) under one umbrella at specific sites. The work camps have the advantage of immediate linkage to the needed care and prevention services.

NUMAT began its support to health facilities after establishing that less than 6% of patients assessing care and support were children. There was lack of knowledge in pediatric counseling. Health workers generally considered care for children to be the exclusive domain of the pediatric specialist. The HIV clinics did not prioritize the care of children at the clinic. In all the clinics visited, children spent long hours in the waiting queues alongside the adult patients.

As a strategy to address care and support for children, NUMAT considered it essential to co-opt the skills of a partner specialized in the care of children to kick-start appropriate pediatric HIV care services in the region. This culminated into the signing of a partnership agreement with Baylor College of Medicine Pediatric Foundation, (BCM) which in turn led to activities that raised recruitment levels for care and support for children at an initial eight health facilities supported by NUMAT. The activities included didactic training for health workers in comprehensive pediatric care, training in pediatric specialized psychosocial support, regular mentoring and technical support. Assistance was offered to respective district local governments to recruit and retain pediatric nurses, clinicians, social workers and data clerks. BCM also provided drugs for treatment of opportunistic diseases as well as cotrimoxazole for prophylaxis. NUMAT, on the other hand, afforded the sites CD4 lymphocyte monitoring for initiation and clinical follow-up of children on ART. In addition NUMAT supports the community follow-up of children on treatment.

In FY2010, an additional 17 NUMAT-supported sites will receive the full range of support stipulated by the partnership agreement akin to the support provided to the 8 initial sites. An additional 8 sites that NUMAT intends to support may not benefit from the agreement with BCM. As a solution NUMAT will work closely with MOH, scaling up provision of pediatric formulations of OI drugs for treatment and prophylaxis to these sites through strengthening essential drug logistics centrally and at the sites. NUMAT will also work with WHO and the AIDS Control Programme to build the capacities of health workers in pediatric counseling and support. NUMAT will also partner with ACDI-VOCA, and the Nu-Life project to provide nutritional supplements for these children.

Pediatric treatment has been inadequately addressed in Northern Uganda. Less than 3% of patients accessing ART were children. The initiation of HIV-infected infants was virtually non-existent in HIV clinics in the lower level health facilities-there was lack of knowledge in pediatric counseling. Health workers generally considered care for children to be the exclusive domain of the pediatric specialist. The HIV clinics did not prioritize the care of children at the clinic. The needs of both children and their caregivers that affected adherence were poorly addressed and led to significant levels of loss to follow-up and death amongst the few children initiated on treatment. In literally all the clinics, children spent extended hours waiting to be attended to alongside the adult patients.

MoH made an attempt, though inadequate, to improve treatment for the HIV infected child in HIV clinics in the region. There was the provision of pediatric formulations to the sites. However, on many occasions the drugs were provided through a push system and had a limited shelf life, often expiring before children could access from the drugs. There was a lack of laboratory backup to help determine eligibility for ART amongst the children, lack of knowledge and functional equipment for weight and growth monitoring. In this regard, there was no demand for health workers to make fresh orders for more pediatric formulation.

NUMAT has partnered with the Baylor College of medicine, Pediatric foundation (BCM) to develop a strategy to improve treatment for children. By these efforts, BCM is now providing pediatric formulations to children at 25 of the NUMAT-supported sites. Another eight HIV clinics supported by NUMAT in FY2010 may not benefit from the arrangement with BCM. NUMAT will address this gap by working closely with MOH, scaling up provision of pediatric ARV formulations and strengthening ART logistics centrally and at the sites. NUMAT will also work with WHO and the AIDS Control Programme to build the capacities of health workers in the provision of pediatric ART formulations. This will increase the number of children on ART at the sites to 428 individuals in FY2010; representing almost 10% of all the HIV patients on antiretroviral therapy.

The overall goal of the Northern Uganda Malaria AIDS & Tuberculosis (NUMAT) Strategic Information (SI) activities is to provide greater support to the national capacity building in the collection, management, analysis and utilization of health data. NUMAT's specific support to this mechanism falls under the following three broad areas:

1. Support to the National Health Management Information System (HMIS):

NUMAT has been supporting the HMIS through building the technical capacity of district biostatisticians to manage data collection from the lower level health units and facilitate analysis, reporting, dissemination and utilization of data. Record assistants at health facilities are also being equipped with skills and trained to extract data from service registers and enter into the HMIS summary formsthe emphasis being on HIV/AIDS, tuberculosis and malaria data. As necessary, NUMAT has also been supporting the procurement of equipment like computers and internet modems to facilitate collection, analysis, storage and timely reporting of data at district, regional and national levels. NUMAT has also supported the scale-up of the Ministry of Health-led Web Enabled HMIS system to facilitate timely reporting of data. NUMAT was part of the technical review of the newly-revised HMIS forms & data collection registers by the Ministry of Health and in the next year, will facilitate the dissemination and utilization of these in the health facilities and the districts.

This year, NUMAT will embark on a process of coaching/mentorship and intense support supervision in HMIS data management. This process is intended to be a milestone activity in building the capacity of biostatisticians & record clerks by improving their knowledge, skills, and experience in data management. As much as possible, this process will be practical and on-the-job to ensure maximum attainment of skills in data collection, detailed analysis and data utilization. This coaching will be complemented by quarterly meetings of biostatisticians aimed at discussing key topics to strengthen their capacity in the execution of their day-to-day tasks. District health officials will also be supported to monitor progress on critical health indicators, and to routinely utilize data for their planning purposes and supporting service delivery. This support will be through quarterly data review meetings to allow the sharing of practices, challenges, lessons and review of service data. In addition, NUMAT will continue providing equipment and stationary including HMIS forms to the districts to facilitate data management.

The above will all be done with and through partnership the Ministry of Health, Uganda AIDS Commission, World Health Organization and other UN agencies, the American Refugee Council, AIDS Capacity Enhancement Project and the network of People living with HIV/AIDS.

2. Surveys

LQAS & HFA: As a program, NUMAT supports the systematic collection, analysis and interpretation of data through the execution of surveys. To date, NUMAT has conducted two Lot Quality Assurance Surveys (LQAS) and one Health Facility Assessment (HFA). These are being used as rapid cost effective sampling methodologies used to measure coverage of key indicators while identifying service related gaps. Overall, over 140 participants from the nine districts have been trained on both methodologies. This coming year, NUMAT will do the same and conduct another LQAS survey and HFA.

Geographical Information System (GIS) Mapping: NUMAT will use GIS as a tool to turn data from these surveys on the location of health facilities, populations, and other variables into maps that can visually display the availability and distribution of health services in the region. This is meant to go a long way in guiding districts and other stakeholders in the allocation and targeting of resources.

3. Monitoring and Evaluation

NUMAT's M&E strategy aims to provide reliable & quality information to satisfy the strategic needs of the district, national and also Program M&E efforts as well as our donors. NUMAT is doing this through building the technical capacity of both the district leadership and organizations to ensure sustainability into the overall national system as discussed below:

District & Grantee M&E Capacity: NUMAT has built the capacity of the districts and local organizations to design M&E plans as tools to monitor and evaluate their outputs and outcomes of their HIV & AIDS activities. To date, NUMAT has supported four out of its nine districts to develop M&E plans. This coming year, NUMAT will support the remaining five districts to develop M&E plans. NUMAT will also build the technical capacity of grantees in M&E.

Data Quality: NUMAT is constantly evaluating the quality of data reported through conducting Data Quality Assessments (DQA). This year, NUMAT will continue these assessments, in partnership with other USG partners such as USAID/Uganda Monitoring & Evaluation Management Services (UMEMS) and Monitoring and Evaluation of the Emergency Plan Project (MEEPP) project.

Data dissemination: Focused documents aimed at informing decision makers such as comprehensive reports, brochures and journal articles will continue to be produced, and meetings and workshops to discuss data will be supported. To share lessons learned and ensure exposure to practices, NUMAT will support staff and partners' participation at national, regional or international conferences. NUMAT will also organize a regional conference in Northern Uganda to share lessons learned with a variety of stakeholders

Project M&E: NUMAT as a program is routinely involved in monitoring and evaluating the implementation of its activities. The program has been engaged in conducting several evaluative studies. This year, NUMAT will continue to conduct these, to evaluate program's performance, share findings and inform strategic decision-making regarding specific programmatic areas. NUMAT will also invest in ensuring that accurate data is reported on its activities and results as per its mandate to the President's Emergency Plan for AIDS Relief (PEPFAR).

The Government of Uganda recently developed the National HIV/AIDS Strategic Plan (NSP) 2007/8-2011/12. Goal 4 of the NSP aims at building an effective system that ensures quality, equitable and timely delivery of HIV/AIDS services for all intended beneficiaries. In line with this goal, NUMAT's emphasis has been to shift the focus of HIV decision-making closer to the lowest decentralized level of government. At the district and sub-county local government level, emphasis has been on strengthening and building the capacities of HIV/AIDS coordination structures that had hitherto been dormant due to conflict. Other forms of leadership and governance issues were supported by the project in the context of the health system as enshrined in the health sector strategic plan. The main focus was on improving the capacities and capabilities of districts to plan, manage, implement and supervise health activities at the district, health sub-district and health facility level.

Apart from working within established government structures, the program also specifically addressed leadership and governance issues within civil society organizations, especially those involved in HIV/AIDS responses. Technical assistance, training, financing and equipment were provided in order to address institutional and organizational gaps.

In terms of supporting human resources for health, the program has mainly focused on the following areas: a) partnering with health training institutions for field attachment of medical students(nurses, pharmacists, medicine and radiology students) to work in peripheral health units with in-adequate staffing; b) supporting districts to advertise, recruit and induct health workers to fill staffing gaps; c) working jointly with Capacity Project and Ministry of Health to improve staff performance and training in various aspects of HRM; d) supporting pre-service and in-service training of health workers; e) strengthening continuing professional development (CPD) of health workers; and finally f) supporting districts to set up human resources information systems for planning and decision-making on human resources for health.

Accomplishments

The program provided technical support and funding for the development of nine district plans and five district HIV/AIDS strategic plans. The funded activities were: support towards functionality of coordination structures (meetings, field monitoring and reporting); functionality of health structures at the district and health sub-district levels (in the form of monthly/quarterly meetings, support supervision and training of health unit management committees).Civil society partners were provided funding and technical support to develop their strategic and operational work-plans.

In terms of human resources for health, 187 undergraduate medical students were attracted to work in 11 health units. Their presence reduced workload for the few health workers within these facilities. Patient waiting time was reduced and demand for health services from the communities increased. Two post- graduate students from Makerere University school of Public Health were also brought in to work at the Apac district hospital. They were able to undertake operational research on malaria and their findings were used by the District Health Management Team (DHTM) for planning; 242 health workers of various cadres were recruited, inducted and deployed in three districts (Gulu, Pader and Kitgum). The program supported 26 health workers for pre-service training in a laboratory assistants course, and out of these, eight health workers have completed and 18 will complete in FY2010. The eight who have completed will be tracked in their respective district to ensure they are re-absorbed as Laboratory assistants, a critically lacking cadre of staff in most project districts. Various in-service trainings were done for health workers in the various program areas notably PMTCT, HCT, TB, ART, RCT and Malaria. Performance improvement focusing on reproductive health and PMTCT services was undertaken in health units offering RH services in all the nine districts. The findings were disseminated in the respective districts and action plans drawn for each of the health units. Human Resource Information System (HRIS) was set in three districts (Gulu, Pader and Kitgum) and Gulu regional referral hospital. The database will be used for planning and making decisions on staff recruitment, deployment, retention and management. A number of advocacy activities were undertaken including meetings with partners such as Capacity Project, Ministry of Health, Ministry of Finance and above all, organizing a regional conference on attraction and retention of health workers in Northern Uganda that attracted stakeholders from the region and the national level.

Barriers:

Meeting the expectations and demands of the communities and the Local Government in the region given the enormous rehabilitation and development needs caused by the 20-year conflict needs a holistic approach that not only address the issues of leadership and governance but also other underlying causes of poverty. The impact of conflict is still evident in the weak government structures characterized by in adequate staffing, poor compensation, absenteeism, poor working and living conditions. Because of these needs and weaknesses the health systems and government structures still need enormous technical and financial support.

Despite the support to districts to recruit health staff, attraction of key cadres of health staff such as medical officers, Orthopedics, Public Health Nurses, Laboratory Assistants, Nursing Officers (Nursing) and Laboratory Technologists, Pharmacists and Public Health Dental staff has continued to be problematic. The lengthy and bureaucratic recruitment process does not adequately address staffing gaps within districts. Even after recruiting health workers, drop-out rates have been alarming due to delayed access to payroll, lack of housing, social amenities and inadequate supplies and equipments in most health units. Other factors include poor remuneration and cross-overs of health staff to NGOs. Inequitable and erratic transfers of health workers to areas where their skills might not be required is also cited as a case for poor retention and morale of health workers. NUMAT was not able to implement distance education due to the lengthy consultation and negotiation process for accreditation with different directorates within the Ministry of Health (MoH) and health professional bodies, not to mention that it is also a rather expensive undertaking.

Rationale for focus:

Due to inadequate capacity of the coordination structures, limited funding, low capacity of civil society organizations, duplication and multiplicity of actors, the need for ensuring effective coordination for quality, equitable and timely delivery of HIV/AIDS services is paramount in NUMAT's operational context. And also, as populations move back to their original homes and social services such as curative and primary health care gets re-established at new and formerly abandoned health facilities, there is need to revamp community oversight structures such as health unit management committees.

HIV/AIDS response in the communities is evident by among other things the proliferation of Civil Society Organizations (CSO). Much of these CSOs are doing commendable work in HIV/AIDS prevention, care, treatment and support for their communities. Most are still organizationally and institutionally weak and hence, the need for external intervention to build their capacity and capability.

NUMAT can only effectively contribute to the achievement of Uganda National Minimum Health Care Package (UNMHCP) if the districts in which it is operating in have the required quality and quantity of health staff.

Injection safety and waste disposal.

In the course of provision of health services, different types of waste are generated. NUMAT will support the nine districts of Gulu, Amuru, Kitgum, Pader, Oyam , Lira, Apac, Dokolo and Amolatar to roll out training of health workers, waste handlers and community sensitization on HCWM to ensure safe and appropriate disposal of health care waste. Health workers will be encouraged to include HCWM activities during CME sessions. With these activities supported, it is expected that all health service providers will be trained in HCWM, communities will be sensitized on HCWM and there will be improvement in safe and appropriate disposal of health care waste. It is also expected that during this period, NUMAT will have built capacity of the nine districts to assess, evaluate and plan for HCWM, as well as analyze outcomes of implemented activities. In FY2009, NUMAT, with support from the MMIS project, conducted an assessment on waste management and safe injection practices in selected sites in the nine districts. In FY2010, the activities to be supported will respond to the findings of this assessment. The assessment discovered that health units are failing to cope with increasing volumes of infectious waste due to: inadequate planning, low level of awareness among health managers, poor waste segregation habits making HCWM unnecessarily expensive, and inadequate coordination especially at district level.

To address these findings, NUMAT plans to do the following.

Training of service providers:

NUMAT will facilitate training sessions of service providers in safe phlebotomy and HCWM. All the nine districts will have teams trained, which will include members of the DHT. NUMAT will support each district team to have competencies in supervising service providers, collecting data on HCWM practices, and selecting priority areas for action basing on the prevailing risks. The district teams will be responsible with support from NUMAT to train operational health workers including waste handlers. NUMAT anticipates teaming up with National trainers whose capacity has been built by MMIS to conduct the initial district level trainings.

Dissemination of HCWM policies and guidelines:

Policies and guidelines on HCWM have been developed by MoH with support from MMIS. NUMAT will support MoH to disseminate these policies and guidelines in all nine districts. NUMAT plans to utilize existing opportunities like trainings, review meetings and support supervision to have this done. At selected facilities, NUMAT will support CMEs specifically on HCWM.

Production and dissemination of educational materials on HCWM:

To support training and to enhance the health workers' understanding of HCWM, concepts like segregation and final disposal, educational materials and job aides will be reproduced and disseminated. The assumption is that these have already been developed at the national level. The job aids will be posted as reference material at all areas where waste is generated.

Supporting waste disposal:

NUMAT will support selected facilities in their waste disposal. Support will range from activities targeting waste generation reduction, waste segregation and final waste disposal. NUMAT will support selected facilities with waste bins and bin liners and personal protection equipment for those handling waste. NUMAT will also support final waste disposal. Improper final waste disposal contributes to biomedical transmission of HIV and other blood borne pathogens. Members of the community are likely to get in contact with hazardous waste if it's indiscriminately discarded in areas where it is not expected to be or is disposed of in open areas that are not restricted to the general public. In an effort to improve final waste disposal, NUMAT will work with District partners to install environmentally friendly final disposal facilities in selected facilities. Options to be installed will depend on the prevailing situations at the specific sites. The options to be supported will include waste pits and incinerators. Where incinerators will be installed NUMAT will support the training of incinerator operators.

Protection of Health workers:

In the ART supported NUMAT sites, PEP is one of the supported services though information about this service is not universally available in these sites. There are also more non ART sites supported by NUMAT where this service is not available. In FY2010 NUMAT, plans to reproduce/disseminate available IEC materials on PEP in the supported health units. Where there is need, the various health workers will be re-oriented through CMEs. Arrangements will also be put in place for those non ART sites to have in stock ARV necessary for PEP.

Incidence modeling reveals that of all new infections in adults 15-45 years in 2008, 43% were among people in discordant monogamous relationship in the past 12 months (UNAIDS Country Report 2009). NUMAT recognizes that more married couples are becoming infected with HIV and therefore the need for targeted messages aimed at enabling married couples to demystify their risk perceptions, and seek HCT, PMTCT and ART services. In FY2010, NUMAT will strengthen prevention messages among couples in monogamous relationships, support discordant couples, mobilize mothers and women for PMTCT services, and reach out to adults involved in multiple and concurrent sexual partnerships through couples seminars and men's and women's groups in both the villages and workplaces. NUMAT will also continue to work with MARPs such as CSWs, bar and lodge attendants, young women, fishing communities and others to respond to HIV/AIDS by dealing with factors that make these populations vulnerable to HIV. As per MTR recommendations, NUMAT will also expand coverage of prevention activities by training CORPs in areas of new settlements. NUMAT's interventions with adults will aim at increasing risk perception through HIV education and self-assessments, with the aim of partner reduction and utilization of risk-reduction techniques such as consistent and correct condom use and skills such as condom negotiation. In FY2010 focus will also be placed on male involvement, continuing couples seminars, and increasing access to HCT services through non-traditional outlets such as moonlight camps for MARPs.

Most at risk groups in the Lango and Acholi region comprise of commercial sex workers, fishing communities (in lango sub region), young wives clubs, drinking clubs, truck drivers, boda boda riders, women's groups and men's groups. Messages disseminated will be tailored to the BCA tool specifically adapted to address HIV prevention issues and vulnerabilities among MARPs in northern Uganda and will be used to disseminate targeted messages. Messages will emphasize partner reduction and utilization of risk-reduction techniques such as consistent and correct condom use and skills such as condom negotiation and strengthening linkages to ART, PMTCT and TB services. To strengthen message dissemination among couples, NUMAT will train 150 couple BCA. 500 couples will be reached with prevention messages integrated with HIV counseling and testing services. Eighteen HCT outreaches will be conducted through the FBOs reaching 500 couples with HIV counseling and testing services.

NUMAT underscores the importance of male involvement in responding to HIV/AIDS, and therefore engage mobile men with money through workplaces and drinking clubs. NUMAT will try to reach adult men's groups such as truck drivers and boda boda riders with messages on partner reduction, mutual faithfulness, secondary abstinence, correct and consistent condom use and access to testing and treatment services. Fathers' unions provide a platform to reach more adult males within the community with messages on the significant role they can play in reversing the trend of infections through testing, mutual faithfulness and becoming role models to younger men. Through this intervention, NUMAT will address both poverty and wealthy as drivers of the epidemic, and alcohol and drug abuse as factors that increase the ones rick to HIV infection. Forty-five workplace meetings and 250 drinking club discussions will be conducted to reach men with HIV prevention messages with focus on multiple reduction and faithfulness.

NUMAT will strengthen prevention for occupationally based MARPs. Men and women working in the region are occupationally associated with high-risk behavior due to factors like extended time away from families, disposable income (and the associated purchasing power to engage in commercial/transactional sex), and alcohol. All of these factors influence high-risk behavior such as multiple and concurrent sexual relationships. NUMAT will engage these MARPs near their workplaces through BCAs, equip BCAs/CORPs with IEC/BCC materials, and make HCT more accessible to these groups. Occupationally-based MARPs include teachers, Uniformed Forces, Boda-Boda drivers, hotel & lodge workers, fishing communities, CSW, and others. To reach fishing communities NUMAT will facilitate "moonlight" HCT outreaches in the night to increase access to testing and treatment services for fishing communities. Targets for activities include: 300 BCAs trained among Boda Boda, Fishing communities, CSW, drinking clubs, and other adult groups to roll out HIV prevention activities among their peers; 46,800 MARPs reached with HIV prevention messages at their workplaces.

Another occupationally-related MARP group is teachers and Uniformed Forces, who also face extended deployments away from home and have income. Joint efforts with SPEAR will engage this target population in behavioral risk assessments and negotiated personalized risk-reduction plan (which include abstinence, partner reduction, correct and consistent condom use, partner testing for HIV, and other risk reducing behaviors as goals). NUMAT will also equip BCAs with condom demonstration tools so that participants can practice risk reduction skills, such as condom negotiation and correct condom use. With SPEAR, NUMAT will identify opportunities for HCT among these workers and services will be provided. NUMAT BCAs & PEs will lay the groundwork for UF and teachers to access VCT and those testing positive will be referred for wrap-around services and positive living skills. 360 teachers/ UF identified by NUMAT to be trained as BCAs by SPEAR. 56,160 UF, teachers and their families reached with HIV prevention messages by NUMAT's existing BCAs

In FY2010, NUMAT will continue to strengthen and sensitize women's groups and young women's groups by training BCAs to reach their peers with mutual faithfulness and OP messages. Community-led dialogues for couples in monogamous relationships, clients of sex workers, persons engaged in causal sexual relationships and women groups to emphasize AB/OP messages and RH/FP will be conducted. NUMAT will strengthen mobilization of expecting mothers and women of reproductive age to access PMTCT services. Messages on benefits of HCT & PMTCT will be disseminated during the integrated work camps and community awareness campaigns Linked with Objective 1, these groups will be supported with kits that will enable them conduct official savings and credit transactions. Targets include: 117,000 women reached with Be Faithful and correct and consistent condom use messages, 60 older women groups supported to practice ASCAs/VSLAs, 14,040 young wives/mothers reached with Be Faithful & Correct and Consistent condom use messages, negotiation skills and family planning, 15 young wives/mothers clubs trained in business development skills training and in-kind support.

In FY2010, NUMAT will support MARP CORPs (BCAs/Master Trainers), other MARPs and adult groups to register as Community Based Organizations (CBOs), and train them in proposal writing, project monitoring and evaluation (linking with Objective 1: capacity building). 9 MARPs/Adults groups supported to register as Business Entities.

In FY2010, NUMAT will support the office of the DHO to distribute condoms to the health centers and equip BCAs with condom demonstration tools (dildos) to implement and support condom promotion and distribution. NUMAT will support establishment of national traditional outlets to increase access to condom supplies during non-working hours for health centres.50 non-traditional condom outlets (bars, lodges, workplaces) and 115 HCs supported to provide condoms; 300 dildos procured and distributed to the BCAs for condom education.

NUMAT will engage community leaders on prevention and response to SGBV and encourage empowering women to speak out and report instances of SGBV and ensure that those who are survivors of SGBV receive appropriate response (health, psycho social, safety/protection and legal/justice). SGBV issues integrated into NUMAT trainings on prevention, discussions, and drama and radio talk shows for the MARPs, CHATTs, Youth, PHA groups, PMTCT counselors, Village Health Teams and all other NUMAT activities. NUMAT will train 450 in basic skills as SGBV community animators in 15 sub counties.

Health workers are vital in the response to sexual and gender-based violence. NUMAT will train 70 health workers on how to respond to cases of sexual violence, provide emergency post exposure prophylaxis and document evidence that is crucial in prosecuting offenders. Health workers will also be trained in counseling and how they can integrate it into their services.

Through faith leaders, NUMAT will continue to advocate for the rights of PHA to access services and live a life free from stigma and discrimination. PHA will be involved in service provision and advocacy activities.

NUMAT will facilitate support supervision visits by TOT every 2 months to check progress of activities and document impact. Quarterly review meetings will be supported to collect data and report. NUMAT will support the CDO to provide on-going support meetings with the MARP/Adult groups and the CORPs to ensure their participation and involvement in HIV prevention activities as one of the ways for sustaining the prevention activities.

Youth in Northern Uganda face high unemployment, breakdown of family and traditional structures, inadequate health facilities and have grown up in constant instability due to conflict and resettlement. These factors, as well as others make youth more likely to engage in risky behaviors such as multiple sexual partnerships, transactional sex, and drug and alcohol abuse, making them at-risk for HIV/AIDS. In PY3, NUMAT youth prevention activities focused on strengthening existing structures to support HIV prevention at community level. Youth prevention approaches include integrated prevention for young positives, advocacy against SGBV, addressing alcohol and drug abuse, supporting young people with disabilities in accessing HIV information and services, and strengthening linkages to HCT, ART, PMTCT, malaria and TB services, as well as youth-friendly RH and STI services. The target group is comprised of both male and females aged 10-24 years. The youth in higher institutions of learning are associated with many risk factors and drivers of the epidemic like casual sex, transactional sex, and multiple concurrent sexual partners. The out of school youth are involved in drug and substance abuse, they are unemployed, some are heading child families, the returnees have been sexually abused, casual and transactional sex is one of their characteristics with many being forced into early marriages. The young positives have long suffered psychological trauma, stigma and discrimination, they have been orphaned, and many have dropped out of school and are faced with challenges of adherences to ART

In FY2010, NUMAT prevention activities will focus on strengthening community structures and building capacities of youth Community Resource Persons (CORPS) as an exit strategy to ensure sustainability. Furthermore, NUMAT will also build on the innovative new program started in PY3 of reaching out to young HIV-positive students and teachers in collaboration with SPEAR, and also begin outreach to students in university/tertiary institutions.

University students, both male and female, are a risk group engaged in casual sex, transactional sex and multiple partnerships. Such behaviors render these young people vulnerable to HIV infection. NUMAT will train selected students as peer educators (PEs) to share risk reduction information with their friends and classmates. Therefore, in FY2010, NUMAT will train students as PEs using the MOH-standardized Peer Education Manual to offer information and services on issues of sexual and reproductive health in universities and tertiary institutions. NUMAT will work in collaboration with Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa (AMICCAL) for purposes of sustainability. This will serve as an avenue to advocate for municipalities' inclusion of universities/tertiary institutions into their HIV/AIDS response plans. Targets include:180 peer educators trained in 6 universities and colleges, 120 peer learning sessions conducted to reach 6000 students with AB and OP messages, and1000 students tested for HIV & supported appropriately for continuity of care.

In FY2010, NUMAT will continue to partner with YEAH to train existing Master Trainers and PEs in value-added skills such as the YEAH curriculum (incorporating topics such as PMTCT, malaria and TB prevention) and ARK (Abstinence and Risk Avoidance) supplemental materials (which address higher risk behaviors for youth and young adults including multiple concurrent partnerships, inter-generational sex, transactional sex, gender-based violence, drug and alcohol abuse, as well as risk reduction strategies such as condom use and male circumcision).YEAH and ARK programs are specifically tailored to meet the health needs and aspirations of both sexually active and not-yet sexually active out-of-school youth age 15-24 years. In PY3 300 peer educators receive updated training for risk reduction and value-added skills. In PY4, NUMAT will support these resource persons to reach their peers with life planning skills as part of AB & OP. Targets include: 90, 000 out-of-school youth reached with AB or OP messages; using the sports and recreation the 18 sports tournaments for out-of-school youth conducted; 72 focus group discussions (25 or less people per FGD) conducted during tournaments, benefiting 1800 out-of-school youth.

In FY2010, NUMAT will support existing 'Young Positives' clubs, ensure enrolment and retention of young positives in schools and provide access to community-based services for positive living, such as counseling, nutrition and referral to young persons living with HIV/AIDS. So far, 9 post test clubs have been established (1 per district).

YAGs, SACs and PAGs are at various life-stages of self-functionality and thus, in PY4, NUMAT will continue to strengthen these established groups so they can sustainably conduct youth prevention & stakeholder coordination. Having had their inter-generational communication skills built, teams of these trained PAG and YAG members will be equipped to lead Parent-to-Youth and Common Ground Melting Pot meetings. Targets include: 1890 PAG members will be trained (210 per district) and 540 dialogue meetings held (270 youth-youth and 270 parent-youth)

Common Ground Melting Pot (CGMP) meetings are the culmination of the series of dialogue meetings occurring within a community (including the above mentioned dialogue meetings), where groups of parents and youth have been meeting and documenting issues of concern that they would like to address in a safe, mediated forum such as a CGMP. At these meetings, the groups aim to reach consensus on unresolved and controversial issues and chart the way forward on how to handle them . Thus, this forum is often used as an opportunity to address socio-cultural issues, such as norms which negatively affect youth behaviour. As such, these meetings often invite an expert from the community such as a Legal Advocate, faith leader, or Probation or Gender Officer to support the trained facilitation team. Targets include: 90 common ground meetings will be facilitated.

NUMAT will support YAGs and PAGS to work with local institutions to conduct holiday youth camps. These activities are aimed at equipping young people with correct information so they can make informed and responsible decisions. Through AIC, on-site HCT is available at these camps. Targets include: Eighteen integrated youth camps will be conducted reaching 1800 young people with HIV testing and counseling services and 3600 youth reached with messages.

NUMAT will also continue to work with out-of-school drama groups to stage HIV/AIDS prevention theatre productions. Targets include: 240 interactive drama shows/outreach and 12 radio talk shows supported reaching 12,000 young people; NUMAT will partner with NUTI to disseminate messages to out-of-school youth groups; 10,000 IEC materials will be adapted, printed and disseminated.

In FY2010, NUMAT will train teachers in essential support for young positive students including psychosocial support and coping mechanisms, creating a conducive learning environment, increasing enrolment and retention of young positive students, improving school-based services such as counseling and nutrition, helping young positives to understand their status and work towards achieving their dreams and ambitions.10 HIV anti stigma trainings will conducted reaching 300 PHA Leaders/teachers who will in turn reach.500 young positives in schools will be linked to Baylor-Uganda to provide pediatric HIV/AIDS care & treatment and other wrap-around services.

Sexual prevention activities will be integrated and linked to other services. During integrated HCT work camps small group discussions for young people are carried out with the aim of motivating them have an HIV test. Young positives are linked to PHA networks where they are educated on use of condoms; in palliative care, use of condoms is emphasized. During training of PHA, abstinence, faithfulness and use of condoms messages to reduce re-infection are emphasized. Condom use is part of the BCP package for PHAs. Under PMTCT for young pregnant mothers and their partners, condom education is essential. At the ART sites, young positives are educated on safer sexual practices to avoid re-infection. The TB campaign in decreasing the burden of TB in HIV patients revolves around the preventative message under the ABC strategy. The integration of malaria lies in the IEC, BCC strategy like use of nets, early treatment and use of VHTs to provide information on malaria and HIV prevention

Promotion of quality assurance will be done through routine support supervision, link CORPS to the local governments and institutions, Quarterly review meetings and technical assistance to CORPS , M&E trainings and documentation of case studies. At various youth meetings, NUMAT will invite an expert from the community such as a Legal Advocate, faith leader, or Probation or Gender Officer to support the trained facilitation team.

The monitoring and evaluation plan will include the Quarterly review meetings, documentation and validation exercises, and special studies to assess impact and technical dissemination forums. NUMAT will continue to strengthen these established groups so they can sustainably conduct youth prevention & stakeholder coordination. This supervision will take the form of increased spot-visits at events and the presence of NUMAT Specialists, DTO's, as well as members of the SAC, at monthly meetings. NUMAT in collaboration with ADCO will review and strengthen the youth group capacity to plan, document and capture data and also provide TA to this group and also help to link them to the village health teams (VHTs) to ensure continuity beyond NUMAT project.

In FY2009, NUMAT PMTCT support in Northern Uganda, which is district wide, increased to 100 PMTCT sites from 80. This scale-up helped increase geographical access to PMTCT services in the 9 districts. The NUMAT support was mainly through the provision of Technical Assistance (TA). The TA was in the form of support supervision to the sites where NUMAT partners with MOH to conduct bi-annual visits to the sites. Through the supervision visits, health workers were oriented on the new PMTCT national guidelines to ensure adherence to standards, mentored on the use of the standard operating procedures (SOPs) and use of logistical management information systems (LMIS).

In FY2010, this support will continue and will be done at 3 levels:

1) Central-led support supervision: This will still be an MOH led activity, conducted bi-annually, which will involve other partners/NGOs involved in PMTCT service provision in Northern Uganda and regional and district supervisors. During this exercise, the MOH team mentors district supervision teams. This team will also provide mentorship to newly recruited staff and will kick-start new PMTCT sites.

2) District-led support supervision: This will be conducted on quarterly basis and will follow up on issues raised by the central (MOH) team. It will be conducted by the district supervisors.

3) HSD-led support supervision: This will be conducted on monthly basis by the HSD team, concentrating on PMTCT site specific issues that are raised by the national and the district supervision teams.

Following the centrally-led supervision, NUMAT will have bi-annual coordination meetings which are used to disseminate the supervision findings and draw action plans for each of the stakeholders with feasible recommendations. NUMAT also continues to enhance capacity building through trainings of health workers. In FY2009, NUMAT conducted several trainings of health workers on different aspects of PMTCT: Orientation of 319 health workers on the new PMTCT policy guidelines; 580 health workers trained in early infant diagnosis (EID); 88 health workers trained in the implementation of the family support groups so that HIV+ mothers and their families are offered psychosocial support; 40 health workers trained in infant and young child feeding counseling and 40 trained as PMTCT counselors. In FY2010, the program will concentrate on job mentoring of health workers. Trainings will specifically target the newly-recruited staffs and those from the newly accredited PMTCT sites.

In FY2010, NUMAT will continue to scale up PMTCT services through partnerships with sub-grantees. In the districts of Kitgum and Pader, NUMAT will yet again work through partnership with AVSI to scale up PMTCT services to reach 19 sites in the two districts. The program also intends to have more sub-grantees for the districts of Gulu and Amuru.

Previously through the direct district grants, health sub-districts were able carry out PMTCT outreaches to the internally displaced people (IDP) camps and the lower health facilities. The situation in the region has normalized and majority of the people have returned to their homes, however these are usually far from health facilities. Putting this into consideration, NUMAT will intensify support for integrated PMTCT outreaches from hospitals, and health sub-districts to lower health facilities mainly targeting the returning and far away communities.

In FY2010, emphasis will again be put on supporting the sites and districts in supply chain management using the "pull system" so that health facilities are able to get supplies from the national medical stores/ MOH. Additionally, NUMAT will procure ARV drugs for PMTCT prophylaxis which will help as buffer stocks to sites experiencing shortages and stock-outs. The ARV drugs will be Nevirapine tablets and Syrup, Zidovudine and Lamivudine (Combivir), Zidovudine Syrup, and Zidovudine Tablets. Emphasis will again be put on supporting the sites and Districts in supply chain management using the "pull system". The buffer stocks will take care of un-foreseeable circumstances like delays in delivery resulting in stock-outs.

In FY2009, IEC/BCC materials were produced and distributed to the PMTCT sites. Also, health equipment in form of video/television sets and tapes for PMTCT sites were procured and distributed to PMTCT sites and as a result, 15 sites got generators, 30 sites got T.V sets and 31 sites received Video decks. PMTCT talk shows on Radio Wa and Mega FM were carried out.

To further increase demand and therefore access for PMTCT, in FY2010 NUMAT will again work with MOH and AIC to review and translate IEC/BCC materials on male involvement in PMTCT, benefits of PMTCT, infant feeding and early infant diagnosis. These will be distributed to the health facilities and the communities. In addition, the program will strengthen radio talk shows on weekly basis and these will focus on PMTCT related issues among other areas. Moreover, the program will again procure health education equipment in form of T.V. screens, video decks and tapes to be used in the PMTCT setting to educate mothers and their spouses for the regional hospitals and the district hospitals of Anaka in Amuru and Apac in Apac.

Through FY2009, NUMAT has supported a cumulative total of 45 family support groups (FSGs ) according to MOH guidelines. The FSG groups helped mothers, their partners and their infants access and adhere to ARV and infant feeding regimens. Over 1000 pregnant women were able to access psycho-social support through the FSG and 800 babies followed up. The members were also linked to 'wrap-around' services such as home-based care, family planning, food and nutrition support.

The program will, in FY2010, strengthen psycho-social support to the HIV+ pregnant mothers, and their spouses, identified in a PMTCT setting through the FSGs. Through the FSG, where HIV+ mothers will be able to meet twice a month, and a continuum of services will be offered; health education, ART adherence counseling, EID for the exposed infants, WHO clinical staging, and linkage to prevention and treatment services.

In FY2009, NUMAT supported early infant diagnosis (EID) in the 9 districts. A total of 580 health workers from 7 districts were, in partnership with MOH, oriented in EID. This is in addition to the 230 who had trained in FY2008 in the two districts of Apac and Amuru. Consequently 80% of the PMTCT sites are now able to offer EID service. As a result of this support, a total of 4,321 DBS samples from HIV exposed babies were tested of which 382 (11%) were positive. Those who tested positive were linked to care and treatment services.

In FY2010, NUMAT will work with MOH to ensure functional EID services in all the PMTCT sites. The program will also facilitate the district laboratory focal persons of the respective districts, twice a month, to collect the dry blood spots (DBS) samples from the health facilities and transport them to the regional laboratory for PCR testing. The DLFPs will in turn take the results back to the sites. Trained health workers will be followed up through support supervision.

In FY2009, efforts were made to strengthen PMTCT-ART linkages mainly in the areas of septrin prophylaxis, CD4 testing, WHO clinical staging and HAART initiation for eligible HIV positive pregnant women. NUMAT was able to carry out CME at the sites in this aspect.

In FY2010, the PMTCT ART linkages will further be strengthened in all NUMAT supported ART sites.

NUMAT will procure infection control materials for the PMTCT sites to be used in MCH/ reproductive health set up i.e. Antenatal care clinic, labor and delivery and the post natal clinic. These are Gloves (surgical and disposables), Jik, Aprons, face masks, Gumboots, caps, Mackintosh, Buckets and soap.

The project will reproduce, and distribute to the facilities, the MOH reproductive health integrated registers (ANC, maternity, and the PNC) to be used as data tools. Additionally, all the reporting and the logistical management tool are to be reproduced and distributed to the facilities. Upon distribution, Health workers are to be mentored on the use of the tools. The program will also produce the SOPs to aide the health workers adhere to the standards according to national guidelines.

The NUMAT project, which is being implemented in the sub-regions of Acholi and Lango, covers nine districts in the post-conflict region of Northern Uganda with an overall goal of expanding access to and utilization of HIV, TB and malaria prevention, treatment, care and support activities in Northern Uganda. With the relative return of peace in the region, most of the populations have returned to their homes. The districts have re-opened health facilities closer to the homes of the returning populations that were closed due to insurgency. NUMAT is working within the existing health structure and, in collaboration with other partners in the region, will continue supporting delivery of quality laboratory services to populations both in the peripheral camps and to those who have returned home. Laboratory services are central in the diagnosis, management and prevention of HIV/AIDS, TB and malaria.

Accomplishments since COP 09:

In FY09, NUMAT completed refurbishment of 12 laboratories at HC III in the districts of Amuru, Gulu, Dokolo and Amolatar, and is in the process of procuring refurbishment services for 16 laboratories in the districts of Apac, Lira, Oyam, Pader and Kitgum, and Dokolo HCIV. Following an in-service training curriculum developed by NUMAT in conjunction with the Ministry of Health and other partners, the project provided refresher training to 49 (cumulative total of 133) practicing laboratory personnel on tests for diagnosis and management of HIV/AIDS/TB and malaria, Disease Surveillance and Laboratory Management; 60 clinicians were re-oriented on rational utilization of laboratory services; twenty six (26) students from the project districts were sponsored for a two-year Laboratory Assistants' course in various laboratory training schools of whom eight sat for end-of-course national examinations; select equipment such as microscopes, manual centrifuges, refrigerators, colorimeters, water filters, microlitre pipettes, counting chambers, tally counters were provided to a total 59 health facilities based on needs; a total of 93 health unit laboratories were visited and 171 laboratory personnel supervised by District Laboratory Focal Persons (DLFPs), national trainers/supervisors and Central Public Health Laboratories (CPHL) staff. Laminated Standard Operating Procedures (SOPs) were provided to 75 health facilities laboratories. Making Medical Injections Safer (MMIS), Ministry of Health and NUMAT trained 159 District Health Team members and health unit in-charges from the districts of Oyam, Amuru, Gulu, Dokolo and Amolatar on Health Care Waste Management, planning and budgeting for HCWM activities. Colour coded bins and bin linners were procured for 74 health facilities. To disseminate innovative approaches; an abstract "Quality assurance in scaling up of HIV testing using rapid tests, NUMAT'S experience was presented as a poster during the HIV Implementers Meeting in Windhoek, Namibia.

Challenges in FY 09:

Stock-outs of laboratory supplies such as reagents, test kits, specimen containers, specimen packaging materials at the facilities.

Inadequate health facility staffing at both clinical and laboratory levels and yet the demand for services is ever increasing.

Increase in the costs for refurbishment prices of fuel, steel products went up; the scope of works therefore had to be scaled down to fit within the budget.

Weak system of equipment maintenance and repair

Ministry of Health with partners and stakeholders finalized the National Laboratory Policy during FY 09 and a three year Strategic Plan for laboratory services is being drawn.

In FY 2010, working in line with the National Laboratory Policy and strategic plan, NUMAT will continue building on the achievements gained through the joined efforts of partners and agencies supporting the laboratory sector in the region and nationally. The central role of districts in implementation of activities to ensure ownership and sustainability will be emphasized. Activities will be directed at further improving the capacity and quality of the laboratory services in the diagnosis and management of HIV, TB, malaria, Opportunistic Infections associated with HIV infection, other Sexually Transmitted Infections; strengthening specimen/patient referral for specialized tests. Laboratory Information Systems and Supply Chain Management Services that form the core for planning for laboratory services will also be emphasized. Support will be targeting 95 health facility laboratories (HCIII through to hospitals) in the region. The main activities will be:

1. Renovating infrastructure of laboratories and counseling rooms to meet the minimum standards set by Ministry of Health. The laboratories to be refurbished are closer to the resettling communities. This will reduce distances traveled by the population to access laboratory services and also increase the population served. The laboratories to be refurbished were selected by the districts authorities and NUMAT following a logical assessment of where the most need was. REDACTED. NUMAT will provide select supplementary equipment and supplies, required in the provision of laboratory services for the management of HIV, TB, malaria, OI's, STIs based on the gaps identified during performance monitoring visits. The equipment will include but not be limited to Microscopes, Autoclaves, Counting chambers, Cool boxes, accessories, spare parts and supplies. Working closely with the ministry of health, partners and stakeholders, NUMAT will strengthen capacity for equipment maintenance and repair (training and mentorship).

2. Training - 30 laboratory staff with formal training that are yet to receive refresher training will undergo a two-week in-service training in HIV rapid tests, sputum smears microscopy, total and differential white blood cell counting, hemoglobin estimation, blood smear examination for malaria parasites and other haemoparasites, diagnosis of other opportunistic infections common in HIV/AIDS, Laboratory management and Laboratory disease surveillance. The training will follow an in-service training curriculum that was developed by NUMAT, Ministry of Health and other partners. Laboratory service providers without formal laboratory training (Microscopists) continue providing laboratory services with minimal supervision due to shortage of laboratory personnel. NUMAT will support a specially tailored training to 35 microscopists currently providing services in the region. One hundred (100) clinicians will receive re-orientation in best practices in utilization of laboratory services, this activity will be conducted by the trainers in the districts. In line with the Ministry of Health's Human Resource Development strategy of increasing availability of qualified laboratory personnel at the health facilities, NUMAT will continue sponsorship of the 18 students in the laboratory training school and also follow up with the districts the deployment of the eight that completed the Laboratory Assistants' course. Laboratories are a big source of health waste. NUMAT project will assist districts in rolling out trainings for all health workers and waste handlers, while conducting community sensitization on health care waste management.

3. Quality Assurance The training will be followed by support supervision visits during which mentorship, quality control activities, re-checking of stored slides/samples and on-site training will be conducted. A team of trainers/supervisors from the ministry of health will be facilitated to conduct quarterly supportive supervision for all laboratory service providers in the project districts. District Laboratory Focal Persons are part of the team of supervisors to further strengthen their supervisory skills. Examined stored slides and samples will be re-read during support supervision and a proportion taken to a reference laboratory for re-reading as part of quality control. Proficiency panels (samples/slides of known results) will be given to participating laboratories to read and immediate feedback provided. Staff from CPHL will be trained to supervise, mentor and provide on-the-job training for DLFPs bi-annually to strengthen their competencies to manage laboratory services in the districts. Laboratory management that includes data management, supply chain management; report writing and dissemination will remain the areas of focus. DLFPs will be facilitated to conduct supervision in the district every two months.

TB/HIV (HVTB)

NUMAT supported the nine districts in the north zone to continue strengthening TB management using community-based directly observed treatment short course (CB-DOTS). TB/HIV collaborative activities were supported to decrease the burden of TB in PHAs and decrease the burden of HIV in TB patients.

Partly as a result of NUMAT's support to CB-DOTS and TB/HIV activities, 2008 NTLP report the North Zone surpassed national and WHO recommended target of case detection rate of 70% by achieving a case detection rate of 75.6% but the 85% treatment success rate target was slightly missed as the zone achieved a treatment success rate of 84.9%. For TB/HIV collaborative activities, 83.7% of all TB patients were counseled for HIV testing while 59.1% were tested for HIV. And 54.6% were HIV-positive of which 78% were put on septrin and 19.5% were put on ART.

CB-DOTS Community-based TB care using the community based directly observed therapy-short course (CB-DOTS) strategy was adopted by the Uganda's ministry of health as the best way to control and treat tuberculosis. In this strategy, the sub county health worker (SCHW) links the health facility to the community where the TB patient lives. NUMAT will continue to work towards improving and maintaining the case detection and treatment success by supporting activities that will empower the community and TB patients to get involved in TB activities in all sub-counties. CB-DOTS will be strengthened at facility and community levels through training of community members and health workers including the prisons, army and police health workers in all the districts. NUMAT will continue to support volunteers for CB-DOTS through the transportation of drugs and other logistics from the health centers to the community volunteers by sub county health workers (SCHWS), supporting their supervision and logistical support by SCHWS, health sub district TB focal persons (HSD TB FPs), district TB and leprosy supervisors (DTLS) and zonal TB and leprosy supervisor (ZTLS). NUMAT will continue supporting the districts to provide sub-county health workers with allowances and other logistics to conduct support supervision and take TB drugs and other logistics to the community or family volunteers. District TB and Leprosy Supervisors (DTLS) together with health sub district TB focal persons (HSD TB-FPs) will continue to be supported to conduct support supervision to the SCHWs and community volunteers on a monthly basis. These district officers will be facilitated with allowances and transport to reach the SCHWs. The clients together with the care givers are advised on sputum follow-ups at months two, five and eight. This is essential on improving treatment success rate and hence controlling development of MDR TB. NUMAT will continue supporting the districts and NTLP to contribute to the control of MDR by: Intensified case finding through improved laboratory coverage and increasing TB and TB/HIV awareness through IEC/BCC messages. Proper treatment of TB by improving CB-DOTS coverage so as to increase treatment success rate. Supporting the districts and NTLP in diagnosis and treatment of MDR. Support the transportation of sputum samples from the districts to the NTLP reference Laboratory for Culture and Sensitivity tests. Support the district and NTLP in transportation of patients to Mulago National Referral Hospital.

The ZTLS will be facilitated to conduct support supervision to the District TB and Leprosy supervisors (DTLS) and health sub district TB focal persons (HSD TB-FPs) in the nine districts. Support will mainly include travel allowances, stationery and other supplies to effectively run the zonal office. NUMAT will also support four quarterly TB zonal meetings to discuss TB and TB/HIV implementation in the region. TB/HIV Collaborative Activities: TB/HIV collaborative activities will continue to be supported as per the National policy guidelines for TB/HIV collaborative activities in Uganda. The supported activities will revolve around the three areas of: Establishing mechanisms for sharing information and collaboration Decrease the burden of TB in people living with HIV/AIDS Decrease the burden of HIV in TB patients

During FY09 a total of 118 Health workers were trained in TB/HIV collaborative activities including being able to screen HIV patients for TB and provide TB treatment to HIV-infected individuals plus infection control measures. These health workers will be able to counsel and test TB patients for HIV and provide HIV and TB treatment plus infection control according to national guidelines. In addition, NUMAT supported the dissemination of TB/HIV policy and communication strategy guidelines to district stakeholders in the nine districts. Lower level dissemination to sub counties was done in five of the nine districts.

Coordination across Partners: NUMAT has been collaborating with the ministry of health from the national level to the health facility level through National TB and Leprosy Programme (NTLP), AIDS Control Programme (ACP), the zonal TB and leprosy supervisor (ZTLS), the district health officers (DHOs), health facility workers and the community through SCHWs. Collaboration with other partners involved in TB control such as WHO, AIC, HCP, MC, ICRC , PHA fora, the uniformed group (Army, Police and prisons) etc has been taking place through planning meetings, trainings and implementation. This has contributed to the combined effort towards TB and TB/HIV control activities. NUMAT will continue to engage in activities that support collaboration with other stake holders involved in TB control activities. This will be at the National, Zonal, District, Facility and community levels. During FY10, NUMAT will provide technical assistance and funding for quarterly meetings at the health sub-district level for review and planning of collaborative activities including data management and referral issues. Participants for these planning meetings will include those in charge of the TB treatment facilities and the HSD, as well as the HSD TB and HIV focal persons and the sub county health workers.

In supporting IEC/BCC activities, NUMAT will continue working with the districts through the IEC/BCC working groups, NTLP, WHO and HCP. The focus for IEC/BCC materials will be infection control both to the communities and health facilities. NUMAT will continue to work with religious leaders and preachers to include TB and TB/HIV control messages in their programs.

Human Resource Capacity and Sustainability: During FY09, NUMAT trained 80 newly recruited health workers on CB-DOTS in all the districts. During FY10, no health workers will be trained on CB-DOTS and instead the focus will now be on training on TB/HIV collaborative activities and infection control.

In addition in FY10, NUMAT will continue supporting training/sensitization of volunteers in TB control and care. These volunteers are village health team (VHT) members will be sensitized on TB and TB/HIV co-infection control using CB-DOTS strategy and infection control measures. The same volunteers have been and will continue to be crucial for successful implementation of other program areas including ART adherence, malaria control and home based care activities

Monitoring and Evaluation: NUMAT staff, in collaboration with the ZTLS and respective DTLS, have been providing technical assistance on records management, data collection and reporting to district staff in sites rendering TB/HIV services .The DTLS's and HSD TB focal persons were supported on a quarterly basis to collect and analyze TB and TB/HIV data using the national TB and leprosy quarterly reporting forms so as to improve data quality and reporting time. During FY10 NUMAT will continue supporting the districts in record management by mentoring the district staff in data collection, recording and reporting. The project in collaboration with NTLP will continue providing registers, referral slips and other materials as needed. At the end of each quarter, NUMAT will support TB/HIV planning meetings from the health sub district level through district and zonal levels up to the national level. At every level, the recorded data on the input and out put indicators are reviewed against the set objectives and targets. It is at the zonal level that NUMAT gets the analyzed data to report on. This information is the same as the zonal TB and leprosy supervisor reports to the national program in the MOH. All revised TB/HIV and TB indicators are being catered for and NUMAT will be reporting on them during each reporting time. In order to continue getting credible and early information, NUMAT will continue facilitating all the districts' TB and leprosy Supervisors (DTLS) and HSD TB focal persons with allowances and fuel to quickly collect TB/HIV quarterly data during the first week of the next quarter to minimize delays in reporting

Accomplishments in FY09: NUMAT supported TB management using community-based directly observed therapy-short course (CB-DOTS) in all NUMAT 9 districts. This was through the following ways: Supporting the sub county health workers to carry out CB-DOTS activities. The SCHWs were supported by giving them bicycles and allowance to facilitate them do CB-DOTS activities which include taking drugs from the health facility to the community volunteers who observe patients taking drugs. Also the SCHWs are important in mobilizing the community to select the volunteers for the patients. They also supervise the treatment and advise both the volunteers and the patients on sputum follow ups. NUMAT technically and logistically supported the ZTLS and all the district TB and leprosy supervisors together with HSD TB focal persons to carry out support supervision to the sub county health workers. Supporting the TB Zonal office to distribute TB drugs, reagents and other supplies. The ZTLS was supported to distribute drugs to the districts. This was mainly by directly involving NUMAT district drivers to help deliver drugs faster in the districts which ensured a continuous drug supply to the districts except for a short time when the country had no Anti TB drugs. Proper education messages through IEC/BCC working groups. NUMAT supported dissemination of health education messages on control of TB using CB-DOTS and TB/HIV collaborative activities. The messages were disseminated by the technical people in the IEC/BCC working group. Also supported TB/HIV collaborative activities whereby a total of 118 Health workers were trained in TB/HIV collaborative activities including being able to screen HIV patients for TB and provide TB treatment to HIV-infected individuals plus infection control measures. NUMAT supported the dissemination of TB/HIV policy and communication strategy guidelines to the districts' TB/HIV stakeholders. The dissemination of the guidelines to the lower structures in the district down to the sub county level was supported by NUMAT in the districts of Lira, Dokolo, Amolatar, Amuru and Oyam.