Strengthening the Tuberculosis and HIV/AIDS Responses in South-Western Uganda (STAR-SW) is a new activity that will provide comprehensive facility and community-based HIV/AIDS and Tuberculosis (TB) services in 9 underserved and high prevalence districts in the South-western region. The goal of this program is to increase access to, coverage of and utilization of quality comprehensive TB and HIV/AIDS prevention, care and treatment services. This new program will integrate activities of the Western/South-western District-based HIV/TB program (RFA No. 69-08-09) and the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) Call to Action project. Program objectives are to: 1) Strengthen decentralized HIV/TB service delivery system, with emphasis on health center IVs, IIIs and community outreaches; 2) Improve quality and efficiency of HIV/TB services within health facilities and community service organizations/groups; 3) Strengthen networks and referrals systems to improve access to, coverage of and utilization of HIV/TB services; and 4) Intensify demand generation activities for HIV/TB prevention, care and treatment service.

The STAR-SW project will provide a comprehensive service package of HIV counseling and testing (HCT), Prevention of Mother to Child transmission (PMTCT), HIV/AIDS chronic care services, HIV/TB collaborative services, community based directly observed TB treatment-short coarse (CB-DOTS), and antiretroviral treatment (ART) for both ARV-naïve people living with HIV/AIDS (PLWHAs) and PLWHAs currently receiving ART through the USAID/TREAT program. This new activity will provide direct technical support to local governments and will use performance-based financing through local competition to civil society organizations in Ntungamo, Kiruhura, Kisoro, Rukungiri, Bushenyi, Kanungu, Isingiro, Ibanda, and Kabale districts. Demonstration of a strong political will and commitment for sustainable TB and HIV programming by local governments will be one of the key priorities for selection. This program will foster the development of strong partnerships with other district-based TB and HIV/AIDS programs in each of the regions in order to improve coordination, expand the referral network, and ensure more efficient use of resources.

Target beneficiaries for this activity are TB patients, pregnant women, HIV exposed children, People Living with HIV/AIDS and their families and communities. At the end of five years, the STAR-SW program has five key results areas: 1) Increased uptake of comprehensive HIV/TB services within supported districts; 2) Decentralized service delivery systems strengthened for improved uptake of quality HIV/TB services; 2 (a) Lot Quality Assurance Sampling Survey is institutionalized at the district level; 3) Quality HIV/TB services delivered in all supported health facilities and community organizations/activities; 4) Networks, linkages, and referral systems established or strengthened within and between health facilities and communities to improve access to and uptake of comprehensive HIV/TB services; and 5) Increased demand for comprehensive HIV/AIDS/TB prevention, care and treatment services.

Despite significant achievements in the reduction of the HIV prevalence in Uganda, it still poses a challenge to the health system in Uganda due to the high incident rate of over 132,000 new infections every year; high population growth rate of 3.2%, overwhelming the already stretched health system. As HIV related deaths reduce, the numbers requiring HIV/AIDS care and support services has increased and access to care and treatment by poor and hard-to-reach people particularly in the rural areas still remains a challenge. The national response has largely focused on scaling up of access to services rather than on strong initiatives to increase utilization and quality of those services.

The STAR-SW program will be implemented within the existing decentralized health systems providing HIV/AIDS care and support services in all health centre IVs and below in the 9 districts in the South western region of Uganda i.e. Kabale, Kisoro, Kiruhura, Isingiro, Ibanda, Bushenyi, Ntungamo, Rukungiri, and Kanungu. Integrated HIV/AIDS care and support services will be implemented at both facility and community levels. Clinical care interventions will include diagnosis and treatment of opportunistic infection, medical prophylaxis using Cotrimoxazole for OIs and Fluconazole for 20 prevention of Cryptococcal meningitis will be provided as part of routine care. Pain and symptom management integrated in to supported health facilities including HC3's. Other services include psychosocial support, spiritual support, bereavement counseling and end-of-life care. The program will strengthen the provision of laboratory tests for diagnosis of HIV and other opportunistic infections; including TB. Target beneficiaries for this program are adolescents, adults, women, MARPs, People Living with HIV/AIDS, their families and communities.

This activity will support best practices and proven interventions and approaches that would improve access to the continuum of HIV/AIDS services, including critical services not directly supported by PEPFAR or other activities. Quality assurance/ Quality improvement in care and support services is a fundamental in addressing client retention. HIV care and support services will be provided according to national and international standards, guidelines and protocols. The program will establish facility-base quality improvement teams. Program monitoring will occur through Lot quality Assurance surveys, integrated support and supervision to strengthen data collection, utilization and reporting.

Establishment of networks, linkages, and referral systems for effective referral strengthened within and between health facilities and communities is a key deliverable for this program in order to improve access to and uptake of comprehensive HIV/TB services. The program will utilize GIS mapping of public and private service providers, community-based organizations providing both HIV/AIDS and other established partnerships and coordination structures with existing organizations/groups/activities supporting prevention, care and treatment services. Capacity building of village health teams will strengthen the continuum of care and support at community level.

Anti-retroviral therapy is one of the key interventions that this new activity will provide as part of the comprehensive HIV/AIDS and TB services. The STAR-SW program will contribute to the national efforts of increasing universal access to ART using standardized ART regimens according to national ART policy guidelines. The national ART guidelines require that ART service delivery be part of a holistic program that integrates all elements of a continuum from HIV prevention to HIV testing, treatment, care and support including integration of HIV/TB services. By the end of September 2008, 79 of the 80 districts in Uganda had at least one accredited ART service delivery outlet with wide variation in ART service coverage ranging from 3% at Health Centre IIIs to 100% at hospital level (MOH, 2008). Only 43% adults and children in need of ART were actively on treatment. With the maturity of the national ART program since 2004, the need for monitoring risk factors of HIV drug resistance (HIV-DR) is increased.

The program will increase access and availability of antiretroviral therapy to adult populations in need. Public health facilities in the region will be supported to attain accreditation for ART and those already accredited will be supported to maintain the standards of offering quality ART services. Adult PHLWAs will be screened for ART eligibility using WHO Staging, CD4+ counts. PLWHAs currently accessing treatment from the TREAT supported health centre IVs in the target districts will be transitioned to this program. The program will establish and/or strengthen adherence to ART at both facility and community level through adherence counseling, community follow-up, and active management of side effects in order to reduce drug resistance. Public health laboratories will be strengthened to conduct clinical monitoring tests for ART toxicity e.g. Full blood counts, renal and liver function tests according to national guidelines. Samples for viral load will be collected and transferred to regional labs at least once a year to monitor response to treatment and ART drug resistance.

Systems will be strengthened at the decentralized level to facilitate improved delivery and uptake of ART services i.e. health management information systems (HMIS), supply chain management, strategic information, and laboratories. The program will strengthen the capacity of human resources to provide ART service through in-service training, mentoring, and continuing medical education. Monitoring and evaluation will involve integrated support and supervision, and data quality assessments. Lot Quality Assurance Surveys will be used to track and evaluate clinical outcomes, improve monitoring and evaluation and ultimately to improve planning and evidence-based decision making at both facility and district level. Integrated support supervision is conducted within each health sub district and ART sites will track the MoH quality improvement indicators.

The STAR-SW program will strengthen access to HIV counseling and testing to promote early knowledge of HIV status, enhance positive behavior change through HIV prevention counseling for both the HIV-negatives and positives and support effective referral of HIV positive clients to HIV treatment and care services. HCT services will be provided at all health units up to health centre II as well as community level through outreaches, HCT camps, and HCT moonlighting. HCT services will be provided at all health units from hospital level up to health centre II. The program will engage in the implementation of the National HCT campaigns in the targeted districts.

Provider initiated HIV counseling and testing will be provided to all patients as part of routine health care services within public and private health units in the target districts. Specific prevention counseling will be offered based on the HIV status and risk assessment.

Target beneficiaries are individuals most at risk populations, pregnant women as an initial step to PMTCT access, HIV exposed children, TB patients, discordant couples, presence of clinical signs and symptoms which indicate increased risk of HIV infection i.e. STDs, opportunistic infections, and during occupational and non-occupational exposure and prophylaxis.

The program will provide in-service training of health workers to strengthen skills for HCT. REDACTED. The program will update and/or develop QA/QI protocols that will be distributed to the service providers.

The STAR-SW program will scale up and strengthen pediatric care and support services at health centre IV level and below. HIV exposed children identified through the PMTCT program will be linked to care and support services. The comprehensive pediatric care and support service package that will be supported by this new activity entails scaling up early infant HIV diagnosis with DNA/PCR starting at 6 weeks of age, Cotrimoxazole prophylaxis, treatment of opportunistic infections, immunization, deworming, treatment of all HIV infected infants regardless of CD4+ count, screening older children for ART eligibility according to national policy guidelines, pediatric HIV counseling, growth and development monitoring, pain and symptom management, nutritional assessment, nutrition counseling and promotion of infant and young child feeding according to national and WHO guidelines. Target beneficiaries are HIV-exposed, infected or affected children, their guardians/parents, families and communities. Pediatric care and support services will be provided as an integral component of routine Pediatric in- and out patient services, MCHN, and community outreach activities. Capacity of providing pediatric care and support services will be strengthened through in-service didactic training of health workers, mentoring, continuing medical education and regular support and supervision. The program will establish networks and referral systems within and between facilities and communities in order to strengthen follow-up, retention in care and adherence to treatment. The program will strengthen linkages to other wrap around services like access to ITNs, hygiene and sanitation programs, food security and other OVC support services.

HIV infected children follow a more aggressive course of illness, and approximately 66% die before the age of 3 years (UNAIDS, 2006). The majority of these deaths could be avoided through early diagnosis and timely provision of effective care, support and treatment. The STAR-SW program will contribute to the national universal access target for Pediatric treatment to provide either antiretroviral treatment or Cotrimoxazole, or both, to 80 per cent of children in need by 2010. Key interventions for pediatric treatment will be scaling up Early infant diagnosis using DNA/PCR tests at the regional referral hospitals, strengthen linkage of HIV exposed infants identified through the PMTCT program to care and treatment, and follow-up for ART adherence. The program will support the increased access and uptake of Pediatric ART according to national guideline increasing it from the current 40%. Infant and young child feeding services will entail counseling on appropriate feeding practices according to national policy guidelines, maternal nutrition counseling, nutrition assessments, and referral of malnourished children to the therapeutic and supplemental feeding programs. Pediatric ART services will be provided as an integral component of routine pediatric care, nutrition and MCH. The program will further support the supply chain management, and monitoring of pediatric ART outcomes in the target districts.

In order to promote evidence-based planning, this activity will support the Government of Uganda to institutionalize the carrying out of the Lots Quality Assurance Sampling (LQAS) and ensure that the data generated is used. The activity will also support the key national HIV/AIDS data use (including reporting) processes and activities taking place at the district in order to build sustainability. These activities will be implemented in nine districts in the South western region of the country, namely: Bushenyi, Kabale, Kisoro, Kiruhura, Kanungu, Ibanda, Isingiro, Ntungamo, and Rukungiri. Evidence-based planning and decision making will be achieved through regular measurement of program performances and progress at the districts and lower levels. Regular and timely feedback to the supported local governments, non-governmental organizations ad civil service organizations will be provided through systems strengthening of district level monitoring and reporting systems including HMIS and PMMP. While the LQAS results will be used to inform district level work planning in order to identify intervention areas and sub-counties on which to focus in the future, this USG investment goes beyond this and achives two other objectives. One, the support is also intended to build the capacity of the central level GOU to design, plan, manage, coordinate, and institutionalize the carrying out of the LQAS. The other objective of this USG support is to ensure that these district-based programs support the existing national data collection, collation, use, and reporting systems at the district and lower levels for purposes of building sustainability i.e. strengthening the local government's capacity to coordinate the collation, management, and use of multi-sectoral data for monitoring performance of service delivery as well as for the overall district planning. Coordination at the district also includes ensuring that the the existing supply of, and demand for, ICT (information, communication, and technology) resources (that includes human) are optimised.

Health Systems Strengthening barriers include inability to pay for services, long distances to access services at facilities, inappropriately skilled staff, poorly motivated staff, shortages and inadequate distribution of appropriately qualified staff, inadequate technical guidance, program management, and supervision, inadequate drugs and medical supplies, lack of equipment and infrastructure, weak drug policies and drug supply system. Other gaps entail reliance on aid agency funding, which reduces flexibility and ownership, corruption.

Key HSS interventions for this new program include supporting institutional capacity building at district level in supply chain or procurement systems, strategic information, human resources for health, service delivery, leadership and governance, and financing.

This activity will enhance the delivery of effective, safe, and quality TB and HIV/AIDS services to the TB patients, PLWHAs, their families and communities. The program will support the dissemination of national policy and implementation guidelines to the direct service providers and establish facility based quality improvement programs to monitor health outcomes of the beneficiaries. The program will create institutional networks and improved referral systems at facility and community level to ensure continuum of care.

The program will provide technical assistance for timely, cost-effective procurement and distribution of medical commodities, drugs and equipment within the decentralized systems in nine districts in the south western region of Uganda i.e. Kabale, Bushenyi, Kisoro, Kiruhura, Kanungu, Rukungiri, Ibanda, and Isingiro.

The program will build the capacity for effective data collection, analysis and timely reporting to the district and national level. The program will update/utilize existing national data collection tools and reporting systems in order to ensure harmony and ownership of the data by the local governments. In order to increase demand for services, the program will provide performance based grants to civil society organizations and build their capacity to engage in advocacy and policy dialogue for HIV/AIDS and TB services.

This program will increase access to TB and HIV/AIDS by providing outreach services at community level and follow-up care. The program will provide continuing medical education to develop planning and management skills in both the public and private sectors. Performance review forums will be conducted regularly. The program will work with District Management Committees to ensure effective recruitment, retention, leadership and motivation of service providers. In order to improve efficiencies in service delivery and reduce work load, task-shifting and supportive supervision will be supported with the leadership of the District health offices.

Strengthening national and regional health systems calls for well coordinated partnerships between government, NGOs, donors and other sector stakeholders such as the private sector. This program endeavors to strengthen collaboration and networking with other key stakeholders at the district level in leveraging HSS.

The STAR South Western project will scale up Medical Male circumscison though training of health workers at 26 health units i.e eight hospitals and 18 health centre IVs. The Project will design and implement a communication strategy that will be used to change negative attitudes on Medical Male circumcision. A network of CBOs, LNGOs, FBOs and other community resource persons will be used to promote positive messages about medical male circumcision (MMC) that is done in health facilities with trained staff using sterile conditions, and to promote it as one of the ways recommended by leaders and the government for HIV prevention. Traditional chiefs and traditional circumcisers will be trained as MMC promoters and counselors in order to support Medical Male Circumcision. Faith-based organizations will be targeted to ensure that the bias against circumcision is minimized and that it is promoted by certain religious denominations

MMC will be addressed by equipping health units with the necessary equipment for MMC, and training of at least two MMC practitioners from among the health workers at each of the Health IVs and all Hospitals. All HCIVs have mini-operating theaters, and all hospitals have full operating theaters that will be upgraded and equipped accordingly to handle MMC.

In order to promote quality assurance, a series of trainings in support supervision for MMC will be held for the clinical officers. The project will adapt training tools from other USG partners e.g.Walter Reed project to ensure that a critical mass of MMC trained staff are present in the 9 districts based at Health Centre IVs and Hospitals.

Sexual transmission is the largest mode of HIV transmission accounting for over three-fourths of all new infections (marital sex 42%, commercial sex work 21%, and casual sex 14%). The HIV epidemic has shifted to the older age groups, for which there has been little prevention programming in recent years. Risky sexual behavior is on the rise, including an increase in casual sex, sex with multiple partners, and a decrease in condom use; yet most people who engage in risky behaviors, such as having multiple concurrent sexual partners, do not perceive themselves to be at high risk of HIV infection. Only 21% of female and 23% of male respondents to the UHSBS (2006) believe it very likely that they will contract HIV.

The STAR South Western program will contribute to the National Strategic Plan (NSP) (2007-2012) focus intervention of making HIV prevention the cornerstone of HIV/AIDS programming. The project will implement comprehensive prevention approaches that are aligned to specific groups, behaviors, and underlying factors in the target population and will support prevention strategies that address social and gender norms that underlie risky sexual behavior. Target beneficiaries are adults, youths, and most-at-risk populations. The STAR SW project will provide financial and/or technical support to increase comprehensive knowledge and risk perception of HIV/AIDS through advocacy interventions that promote positive behavior change for risk reduction and risk avoidance among populations at high risk of HIV infection, and promotion of protective social norms for both women and girls.

The project will strengthen behavior change approaches among youth, including educational counseling and communication efforts, and will utilize lessons learnt and best practices of other prevention interventions. Self-perception of risk among youth and within the general population and correct, consistent condom use will be promoted among sexually active populations. The program will strengthen linkages with other USG-funded social marketing programs to ensure distribution and availability of condoms. Prevention efforts will consolidate youth programming through abstinence programs among young people 10-14 years old, a combination of school-based and out-of-school programs, media, and community approaches. The program will improve programming and linkages across prevention for youth and OVC prevention needs and services addressing prevention with young positives.

Prevention counseling and messages targeting discordant couples and concurrent sexual relations will emphasize faithfulness as well as correct and consistent condom use within discordant relationships. Couples will be encouraged to receive HIV counseling and testing and disclosing their Sero-status to their sexual partners.

The project will provide prevention programming for targeted high risk, vulnerable and mobile populations, as they remain sources of new infections e.g. commercial sex workers, internally displaced persons (IDPs), truck drivers and fishermen. They are more prone to have many sexual partners, to use condoms inconsistently, and consequently increase the risk of acquiring and/or transmitting HIV to several partners, including their cohabiting spouses.

The STAR South Western program will focus its HIV prevention efforts through targeted interventions focused on most-at-risk populations (MARPs); one of the notable drivers of the HIV epidemic in the region. The MARPs include: migrant workers, distance truck drivers, 'boda boda' cyclists, transactional sex workers, bar and lodge attendants, fisher folk and persons in multiple or concurrent sex partnerships. Program focus will be in underserved and/or hard-to-reach areas.

An estimated 12,000 MARPs will be reached with individual and/or small group level HIV preventive interventions mainly through peer-to-peer interactions and community outreach programs. The program will train and utilize VHT or other peers to deliver other HIV prevention messages and distribute condoms.

This new activity will provide training on OP activities focusing on condom education and distribution at health units providing comprehensive HIV and TB services in order to increase access to prevention education to all clients. Condom distribution will further be strengthened though partner CSOs who will focus on community distribution points.

The STAR South western project will support the national efforts to improve access to PMTCT services through support to nine districts in the South Western region of Uganda including Kabale, Bushenyi, Rukungiri, Ntungamo Isingiro, Kanungu, Ibanda, Kisoro and Kiruhura. Whereas these districts are estimated to have more than 77,000 people living with HIV, they are among those districts underserved by USG and non-USG funded partners providing HIV/AIDS care and treatment services. The STAR- SW project will contribute to the national PMTCT strategy (2006 2010 to roll out the revised PMTCT policy guidelines, support the holistic implementation of the four-year pronged PMTCT strategy (primary prevention, family planning, provision of ARV prophylaxis, care and support). In order to achieve the policy implementation goals, the district based program will focus on the following areas:

1. Increasing program coverage for PMTCT: Focus will be placed on strengthening PMTCT service delivery in health units previously supported by the EGPAF program i.e. from hospital up to Health Center III level. PMTCT outreach services will be extended to H/C II or lower level health facilities that do not have the capacity to offer maternity services. the project will strengthen PMTCT quality improvement interventions at health facilities in order to increase PMTCT uptake. Linkages between the community and the health facility will be enhanced through peer educators selected from HIV positive parents (mothers and their male partners) identified during PMTCT, trained, and assigned roles alongside professional health workers at the care and treatment sites.

2. Increase the uptake of combination ARV regimen for the maternal/infant pair. Capacity to offer the more efficacious regimen will be developed through increased training and the streamlining of logistics management at both national, district and health facility level. Logistical support for the procurement and distribution of ARVs, drugs for opportunistic infections and HIV test kits will be major activity. All of eligible HIV positive pregnant women (CD4+ > 350/ml) will be started on HAART and pregnant women (CD4+ <350) will receive Combined ARV regimens according to national guidelines.

3. Continuum of care and treatment of the HIV positive mothers and their families: The provision of treatment, care and support services to eligible individuals has been shown to improve the uptake of all other PMTCT services. Focus will be directed at strengthening the enrollment of identified HIV-exposed and infected infants into continuum of treatment and care programs through the scale up early infant diagnosis of HIV and follow-ups. This project will further support HIV infected families to adopt safe infant feeding practices in relation to the revised infant feeding materials. Malnourished HIV positive pregnant women and their infants will be linked to the therapeutic or supplemental feeding program implemented by NuLife.

4. Capacity building and mentoring: The program will reinforce the skills of health workers in the MCH/HIV/AIDS/ART clinics by the provision of mentoring programs (from the Regional Referral hospitals) and Continuing Medical Education (CME) in order to improve program uptake. Approximately, 150 service providers (such as counselors, mid wives, laboratory staff and data/records management assistants) will be trained. Individuals trained from the community will focus on encouraging community discussions in areas such as gender power relations aimed at reducing gender-based violence, increasing male involvement and facilitating couple dialogue. Support and supervision will be directed at enhancing the quality of PMTCT service delivery and the development of linkages between PMTCT and other HIV/AIDS care services, including care and treatment, and supporting the full integration of PMTCT programs into district and MOH work plans.

5. In collaboration with other stakeholders, the STAR South western project will review, print, distribute and disseminate new/updated information, education and communication (IEC) materials (including job aides) that will focus on increasing uptake of PMTCT services and create positive behaviors such as supportive male involvement, appropriate/alternative infant feeding practices, spouse disclosure, partners support, living positively and IPT uptake.

6. Integration of family planning services into HIV/AIDS/MCH/Treatment services.

7. Through community mobilization, support will be provided to psychosocial support (PSS) groups for HIV+ mothers and their spouses as coping mechanism on top of accessing the care services. The PSS groups will be supported to leverage other wrap around services such as mosquito nets from the President's Malaria Initiative (PMI), nutrition support from World Food funded programs, etc

8. This activity will also support integrated support supervision conducted quarterly within each health sub district; establish and/or maintain facility based quality improvement teams; introduction of continuous ART quality improvement tools in coordination with HCI or HIVQUAL; support accreditation of new ART sites, mapping community resources; and create community and facility networks.

Laboratory systems strengthening for TB and HIV/AIDS services are a key component of the STAR-SW activity. The program will focus on public health unit laboratories at health centre IV and III where the majority of the target population for this program can easily access health services. The program will establish linkages/coordination structures and referral systems with National Public Health Laboratory and other laboratories at district and regional referral hospital for external quality assurance, and handling of tests that are not offered in the lower health units i.e. biochemistry tests, CD4+ tests, DNA/PCR, Serum Crag, etc.

Key program interventions will be the improvement of laboratory infrastructure for improved ventilation, waste management, and water supply in order to ensure safety. Laboratories will be renovated to conform with national standards and guidelines for space and safety. The program will support laboratories at each level of health care to provide the recommended tests for that level according to the national MOH guidelines. These include complete blood counts, Hemoglobin tests, malaria tests, TB diagnosis, and HIV diagnosis at District hospitals, health centre IVs, and health centre IIIs. In addition, the program will support provision of liver function tests, renal function test, pregnancy tests and serum glucose tests at the districts hospitals. Blood samples for CD4+ testing will be transported to regional referral hospital laboratories. During program year II, districts hospitals that are not co-located with Regional Referral hospitals will be supported to provide CD4+ machines on a case by case basis.

This new activity will strengthen the capacity of laboratory personnel to conduct quality laboratory tests as recommended by the national laboratory policy guidelines. They will receive pre-service training, in-service training, mentoring from teams from the Regional referral hospitals or National Public health laboratory, and on-going coaching to ensure adherence to laboratory standard operating procedures.

The program will strengthen the laboratory logistics management systems to ensure an effective supply chain management system for supplies. A system for equipment maintenance and servicing will be established utilizing MOH Regional/Central maintenance units. The program will establish a system of quality assurance for laboratory tests including internal quality control, external quality assurance and quality improvement. Regular support and supervision will be done to monitor efficiency and effectiveness of laboratory services.

The program will enhance collaboration between tuberculosis and HIV/AIDS services in the provision of a continuum of quality care in the target districts for people with, or at risk of, tuberculosis and people living with HIV/AIDS. The program will contribute to the national TB and HIV/AIDS response through implementation of collaborative TB/HIV strategic interventions that include1) active participation in the Stop TB Partnership in collaboration with the National TB and Leprosy program and AIDS Control Program; 2) decrease the burden of tuberculosis in people living with HIV/AIDS; and (3) to decrease the burden of HIV in tuberculosis patients.

At the national, district and sub-county level, the STAR-SW program will be a key stakeholder in the national coordination committee of the Stop TB partnership. The program will establish and/or strengthen surveillance systems for HIV prevalence among TB patients through utilization of data from the routine HIV testing and counseling of tuberculosis patients, carry out joint TB/HIV planning, conduct monitoring and evaluation of TB/HIV collaborative activities according to national guidelines.

The second TB/HIV collaborative strategy is to decrease the burden of tuberculosis in people living with HIV/AIDS through: 1) intensified tuberculosis case-finding where TB patients or suspects will receive HIV counseling and testing at facility and community level; 2) strengthen Isoniazid preventive therapy according to national guidelines; 3) and establish tuberculosis infection control in health care and congregate settings. Intensified case finding comprises screening for symptoms and signs of TB in PLWHAs, diagnosis and prompt TB treatment in PLWHAs co-infected with TB, and their household contacts. The program will strengthen access and availability of TB services for populations at high risk for HIV and those in congregate settings (e.g. prisons, workers' hostels, police and military barracks) with the goal of improving their quality of life. The program will use administrative, environmental and personal protection measures to for infection control for health care workers, prison staff, police and their clients, and any other persons living in the congregate settings. Administrative measures will include early recognition, diagnosis and treatment of tuberculosis suspects, particularly those with pulmonary tuberculosis, and separation of pulmonary tuberculosis suspects from others, until a diagnosis is confirmed or excluded. Environmental protection will include maximizing natural ventilation. Personal protection will include protection of the PLWHAs from possible exposure to tuberculosis. Each supported health unit will have a tuberculosis infection control plan, which includes administrative, environmental and personal protection measures to reduce transmission of tuberculosis in health care and congregate settings.

The program will decrease the burden of HIV in tuberculosis patients through provision of HIV testing and counseling to all TB patient and their families, provision of comprehensive HIV prevention services, Cotrimoxazole prophylaxis to > 80% of TB patients, linkage of HIV co-infected TB patients to care and support services and screening them for ART eligibility using WHO staging and CD4+ counts. Eligible TB patients will be started on HAART according to national guidelines.

Quality of TB/HIV collaborative services will be enhanced through capacity building of service providers at facility and community level including training, and mentoring. Community based DOTS will be implemented in order to improve adherence to therapy and improve treatment success. The program will enhance the health care system to in order to increase access to TB/HIV laboratory diagnosis, logistics management and referral systems. The program will utilize the existing national M&E tools, IEC materials and reporting systems at district level to implement TB/HIV collaborative activities.