This a cost extension with the purpose of supporting continued delivery of comprehensive HIV/AIDS prevention, care and treatment services to an existing pool of HIV positive clients in Rakai district and to strengthen development of public health workforce in Uganda. The program will offer comprehensive HIV/AIDS services to children, adolescents and adults in line with the national guidelines and will provide technical assistance to the supported districts to plan and integrated GHI principles into HIV/AIDS and other health services. The HIV/AIDS services will include PMTCT, HIV counseling and testing, Male circumcision, TB/HIV, ART, health system strengthening and supporting laboratory services. These services will be implemented in collaboration with the districts and other implementing partners to harness synergy, ensure sustainability and ownership. The program will achieve the following objectives; 1) Scale up access to comprehensive HIV combination preventive services 2) Scale up access to comprehensive HIV and TB care and treatment services and 3) Strengthen development of public health work force through fellowship trainings in HIV, FETP/FELTP, informatics and Masters program in Monitoring and Evaluation.

The Makerere University School of Public Health (MUSPH) program will focus on supporting the Government of Uganda (GOU) expand access to HIV care and support with the goal to achieve universal access of 80% in care by 2015. This program will support delivery of care and support services to 18,318 as a contribution to the overall PEPFAR target of 812,989 HIV positive individual in care. This target was derived using burden tables based on district HIV prevalence and treatment need.

Specific attention will be given to key populations such as truck drivers, fishermen, commercial sex workers and men who have sex with men. The Continuum of Response (CoR) model was applied to ensure improved referrals and linkages. The MUSPH program will be expected to implement approaches to promote an effective CoR model and monitor key indicators along the continuum in of Rakai district.

This program will support health facilities to provide comprehensive care and support services in line with national guidelines and PEPFAR guidance including: strengthen positive health dignity and prevention; strengthen linkages and referrals using linkage facilitators; implement quality improvement for adherence and retention; pain and symptom management; and provide support to targeted community outreaches in high prevalence hard to reach and underserved areas within the district like Kasensero fishing village.

Focus will be placed on increasing access to CD4 assessment among pre-ART clients for ART initiation in line with MoH guidance. This has been a major bottleneck to treatment scale up nationally and working with the Central Public Health Laboratory and other stakeholders, CD4 coverage will be improved in the coming year 2013. The program will support the sample referral network in line with the national CD4 expansion plan. Clients access to CD4 will be monitored and reported on quarterly basis as well as regularly keeping track and report on client CD4 waiting lists.

MUSPH will facilities address linkages between GBV and HIV, including tracking linkages to services for survivors of sexual violence, provision of post-exposure prophylaxis, treatment of STI, and health RH counseling and linkage.

MUSPH will liaise with PACE for provision and distribution of basic care kits to clients using the District, VHT and PHA networks. Additionally, collaborate with National Medical Stores, and Medical Access Uganda Limited for other HIV commodities; cotrimoxazole, lab reagents. The program will build the capacity of facility staff to accurately report, forecast, quantify and order commodities in a timely manner.

In addition, the MUSPH program will work with USG partners such as PIN, SPRING, HEALTHQual, ASSIST and Hospice Africa Uganda in their related technical areas to support integration with other health and nutritional services. Collaboration with other key stakeholders at all levels for provision of required wrap around services including family planning.The program will be aligned to the National Strategic Plan for HIV/AIDS (2011/12-2014/15); support and strengthen the national M&E systems as well as supporting provision of data collection and reporting tools, and working within district health plans. MUSHP will work under the guidance of MoH AIDS Control Program (ACP) and Quality Assurance Department for trainings, mentorship and support supervision in an effort to contribute to delivery of quality HIV care and support services.

The MUSPH program will support the GOU to scale up TB/HIV integration, and specifically the PEPFAR goal to achieve TB screening of 90% (731,690) of HIV positive clients in care and initiate 24,390 HIV positive clients in care on TB treatment. This program will contribute to this target by screening 16,486 HIV positive clients for TB; and 550 of these will be started on TB treatment in the district of Rakai in Uganda. This target was derived using burden tables based on district HIV prevalence and treatment need. The Continuum of Response (CoR) model was also applied to ensure improved referrals and linkages.

The program will work to improve Intensified Case Finding (ICF) and the use of the national ICF tool as well as improve diagnosis of TB among HIV positive smear negative clients, extra pulmonary TB and pediatric TB through the implementation of new innovative technologies- fluorescent microscopy and GeneXpert. MUSPH will support MDR-TB surveillance through sputum sample transportation to Gene Xpert hubs and receipt of results at facilities.

In FY 2013, MUSPH will ensure early initiation of all HIV positive TB patients on ART through the use of linkage facilitators and or the provision of ART in TB clinics. The MUSPH program will increase focus on adherence and completion of TB treatment, including DOTS through use of proven low cost approaches. A TB infection control focal person will be supported to enforce infection control at facilities using interventions such as; cough hygiene; cough sheds and corners; fast tracking triage by cough monitors and ensure adequate natural ventilation. We will support MOH/ACP and National TB and Leprosy Program (NTLP) to roll out provision of isoniazid prophylasix therapy, in line with the WHO recommendations.

In addition, MUSPH will work with USG partners such as PIN, SPRING, HEALTHQual, and Hospice Africa Uganda in their related technical areas to support integration with other health and nutritional services. MUSPH will collaborate with other key stakeholders at all levels for provision of required wrap around services.The program will be aligned to the National Strategic Plan for HIV/AIDS and National TB Strategic Plan (2011/12-014/15), support and strengthen the national M&E systems and work within district health plans. MUSPH will work under the guidance of MoH/ACP, NTLP and the Quality Assurance Department in trainings, TB/HIV mentorship and supportive supervision. Additionally, MUSPH will support facilities to participate in national external quality assurance for TB laboratory diagnosis.

The MUSPH program will support the GOU to further expand pediatric HIV care and OVC with the goal of achieving universal access to care by 2015. This program will contribute 1,649 children to the overall PEPFAR target of 812,989 HIV positive individuals in care and support services of which 74,555 are children in the district of Rakai in Uganda.

The MUSPH program will ensure provision of comprehensive child friendly care and support services in line with national guidelines and PEPFAR guidance, improve adolescent services, strengthen linkages and referrals using linkage facilitators, implement quality improvement for adherence and retention and provide support to targeted community outreaches in high prevalence hard to reach and underserved areas. Early Infant Diagnosis (EID) services and focal points at facilities will be scaled up to ensure follow up and active search of exposed children in facilities and communities to enable early enrolment of children in care. A focus will be on scaling up low cost approaches, such as use of care taker support groups so as to support retention in care. The program will support health facilities to implement community mobilization and targeted activities such as Know Your Childs Status campaigns to identify more children. Focus will be placed on improved assessment of pre-ART children for ART eligibility to ensure timely initiation on treatment in line with MoH guidance.

The MUSPH program will support retention of adolescents in care as well as ensure a smooth transition into adult life using expert peers and adolescent support groups. They will be provided with positive health dignity and prevention services including, psychosocial support and life skills training and linked to sexual and reproductive health services. Lessons learned from the planned national adolescent service assessment will be incorporated in activities to improve adolescent care.

To further strengthen service delivery in a Continuum of Response (CoR) model, a key priority will be to establish strong referrals between OVC and care and support programs to ensure HIV positive children are linked to OVC services, and children provided with OVC services are screened for HIV and appropriately linked to care and support.

MUSPH will work in liaison with PACE for provision and distribution of basic care kits to clients. For ARVs and other commodities including cotrimoxazole and lab reagents the program will work in collaboration with National Medical Stores and Medical Access Uganda Limited to ensure availability. The program will build the capacity of facility staff to accurately report, forecast, quantify and order commodities in a timely manner.

The program will work with USG partners such as SCORE, SUNRISE, PIN, SPRING, HEALTHQual, ASSISTand Hospice Africa Uganda in their related technical areas to support integration with other health, nutrition and OVC services. MUSPH will collaborate with other key stakeholders at all levels for provision of required wrap around services.The program will be aligned to the National Strategic Plan for HIV/AID (2011/12-2014/15), support and strengthen the national M&E systems and work within district health plans. MUSPH will work under the guidance of MoH AIDS Control Program and Quality Assurance Department in pediatric trainings, national pediatric mentorship framework and support supervision.

During FY 2013, changes will be made in PEPFAR support for laboratory program in Uganda in line with the identified pivots. The pivots will focus on a change from facility based to lab network strengthening. Building on success of Early Infant Diagnosis (EIDI hubs there will be an increase in the number of hubs for from 19 to 72 thus increasing the geographical coverage and access for specimen transportation, testing and result transmission. This is aimed at ART targeted population receiving CD4 tests to increase current coverage from 60% to 100% improving the quality of laboratory services, reducing stock out of reagents, laboratory supplies and commodities, reducing equipment downtime and improving data collection, transmission, analysis and utilization. To achieve this, technical staff will need to be hired and retained and where possible task shift non-technical activities to appropriately trained lay health workers.

Implementation of the WHO Strengthening Laboratory Management Towards Accreditation (SLMTA) will be the mainstay for quality improvement in addition to other quality assurance activities.

The hubs are strategically located health facilities identified by the MoH to serve as coordination centers for specimen referral, testing and result transmission for a catchment area of 30 to 40km radius serving 20 to 50 facilities.

MUSPH will support the establishment of one hub for specimen transportation, testing and result transmission at Rakai Hospital which will undergo minor renovations. Through Medical Access the hub will be strengthened with capacity to carry out CD4, clinical chemistry and hematology tests by procurement hematology equipment and supplies. MUSPH will support the Districts in the recruitment of two Laboratory Technologist and two Technicians in an effort to avert the dire HRH gap in the District Lab sector. The support will also be extended to strengthening laboratory management towards accreditation in the labs to acquire WHO III star level by 2013. The program will also support rolling out of geneXpert in an effort to improve diagnosis of TB. MUSPH will support Kalangala District for specimen transportation, testing and result transmission for all specimen that cannot be tested at Kalangala to the nearest hub.

MUSPH will work to strengthen and expand the development of national public health work force through apprenticeship training in the fellowship and field epidemiology training programs. The capacity building activities and training will include:

1) the two-year long-term fellowships (including public health informatics);2) the six-eight months medium-term fellowships;3) graduate training programs in FETP (field epidemiology training program);4) M&E short courses;

The strategies of strengthening workforce development and training will include:

1) Working in close consultation with stakeholders in project implementation;2) Working with public and private sector implementers to provide hands-on training while enhancing management capacity as well as innovations within their programs;3) Strong M&E mechanisms to enable continuous improvement of the effectiveness, efficiency and quality of programs;4) Dissemination of experiences at the national, district and community levels to guide public health policy and practice.

The fellowships will focus on: HIV/AIDS, TB, malaria, tuberculosis, maternal and child health, field epidemiology, and public health informatics. The capacity building program will span beyond Rakai district, in order to achieve a national impact.

MUSPH will also provide the FETP, a two-year competence based Masters Degree program that provides 60 70% time of field based training in selected districts. This is intended to improve national capacity to: (i) investigate of disease outbreaks (ii) design and evaluate a surveillance system (iii) evaluate a public health program/intervention. This will be done within the National Strategic Health Plan and close participation of the MoH. Partnerships with other stakeholders like CDC, WHO, AFENET will be strengthened to improve their involvement in annual field supervision of residents. Additionally, epidemiologists from MoH will co-supervise residents for outbreak investigations. In addition to publications, dissemination of program outputs will be done annually, within the districts.

Given the results of the 2011 UAIS showing an alarming increase in HIV prevalence and very low circumcision prevalence (approx 25%), PEPFAR Uganda is prioritizing this prevention intervention as it is a major pivot to reduce the number of new HIV infections. By scaling up SMC and circumcising 4,200,000 men by 2015, 428,000 new adult HIV infections will be averted by 2025.

MUSPH will scale up Safe Male Circumcision and Health Systems Strengthening in Rakai district. Voluntary Medical Male Circumcision (VMMC) will be offered as part of a comprehensive HIV prevention package, which includes: promoting delay of sexual debut (for primary abstinence), abstinence and reduction in the number of sexual partners and be faithful; providing and promoting correct and consistent use of male condoms; providing HIV testing and counseling services and refer to appropriate care and treatment if necessary, and providing services for the treatment of sexually transmitted infections.

MUSPH will create acceptance and demand for VMMC through community campaigns based on information from the Uganda National Communication Strategy on Safe Male Circumcision employing both media campaigns and person to person communication targeting localities with high numbers of men like markets, churches, taxi parks and boda boda stages.

MUSPH with it vast experience in circumcision research and service provision, will provide VMMC training to providers from Rakai district and other districts around the country at the Rakai center and through regional VMMC skills training organized in collaboration with district health offices, and other partners in regions that have adequate facilities for training. Training will utilize the current WHO circumcision skills training manual. Twenty percent of thetrainees will be visited at their work place to assess their proficiency as well as provide supportive supervision post-training.

MUSPH will implement the Model for Optimizing the Volume for Efficiency (MOVE) to optimize the efficiencies and increase the volume safely at Kalisizo, Kakuuto and Rakai Hospital. Special focus will be placed on quality assurance and regular quality assessments (internal and external) including support supervision of the VCCM program, will be done and daily reports sent to the SMC National Operational Center as required by MOH.

MUSPH will provide training for 300 providers including 100 surgeons, 100 operating room (OR) assistants and 100 VMMC counselors every year. MUSPH will also train 36 VMMC skills trainers (TOT), including 12 surgeon trainers, 12 OR trainers and 12 VMMC counselors. The program will train six trainers from each of the six regions of the country including two surgeons, two OR assistants and two VMMC counselors. These interventions will increase the number of providers with skills to provide VMMC and ultimately the number of men accessing VMMC in Uganda.

In FY 2012, a total of 30 staff in the four HCF shall be trained in VMMC and 7,033 males offered a comprehensive package of VMMC in line with MoH guidelines. VMMC supplies and commodities will be sourced from Medical Access Uganda Limited.

The MoH policy guidelines on Safe Male Circumcision will guide the integration of VMMC services in Ugandas national health system. Through these established policy guidelines on VMMC, MUSPH will contribute to the national SMC target of 1 million circumcisions in2012/2013.

The goal of HIV Testing and Counseling Services (HTC) Program in MUSPH is to increase HTC capacity by training more government health workers. The staff to be trained will be in public facilities in Rakai district. The training will cover both didactic and hands-on practice, under the guidance of senior counselors. In collaboration with the MoH, MUSPH shall integrate skills in collection of dry blood spot samples for DNA-PCR for Early Infant Diagnosis (EID). The program will contribute to the overall HTC goals for PEPFAR by increasing access to and use of essential counseling and testing services for the most-at-risk populations and other key populations determined by existing data on HIV prevalence in Uganda. The program will engage in scaling up both Provider-and Client-Initiated Testing and Counseling (P/CITC) and customized interventions relevant to key populations. This program will contribute to the continuum of response by linking clients to other health services including HIV Care and Treatment and social support services in the community with the aim of increasing demand and adherence for positive clients.

Program targets reflect the prioritization of districts with high HIV/AIDS prevalence and unmet need. Partner- and district-level capacity was also key factors in determining the allocation of program resources. The target populations in these districts will vary depending on need, however, the following groups have been identified for priority focus: pregnant women, fishing communities, commercial sex workers and their clients and partners, uniformed forces, long distance truck drivers, and men who have sex with men. This is in addition to the usual target populations of HTC services that includes: men seeking Voluntary Medical Male Circumcision (VMMC), clients walking-in for testing at the HIV clinics to children 0-14 years and repeat testing for HIV negative partners in HIV discordant relationships (with facilitated couples counseling and disclosure), and via community outreaches to the general population.EID will be implemented in collaboration with MoH, through the Central Public Health Laboratory (CPHL).

Currently, PEPFAR contributes to more than half of the MoHs HTC targets. Recognizing the important role of GOU, HTC program activities shall be conducted in partnership with district local governments under stewardship of the MoH, recognizing that the scale-up of activities will require a continued commitment by the USG.

Additionally, in order to maximize program success, this program will work towards evidence gathering for the purpose of standardizing service delivery, to ensure consistency with World Health Organizations HTC Quality Assurance/Quality Improvement guidelines.

In FY 2013, MUSPH will facilitate the implementation of PMTCT Option B+ activities in 28 PMTCT sites in Rakai district.

Key strategic pivots for PMTCT will focus on:

1) Improving access and utilization of eMTCT services in order to reach more HIV infected pregnant women as early as possible during pregnancy. To achieve this MUSPH will ensure provision of universal HTC services during ANC, labor/deliver and community mobilization.

2) Decentralizing Treatment and Option B+ through the accreditation of all PMTCT sites at hospital, Health Center (HC) IV and HC III levels. Activities will include site assessments for accreditation, identification of training needs, procurement of equipment, printing M&E tools, job aides, Option B+ guidelines, training of service providers and sample referral system for CD4+ and early infant diagnosis. The transition of Option B+ by MUSPH in Rakai district sites will be done in accordance with MOH guidance and a total of 24 sites will be accredited by end of FY 2013. MUSPH will support the delivery Option B+ services using a Family Focused model within MNCH settings. In this model family support groups will be formed at all PMTCT sites and will meet monthly to receive adherence counseling and psycho-social support, Infant and Young Child Feeding (IYCH) counseling, Early Infant Diagnosis (EID), family planning (FP) counseling, couples HTC, supported disclosure and ARV refills. Village health teams will also be utilized to enhance follow-up, referral, birth registration, and adherence support. Through this model, male partners will receive condoms, STI screening and management, support for sero-discordant couples treatment for those who are eligible and linkage to Voluntary Medical Male Circumcision. At least 10,000 partners of pregnant women will be tested within the MNCH setting.

3) Supporting intensive M&E of activities to inform Option B+ roll out through cohort tracking of mother-baby pairs and electronic data reporting. All sites will actively document services provided to the mother-baby pairs at both facility and community level. Each beneficiary will have a standard appointment schedule that will be aligned to the follow-up plan of each PMTCT site. Mobile phone technology will be used to remind mothers and their spouses on appointments, EID results and ARV adherence. Service providers will conduct home visits to trace client who are lost to follow-up. All sites will submit daily reports on key program elements electronically to support effective monitoring and timely management.

4) Facilitating quarterly joint support supervision and mentorships at all PMTCT/ART sites involving MOH, AIDS Development Partners, districts, USG, and implementing partners staff in accordance with MOH guidance. Site level support will entail cohort reviews, adherence rates, retention rates, data management, availability of supplies, commodities and tools, and knowledge gaps.

5) Integrating voluntary and informed Family Planning services with PMTCT service MUSPH will ensure FP sessions are integrated within PMTCT trainings, counseling, education, and information during ANC, labor and delivery, and postnatal periods, as well as, for women in care and treatment; based on respect, womens choices and fulfillment of their reproductive health rights.

The MUSPH program will focus on supporting the National Strategic Plan 2011/12-2014/15 objective of increasing access to ART from 57% to 80% by 2015, enrolling at least 4,202 new clients and support 10,724 adults and children on ART by APR 2013, contributing to overall national and PEPFAR target of 190,804 new clients and 490,028 individuals current on treatment. This target is not a ceiling, allowing for higher achievements with continued program efficiencies. Priority will be given to enrolment of HIV positive pregnant women, TB/HIV patients, and key populations in the district of Rakai in Uganda.

This program will support the MoH roll out Option B+ for eMTCT through the following activities; accreditation of 26additional health facilities; training, mentorship and joint PMTCT/ART support supervision. This program will support ART/PMTCT integration at facility level piloting feasible service delivery models, such as same day integrated HIV clinics and reducing the ART preparation period while ensuring quality of ART treatment services. The continuum of response linkages and referrals will be strengthened using linkage facilitators across different service points in facilities and communities. Facilitators will also be utilized for TB/HIV integration to ensure early ART initiation for TB/HIV patients. Further support will be provided for service integration including informed voluntary family planning and cervical cancer screening at facility level through provision of the services or referrals.

Targeted community outreaches in high prevalence hard to reach and underserved areas of Rakai will be conducted. MUSPH will also target key populations using innovative approaches including setting up specialized services; such as moonlight services.

The program will also implement quality improvement initiatives for the ART framework: early initiation of ART eligible clients on treatment; improve adherence and retention; and monitor treatment outcomes. Use of innovative, low cost approaches for adherence, retention and follow up such as: phone call or SMS reminders, appointment registers and alert stickers will be supported.

Special focus will be placed on adherence and retention of women enrolled under Option B+.Focus will be placed on increasing access to CD4 for routine monitoring of ART clients in line with MoH guidance. We will support the sample referral network in line with the national CD4 expansion plan; and will monitor and report clients access to CD4 in quarterly reports.

The MUSPH program will liaise with PACE for provision and distribution of basic care kits to clients with National Medical Stores, and Medical Access Uganda Limited for ARVs and other HIV commodities including cotrimoxazole and lab reagents. The program will build the capacity of facility staff to produce accurate and timely reports, forecast, quantify and order commodities. Further to this MUSPH will work with USG partners and other key stakeholders for provision of required wrap around services.The program will be aligned to the National Strategic Plan for HIV/AID (2011/12 2014/15), support and strengthen the national M&E systems and work within district health plans. The MUSPH program will work under the guidance of MoH/ACP and the Quality Assurance Department in trainings, ART/PMTCT mentorship and support supervision.

The MUSPH program will focus on supporting the National Strategic Plan 2011/12-2014/15 objective of increasing access to ART from 57% to 80% by 2015 . This program will support enrolling at least 840 new HIV positive children and support 1,394 children on ART by APR 2013. This will contribute to overall national and PEPFAR target of 38,161 new children and 63,704 children current on treatment and MUSPH will provide support to all accredited ART facilities in Rakai district as well as supporting accreditation of more facilities including all Health Centers (HC) IIIs.

In FY 2013, this program will support the national program scale up pediatric treatment through strengthening the identification, follow up and treatment for all infants through Early Infant Diagnosis (EID) focal persons, peer mothers, SMS messages or phone calls and flagging files with initiate ART immediately stickers. Health facilities will be supported to strengthen test and treat for all HIV positive children under two years in line with the national treatment guidelines.

We will prioritize support for early initiation, adherence and retention of adolescents on treatment using expert peers and adolescent support groups. T hey will be provided positive health dignity and prevention services including, psychosocial support and life skills training and linked to sexual and reproductive health services.

Of critical importance will be establishing strong referral links between OVC and care and support programs to ensure children on treatment are linked to OVC services, and children provided with OVC services are screened for HIV and appropriately linked to treatment.The MUSPH program will support the integration of HIV services in routine pediatric health services, including the National Child Health Days.

MUSPH will liaise with PACE for provision and distribution of basic care kits to clients and also working in liaison with National Medical Stores and Medical Access Uganda Limited for ARVs and other HIV commodities including cotrimoxazole and lab reagents. To further improve service delivery MUSPH will support capacity building of facility staff to accurately report, forecast, quantify and order commodities in a timely manner.

In addition, MUSPH will work with USG partners such as SCORE, SUNRISE, PIN, SPRING, HEALTHQual, ASSIST and Hospice Africa Uganda in their related technical areas to support integration with other health, nutrition and OVC services. The program will collaborate with other key stakeholders at all levels for provision of required wrap around services.To achieve program objectives we will work in alignment to the National Strategic Plan for HIV/AID (2011/12-2014/15), support and strengthen the national M&E systems and work within district health plans. To ensure adherence to National standards. MUSPH will work under the guidance of MoH/ACP and THE Quality Assurance Department to support pediatric trainings, implementation of the national pediatric mentorship framework and supportive supervision.