Uganda Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

UGANDA

Project Title: Uganda Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

Budget Summary:

	Field Programs Funding by Account						Central Programs
	Notified November 2007			Notified February 2008			Notified as of February 2008	Allocations to Date
Implementing Agency	GAP	GHCS - State	Subtotal: Field Programs Funding	GAP	GHCS - State	Subtotal: Field Programs Funding	Subtotal: GHCS Central Programs	Grand Total:  Field & Central Funding
DOD	-	-	-	-	4,038,024	4,038,024	-	4,038,024
DOL	-	-	-	-	-	-	-	-
HHS	-	5,607,060	5,607,060	8,040,000	106,293,187	114,333,187	9,764,675	129,704,922
Peace Corps	-	-	-	-	2,096,020	2,096,020	-	2,096,020
State	-	-	-	-	4,081,390	4,081,390	1,400,000	5,481,390
USAID	-	-	-	-	128,646,321	128,646,321	9,430,801	138,077,122
TOTAL	-	5,607,060	5,607,060	8,040,000	245,154,942	253,194,942	20,595,476	279,397,478

HIV/AIDS Epidemic in Uganda:
Adults (aged 15-49) HIV Prevalence Rate – end 2003: 6.4% (Uganda HIV/AIDS Sero Behavioral Survey 2005)
Estimated number of People Living with HIV: 1,100,000 (UDHS 2006)
Estimated number of Orphans due to AIDS: 1,000,000 (2001 Situation Analysis, 2004 Household Survey)

Country Results and Projections to Achieve 2-7-10 Goals:

Uganda	Total # Individuals Receiving Care and Support	Total # Individuals Receiving ART
End of FY 2004*	252,500	33,000
End of FY 2005**	371,200	67,500
End of FY 2006***	511,800	89,200
End of FY 2007****	722,300	106,000
End of FY 2008*****	657,698	120,000
End of FY 2009*****	914,090	141,101

^* "Engendering Bold Leadership: The President’s Emergency Plan for AIDS Relief.” First Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, March 2005.
^** “Action Today, a Foundation for Tomorrow: The President’s Emergency Plan for AIDS Relief.” Second Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, February 2006.
^*** "The Power of Partnerships: The President’s Emergency Plan for AIDS Relief.” Third Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February 2007.
^**** "The Power of Partnerships: The President's Emergency Plan for AIDS Relief." 2008 Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, January 2008.
^***** Projections from FY 2008 Country Operational Plan

Program Description/Country Context:

The results of the recently released Uganda HIV Sero Behavioral Survey (UHSBS), revealed an adult HIV prevalence of 6.4%. Approximately 1.1 million Ugandans are HIV positive, of which approximately 100,000 are children under the age of 18. Women, urban dwellers and those living in the conflict regions are the most severely affected. Forty percent of those who are HIV positive have an HIV negative spouse. HIV incidence in Uganda’s mature epidemic is showing signs of stagnating, rather than declining and recent data suggests that the epidemic has shifted into older age groups. More than one million people have died and there are an estimated one million orphans as a direct result of HIV/AIDS.

All HIV positive Ugandans require access to comprehensive care and support services. In view of a severely burdened public health system, the USG is supporting faith-based networks, civil society, and the private sector to complement the public sector and play a key role in ensuring the delivery of services and essential commodities. An estimated 250,000 people in Uganda are currently in need of antiretroviral treatment (ART). Of these, approximately 105,000 are receiving ART with the USG directly supporting ART for 66,000 in 144 service outlets throughout the country as of March 31, 2007. The USG is the largest provider of pediatric AIDS treatment services in the country, supporting approximately 7,000 pediatric patients.

As a result of the HIV/AIDS epidemic, Uganda is among the 22 countries in the world with the highest tuberculosis (TB) burden. TB remains the leading cause of morbidity and mortality for people living with HIV/AIDS (PLWHA). In FY 2008, a key goal for PEPFAR in Uganda will be to increase the number of HIV positive TB patients receiving palliative care (PC) and ART. PEPFAR funding will focus on the following programmatic areas to achieve the Plan’s 2-7-10 targets.

Prevention: $54,450,912 ($44,267,851 Field; $10,183,061 Central) (22.5% of prevention, care and treatment budget)

The Government of Uganda (GOU) 2007-2012 National Strategic Plan (NSP), which is based on epidemiological data and analysis, emphasizes HIV prevention. Sexual transmission accounts for 76% of all new infections, followed by mother to child transmission at 22%. The main driver of the epidemic is identified as high risk sex, defined as having multiple concurrent partners and unprotected sex. GOU prevention priorities include behavior change for risk reduction and risk avoidance; improving counseling and testing uptake; increasing condom availability; integrating HIV prevention into care and treatment; post-exposure prophylaxis; preventing sexually transmitted infection (STIs), and promoting of protective social norms.

In FY 2008, the USG will support HIV prevention strategies that target the general population (particularly men), discordant couples, and high-risk groups, including at-risk youth, and support prevention strategies that address the social and gender norms that underlie risky sexual behavior using mass media, interpersonal communication, and community mobilization.

Given positive trends among young people toward delayed sexual debut and increased abstinence, the USG will continue to strengthen abstinence programs through school-based and out of school programs. In addition, the USG will strengthen its focus on most at-risk populations, including people in prostitution, truck drivers, fishermen, and Internally Displaced Persons (IDPs). USG will address areas with highest prevalence, including urban areas and the Northern districts where armed conflict have contributed to high risk sex, including forced sex. USG will continue to target members of the Uganda People’s Defense Forces (estimated 24% prevalence) and their families. Projects will also educate and advocate against alcohol consumption. USG will focus prevention strategies on discordant couples, including couple testing and mutual disclosure, and consistent and correct condom use both amongst discordant couples and with casual partners.

USG will collaborate with an increased number of partners to target HIV-positive mothers and their families with prevention of mother-to-child transmission (PMTCT) services. Routine opt-out counseling and testing (CT) using rapid HIV test kits with same day results will be integrated in all maternal and child health (MCH) services to increase coverage and reduce drop out and increase eligible HIV-positive pregnant women’s access to ART. Lay counselors will be used to increase capacity for CT in health care setting. Districts’ capacity to provide quality PMTCT services will be strengthened using routine supervision and support. Community-led approaches such as behavior change communication and social mobilization will be used to address social and behavioral factors affecting the uptake of PMTCT and MCH services.

The NSP includes Medical Male Circumcision as an effective prevention intervention. Results of the USG-supported assessment, using WHO-developed tools, will be available and disseminated in mid 2008. USG support in 2008 will take better shape as these results become known. In FY 2008, the USG will continue support for the Blood Safety program, consolidating past achievements and bridging gaps in service delivery. Program strategies include improving service provider skills; behavior change and communication; improving the logistics system to ensure full supply of injection commodities; and improving medical waste management.

Principal Partners: CORE Initiative, Catholic Relief Services, Center for Disease Control, Commodity Security Logistics, Deloitte and Touche, Family Health Internationals, International Medial Corps, Inter-Religious Council of Uganda, Joint Clinical Research Center, John Snow International, Northern Uganda Malaria, AIDS and TB Program, Uganda Program for Human and Holistic Development, Johns Hopkins University Center for Communication, Makerere University Walter Reed Project, Makerere University Faculty of Medicine, International Study Center-Clinical and Laboratory Training in HIV/AIDS, Ministry of Health, National Medical Stores, Partnership for Supply Chain Management, Peace Corps, Population Services International, Protecting Families Against AIDS, Regional Center for Quality Health Care, Research Triangle International, Straight Talk, Rakai Institute of Public Health, Pediatric Infectious Disease Clinic, The AIDS Support Organization, Elizabeth Glazer Pediatric AIDS Foundation, Private Sector, Presidential Initiative on AIDS Strategy for Communication to Youth and US Department of Defense.

Care: $81,367,668 ($77,219,928 Field; $4,147,740 Central) (33.6% of prevention, care and treatment budget)

Care activities in Uganda include CT, PC, support for integrated TB care and treatment, and assistance to orphans and vulnerable children (OVC). The 2002 Demographic Health Survey reported that 70% of the population wanted to know their HIV status, but only 10% had access to CT services. FY 2008 will emphasize using innovative approaches to increase the access and utilization of CT by those who engage in high risk behaviors, including mobile populations; children, adolescents, and couples. As part of the overall strategy, the USG will build the capacity of health workers and support the training and use of alternative manpower including PLWHAs to bridge the human resources gap. Public-private partnerships to make CT accessible in the work place will be strengthened. District-wide door-to-door CT will be initiated in high prevalence districts. USG will support MOH and partners to roll out Routine Counseling and Testing initially in regional hospitals and progressively to the lower health centers. The USG implementing partners will also support the MOH’s “Know Your Status” campaign using media, advocacy, interpersonal communication, and national testing days, and by mobilizing national and district leadership.

USG support for PLWHA includes a broad range of services to address the continuum of illness ranging from management of opportunistic infections, psychosocial support, home based care, nutrition, basic preventive care, TB management, pain and symptom control, and spiritual care, to culturally appropriate terminal care. The USG will continue to utilize various community based structures for delivery of care and referral at the community level. Access to the basic preventive health package, which includes two long-lasting insecticide treated mosquito nets, a water safety vessel and chlorine solution, condoms as appropriate, and prevention for positives educational materials, will be expanded through both the public and private sectors.

In FY 2008, USG will continue to support the implementation of the national TB/ HIV integration policy and communication strategy through training of health care providers. The USG will support the National HIV/AIDS/TB Collaboration Committee to develop implementation plans, provide support supervision, and facilitate working relationships between the National TB and Leprosy Program and the AIDS Control Program. The USG will support districts to set up TB/HIV integration committees, integrate TB/HIV activities in health plans and develop structures to provide support supervision to health facilities. The USG will further provide technical support to health facilities to establish infection control committees, implement infection control procedures, and provide HIV screening for TB patients. The USG will support the training of health workers in TB diagnostics, CT for TB patients and TB suspects, routine TB screening for clients that test HIV-positive, and the provision of palliative care and treatment for co-infected patients.

Of the one million children directly affected by HIV/AIDS, an estimated 110,000 children age 0- 14 are HIV positive. Approximately 43,000 of them are eligible for treatment, but only about 11,000 are on ART. Most HIV-infected children are also in need of other services such as food and education. The USG, in close partnership with the GOU, will support the newly-established Civil Society Fund for AIDS, TB and Malaria to provide grants for OVC programming; dissemination of a quality standards guiding tool for applying national standards in OVC core program areas; and strengthening networks between pediatric care and treatment programs and community based OVC services. In FY 2008, the USG will support the GOU to conduct an OVC situation analysis to obtain data needed to develop stronger OVC programs.

Principal Partners: AIDS Enhancement Capacity, African Education Initiative Girls Scholarship, AIDS Information Center, African Medical Research Foundation, APEP Food Security Nutrition, CORE Initiative, Catholic Relief Services, Center for Disease Control, Chemonics International, Deloitte and Touche, Family Health International, Hospice Africa, International HIV/AIDS Alliance, International Medical Corps, Inter-Religious Council of Uganda, Joint Clinical Research Center, The AIDS Support Organization, Northern Uganda Malaria, AIDS and TB Program, Uganda Program for Human and Holistic Development, John Hopkins University Center for Communication, Makerere University Walter Reed Project, Makerere University Faculty of Medicine, Ministry of Health, Partnership for Supply Chain Management, Peace Corps, Population Services International, Research Triangle International, Rakai Institute of Public Health, Pediatric Infectious Disease Clinic, Private Sector, US Department of Defense, US Department of State, Uganda Viral Research Institute and World Vision International.

Treatment: $106,055,747 ($99,791,072 Field; $6,264,675 Central) (43.8% of prevention, care and treatment budget)

Treatment activities in Uganda include the provision of ART services, which are strongly supported by laboratory infrastructure development. Uganda, with support from the USG, is making significant progress towards its target of providing ART for 250,000 people. Uganda is in the process of revising the National ART policy, which will increase the number of people in need of ART from 250,000 to over 350,000. In direct response, the USG will support expansion of clinical space in rural health centers, train additional health workers to provide ART, and build the capacity of local governments to increase access to ART. The USG will also scale up financial and technical support to workplaces, faith based institutions and private for-profit health providers to provide ART. A key focus will be to facilitate linkages and referrals between health facilities, between the community and health facilities, and within the community. The USG will support programs that build capacity of PLWHA groups to support linkages between facility- and community-based care services, provide adherence counseling and support, increase ART literacy, identify HIV-infected children in the community and link them to services, and improve prevention-with-positives efforts.

USG will consolidate laboratory gains made to date with particular emphasis on management, coordination, and quality assurance activities. Laboratory data collection and reporting will be supported to include more laboratories for the improvement of service provision. National programs, such as the rapid HIV test training roll-out will be expanded to include new laboratory techniques for patient monitoring and treatment. The laboratory rehabilitation program at lower health facilities will be expanded. Training and re-training activities will continue with increased emphasis on management and quality assurance. Finally, FY 2008 funding will continue to support the established Ugandan procurement structures and increase local institutions’ capacity with technical assistance in forecasting, distribution logistics, and warehousing of commodities.

Principal Partners: African Medical Research Foundation, Catholic Relief Service, Center for Disease Control, Chemonics International, Engender Health, Hospice Africa, International HIV/AIDS Alliance, Inter-Religious Council of Uganda, Joint Clinical Research Center, The AIDS Support Organization, Northern Uganda Malaria, AIDS and TB Program, Uganda Program for Human and Holistic Development, Johns Hopkins University Center for Communication, Makerere University Walter Reed Project, Makerere University Faculty of Medicine, Mildmay International, Ministry of Health, Medical Research Council, Management Science for Health, New York AIDS Institute, National Medical Stores, Regional Center for Quality Health Care, Regional Procurement Support Office, Rakai Institute of Public Health, Pediatric Infectious Disease Clinic, National Drug Authority, Elizabeth Glazer Pediatric AIDS Foundation, Private Sector, University Research Corporation, US Department of Defense, Uganda Viral Research Institute.

Other Costs: $37,523,151

PEPFAR Uganda supports a variety of strategic information activities including routine data collection at district and national levels. A central component involves building the capacity of national and local government, civil society and faith-based organizations to develop and implement effective monitoring and evaluation systems. Partners are trained in data collection, analysis and use of data in decision making for more effective and efficient program management. The USG is actively engaged in strengthening routine health services data collection through MOH’s Health Management Information System; sentinel surveillance rounds in antenatal and sexually transmitted disease clinics; information systems development and strengthening of national/implementing partner service delivery sites; and technical assistance to the GOU for the analysis and dissemination of population based surveys and on-going public health evaluations.

In FY08, USG will continue to ameliorate the human resources crisis by enhancing the capacity for human resource policy and planning at central and district levels; strengthening systems for effective performance-based health workforce development; and identifying and promoting health workforce management practices for improved performance and retention.

Principal Partners: John Snow International, Social and Scientific Systems, New York AIDS Institute, Ministry of Health, Macro International, Makerere University Institute of Public Health, Medical Research Council, The AIDS Support Organization, and the University of California San Francisco, Ministry of Health, Uganda AIDS Commission, Ministry of Defense, and JHPIEGO.

Management and staffing funds will support the in-country personnel for USAID, Department of Health and Human Services, Department of State, Department of Defense, and Peace Corps. Funds will ensure program monitoring and accountability, ensure USG policy and technical leadership within Uganda’s national response, and cover compensation, logistics, and office and administrative costs.

Other Donors, Global Fund Activities, Coordination Mechanisms:

The United States is the largest bilateral donor, contributing about 80% to Uganda’s HIV/AIDS national response. In addition to the Global Fund to Fight HIV/AIDS, TB, and Malaria (Global Fund), other major donors include DANIDA, DFID, and Irish AID.

The USG works collaboratively with other AIDS development partners, including UNAIDS, to support the Uganda AIDS Commission (UAC) to lead the national response and in collaboration with UAC, DFID, and Irish AID, established the Civil Society Fund (CSF) to administer grants to civil society for prevention and care programming. Round 3 Phase 2 Global Fund OVC resources and pending Round 7 HIV Global Fund HIV resources for civil society are also to be programmed to go through the CSF. To ensure the GOU’s national priorities are supported, the USG meets regularly with officials from the MOH and other relevant ministries and the PEPFAR Advisory Committee, which was established by the President’s Office and consists of all key national HIV/AIDS stakeholders.

Internally, the US Ambassador is responsible for the overall leadership of the PEPFAR Uganda program. He is supported by the Deputy Chief of Mission, the PEPFAR Country Coordinator, four Agency Heads, the Country Team, and interagency technical working groups.

Program Contact: PEPFAR Coordinator, Premila Bartlett

Time Frame: FY 2008 – FY 2009

Approved Funding by Program Area: Uganda