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The project with support from the National TB and Leprosy Control Program continues to strengthen implementation of the MOH TB/HIV collaborative activities in the Rwenzori region and at the COE,
Mulago Hospital, Kampala. Interventions to decrease the burden of TB among PLHA (Intensified TB case finding-ICF, contact and defaulter tracing and infection control) and HIV/TB co- management of patients (PITC, CPT and ART for TB/HIV co-infected patients) have continued to be supported in the region through several avenues. Focused mentorships in 80 DTUs in ICF for TB, gene-expert utilization,
TB recording and reporting were conducted with support from NTLP/NTRL supervisors across the region. Four new DTLSs were trained with project support at Buluba TB/Leprosy Treatment Center and have been oriented and supported to supervise all health facilities and mentor TB focal persons to properly compile the TB/HIV periodic reports. The TB supply chain was strengthened through procurement and distribution of buffer stocks of 20,000 sputum mugs TB stains, mentorship and training of health workers in proper ordering and quantification of Anti-TB meds and lab reagents. TB screening
is now being integrated at all service points using trained CHWs through the community-facility framework model working through the 25 supported CBOs in the region. The CHWs are now actively
referring eligible presumptive cases from the community to health facilities for definitive diagnosis and management. Gene X-pert utilization, sample transportation and TB/HIV service delivery reporting is
also being supported. Six Gene expert hubs have been supported adequately and administrative support provided to the hubs to help in reporting to NTLP/MOH. Surveillance for MDR TB through Gene Xpert and sputum cultures is also supported as well as transportation of MDR patients to the Fort Portal Regional referral hospital. The quarterly zonal TB/HIV/Leprosy performance review meeting for the
reporting period was supported under the project and data was shared with key stakeholders.

viii. Laboratory Services
To strengthen capacity of Laboratory services in provision of quality laboratory services essential to HIV care as per MOH guidelines; 83 health facilities were mentored on laboratory quality management systems (LQMS), 83 on viral load patient management guidelines and 73 were supported with clinicianlaboratory interface meetings. Six hub labs received training and mentorships in preparation for
accreditations. To address supplies management, 16 lab staff received SPARS training. A total 58268 patient’s samples were processed in the six hubs between April- June 2017 quarter.

ix. Community-Facility Health Services Framework/OVC programming:
The project strengthened the rolled out of the community-facility health services model through 25 CBOs/PHA groups that were assessed and sub-granted to implement key activities aligned to the MOH/UNAIDS 90-90-90 targets geared at bridging the existing gap of comprehensive HIV/AIDS service delivery in the communities served. CBOs identified, recruited and trained 290 Community health workers to support the provision of HIV/TB community based care and strengthen community to facility referrals through CDOs/CBOs for clients requiring services. Linkage desks were established and
133 Linkage and Referral Assistants identified, trained and supported in 119 health facilities to coordinate referral processes with the identified CBO/PHA groups. CBO based staff were also trained
on effective tracking of linkages and referrals with health facilities. As a result of the bi-directional linkages, 9,603 individuals were referred from the community to the facilities and of these 7565 received
the service indicating 79% completeness of referrals. The number of referrals from facility to community this quarter was 1,453 individuals and of these 1,250 received the service in the community indicating
85% completeness of referrals. The service most referred for to the health facility was HTS representing 57% of the overall services referred for. The retention of all clients living with HIV in care from 87% to 91% aside from Ntoroko district which mostly has pastoral and fisher-folk who are migrant communities. More tailored interventions aimed at ensuring clients are differentiated to receive ART in
the most convenient way to improve retention. Additionally these Community Health Workers working alongside 81 sub-county CDOs and attached CBOs have been empowered to strengthen OVC
programming (with support to at least 4 core program areas; child protection, health, education, food security and economic strengthening) across the 7 districts of the region. Collaboration between District
Health Offices (DHO), Community Development Offices (CDO), Community Based Organizations (CBO), PHA networks and Faith Based Organizations (FBO) has improved ownership and coordination
of service delivery. OVCs are periodically mapped and re-mapped periodically using the Vulnerability Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “5 NU2GGH000848-05-00” from Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.”
Index tool developed by the Ministry of Gender, Labor, Culture and Social Development. Needs assessment for OVCs is conducted using the Child Status Index tool. By the end of the reporting period a total of 12067( 89% of the annual target) OVCs were served while 4 of the 7 districts have so far been supported to graduate OVCs from the program. Bundibugyo and Ntoroko as sustain District were supported to graduate 224 children while working on transitioning OVC to other partners in the Districts. Organised groups of caregivers have been transitioned to operation wealth creation programs in the District of Ntoroko. The transition process of OVCs continues and will be complete by September, 2017. In order to redefine the kind of services to be offered to the OVCs, meetings with caregivers of the OVCs are regularly held with 265 VSLA groups formed.

x. Health systems strengthening
Health systems strengthening (HSS) approach is being employed since it promotes ownership and sustainability of the project. This concept is premised on the 6 blocks of: Service delivery where DLGs are supported to decentralize HIV/AIDS services and integrate them with
other services; Human resources for health – The project Human Resource technical team conducted integrated onsite mentorships to 25 health facilities addressing staffing needs for the HIV clinics, staff performance(appraisals),availability of job descriptions as well as ensure the above site(DHT) human resource management systems for the 7 districts. Subsequent CDC SIMs assessments for supported sites showed good scores for the HRH component across the region. The regional project HR coordinators worked with DLGs (DHOs) to identify critical staffing gaps over the period, the project with PEPFAR grants has supported absorption of 20 cadres by the DLG across the region. Additionally with support from Intra-health the project officers started strengthening the utilization of HRIS through ensuring a fully updated HRIS database with staff records, training and performance with so far 4 of the 7 districts technically supported. This is an ongoing activity that will be scaled up across the rest of the districts. Strategic information – Through twinning of the project M&E officers and district biostatistician, we carried out HMIS, Data modelling trainings, integrated and M&E specific mentorship, CQI Facility
specific performance dissemination, Joint Data quality Validation and Assessment, as well as logistical support in form of patient files, filing cabinets, computer set and suspension files to both facility and CBO’s. The average reporting rate was 96.1% in DHIS2 with system breakdown in July 2017. In order to enhance the capacity of districts in electronic data management, the Biostatisticians were trained in Uganda EMR as trainers of trainers. Currently sixty five (65) health facilities have got a functional Uganda EMR and 25 CBOs have an e-data base to capture community data. Medical logistics and commodities – Since October 2016, Baylor Uganda has consistently achieved 100% ordering for medical commodities for HIV/AIDS in WAOS. However only 61% of commodities ordered were accurately quantified and this is attributed to limitation in quantification skills and low health facility/district leadership involvement in the ordering process. To mitigate this gap, the project supported ordering review meetings with stakeholders and targeted technical support to problematic health facilities to address poor quantification for HIV commodities. Additionally health workers will be given onsite training on an improved WAOS tool to achieve 100% quantification accuracy. Over the reporting period, stock outs for HIV commodities were significantly minimized despite the increased demand following the roll out of test and treat guidelines. Stock outs were mitigated by vigorous redistribution and tracking of stock levels for TDF/3TC/EFV and NVP syrup that were in high demand and limited supply from NMS since January 2017. However stock outs of Nevirapine syrup and Lopinavir/Ritonavir 200/50mg tablets continue to hamper HIV service delivery due to lack of supply from NMS. The project plans to address this gap in the interim through soliciting redistribution of these items from other regions. Financing – The project supports District Local Governments, CBOs and PHA networks to plan and allocate resources for HIV response. As mandated by CDC,the SNAPS west project allocates 30% of the total CDC grant to health facilities and community based organization in form of sub-grants, conduct district planning meetings. Following successful planning & budgeting at district level, a total fund of Ug. Shs 1,188,086,500 was sub granted to 125 health facilities and Ug. Shs. 931,802,072 to 25 CBOs to facilitate health services delivery as well as strengthen and functionalize the community –facility referral framework. Implementation is ongoing and currently visible outcomes are being realized due to the effect of this financial support. Leadership and governance – The project working in close collaboration with the Caring Together project has strengthened leadership skills among frontline health workers, health unit management
committee members (HUMC), sub-county and district leaders. Onsite quarterly leadership mentorships targeting frontline health workers were conducted across the region to deliver trainings, review previous
improvement action plans and promote use of data at facility level for planning and decision making. Orientations were jointly conducted for HUMC members, sub county leaders and DHT members. These were targeted at improving their supervisory roles to health facilities, heighten coordination for improved reporting and implementation of identified action plans to close the gaps noted in site support supervision. Findings gathered from the site mentorship follow up visits were shared with the District Health Officers at the performance review meetings, and actions to address issues of staff absenteeism, strengthening joint support supervision to health facilities drawn. A cross cultural leadership training to explore the facility leadership trainings sustainability and tools developed, integration, research, advocacy and communication of best practices arising from this intervention was conducted in the region for project mentors and leaders from Jansen Pharmaceuticals in Belgium and facilitated by
leadership experts from London Business School. During this exchange, the idea of Caring Together approach to improve quality of health care was piloted among the clinical and nursing students from institutions around Rwenzori region, at a leadership seminar that was hosted by Mountains of the Moon University. To enhance data use at facility level and Increase the number of sites having regular and
effective performance review meetings, the Team Performance Monitoring Tools (TPMT) and customized meeting books were rolled out in all the sites.
C. General Summary of Activities Conducted and Achievements during the quarter This section provides a general summary of the activities implemented and results achieved during the April 2017 –June 2017 and how they contributed to the achievement of the cooperative agreement objectives and targets.
Objective
1: Scale up access to comprehensive pediatric and adolescent HIV/AIDS/TB care and treatment from the current 7,435 clients (80% children, 20% family members at the Center of Excellence (COE) to 8,986 by September 2017

1.1 HIV Counseling and Testing Services (HTS)
The annual target was to test 4, 899 clients and diagnose 409 new HIV infections with quarterly targets of 1, 225 tests and 103 diagnoses. During the quarter (table 1) 1, 457 clients (118% of quarterly target)
were tested and given results of whom 86 (83% of quarterly target) were diagnosed with HIV (6 % positivity yield). Cumulatively since October 2016 there have been 6, 045 HIV tests done (123 % of the annual target) and 218 clients diagnosed with HIV (53% of the annual target). Of the total tested in the quarter 747 (73%) were under the age of 15 years with a female: male ratio of 1:1 (364: 383) while among the 710 clients 15 years and older who tested for HIV 66 % were females and mainly in the 25- 49 age category. There should be efforts to scale up HTS among the 10- 24 year old age groups. The points of testing for the COE varied with those at the PNC, at the latter clinic all tests were carried out under the VCT section as clients were brought in for EID services following referral from the Makerere University- John Hopkins University PMTCT program. At the COE the points of HTS were under both the community and facility service delivery modalities. Facility based VCT yielded the most HIV
positive tests 74/86 (86%) followed with community PP/ KP testing 9/86 (11%) and least was by index client contact tracing 3/86 (3%). The facility based VCT yield was highest and this could be due to selection bias where by sickly clients are advised in their communities to test for their status at the COE. Efforts to continue with targeted testing will continue into the next quarter with emphasis on reducing
missed opportunities. Makerere University John Hopkins University Limited (MUJHU) and Baylor Uganda continued to work closely to ensure that PMTCT/ EID services were offered under a mother baby care point at Kawempe hospital. Additionally the PNC clinic also continued to function as an EID center despite most newly identified clients receiving services at the Kawempe hospital mother baby care point. At the Kawempe mother baby care point and PNC clinic, it was agreed between the IPs until March 2018 that reporting on PMTCT women is the mandate of MUJHU while EID is for Baylor Uganda. The annual target was to test 596 (149 per quarter) HEI between the ages of 2 and 12 months and identify 7 (2 per quarter) positives. There were 62% (93/149) HEI tested between 2 and 12 months of age and of these 50% (1/2) positives were identified. The high positivity rate is due to 1 of 2 clients testing HIV positive. The annual target was to test 168 (42 per quarter) HEI under the age of 2 months and identify 30 (8 per quarter) perinatally infected with HIV. In the quarter 75/42 (178%) were tested in this age category, 0 were identified as HIV positive.
Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “5 NU2GGH000848-05-00” from Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.”

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