END of PROJECT REPORT Use One Template for All CDC Awards

“BAYLOR COLLEGE OF MEDICINE CHILDREN’S FOUNDATION - UGANDA”

END OF PROJECT REPORT

Use one template for all CDC Awards managed by the organization Send the completed report to Cooperative Agreement’s Activity Manager, the Monitoring Team Lead on [email protected] and Program Grants Office on email [email protected]. For inquiries/comments, send to [email protected]

Partner Name: Baylor College of Medicine Children’s Foundation - Uganda Physical Address: Mulago Hospital Complex Block 5, Kampala

Program Title: Strengthening National Pediatric HIV/AIDS and Scaling up comprehensive HIV/AIDS Services in The Republic of Uganda under the President’s Emergency Plan for AIDS Relief (PEPFAR) Cooperative Agreement Number:

Reporting period: 1st October 2012 – 31st March 2018

Contact Information: (PI, M&E and Finance) Name: Adeodata Kekitiinwa Name: Albert Maganda Name: Title: Executive Director Email:akekitiinwa@bylor- Title: Director Planning and Title: Director Finance uganda.org M&E Email: Tel No:+256 772-462686 Email:amaganda@baylor- Tel No: Signature: uganda.org Signature: Tel No: +256 772-485174 Signature: Date of submission:

Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “1U2GGH000848-02” 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.” Page 1 of 82

Table of Contents Table A: Partner intervention area summary ...... 9 Executive Summary ...... 10 Acronyms and definitions ...... 12 A. Cooperative Agreement Background ...... 13 B. Program Area Summaries ...... 15 C. Project Achievements, lessons learned, pending gaps and follow‐up issues ...... 18 C.1 Objective 1: Scale up access to comprehensive pediatric and adolescent HIV/AIDS/TB care and treatment at the Baylor Uganda Center of Excellence (COE)...... 18 C.1.1 HIV testing and early infant diagnosis (EID) program: ...... 18 C.1.2 Care and Treatment: ...... 18 C.1.3 TB/HIV Services: ...... 20 C.1.4 OVC services: ...... 20 C.1.5 Medical logistics and commodities: ...... 20 C.1.5 Laboratory services: ...... 20 C.2 Objective 2: Scale up access to comprehensive HIV care and treatment services in Rwenzori region...... 21 C.2.1: Increasing the coverage and utilization of Provider Initiated Testing and Counseling (PITC) services within the health facilities in Rwenzori region ...... 21 C2.2 HIV testing services (HTS) among children and adolescents ...... 22 C2.3 Care and Treatment ...... 23 C2.4 Peadiatric and Adolescent care & treatment: ...... 23 C2.5 Viral load suppression among children and adolescents ...... 25 C2.6 Trends of patients in care (2012-2018)-TX-CURR ...... 25 C2.6 12 months ART Retention...... 26 C2.7 Serum CRAG Performance: ...... 30 C2.8: Increased access to TB/HIV services ...... 31 C2.8.1: TB Case Notification...... 31 C2.9 TB Case Notification rate by district, March 2018 ...... 32 C2.10 TB Treatment Outcomes ...... 32 C2.11 Nutritional Support among PLHIV: ...... 33 C2.12 Burden of malnutrition among active ART clients ...... 35 C3 Expanding coverage and utilization of PMTCT services in target districts ...... 36 C3.1 Access to HIV testing services within ANC ...... 36

C3.2 PMTCT linkage to care ...... 36 C3.3 Exposed Infant Diagnosis (EID) services ...... 37 C3.4 Reduction in HIV positivity rate among HIV Exposed Infants by 1st PCR (2012 - 2018) ...37 C3.5 PMTCT-EID Final Outcomes ...... 38 C4 Increased access to and utilization of prevention services to reduce sexual transmission of HIV ...... 38 C4.1 Access to HTS among Key and Priority Populations ...... 38 C4.2 Pre-Exposure Prophylaxis (PrEP) ...... 40 C4.3 GBV/HIV integration ...... 40 C4.4 Condom promotion and distribution ...... 41 C4.5 Voluntary Medical Male circumcision:...... 42 C5 Scaling up access to comprehensive OVC services to OVCs and their Household ...... 42 C5.1 OVC Served in Rwenzori region ...... 42 C5.2 Case management:...... 45 C5.3 Health: ...... 45 C6 Community facility framework ...... 45 C6.1 Facility-Community referrals, linkages and service delivery: ...... 46 C7. Objective 2.1: Scale up access to comprehensive HIV care and treatment services at Fort Portal Regional Referral Hospital...... 47 C7.1 HTS Performance SNAPS-West Project Support to the FPRRH- ...... 47 C7.2 PMTCT: ...... 47 C7.3: CARE AND TREATMENT: ...... 49 C7.4 FPRRH Viral load Monitoring: ...... 49 C7.5 TB/HIV: ...... 50 C7.6 TB treatment outcomes: ...... 51 C8. Objective 3: Support MOH and its partners Strengthen National Pediatric/adolescent HIV/AIDS Care and provide training, mentorship and technical support supervision to RRHs and lower health facilities providing HIV care and ART services over the project period. ....52 C9. Objective 4: Strengthen implementation of district based programming approach and support integration of GHI principles into comprehensive HIV/AIDS care and treatment and other health services over the project period...... 54 C9.1 Leadership and governance ...... 54 C9.2 Strategic Information (I/M&E) ...... 55 Reporting in DHIS2 and OVCMIS ...... 55 Electronic Medical Records System (OPENMRS)...... 56 Data Quality Assurance ...... 57

C9.3 Strengthened capacity of Laboratory services to enhance comprehensive care, treatment and TB/HIV services...... 57 C9.3.1 Laboratory Quality Management System (LQMS) ...... 57 C9.3.2 Laboratory Accreditation Technical Support ...... 58 C9.3.3 Strengthen Specimen Referral Systems and Hub Support ...... 58 C9.3.4 EQA Monitoring ...... 58 C9.3.5 Laboratory Logistic support ...... 59 C9.4 Strengthening system of Logistics & supply chain management ...... 59 C9.5 Strengthened capacity of target district and health facilities to implement CQI initiatives ..63 C9.6 Human Resources for Health (HRH) ...... 65 C9.7 Strengthened organizational and technical capacities of target districts to plan and manage a sustainable program for comprehensive HIV/AIDS services ...... 67 C9.7.1 Financing ...... 67 C9.8 Capacity Building ...... 68 C9.8.1 Trainings...... 68 C9.8.2 Pre-service training ...... 68 C9.8.3 In-service training ...... 69 C9.8.4 Mentorships ...... 69 C10 Infrastructural Improvement ...... 70 C11.Success stories ...... 70 APPENDICES: ...... 75

List of figures

Table A: Partner intervention area summary ...... 9

Figure 1: Graph showing trends in ART initiation during the SNAPS West project...... 19

Figure 2: Graph showing pediatric and adolescent trends in numbers ...... 19

Figure 3: Comparison of prevalence of TB among active PLHAs on ART ...... 19

Figure 4: Graph showing 12 months retention in care at the COE ...... 20

Figure 5: HTS Performance (2012-2018) ...... 21

Figure 6: Linkage to care ...... 21

Figure 7: Trends in HTS and yield among children < 15 years during the project time ...... 22

Figure 8: Trends in HTS and yield among adolescents 15-19 years during the project ...... 22

Table 1: Care and Treatment Performance (End of project Vs Baseline) ...... 23

Figure 9: Trends of Children in Care and ART in Rwenzori Region ...... 24

Table 2: Paediatric and Adolescent Care and Treatment Performance ...... 24

Figure 10: Viral load suppression for children and adolescents <15 years ...... 25

Figure 11: Viral load suppression for children and adolescents 15-19 years...... 25

Figure 12: Trends of Patients in Care (2012 - 2018) ...... 26

Figure 13: Trend of ART Retention in Rwenzori region (2013 – 2018) ...... 26

Figure 14: Geomap for ART retention by March 2018 (12 months cohort) ...... 27

Figure 15: ART retention for children and Adults by March 2018 (12 months cohort) ...... 27

Figure 16: ART retention by by gender by March 2018 (12 months cohort) ...... 27

Figure 17: VL monitoring performance: ...... 28

Table 3: Viral Load Coverage by gender and age, March 2018 ...... 28

Figure 18: Viral Load Suppression by age and gender, March 2018 ...... 29

Table 4: IAC Cascade (Jan – March 2018) ...... 29

Table 5: Serum CrAg (CD4) Cascade among TX NEW patients (Jan-Mar 2018): ...... 30

Table 6: Serum CrAg Cascade (VL failures) for Rwenzori region (Jan-Mar 2018) ...... 30

Table 7: Performance of TB indicators (End of project Vs Baseline) ...... 31

Figure 18: Trend of Case Notification Rates for Rwenzori region (2012 – 2018)-NTLP ...... 31

Figure 19: District Performance against the TB CNR target-project end line: ...... 32

Figure 20: Performance trends for TB Treatment Outcomes over the project period (NTLP data source) ...... 32

Figure 21: TB Treatment Outcomes at Project end line-March 2018 ...... 33

Figure 22: TSR performance by district at project end line-March 2018 ...... 33

Figure 23: VHT members being trained in quick Nutrition assessment and referral ...... 34

Figure 24: Proportion of active clients on ART assessed for malnutrition -2013 to 2018 ...... 34

Figure 25: HIV Positive malnourished who received RUTF ...... 34

Figure 26: Trend of Malnutrition Management over the project period...... 35

Figure 27: HIV positivity yield among newly identified malnourished cases ...... 35

Figure 28 Proportion of pregnant women attending ANC with known HIV status ...... 36

Figure 29: Linkage to care Trends-PMTCT-Option B+ ...... 36

Figure 30: Trend of Early Infant Diagnostic services (1st PCR< 2months) by quarter ...... 37

Figure 31: EID HIV Positivity Trend over the project period ...... 37

Figure 32: HIV Exposed Infant outcomes over the project period ...... 38

C4.1 Access to HTS among Key and Priority Populations ...... 38

Figure 33: KPs served vs. targets ...... 39

Figure 34: PPs served vs targets ...... 39

Table 8: Number of clients initiated on PrEP (achieved vs. target) ...... 40

Figure 35 :Police officer I/c-CFPU Fort-portal training CHEWs and Para-Social Workers in GBV mgt. (Rwebisengo Ntoroko) ...... 41

Figure 36: District Gender officer and DCDO discussing with stepping stone participants in Bundibugyo...... 41

Table 8: Males Circumcised against annual Target ...... 42

Figure 37: Reduction of adverse events ...... 42

Figure 38: OVC served in Rwenzori region annually (Results Versus Targets): ...... 43

Figure 39: VSLA group meeting-Kabarole ...... 43

Figure 40: Follow up of apprenticeship in Kamwenge ...... 43

Figure 41 Left: LC III handing over seedlings to OVC caregivers -Kamwenge .Right OVC caregiver watering onion demonstration garden- Kamwenge ...... 44

Figure 42: OVC after receiving their scholastics materials-Kasese Left: ECD in Kyenjojo Sub County...... 44

Figure 43: SOVCC meetings discussing Sub county OVC issues - Kyegegwa Left: Care giver meetings aimed at improving relationship- Kabarole ...... 45

Figure 44: Pictures showing HIV testing at community level for OVC in Kamwenge ...... 45

Figure 45: Graph Community-Facility Bidirectional referrals from 2017 -2018 ...... 46

Table 8: showing bidirectional community-facility referrals between 2017-2018 ...... 46

Figure 46: HTS Yield trend in FPRRH ...... 47

C7.2 PMTCT: ...... 47

Table 9: PMTCT Indicator Cascade-Project Performance ...... 47

Table 10: Early infant diagnosis Apr 17-Mar 18 FPRRH...... 48

Figure 47: EID Cascade Jan – March 2018 ...... 48

Table 11: showing final outcomes of HEI Apr 17-Mar 18...... 48

C7.3: CARE AND TREATMENT: ...... 49

Table 12: Trends of ART enrollment in FPRRH April 2017 – March 2018...... 49

Figure 48: Retention at FPRRH Performance ...... 49

C7.4 FPRRH Viral load Monitoring: ...... 49

Table 13: Viral Load Monitoring performance-FPRRH ...... 50

Figure 49: Non-suppressed client management at FPRRH (Jan-March 2018) ...... 50

C7.5 TB/HIV: ...... 50

Table 14: TB/HIV services performance at the FPRRH ...... 50

C7.6 TB treatment outcomes: ...... 51

Table 15: TB Treatment Outcome Performance-SNAPS West Project Support ...... 51

Table 16: Key MOH National Paediatric and Adolescent HIV/AIDS Care and Treatment Performance ...... 52

Figure 50: Examples of A Team Performance Monitoring Tool (TPMT) and Employee of the Quarter Certificate ...... 55

Figure 51: Trend of HMIS Reporting rates in Rwenzori Region ...... 55

Figure 52: Number of sited using OPENMRS in Rwenzori Region ...... 56

Figure 53: OPENMRS coverage by district by March 2018 ...... 56

Data Quality Assurance...... 57

Table 17: Laboratory Star Score Status ...... 58

Figure 54: ARV stock out rate Rwenzori Region 2014 – March 2018 ...... 60

Figure 55: HIV Test kits stock out rate-Rwenzori Region 2014- March 2018 ...... 61

Figure 56: Quantification accuracy Rwenzori Region ...... 61

Figure 57: District SPARS performance-Rwenzori Region- March 2018 ...... 62

Figure 58: 5S reflected for stores at Bwera Hospital stores in Kasese District ...... 62

C9.5 Strengthened capacity of target district and health facilities to implement CQI initiatives ...... 63

Figure 59: SIMS performance –Rwenzori Region ...... 64

Figure 60: HRH-Support performance: ...... 66

Figure 61: HRH absorption per district ...... 66

Table 18: Sub grant Disbursements from April 2012 – March 2018...... 67

Figure 62: Tidying up pictorial ...... 68

Table 19: Scholarship recipients under SAINTS Project in Rwenzori region (Pre-service training) ...... 69

Table 20: showing Major Refurbishments done during the project period ...... 70

Table 21:Refurbishment costs and status ...... 70

Table 22: Success Stories over the project period ...... Error! Bookmark not defined.

Table B: Partner sites intervention summary ...... 75

Table C: Number of staff trained by title of training (in-service training) (2012 -2018) ...... 80

Table A: Partner intervention area summary

Thematic Specific Area Specify Specify other Area proportion Funders other of funding than CDC- through Uganda CDC Sexual Abstinence/ Be Faithful Prevention Condoms and Other Prevention 100% Blood Safety PEP 100% Biomedical Injection Safety Prevention Prevention Injecting and non-Injecting Drug Use Male Circumcision 100% Prevention of Mother to Child Transmission 100% Prevention with People Living with HIV 100% Counseling and Testing 100% Strategic Information 100% Indigenous Organizational Capacity Development 100% Human Resources for Health 100% Commodities and supplies 100% Health Public Private Partnerships Systems Workplace Programs Strengthening Engagement with Multilateral and Bilateral Partners Linking with Food and Nutrition, Safe Water, 100% Education and Other Services Palliative Care (non-ART) 100% Basic Health Care & 100% Adult Care and Support(excluding TB/HIV) Treatment TB/HIV 100% ARV Drugs 100%

Care and Palliative Care (non-ART) 100% Treatment Basic Health Care & Support 100% Pediatric Care (excluding TB/HIV) and Treatment TB/HIV 100% ARV Drugs 100%

Food and Nutrition 100% Orphans and Vulnerable Children 100% Laboratory Infrastructure 100% Laboratory logistics 100% Add any other not listed above

Executive Summary

Baylor-Uganda implemented a PEPFAR funded project through CDC referred to as““Strengthening National Pediatric HIV/AIDS and Scaling up Comprehensive HIV/AIDS Services in Western Uganda (SNAPS WEST)” The goal was to contribute to MoH efforts to reduce the incidence of HIV infection and HIV/AIDS related morbidity and mortality among children and adults in Uganda.The project supported 1); 125 Health Facilities in the 8 districts of Rwenzori region; Bundibugyo, Kabarole, Bunyangabu, Kamwenge, Kasese, Kyegegwa, Kyenjojo and Ntoroko in addition to 25 community based organisations across the region .2) Fort Portal regional referral hospital; 3) the Mulago Hospital Paediatric Infectious Disease Clinic (PIDC) at the Baylor-Uganda’s Centre of Excellence (COE) in Kampala and; 4) the Paediatric and Adolescent Unit at the AIDS Control Program, Ministry of Health. The project was implemented through a Health Systems Strengthening (HSS) approach and supported districts/health units to increase access and utilization of quality comprehensive adult and paediatric HIV/AIDS & TB services. Over the project period, significant gains were registered in scale up of comprehensive HIV/AIDS/TB services in the quest to attain HIV epidemic control in line with the 90-90-90 UNAIDS targets. Key achievements attained include; Health facilities accredited for ART services increased from 60 to 134. The project accelerated HIV Testing services (HTS) through scale up of targeted PITC with the project reaching a total of 2,618,864 individuals with 66,278 HIV positive individuals identified by March 2018.Linkage improved from 69% to 90% due to strengthened implementation of the linkage package by linkage and referral assistants (LARAs) at all high volume sites and a stable supply chain of HIV commodities. The project supported the start–up of SURGE for epidemic control with implementation of high yielding (>4% yield) risk based HTS modalities like workplace testing, moonlight clinics targeting KPs/PPs and assisted partner notification (APN) in the last quarter.

The number of HIV positive clients enrolled in care increased from 19,215 (baseline) to 80,221 by March 2018 with an improvement from 62% to 99.9% on ART with adherence levels (>95%) over 98%.The 12 month retention registered an improvement from 62% to 94%.Viral load coverage stood at 92% while overall viral load suppression stood at 89% by march 2018.Assessment for malnutrition improved from 74% to 98% for ART clients in care. This performance was attributed to a shift of policy from CD4 based criteria (2012) for ART initiation to “Test and Treat” in 2014 as well as roll-out of the 2016 consolidated HIV/AIDs prevention, care treatment guidelines and subsequently the SURGE strategy scale up from 15 targeted sites to 49 sites. The number of children started in care increased from 1460 to 4521 by March 2018 with an improvement from 58% to 100% those started on ART with viral load coverage of 106%.However there were challenges of low viral load suppression for children and adolescents (75.4% and 78% respectively) due to inadequate adherence, psychosocial support, over-representation and pediatric ART under-dosing. Viral Load CQI collaborative activities at site level in IAC, case conferencing and switch meetings were scaled up to address this gap. TB assessment for HIV positive clients in care increased from 65% to 99% while the number of TB cases identified annually increased from 422(baseline) to 698 by March 2018 while 100% of all TB/HIV co-infected patients were on ART. TB treatment success rate (TSR) was 89% while loss to follow-up was reduced from 15% to 8%. The total number of pregnant women that received HTS stood at 466,988 with 35,000 HIV positive pregnant women identified and linkage improved from 71% to 98%. 1st DNAPCR testing coverage for HIV exposed infants increased from 45% to 75% by March 2018 while HIV positivity reduced from 15.1% to 2.2% ( below the national eMTCT target of 3%).This was through strengthened Option B+, ”Test and Treat” and EID program across the region. HIV free survival increased from 59.3% to 74%. The number of Key Populations(KPs) served increased from 2421(54% annual target) to 3867(89% annual target)by march 2018.The number of priority populations(PPs) increased from 9900 to 13,985.PreP (2 sites) attained 24% performance of the annual target however this was because Prep services started 6months towards the endline of the project. The project served 88,370(99% annual target achievement) with VMMC services (39 % in the pivot age group of 15-29) with 0.1% adverse event rate. Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 10 of 82

Over the period the project supported districts to serve over 12,000 OVCs annually (90%) through working with District community department offices and 25 selected CBOs in the region to provide a full package of 3-4 core OVC program areas. Over 524 out of school youths attained apprenticeship skills while 5872 OVCs were supported with education subsidies. The project supported the facility-community framework with a total of 51,210 referrals done between the facilities and communities for various services attaining a referral success rate of 97%. Through the health system strengthening approach the project supported leadership and governance training for 147 health facility in-charges and all DHT members for 8 districts) with support from the PEPAL-Caring together project. The project scaled up Uganda-EMR from 14 to 82 high volume sites. DHIS2 reporting rates improved from an average of 50-70% to 99% for HMIS105, 106a and 108 reports. WAOS ordering quality for HIV commodities improved from 60%(2013) to 95% while quantification accuracy improved from 40.6% to 70.3%.Stock out rates reduced from 13% to 3%(2017) due to strengthened supply chain mechanisms gained from capacity building in WAOS,ART SPARS,Rx solution and redistribution mechanisms working with district Medicines management supervisors(MMS).However the low rate of order fulfillment by NMS hampered the morale of health facility workers involved in orders. Through lab strengthening support, 12 hub riders were supported to transport samples from lower health units to lab hubs,while 281 labarotory staff were trained in LQMS. Over the period,6 labarotory hubs were supported through SLMTA and moved from Star 0 to Star 2-3.The project supported significant infrastructure improvement efforts through tidying up across the region which improved the work environment for health workforce.Over 12 bn UGX was disbursed to DHOs,health units and CBOs across the region as performance based subgrants to bridge the gap in PHC grants in the health system with 99% accountability. The project,with PEPFAR support, supported recruitment of over 167 critical cadres to support HIV care with 61 absorbed by the project endline. The low absorption rates were a challenge facing the supported districts who cited a low wage bill from central government. Over 8050 health workers were trained in various aspects of comprehensive HIV/AIDS/TB prevention, care and treatment over the period which significantly contributed to the observed good project achievement. Key challenges encountered included; stock outs of key HIV commodities, RUTF and low order fulfilment by NMS, low viral load suppression, low data utilization by health-workers and staff absenteeism in some facilities. Mobility of PPs/KPs within the region affected their retention. Low absorption rates of HRH supported cadres by district local governments was a challenge. Key recommendations are provided in this report.

Acronyms and definitions

Budget Period The intervals of time (usually 12 months each) into which a project period is divided for budgetary and funding purposes CoAg Cooperative Agreement: is an agreement in which the Federal Government provides funding authorized by public statute and the government plays a substantial role CoAg Number A 12 figure number assigned to a financial assistance support mechanism as specified in the notice of award Date of Award A date when a document is signed that provides funds to a recipient to carry out an approved program or project. IPYr Implementing Partner’s Year: The intervals of time (usually 12 months each) into which a project period is divided Palliative care Encompasses care provided from the time that HIV is diagnosed and throughout the continuum of HIV infection. (Ref. HIV/AIDS Palliative Care Guidance#1, The President's Emergency Plan for AIDS Relief Office of the U.S. Global AIDS Coordinator). Performance Monitoring A tool used to manage and monitor the activities of an organization to Plan ensure that goals are consistently being met in an effective and efficient manner Performance Monitoring A tool for planning, managing, and documenting data collection and Management Plan activities of the organizations. It contributes to the effectiveness of the performance monitoring system by assuring that comparable data will be collected on a regular and timely basis. TDYers Temporary duty staff: Non-permanent staff that come in to support the functions of the organization. Total obligations The amount of orders placed, contracts and sub awards, goods and services received by a recipient during a budget period that will require payment during the same budget period Total liquidations The amount of obligations incurred by the recipient that has been paid (for financial reports prepared on a cash basis) or the amount of obligations incurred by the recipient for which an outlay has been recorded (for reports prepared on an accrual basis). Unliquidated obligations The amount of obligations incurred by the recipient that has not been paid (for financial reports prepared on a cash basis) or the amount of obligations incurred by the recipient for which an outlay has not been recorded(for reports prepared on an accrual basis).

1. Activity Report

A. Cooperative Agreement Background Background: Baylor-Uganda was awarded (in October, 2012) a cooperative agreement titled: Baylor Uganda implemented the cooperative agreement titled “Strengthening National Pediatric HIV/AIDS and Scaling up Comprehensive HIV/AIDS Services in Western Uganda (SNAPS WEST)” which is a 5-year project funded by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) awarded in October 2012. The project supported at least 140 health facilities and 23 community based organizations (CBOs) across 8 districts and 2 municipalities in Western Uganda. The overall aim was to strengthen the district, municipal health systems and community structures for better service delivery using the following interventions: (1) capacity building through didactic trainings through a Training of Trainers(TOT) mechanism and onsite mentoring of health workers of comprehensive HIV/AIDS/TB prevention, care and treatment guidelines with support from the MOH, infrastructural improvement(tidying up of the workplace environment), strengthening the stock stability of the HIV/AIDS/TB and other OI medicines and other supplies through improving timeliness and quality of ordering and redistribution mechanisms, procurement and distribution of relevant buffer medical logistics and technologies to supported sites; (2) community mobilization for pediatric HIV/AIDS testing, treatment and care and improving referrals and linkages to care and treatment ; (3) service delivery through provision of integrated and comprehensive HIV/AIDS/TB family treatment and care services; and (4) establishment of mechanisms for joint targeted support supervision, monitoring and evaluation with District and Municipal Health Teams. The eight districts that were supported for scale-up comprehensive HIV/AIDS services under this project include; Bundibugyo, Kabarole, Bunyangabu, Kamwenge, Kasese, Kyegegwa, Kyenjojo, and Ntoroko; with support to the Fort Portal Regional Referral Hospital (handed over from SUSTAIN in April 2017) as well as the Mulago Hospital Pediatric Infectious Disease Clinic (PIDC) at the COE in Kampala as a Pediatric HIV/AIDS national referral and training center. A Health Systems Strengthening approach was employed as a strategy for improved utilization of health services at all levels of care. This was envisaged to enhance sustainability of the district led programming approach as stipulated in the principles of collaboration between Baylor-Uganda and the district and municipal local governments. All the six (6) pillars of Health Systems Strengthening model were emphasized: service delivery systems, human resources for health, strategic information, medical commodities and technologies, health care financing, leadership and governance. Besides HIV/AIDS, the project through a Global Health Initiative (GHI) model supported other services that address the major causes of morbidity and mortality in the region for instance; malaria, respiratory tract infections and diarrheal diseases. This involved integration of project activities into the wider scope of health care and supporting antenatal, nutrition and immunization services. Health facilities were supported with basic laboratory and clinical care equipment for growth monitoring, hemoglobin estimation and diagnosis of malaria. In addition, the project supported districts in logistics management i.e. the general supply chain through technical support and training of key staff like medicines supervisors, district logistics officers in timely and quality ordering of medicines and lab supplies using a district centralized WAOS

Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 13 of 82 and strengthened availability of stocks through use of Rx Solution (as a software at 24 sites) as well as redistribution mechanisms across the region. This was in addition to quarterly joint technical support supervision to targeted health facilities with challenges in ART and RTK stock management in the region. i) Overall objectives and goals of the program Project Goal: To contribute to MoH efforts to reduce the incidence of HIV infection and HIV/AIDS related morbidity and mortality among children and adults in Uganda. Project Purpose: To support the target districts, health facilities and Civil Society Organizations (CSO) to provide quality and sustainable comprehensive HIV/AIDS services. Project specific objectives: 1. Scale up access to comprehensive pediatric and adolescent HIV/AIDS/TB care and treatment at Baylor Uganda Center of Excellence (COE) 2. Scale up access to comprehensive HIV care and treatment services in Rwenzori region including the FPPRH 3. Support MOH and its partners Strengthen National Pediatric/adolescent HIV/AIDS Care and provide training, mentorship and technical support supervision to RRHs and lower health facilities providing HIV care and ART services over the project period 4. Strengthen implementation of district based programming approach and support integration of GHI principles into comprehensive HIV/AIDS care and treatment and other health services over the project period. ii) Where the project worked: Baylor-Uganda supported eight (8) districts in the Rwenzori region - Western Uganda: Kabarole, Bunyangabu, Kasese, Kyenjojo, Kyegegwa, Kamwenge, Bundibugyo, and Ntoroko in addition to the Fort Portal Regional Referral Hospital (FPRRH) located in Fort Portal. Outside the Rwenzori region, the project supported the Mulago Hospital – COE and postnatal EID clinic (family centered and adolescent HIV care), and MoH / regional referral hospitals (pediatric and adolescent HIV services). iii) Who implemented the project (partners and sub-contractors): The project supported the Ministry of Health (MoH), District Local Governments (DLGs) and Municipal Local Governments (Municipal Councils) to decentralize HIV services in order to increase accessibility, availability and utilization of quality health services by the population of the Rwenzori region. The key project stakeholders in the implementation process were public and Private-Not-for-Profit (PNFP) health facilities as well as civil society organizations and community-based organizations in the project area. iv) How the project contributed to USG PEPFAR goals: Several stakeholders were involved in the fundamental and strategic shift to “combination HIV prevention and scale up a structured package of behavioral, biomedical, and structural interventions to avert new HIV infections and improve health outcomes of PLHAs”. In addition, there was increased demand creation for HIV services, improved referral networks under the community-facility referral framework supported by the MOH to strengthen bi-directional referrals and linkage to services. The project also enhanced positive behavioral change in the community in collaboration with other USG Implementing Partners in the area, the media plus other PEPFAR stakeholders.

v) How the project contributed to GOU’s strategy and framework for HIV/AIDS: Under the project, Baylor-Uganda in collaboration with GOU’s Ministry of Health (MoH) supported the DLGs/MCs to lead, plan, execute and coordinate the HIV/AIDS service response in line with district development and strategic plans. In line with the National Strategic Plan for HIV/AIDS, the project supported the MoH and the Strengthening Uganda’s Systems to Treat AIDS Nationally (SUSTAIN) project through Regional Referral Hospitals (RRHs) to build human resource capacity for scale up of quality pediatric HIV/AIDS services in district health facilities.

B. Program Area Summaries The project was funded to support the following program areas; 1. HIV Testing and Services (HTS): This program area aimed at supporting districts, municipalities and health facilities to improve access to quality targeted HTS and to improve linkage and referral to other service areas e.g. care and treatment. This was achieved through didactic and onsite training, mentorship, and support supervision. Special focus was put on Provider Initiated Testing and Counselling (PITC) and risk based HTS for Key Populations (Sex workers, Men who have sex with men) and other priority vulnerable populations (Fisher folks, Truckers and Adolescents LHA). To ensure quality of testing by Linkage and Referral assistants/screeners and front-line health workers, the project supported onsite QI mentorship to particularly address the quality of HIV test results and documentation. 2. Adult Care and Support: Activities under this program area were aimed at holistic improvement of the lives of people living with HIV/AIDS (PLHIV), through prevention, diagnosis and treatment of opportunistic infections; prevention among positive clients(PHDP); cancer screening; nutrition counselling and support; psychosocial support; and supporting community structures through the community-facility framework that works with Village Health Teams (VHT)/CHEWs in providing Community Home Based Care (CHBC) services as well as strengthening bi-directional referrals and linkages between the community and health facilities for service delivery. 3. Adult Treatment: Under this program area the project aimed at improving access to and provision of quality services for antiretroviral therapy (ART) for PLHIV. This was done through: supporting accreditation of health units to provide ART, building the capacity of health workers to provide quality HIV/AIDS services (through didactic and onsite training, mentorship and support supervision); supporting treatment and monitoring services (reproduction and supply of data tools, laboratory support, referral and linkages); provision of essential diagnostic equipment and supplies; and supported implementation of Differentiated Service Delivery Models(DSDM) in 25 high volume pilot sites with support from MOH; supported redistribution of antiretroviral (ARV) medicines from overstocked to understocked health facilities to avert stock-outs and ensure stability of clients’ continuum of care. 4. Paediatric and Adolescent Care and Support: This program area aimed at holistic improvement of the lives of children living with HIV/AIDS (CLHA). This was attained through enhanced identification of HIV infected children, linkage to care, prevention and treatment of opportunistic infections, nutrition counselling and support and providing psychosocial support. Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 15 of 82

5. Paediatric Treatment: Under this program area the project aimed at improving access to, and provision of quality ART services for CLHA. This was through: building the capacity of health workers at accredited health facilities to provide ART, monitor patients on ART by; provision of essential diagnostic equipment and supplies; infrastructure refurbishment; and provision of pediatric ART formulations, buffer stocks of ARVs. 6. Tuberculosis and HIV/AIDS: This program area aimed at improving the access to; quality screening, diagnosis, prevention, treatment and monitoring services for integrated HIV/AIDS/TB services. This was done through building the capacity of health workers and provision of essential diagnostic equipment and supplies inclusive of gene-Xpert, integration of TB/HIV services in maternal &Child health services. 7. Orphans and Other Vulnerable Children (OVC): The project aimed at supporting and strengthening district systems to improve service delivery to OVC and their families. This was done through working with the Community Development Office (CDO) and selected Community Based Organizations (CBO) in the districts. Supported core OVC program areas included; education, economic strengthening, food and nutrition, health and psychosocial support. For services beyond the scope of the project, the CDO working with the CBOs were able to ensure families in need of these services are linked to other organizations and service providers. 8. ARV Logistics: In this program area, the project aimed at supporting the MoH logistics and supply chain system for ARVs to minimize stock outs and wastage. This was done through capacity building in WAOs, Rx Solution and ART SPARS mentorships of relevant district staff in Logistics and Supply Chain Management with support from UNHSC and MOH. 9. Voluntary Male Medical Circumcision (VMMC): The project aimed to enhance prevention of sexual transmission of HIV through supporting safe male circumcision. There were two models for delivering and managing VMMC services: Strengthening district and HF systems for planning, delivery and management of VMMC services through training, mentorship, and support supervision, supply of surgical equipment and consumables, and refurbishment of minor surgical theatres; Outreaches and surgical camps. 10. PMTCT: PMTCT is a major component of the project package towards the elimination of mother-to- child transmission of HIV through a family-centered approach. Services supported by the project for PMTCT include universal HTS for every pregnant and lactating woman and enrolment into chronic HIV/AIDS care and treatment for all HIV positive mothers. Identification of HIV exposed infants and uptake of EID/eMTCT services was strengthened through integrating EID services in YCC/Immunization clinics and also emphasized through routine monthly MCH outreaches especially in hard to reach communities in the region. Chronic care including ART was provided according to the PMTCT policy – eMTCT strategy. 11. Sexual Prevention: The project supported the Ministry of Health national HIV prevention strategy 2014 and the National Priority Action Plan 2015-2018 that emphasizes focus on the key population (KP) and other vulnerable and priority populations (PP) through provision of comprehensive HIV

prevention package. The project aimed at increasing coverage of sexual prevention services through collaborations with community-based organizations (CBOs), faith based organisations and health unit staff at all levels in the region to; promote risk reduction, advocate for no stigmatizing health services for KPs and increase demand, uptake and adherence to biomedical prevention interventions (HTS, PMTCT, Care and treatment). The project utilized the peer-to-peer approach to provide services to the Key Populations (Sex workers, Men who have sex with men) and other priority vulnerable populations (Fisher folks, Truckers and Adolescents LHA). 12. Continuous Quality Improvement (CQI): Continuous Quality improvement was integrated in routine data reviews and fixing of gaps identified in targeted supported health units, CBOs and above site level. Districts received monthly technical support from the cluster public health specialists to functionalise and support district and health CQI committees to meet monthly with sub-grant funding. 13. Laboratory Services Strengthening: District HFs were supported to provide tests essential to HIV care according to MoH guidelines. Staffs were trained and mentored in Good Laboratory Practice (GLP) annually. To ensure quality care, proficiency testing and other aspects of quality assurance/ quality control (QA/QC) were done in collaboration with UNHLS, National TB and Leprosy Program (NTLP) and the Uganda Virus Research Institute (UVRI). Seven (7) laboratories were supported for accreditation using the WHO/CDC Strengthening Laboratory Management towards Accreditation (SLMTA) approach. 14. Health systems strengthening: The project emphasized and strengthened District-Led programming under the Health systems strengthening (HSS) approach in order to promote ownership and sustainability of the project interventions across the region. This concept is premised on 6 blocks of:  Human resources for health - Relevant trainings and mentorships were conducted with support from MOH and CDC to build a competent health workforce every quarter. The project, over the period, supported monthly updating of the HRIS across the 8 districts. To address critical staffing gaps, the project supported recruitment of key cadres in preparation for absorption by the DLG;  Strategic information – The project aimed at strengthening the capacity of districts to report timely and accurate data in national MISs and using the data for planning through capacity building, computerisation, supervision, provision of HMIS tools, routine data quality assessments and recruitment of MRAs.  Medical logistics and commodities –In partnership with UNHSC, NMS, CPHL and MAUL, district and HF staff, the project aimed at minimizing stock outs and wastage of HIV drugs and commodities through training, mentorship, short message services (SMS) for reminders, strengthened redistribution of ART and RTK stocks through use of Logistics MISs such as RASS and Rx solution;  Financing - DLGs were supported to plan and allocate resources for HIV response. The project aimed at bridging the gap in primary health care (PHC) funding through provision of performance based sub-grant funds geared at improving service delivery and epidemic control.

 Leadership and governance - A multi-sectoral district led HIV response, involving district departments, private and public HFs and CSOs were coordinated under the stewardship of HIV/AIDS Committees at respective levels of operation. DLG leadership and DHTs and CBO managers were provided with leadership and management skills to supervise and manage the health service delivery workforce efficiently.

C. Project Achievements, lessons learned, pending gaps and follow‐up issues

C.1 Objective 1: Scale up access to comprehensive pediatric and adolescent HIV/AIDS/TB care and treatment at the Baylor Uganda Center of Excellence (COE). At the Baylor Uganda Clinical Center of Excellence (COE) the project objective was to scale up access to comprehensive pediatric and adolescent HIV/AIDS care and treatment with 80% of the beneficiaries as children and 20% adult family members. The main strategy was to increase the identification of people living with HIV both in the Mulago hospital wards and in the community through know your child’ s status and outreaches to key and priority populations. Additionally efforts were made to offer comprehensive care services including ART initiation, viral load monitoring, screening for tuberculosis, supporting OVCs and supporting clients to remain in care. Below is a summary of the achievements during the project period. C.1.1 HIV testing and early infant diagnosis (EID) program: During the project period 34 new HIV positive babies under the age of 18 months were identified from the 4, 280 who received a 1st HIV DNA PCR test giving an overall HIV positivity yield of 0.8% among HEI. Over the years the number of HEI decreased from 2, 562 in year 1 to 563 in year 5 owing to increased uptake of comprehensive HIV care and treatment services by previously adult focused ART clinics around Mulago hospital hill but also this trend could be due to increased uptake of SRH and family planning services. Initially only 17% of HEI received their 1st PCR in less than 2 months however by the end of the project access was at 78%. Efforts to encourage EID needed to be strengthened. Children who presented late for 1st PCR were usually index admissions at Mulago Hospital wards with severe diagnoses and had mothers who had not accessed eMTCT services. A total of 32, 173 clients tested for HIV in the project period of whom 3, 083 were positive giving an average yield of 10%. There was a gradual decline in HIV positivity over the years from 25% in year 1 to 4% in year 5. Initially admitted clients confirmed to have HIV together with their family members were the most commonly tested individuals and the difference between new and repeat testers was not defined however later as testing included communities the yield declined but by the close of the project targeted testing was the standard. C.1.2 Care and Treatment: At the start of the project period, the COE clinic had 5, 577 clients in care and in the last year they were 8, 021. There was a peak in ART initiation in year 2 following the introduction of the test and start policy when 1, 178 PLHIV were started on treatment compared to 194 the previous year. Across the years, the proportion of clients on ART increased from 88% to 99.8% a reflection of the improving national policies on ART initiation. The number of children under 10 years and in care declined over the years from 2, 185 in year 1 to 1680 in year 5 because of the success of the national eMTCT program and additionally children transitioned to adolescents whose numbers increased on the contrary from 2,336 to 3, 413 over the same period. At the project start viral load testing was only accessible to clients suspected to be failing on treatment and was at 39% however in year 3, there was a nation- wide roll out for the test and 96% of the client were tested. Viral suppression rates among children under 10 years when the national rollout occurred gradually improved from 79% to 88% owing to the introduction of intensified adherence counselling. Viral suppression rates ranged between 81% and 84% among adolescents 10-19 years with commonly cited reasons for poor adherence namely stigma, lack of adult supervision, drug fatigue and big

Figure 1: Trends in ART initiation at the COE

Figure 2: Pediatric and adolescent trends at the COE

Figure 3: TB prevalence trend among active PLHAs on ART at the COE

Figure 4: 12 months retention in care at the COE 100% 91% 90% 85% 84% 80% 80% 80% 77%

% retention % 70% 1 2 3 4 5 extension project years

C.1.3 TB/HIV Services at the COE: Initially all clients were screened for TB as they reported to the COE however the numbers dropped to a minimum 93% due to representation of well clients. The number of identified TB cases increased over the project period from 20 in year 2 to 101 in year 5 although year 4 had the highest prevalence at 140 cases (table 3). Increased TB diagnosis was observed following the emphasis to use the 4 symptom check list to guide clinical decisions as well as the introduction of the Gene-Xpert machinery. All clients with TB were initiated on anti- tuberculous treatment. Less than 5 MDR TB cases were diagnosed in the reporting period and all were treated at the MDR treatment center. C.1.4 OVC services: The clinic served 6, 277 as the highest number of OVCs during the project period. The program areas they were served with were education, psychosocial support, health services and economic strengthening services. Families were able to start up small businesses such as retail shops, salons, welding workshops, vending fresh market produce etc. All OVCs (100%) served during the period had a known HIV status. C.1.5 Medical logistics and commodities: There was no stock out of ART and cotrimoxazole prophylaxis. The pharmacy timely reported and submitted all (100%) required forms to the central warehouse (Medical Access Uganda Limited) and this assured a continuous supply of ARVs. Additionally, Baylor Uganda COE received a Golden award in March, 2017 from MAUL in recognition for excellence in good pharmaceutical practice. C.1.5 Laboratory services: The COE laboratory was set up to support high quality family centered pediatric and adolescent healthcare, education and clinical research in Uganda. The laboratory was accredited by the College of American Pathologists (CAP) in 2012 and continued to maintain this accreditation after each bi-annual inspection. The laboratory achieved CAP certification by June 2019. The lab has clinical capacity for safety labs, rapid diagnostic serology, Immunophenotying and processing including long term storage of plasma/serum samples. Support is also given to internal protocols providing quality control and processing for the ongoing research projects. Because of the sustained CAP accreditation this has attracted more research to the facility. By close of the project, the team had ensured uninterrupted supply of reagents by ensuring timely ordering of supplies from MAUL and procurement of items not provided on the MAUL list. Due to our excellent services, a silver medal from MAUL was given to the lab team. External Quality Assurance (EQA) performance for UKNEQAS (monthly) and CAP (quarterly) Proficiency Testing panels for CD4, CBC, chemistry, urinalysis, blood parasites, HCG, and HIV testing registered 100% satisfactory performance. All patient samples submitted to the laboratory including those for critical laboratory patient care had their results submitted to the clinicians within the defined TAT for the laboratory.

C.2 Objective 2: Scale up access to comprehensive HIV care and treatment services in Rwenzori region.

C.2.1: Increasing the coverage and utilization of Provider Initiated Testing and Counseling (PITC) services within the health facilities in Rwenzori region

Figure 5: HTS Performance (2012-2018) Increase in utilization of PITC

800000 620346 644144 6.0% 4.8% 601981 600000 457764 4.0% 336396 3.4% 400000 256858 2.4% 2.1% 2.2% 2.2% 2.0% 200000 16278 15711 15040 13772 13318 5636 0 0.0% Oct 12 - Sept 13 Oct 13 - Sept 14 Oct 14 - Sept 15 Oct 15 - Sept 16 Oct 16 - Sept 17 Oct 17 - Mar 18

Tested Tested HIV+ HTS yield

Through district led, facility initiated HIV testing services, the project supported seven districts of rwenzori region to scale up HIV testing services through training of health workers on quality assured Provider Initiated Testing and Counselling (PITC). At the end of year 1, the number of individuals tested for HIV had increased by 36.1%. Year 3 registered a similar increase in the number of individuals tested for HIV (35.5%). This achievement was attributed to introduction and scale up of PITC at both OPD and other entry points. Health facilities were also supported through mentorships and subgrants to implement community based testing targeting children, pregnant women as well as key and priority populations. While there was no increase in the proportion of individuals identified as HIV positive, over 13,000 new HIV positive cases were identified from year 2 to year 5.

Figure 6: Linkage to care Proportion initiated on ART 20000 150% 15000 112% 100% 82% 90% 10000 69% 74% 76% 50% 5000 0 0% Oct 12 - Sept 13 Oct 13 - Sept 14 Oct 14 - Sept 15 Oct 15 - Sept 16 Oct 16 - Sept 17 Oct 17 - Mar 18

Tested HIV+ Started on ART % started on ART

Linkage to care gradually improved from 69% in year 1 to over 100% in year 5; this was attributed to better tracking of linkage using the MoH pre-ART register and the ART register. In addition, the projected recruited lay counsellors to support same day pre-ART preparation and initiation including physical escort

C2.2 HIV testing services (HTS) among children and adolescents Figure 7: Trends in HTS and yield among children < 15 years during the project time 100000 87472 89270 3.0% 78988 80000 2.6% 2.5% 2.0% 60000 49019 2.0% 36738 1.5% 40000 0.8% 0.6% 33269 0.6% 0.6% 1.0% 20000 943 959 661 499 526 195 0.5% 0 0.0% Oct 12 - Sept 13 Oct 13 - Sept 14 Oct 14 - Sept 15 Oct 15 - Sept 16 Oct 16 - Sept 17 Oct 17 - Mar 18

Tested Tested HIV+ HTS yield

Figure 8: Trends in HTS and yield among adolescents 15-19 years during the project 91807 100000 1.19% 86551 1.20% 80000 1.15% 60000 1.08% 1.10% 1.04% 40252 40000 1.05% 20446 1.05% 20000 1.00% 243 898 993 421 0 0.95% Oct 14 - Sept 15 Oct 15 - Sept 16 Oct 16 - Sept 17 Oct 17 - Mar 18

Tested nd nd Tested HIV+ nd nd HTS yield nd nd

Over the project period, targeted interventions implemented to improve case finding for HIV positive children included; testing children of newly identified index clients, testing orphans and vulnerable children, testing children in private health facilities and at immunization points. HIV positive women identified were tracked and encouraged to bring their biological children for testing. To improve early diagnosis of adolescents living with HIV the following interventions were done; strengthening PITC at key entry points, differentiated HTS services for adolescents at flexible hours (that is, evening hours, over the weekends), targeted HTS outreaches for adolescents including those in key population areas, assisted partner notification targeting adolescents and young people, testing adolescents attending private health facilities. Technical support was provided to health workers to strengthen the use of the screening

C2.3 Care and Treatment Table 1: Care and Treatment Performance (End of project Vs Baseline) Category Indicator Baseline End of project (Oct 2012) (March 2018) # of sites accredited to provide ART 60 134 Number of HIV-positive adults and children receiving a minimum of one 19,215 80,221 clinical service HIV Care Number of children and adults currently receiving ART 12,237 80,196 and % of children and adults currently receiving ART 64% 99.9% Treatment % of ART patients adhering on treatment greater than 95% No Data 98% % of clients still active on ART after 12 months of initiating on ART 62% 94% % of ART patients with viral load test done in last one year N/A 92% % of ART patients with suppressed viral load (<1000 copies/ml) N/A 89% Nutrition % of clients assessed for malnutrition 74% 98% support % HIV+ clinically malnourished received therapeutic food No Data 77% The project supported scale up of accreditation of ART sites from 60 to 134 over the period. The number of clients currently receiving ART improved from 12,237(64%) to 80,196 (99.9%) by March, 2018 with 98% of the clients achieving good adherence (>95%).The 12 months retention of clients on ART improved from 62% (2012) to 94% while 92% of clients on ART had accessed viral load and 89% of the clients were virally suppressed. The proportion of clients who were assessed for malnutrition improved from 74% at the beginning of the project to 98% by the end of the project while 77% of HIV positive, clinically malnourished clients had received therapeutic food. This improvement is attributed to a number of factors including; working with Ministry of health and the district health teams to build capacity of health workers through periodic trainings, mentorships and technical support supervisions as well as working with expert clients and Community Based Organizations (CBOs) as detailed in the different sections below.

C2.4 Peadiatric and Adolescent care & treatment: Over the project lifetime, the number of health facilities providing pediatric antiretroviral therapy (ART) increased from 22 in 2012 to 124. The number of children 0-14 years in care increased from 2509 to 4521 children while those receiving ART from 1460 to 4521 (58% to 100% ) by March 2018.

Figure 9: Trends of Children in Care and ART in Rwenzori Region 5,000 100% 100% 100% 100% 120% 82% 4,000 100% 58% 3,000 80% 60% 2,000 40% 1,000 20% - 0% Oct 12 - Sept Oct 13 - Sept Oct 14 - Sept Oct 15 - Sept Oct 16 - Sept Oct 17 - Mar 13 14 15 16 17 18

andART # in Care 2,509 2,828 3,022 4,112 4,407 4,521

# on ART 1,460 2,307 3,017 4,111 4,407 4,521 children ART on of Proportion % on ART 58% 82% 100% 100% 100% 100% Number of children care in This achievement is attributed to strengthened linkage through; use of linkage referral assistants, community health workers, tracking weekly data, bring back to care campaign and use of adolescent peer leaders. To improve the HIV continuum of care for children, health facilities were supported to establish and run family clinics, and to conduct caregiver meetings. Adolescent only clinics through functionalization of adolescent corners were established in facilities and adolescent peer leaders were engaged in mobilising fellow adolescents to utilize HIV care services through adolescent peer support meetings. Additionally the project built the capacity of health workers to provide quality paediatric and adolescent HIV care through quarterly technical support supervision and mentorships

Table 2: Paediatric and Adolescent Care and Treatment Performance Category Indicator Baseline End of project (Dec 2012) (Mar 2018) Proportion of supported sites providing peadiatric treatment 22 124 Number of HIV-positive children (0-14 yrs) receiving a minimum of 2,606 4,453 one clinical service Number of children (0-14 yrs) currently receiving antiretroviral 1,715 4,453 therapy (ART) Paediatric % of children (0-14 yrs) currently receiving antiretroviral therapy 66% 100% Care and (ART) Treatment % of children (0-14 yrs) retained on ART after 12 months of 75% 92% initiating ART % of HIV+ children assessed for malnutrition 27% 98% % HIV+ clinically malnourished received therapeutic food No Data 83% % of children with VL test done in last one year N/A 71% % of children on ART with suppressed VL (<1000 copies/ml) N/A 75% Adolescent Number of sites providing adolescent friendly services - 74 Care and Number of HIV-positive adolescent (10-19 yrs) receiving a No Data 3,693 Treatment minimum of one clinical service % of adolescents (10-19ys) currently receiving antiretroviral therapy No Data 100% (ART)

% of adolescents adhering on treatment greater than 95% No Data 97% % of adolescents retained on ART after 12 months of initiating ART No Data 87% % of adolescents with viral load test done in last one year No Data 83% % of adolescents on ART with suppressed viral load (<1000 No Data 77% copies/ml) C2.5 Viral load suppression among children and adolescents To address the low viral suppression rates in children and adolescents across the period,the project supported quarterly technical support supervision in viral load monitoring to health facilities. This was through strengthening knowledge and skills in intensive adherence (IAC) counselling and case conferencing. Facility group meetings (i.e. caregiver meetings and adolescent peer support meetings) to discuss adherence were facilitated to enhance adherence. Additionally, health workers as well as community health workers were supported to conduct home visits to children and adolescents with non- suppressed viral loads to assess home characteristics, adherence issues and offer psychosocial support.

Figure 10: Viral load suppression for children and adolescents <15 years 80.0% 67.8% 73.40% 67.30% 75.40% 60.0% 40.0% 20.0% 0.0% Oct 14 - Sept 15 Oct 15 - Sept 16 Oct 16 - Sept 17 Oct 17 - Mar 18

Figure 11: Viral load suppression for children and adolescents 15-19 years. 100.0% 75.00% 77.80% 80.0% 67.7% 69.40% 60.0% 40.0% 20.0% 0.0% Oct 14 - Sept 15 Oct 15 - Sept 16 Oct 16 - Sept 17 Oct 17 - Mar 18

C2.6 Trends of patients in care (2012-2018)-TX-CURR Over the period, there was progressive increase in the proportion of clients on ART with a peak in 2017, when the ‘test and treat’ model was started. By 2017, all the clients who were previously Pre-ART were initiated on ART. This good performance was as a result of consistent use of the HTS eligibility screening tool, integration of HTS in YCC and immunization outreaches, client appointment tracking and index client testing targeting all family members of HIV positive clients using as well as workplace and evening testing.

Figure 12: Trends of Patients in Care (2012 - 2018)

100,000 99.9% 99.9% 150% 81% 89% 92% 64% 64% 100% 50,000 50% - 0% 2012 2013 2014 2015 2016 2017 2018 (March)

Pre-ART ART % on ART

C2.6 12 months ART Retention Figure 13: Trend of ART Retention in Rwenzori region (2013 – 2018) ART Retention 94% 100% 84% 85% 86% 80% 70% 62% 60% 40% 20% 0% 2013 2014 2015 2016 2017 2018

The retention of clients on ART followed an upward trend throughout the project. The best retention was achieved in Kyenjojo and Kyegegwa districts (figure 13).Poor retention was attained along the lakes in Kasese and water ways of Kamwenge where there are mobile fishing communities.The progressive improvement in retention was attributed to;Community Health Extension Workers (CHEWS) ensuring early follow up of clients who miss clinic appointments, use of clients’ national identity cards and passport photographs during registration for easy tracing of lost clients and health education by expert clients on importance of keeping clinic appointments. The health facility staff worked closely with the CBOs to initiate early follow up of clients who miss clinic appointments, thereby minimizing lost to follow up rates.

Figure 14: Geomap for ART retention by March 2018 (12 months cohort)

Figure 15: ART retention for children and Adults by March 2018 (12 months cohort) Children <15 yrs Adults 15+ yrs Target 94% 91% 100% 88% 86% 86% 84% 81% 76% 90% 80% 67% 60% 40% 20% 0%

Figure 16: ART retention by by gender by March 2018 (12 months cohort)

By the end of March,2018,the 12 month cohort analysis of retention showed Kyejojo district achieved the best retention(94%), while the least retention were attained in Ntoroko,Bundibugyo and Kasese.The low retention of clients on ART in these districts was largely attributed to mobile populations especially the

Figure 17: VL monitoring performance: Viral Load Coverage (2012 - 2018) 80,000 106% 120% 92% 70,000 100% 60,000 72% 50,000 80% 40,000 60% 30,000 40% 20,000 8% 10,000 0% 0% 20% - 0% 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Eligible for VL (all pts) 7,292 28000 39,140 52,413 73,689 56,489 # Viral Loads done (all pts) 0 0 3015 37,738 67,942 59879 VL Coverage 0% 0% 8% 72% 92% 106%

Ministry of health adopted viral load monitoring among HIV clients on ART to track the 3rd 90, in 2014.From 2014 to 2017, the viral load coverage in Rwenzori region steadily improved over time. The greatest improvement in viral load coverage was noted in 2017 as a result of the demand creation for viral load. This was done through viral load mop-up campaigns, provision of IEC materials through Communication for Health Communities (CHC), mobilization of clients by PHAs networks and CBOs for viral load. There was also intensified supervision with formation of district viral load technical working groups to supervise the health facilities, health facility monthly performance reviews, patient chart reviews and use of stickers for eligible clients. Capacity of health workers and expert clients to monitor viral load was built through periodic mentorships, technical support super vision and facility-based CMEs. Table 3: Viral Load Coverage by gender and age, March 2018

By March, 2018, viral load coverage in Rwenzori region was 92% with more females who accessed viral load compared male conterparts (table 3 above)

Figure 18: Viral Load Suppression by age and gender, March 2018

As seen in figure 18 above, adults (25+years) had achieved the UNAIDS 3rd 90, with viral load suppression of 92%.However,viral suppression among children (<10 years) and adolescents remained below the target. This achievement in viral suppression can be attributed to capacity building of health workers to manage clients with non-suppressed viral loads. Health workers were trained on appropriate management of clients with non-suppression. Health educators were also equipped with knowledge to provide appropriate messages to encourage adherence of clients. Through peer support meetings such as caregiver meetings, adolescent peer support meetings, caregivers and adolescents were equipped with knowledge and supported to achieve good adherence.

Table 4: IAC Cascade (Jan – March 2018) Age non- suppressed Non- clients who clients whose clients failing group Clients identified suppressed received a VL improved who failed clients that (years) (6 months prior to that received 2nd VL or to improve were reporting period) the 3 IAC test suppressed or switched to sessions. after IAC suppress 2nd line after IAC # # % # % # % # # % <10 191 126 66% 76 60% 15 20% 61 21 34% 10-14 94 64 68% 41 64% 18 44% 23 9 39% 15 - 19 79 63 80% 37 59% 18 49% 19 8 42% 20-24 85 54 64% 34 63% 22 65% 12 8 67% 25 - 34 356 234 66% 144 62% 75 52% 69 37 54% 35 - 49 394 264 67% 160 61% 85 53% 75 37 49% 50+ 98 69 70% 45 65% 25 56% 20 10 50% Overall 1297 874 67% 537 61% 258 48% 279 130 47% During the January-March 2018 quarter, 67% of unsuppressed clients had 3 IAC sessions with 61% with a repeat viral load and 48% had improved/suppressed. However, only 47% were switched to 2nd line ARV therapy. This improvement in management of virally non-suppressed clients was attributed to the support given to the health facility workers through training in management of clients with non-suppression.

C2.7 Serum CRAG Performance: Table 5: Serum CrAg (CD4) Cascade among TX NEW patients (Jan-Mar 2018):

ents with CD4 withents CD4

Age group (years) newlyclients # HIV of initiated ART on (TX_NEW) ART patients# New of offered baseline CD4 test % of ART New offered patients baseline CD4 test # TX_NEW patients of with CD4 <100 # pati <100 received who test CrAg screening % patients CD4 with <100 received who test CrAg screening # whopatients of started Fluconazole <10 105 12 11% 1 0 0% 0 (10 -14) 21 4 19% 0 0 0% 0 (15 - 19) 235 53 23% 4 1 25% 0 (20-24) 576 130 23% 12 2 17% 0 (25 - 34) 1087 214 20% 30 2 7% 0 (35 - 49) 680 137 22% 22 7 32% 3 50+ 130 27 21% 1 0 0% 0 Total 2834 577 20% 70 12 17% 3 (25%)

Table 6: Serum CrAg Cascade (VL failures) for Rwenzori region (Jan-Mar 2018)

ed Fluconazole ed Fluconazole

# of PLHIV with# PLHIV of # VL suppression Non % Non VL suppression pts # CrAg positive of % CrAg positive pts

Age group (years) VL failuresuspected (VL ≥1000) (VL>1000) received who test CrAg screening (VL>1000) received who test CrAg screening with# VL failures of CrAg positive test who start who started Fluconazole # CrAg positive of patientson started Fluconazole months (3 cohort) # CrAg positive of patients completed Fluconazole <10 124 36 29% 3 1 33% 0 0 (10-14) 49 19 39% 2 2 100% 0 0 (15 - 19) 39 11 28% 1 1 100% 0 0 (20-24) 40 21 53% 3 3 100% 0 0 (25 - 34) 174 92 53% 8 5 63% 0 0 (35-49) 271 90 33% 8 5 63% 0 0 Total 697 269 39% 25 17 68% 0 0 Data source: Program database, April 2018 Training of trainers for 17 health workers was done in serum CrAg screening and management of cryptococcal infection, in December, 2017. During the January-March, 2018 quarter, 20% of new clients had a baseline CD4 of which 17% received serum CrAg screening while 39% of un-suppressed clients received serum CrAg screening. Only 25% of clients with low CD4 and 68% of eligible clients for fluconazole had started fluconazole. The poor performance was partly attributed to the inadequate supplies of fluconazole and serum CrAg screening kits.

C2.8: Increased access to TB/HIV services

C2.8.1: TB Case Notification The proportion of clients in care assessed for TB improved (TB_ASSESS) from 65% in 2012 to 99% by end of March 2018. The number of ART clients diagnosed with TB from 24 to 159, both of which comprised only 0.2% (below the target of 2.5%).The number of new and relapsed TB cases identified in a quarter increased from baseline of 422 in 2012 to 698 by end of the project period. These improvements in TB case notification resulted from project support to facility- based mentorships at 118 DTUs with emphasis on intensified TB case finding at all entry points, house hold contact tracing and reverse contact tracing, increasing utilization of gene Xpert, Furthermore there was improved capacity of HWs in diagnosis of childhood TB especially in clinical diagnosis with support from the DETECT-TB child model in Kabarole/Bunyangabu Districts. The project rolled out the NTLP DHIS2 guidelines which led to better data capture on TB case notification and TB treatment outcomes in the two districts. The best practices and interventions have since been scaled up to the rest of the region. Implementation of the one STOP shop where co-management of TB and HIV was contributed to the improvement of key TB HIV indicators. Out of the identified new and relapse TB cases, the proportion screened for HIV increased from 92% to 97% by the end of project, of whom 156 and 217 TB and HIV co-infected patients were identified respectively. All (100%) HIV/TB Co-infected patients were started on ART (TB_ART) by end of the project which was a major milestone in the project performance.

Table 7: Performance of TB indicators (End of project Vs Baseline) Category Indicator Baseline (2012) End of project(Mar 2018) Number of clients on ART 12237 80,196 Proportion of clients in care assessed for TB 65% 99% Number of ART clients diagnosed with TB 24 159 Proportion ART clients diagnosed with TB 0.20% 0.21% Number of new and relapse TB cases identified 422 698 TB/HIV Proportion of new and relapse TB pts screened for HIV 92% 97% # of patients co-infected with TB and HIV identified 156 217 % of HIV/TB co-infected patients on ART 61% 100% CNR (Target=128)* 97 TSR* 89% * Baseline data for CNR and TSR was not available from datim.

Figure 18: Trend of Case Notification Rates for Rwenzori region (2012 – 2018)-NTLP 5000 200 4000 154 150 3000 103 97 91 103 100 95 100 2000 CNR

cases 1000 50 0 0 2018 2012 2013 2014 2015 2016 2017 # of of and # new relapse March New and Relapse cases 2412 3844 2487 2412 2801 2809 1336 CNR 103 154 97 91 103 100 95

TB case notification rates had generally averaged around 100/100,000 population except in 2013 were it reached 154 above the 128 national target.

C2.9 TB Case Notification rate by district, March 2018 By the end of the project, the regional TB case notification rate was 97/100,000 population based on DATIM and 95/100,000 based on NTLP data. This was still below the national target of 128. Two districts, Kabarole with166/100,000 and Ntoroko163 attained CNR above the target. Kabarole district high performance was due to implementation of DETECT Child TB project.

Figure 19: District Performance against the TB CNR target-project end line: 200 166 163 111 90 87 95 97 100 49

0 Bundibugyo Kabarole Kamwenge Kasese Kyegegwa Kyenjojo Ntoroko Region

CNR CNR Target =128

C2.10 TB Treatment Outcomes According to the NTLP data source, the regional TB treatment success rate ranged from 81-87% and averaged at 85% and the cure rate regional average was 47% (Fig 20).

Figure 20: Performance trends for TB Treatment Outcomes over the project period (NTLP data source) 100 87 86 86 81 80

60 51 49 43 46 40

20 8 8 11 8

0 2014 2015 2016 2017

Cured TSR Lost to follow up

The TSR regional average at the end of the project was 89% (close to the target of 90%) and cure rate was 57% which is close to the target of 60%. This improvement was attributed to implementation of DOTS, tracking of LTFU and exchange of treatment outcomes transfers out between districts during the data verification at the regional meetings.

Figure 21: TB Treatment Outcomes at Project end line-March 2018

11% 0% 1% 5% Cured Completed Rx Died Failed 57% Lost to follow-up 25% Not evaluated

The challenge for the low treatment success in Bundibugyo and Ntoroko was due to high LTFU of clients due to cross border migrations with neighboring Congo. Kyegegwa district was frequently significantly affected by loss to follow up (LTFU) of TB cases among the refugee population.

Figure 22: TSR performance by district at project end line-March 2018 92% 100% 86% 88% 89% 89% 80% 72% 60% 57% 60% 40% 20% 0% Bundibugyo Kabarole Kamwenge Kasese Kyegegwa Kyenjojo Ntoroko Region

TSR TSR Target =90%

C2.11 Nutritional Support among PLHIV: Over the period, the project supported the District Nutrition Coordination Committees (DNCCs) using the district led programming approach to provide oversight, planning, implementation and reporting for nutrition activities in all health facilities. Emphasis was on onsite data driven mentorship and Technical Assistance (TA) in Nutrition Assessment, Counseling and Support (NACS), Integrated Management of Acute Malnutrition (IMAM) and Infant and Young Child Feeding Programme (IYCF), food preparation demonstrations at selected high volume ART sites and nutrition referrals through the community-health facility frame work. Over the project life time, nutritional assessment in HIV clinics was maintained at over 95% of clients, while in ANC, Maternity and PNC assessment for nutrition improved from less 10% to over 65% and in OPD from close to 0% to over 75%. In addition, 760 Village Health Teams (VHTs) were trained in community nutrition assessment, referrals and follow-up.

Figure 23: VHT members being trained in quick Nutrition assessment and referral Over the period, more than 20,000 sets of color coded MUAC tapes, 620 adult weighing scales, 274 infant meters, 460 height meters, 200 neonatal weighing scales were procured and provided to facilities, Over 4000 clients with acute malnutrition were treated with therapeutic feeds(RUTF) with 29% HIV positive. The project supported accreditation and functionalization of 46 Out Patient Therapeutic Care (OTC) sites and through sub grant funding to health units, more support was provided through monthly food preparation and demonstration gardens in over 117 health facilities. Special focus was given to the Mother- Baby care points and Neonatal Care Units (NICU) at all accredited ART sites to improve breast feeding practices in maternity, post-natal and Young Child Clinics (YCC) in the region. A total of 120 high volume health facilities and at least 680 health workers across the region were mentored in early initiation of breastfeeding, breastfeeding techniques (positioning and attachment) and establishing breastfeeding corners in pediatric wards.

Figure 24: Proportion of active clients on ART assessed for malnutrition -2013 to 2018

In the first 2 years (2012-2014) of the project, there were no quality of care indicators for nutrition assessment and support and as a result no data was reported in the District Health Information System (DHIS-2).In the subsequent three years of project implementation, health workers and community volunteers received training and mentorships in Nutrition Assessment, Counseling and Support (NACS) and Integrated Management of Acute Malnutrition (IMAM) among HIV positive clients. Following capacity building, there was improvement in assessment for malnutrition from 96.2% to 97.6% of clients on ART assessed for malnutrition consistently the reporting periods. Over 77% and 83% malnourished adults and children respectively were rehabilitated using Ready to Use Therapeutic Feeds (RUTF).

Figure 25: HIV Positive malnourished who received RUTF

The number of HIV positive clients receiving RUTF increased from 837 in 2015 to 2634 by september 2016. This was attributed to capacity built among health workers to identify eligible clients for RUTF and stable supply of RUTF by RECO industries and UNICEF to all OTC sites through collection hubs at hospitals and H/CIVs across the region.The decline from october 2016 to march 2018 was due to ceasation of RUTF production by RECO industries and the change in global management of malnutrition policy in the eligibility criteria for RUTF from both MAM and SAM to SAM alone. C2.12 Burden of malnutrition among active ART clients Figure 26: Trend of Malnutrition Management over the project period

In general, the burden of malnutrition among HIV clients on ART is low.Beginning October 2014, the proportion of malnourished ART clients gradually reduced from 1.9% in 2015 to 1% in 2017.This was attributed to increased capacity to manage cases of malnutrition and constant supply of therapeutic feeds. In the period between 2017 to 2018, supply of RUTF was interupted due to ceasation of production by RECO industries and supplementary supplies from UNICEF were rationed and limited to only the regional referral hospital leaving the other high volume Out Patient Therapeutic Care (OTC) sites unserved. The sudden increase in malutrition(from 1% in 2017 to 3% in 2018) among PLHIV took place during the period of interrupted RUTF supply to the region. Overall there was a high HIV positity yeild among malnourished clients. In addition the project revealed that interupted supply of RUTF negatively impacted on nutrition outcomes among PLHIV.

Figure 27: HIV positivity yield among newly identified malnourished cases

Health workers were trained to identify and refer malnourished clients for HTS services. From year three onwards, the number of newly identified malnourished cases increased 4 fold from 1317 in 2015 to 5867 in 2017and this included both Moderate Acute Malnutrition(MAM) and Severe Acute

Malnutrition(SAM) cases. The decline in 2018 was attributed to policy change in the eligibility criteria for RUTF from both MAM and SAM to SAM alone.

C3 Expanding coverage and utilization of PMTCT services in target districts C3.1 Access to HIV testing services within ANC Figure 28 Proportion of pregnant women attending ANC with known HIV status 200,000 120% 101,643 103377 108,772110% 103,931 103,489 100,000 106% 112% 106% 103% 47,42999% 100% - 80% Year 1 Year 2 Year 3 Year 4 Year 5 Oct 2017-March 2018

Number of pregnant women attending antentatal care for the first time Number of pregnant women with known HIV status Proportion with known HIV status (newly tested and known status at ANC1)

HIV testing services were integrated into antenatal care during the roll out of PMTCT option B+ guidelines in December 2012. Midwives and lay counselors received training on how to provide HIV counselling and testing within ANC as a standard of care. This consistent achievement in good testing coverage at ANC1 was attributed to a critical mass of lay counsellors with skills in HTS and minimization of test kit stock- out through timely and accurate ordering of HIV commodities. In addition, the Ministry of Health introduced the weekly option B+ online dashboard to track the number of pregnant women tested for HIV during their ANC1 visit; this data was utilized at both facility and national level to identify problem sites and implement action plans in real time. The online dashboard also helped districts follow up non- compliant health facilities. Whereas the MOH recommended same day ART for pregnant women that tested HIV positive during ANC1, it was observed that a significant number of HIV positive women declined treatment simply because they were not ready to take lifelong medication. C3.2 PMTCT linkage to care Figure 29: Linkage to care Trends-PMTCT-Option B+ Linkage to care (option B+) trends year 1 to year 5 6724 8,807 10,000 4,501 5,972 6,010 2,986 200% 71% 79% 89% 95% 98% 98% - 0% Yr1 (Oct 12-Sep13) Yr2 (Oct13-Sep14) Yr3 (oct14-Sep15) Y4 (Oct15-Sep16) Y5 (Oct16-Sep17) Y6 (Oct17 march18)

Total HIV+ women identified at ANC Number of HIV+ pregnant women given ART for eMTCT during pregnancy and delivery %initiated on ART Linear (%initiated on ART )

Following national roll out of the PMTCT option B+ guidelines, the project undertook to integrate ART services in ANC and also scale up implementation at all PMTCT accredited sites. Overtime, linkage to ART improved from 71% in year 1 to 98% in year 5. This improvement in linkage to care is attributed to training of midwives in implementation of option B+ and same day ART preparation and initiation. The

C3.3 Exposed Infant Diagnosis (EID) services Figure 30: Trend of Early Infant Diagnostic services (1st PCR< 2months) by quarter

DNA 1st PCR testing improved from 45% (baseline) to 72% by March 2018. This improvement was attributed to improvement in the proportion of health facility deliveries through SMGL initiatives in the districts of Kabarole, Kamwenge and Kyenjojo districts. In addition, the project innovated the 1st PCR tracking tool which enabled midwives to follow up the unborn exposed baby from the time the HIV positive pregnant woman attends ANC to the time she returns her exposed child for immunization. The established regional hubs supported DBS sample and results turnaround time. Despite the above gains, districts like Kamwenge, Kasese and Bundibugyo still had suboptimal EID coverage because of poor EID testing access in sub counties without HCIIIs and had migrants from the Democratic Republic of Congo that present late for both immunization and HIV testing.

C3.4 Reduction in HIV positivity rate among HIV Exposed Infants by 1st PCR (2012 - 2018) Figure 31: EID HIV Positivity Trend over the project period 10,000 20%

15.1% 9.6% 6.0% 5,000 4.7% 10% 3.4% 2.4% 2.2%

0 0% 2012 2013 2014 2015 2016 2017 2018 (Jan-Mar) Total number of HEIs tested for HIV % of HEI tested HIV+ Following change of policy from option A to option B+ in 2012, the proportion of HIV infected pregnant and breastfeeding women initiated on ART significantly improved from under 50% in 2013 to over 90% in 2017; subsequently, the HIV positivity rate by 1st PCR among HIV exposed infants reduced from 15.1% in 2012 to less than 2.5% in 2017. This was attributed to scale of EID testing and increased coverage of linkage to care among HIV infected pregnant and breastfeeding women. While progress was progress was

C3.5 PMTCT-EID Final Outcomes Figure 32: HIV Exposed Infant outcomes over the project period 18 months HIV Exposed Infant oucomes (Cohort data) 100.0% 71.5% 73.9% 50.0% 59.3% 53.8% 57.0%

0.0% 6.2% 6.0% 4.0% 3.2% 2.8% Oct 2013-Sept 2014 Oct 2014-Sept 2015 Oct 2015-sept 2016 Oct 2016-Sept 2017 Oct 2017-March 2018

MTCT rate Lost to follow up HIV free survival

In April 2016, the Ministry of Health introduced the EID birth cohort and early retention monitoring system for purposes of tracking exposed infant outcomes using their birth cohorts. The index cohort followed up was the 2014 birth cohort as showed in the table above. Overtime, the project achieved significant reduction in Mother to Child Transmission rate of HIV from 6.2% in 2014 to 2.8% at the end of March 2018. This was attributed to good option B+ coverage, over 90% viral suppression among both HIV infected pregnant and breastfeeding women as well as substantial reduction in the number of HEI lost to follow up. Equally, the proportion of exposed infants discharged HIV negative at the end of the recommended 18 months of follow up (HIV free survival) improved from 59.3% to 73.9%. In addition, reduction in lost to follow up was attributed to recruitment of peer mothers to support midwives in follow up and promotion of adherence and implementation of the Bring Back Mother-Baby campaign initiative (Line list all lost infants and use VHTs and community structures to follow up).

C4 Increased access to and utilization of prevention services to reduce sexual transmission of HIV C4.1 Access to HTS among Key and Priority Populations In the period from October 2014 -March 2018, the project served Key and priority population as one of the approach for HIV combination prevention intervention for those communities considered to be at high risk of acquiring HIV. The project supported the MOH strategy of achieving the National HIV Prevention goal of reducing new HIV infections with a goal to contribute to reduction of new HIV infection among Key & priority population within the 8 district of Rwenzori region .Using a peer led approach,the project targeted to reach different KPs; Female Sex workers (FSW) Men who have sex with Men (MSM) and transgender from 3 districts of Kabarole, Kasese and Kamwenge and priority populations (fisher folk) in Kasese, Kamwenge and Ntoroko Districts as well as partners to sex workers and truckers along the corridors of the main routes to the border within the different districts. Working with different CBOs in all districts specific health facilities were supported to provide services to Priority population while Kabarole Women Health Support Initiative and Kasese Women Health Support Initiative were very instrumental in supporting health service providers to mobilize Key population for accessing health service with guidance from district local government authority.

Figure 33: KPs served vs. targets

5,000 KPs served vs targets 150% 4,000 3,000 98% 89% 100% 2,000 54% 50% 1,000 42% 0 0% Oct 2017- served Oct 2014- Oct 2015- Oct 2016-

March Number of KPs served Number KPs of served

Sept 2015 Sept 2016 Sept 2017 percentage KPs of 2018 Total served 2,421 0 2,380 3,867 percentage achieved 54% 42% 98% 89% Figure 34: PPs served vs targets PPs served vs target 13,985 18,108 20,000 14,654 4000% 2884% 3000% 15,000 10,9949,900 2000% 10,000 1000% 90% 95% 81% 0% 5,000 0 0 0 -1000% 0 -2000% Oct 2014-Sept Oct 2015-Sept Oct 2016-Sept Oct 2017-

Number served served Number 2015 2016 2017 March 2018

Target 10,994 0 18,108 0 percentage served Total served 9,900 0 14,654 13,985 % achieved 90% 95% 81% 2884% Axis Title

Target Total served % achieved Linear (% achieved)

The KP were served through the project cycle showing some varying results per each year due to different environment influences like mobility and business trucking by FSW who looked for business in other areas etc. PP target was reduced in the last implementation year to give priority to focus on Key Population. In order to provide friendly services to KP and PP targeted communities, we conducted district stakeholders’ inception meeting for creating awareness on the KP programming. We then remapped old and new hot spots every year to ensure that the high risk groups are well demarcated and reached appropriately in all the seven district of Rwenzori region. This process enabled a more efficient approach of providing targeted services to Key & Priority populations at their designated areas. During the project profiling of 1323 FSW was done in the 3 districts of Kabarole, Kasese and Kamwenge to know their health seeking behavior and characteristic and we estimated numbers of FSW at each hotspot mapped .3452 family members were profiled living with FSW and among these 87 (4%) tested HIV positive with 40 being new testers. In order to keep KP in constant communication and promote ART adherence, quarterly safe space meetings were done per each category in each district. KPs with legal issues were supported with referrals to different legal NGO and Human Rights Lawyers. Health service providers, District Heath teams and KP/PP peers were trained in provision of KP

C4.2 Pre-Exposure Prophylaxis (PrEP) Table 8: Number of clients initiated on PrEP (achieved vs. target) Period COP 2017 Target (2 sites) Achievement %achieved Oct 2017-March 2018 600 143 24% One of the key HIV prevention biomedical interventions is Pre-Exposure Prophylaxis. In the period, October 2017-March 2018, the project initiated PrEP implementation at two pilot sites targeting HIV negative female sex workers, HIV negative partner in discordant relationship and HIV negative individuals in the general population who are at risk of HIV acquisition. Six months following implementation of the PrEP program, there was no reported sero-conversion and majority of clients accessing PrEP services were from Kagote HCIII located in Fort Portal Municipality. The biggest challenge of PrEP implementation was mobilization of eligible clients and monitoring retention and adherence to PrEP. Implementation was also negatively impacted by stock out of serum creatinine test kits which are useful for assessment of baseline kidney function prior to PrEP initiation.

C4.3 GBV/HIV integration Gender integration in health care delivery remained high on Baylor’s agenda and for the entire SNAPS-West project period efforts were focusing on identifying and addressing the gender related concerns that directly and indirectly affect attainment of our UNAIDS 90, 90, 90 goal. The project had recognised that more than one third of women globally experience sexual/ gender based violence and increased chances of HIV infections SNAPS West project put much emphasis on GBV screening both at facility and community level as well as GBV prevention awareness creation among the communities. Baylor Uganda under SNAPS West continued strengthening the capacity of health facilities to offer Post GBV Care/ services to survivors and a total of 278 health care providers were trained in GVB response and management basing on MOH curriculum, 611 health workers across 131 health facilities were mentored in GBV screening, response and management. Following trainings and facility based mentorships, a total of GBV 6621 survivors were served with clinical services including HTS, PEP ECP STI and counselling. Additional total number of 23757 were assisted to access legal and child protection services. Under community facility framework mentorships were organised to build the capacity of the community structures to screen, identify, manage and refer cases of GBV and to this effect 78 community social workers working with 24 partner CSOs were trained through onsite mentorship. Aware that much of the GBV occurs and is concealed at community level, Baylor Uganda supported all the 8 districts to train 425 community health workers, religious leaders in GBV screening and Post GBV care/ response. The project prioritised S/GBV awareness meetings/ sessions to the highly vulnerable communities and a total of 23757 individuals mostly adolescent girls were sensitised on GBV causes and response. This led to progressive increase in the number of survivors seeking and accessing Post GBV care.

Figure 35 :Police officer I/c-CFPU Fort-portal training CHEWs and Para-Social Workers in GBV mgt. (Rwebisengo Ntoroko) Baylor Uganda under SNAPS-West continued employing evidence based approaches and strategies as a means of addressing gender related challenges that propel HIV infections, and Gender based violence and to this effect stepping stone methodology was prioritized to address and change harmful gender norms. A total of 230 stepping stone facilitators were trained across the 8 districts and these comprised of PPs, KPs, and other school going adolescents. For this same period a total of 2854 in school adolescents, 2020 boda riders and garage teams, 84 fish folk, and 213 FSW in the region were reached with prevention messages using stepping stone methodology. Through stepping stone group sessions uptake of Prep services was realised and for Feb – march 2018 period 103 CSW 54(females) and 12(males) boda riders were initiated on PreP.. Through stepping stone methodology FSW of kabarole, under Kabarole Women health support initiative realised the chronic need for borrowing in need any of their members would be in great urgent need. To this effect, 30 FSW attending stepping stone sessions formed a VSLA “Together we can saving group” in which every member saves 5000= daily and any member of the group can easily access a loan in cases of need for health care, and in most cases to facilitate access to justice in incidences when a member’s rights are violated. During the week accommodating the 8th March 2018 international Women’s day, Baylor Uganda supported 7 CBOs in the region to run “know dangers of teenage pregnancy campaign” in 21 secondary schools targeting the adolescents. Over 4150 adolescents were sensitised on SGBV prevention, and dangers of teenage pregnancies

Figure 36: District Gender officer and DCDO discussing with stepping stone participants in Bundibugyo.

C4.4 Condom promotion and distribution Over the period, the project scaled up condom programming across the supported health units and 500 established community condom outlets. This was through trained health workers and use of KP/PP peers to manage condom distribution and education to clients and communities. A total of 3,096,081 condoms (98.8% male condoms) were distributed by March 2018. The uptake of female condoms ( total of 38,633) was still low due to stigma and cultural norms in the region. Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 41 of 82

C4.5 Voluntary Medical Male circumcision: Following roll out of VMMC services among eligible males, the project consistently reported over 90% achievement of VMMC targets. This was attributed to introduction and scale up of VMMC camps and outreaches targeting males in the VMMC pivot age; In addition, the projected supported district and community staff in mobilization and sensitization about the benefits of VMMC in the context of HIV. VMMC was implemented in districts that don’t traditionally circumcise and these included Kabarole, Kyenjojo, Ntoroko and Kamwenge districts. VMMC teams were trained on how to minimize adverse events and also how to manage them if they arise and as a result, VMMC adverse events were either minimal or did not occur at all. Table 8: Males Circumcised against annual Target Males circumcised against annual target 46,681 50,000 107% 42,423 110% 40,000 105% 30,000 22,135 23,602 22,472 22,345 100% 20,000 99% 10,000 91% 95% - 90% Oct 2015-Sept 2016 Oct 2016-Sept 2018 Oct 2017-March 2018

Annual VMMC target Number of males circumcised %achieved

Figure 37: Reduction of adverse events

Proportion of males circumcised reporting adverese event

6% 4% 2% 0% 0.5% 0.1% 0.1% Oct 2015-Sept 2016 Oct 2016-Sept 2018 Oct 2017-March 2018

Target % with adverse events

C5 Scaling up access to comprehensive OVC services to OVCs and their Household

C5.1 OVC Served in Rwenzori region OVC program was implemented in the region through 23 Community Base Organizations (CBOs) and District Community Base Services Department (CBSD) in the region. Over the period, the project has had different COP targets and their performance recorded as below: (See Table xx). The achievements over the period can be attributed to intensified identification of OVCs, monthly home visits to households, technical assistance rendered to CBOs, mentorships, and effective referral of households for other OVC serves and provision of OVC tools

Figure 38: OVC served in Rwenzori region annually (Results Versus Targets): 35,000 128% 129% 140% 30,000OVC served in Rwenzori region annually (Results100% versus Target) 120% 95% 90% 25,000 80% 100% 20,000 80% 15,000 60%

COP Target COP 10,000 40% 5,000 20% - 0% 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Target 5,300 5,300 7,276 31687 13616 13,816 Result (OVCs served) 6,761 5032 9,397 31,679 10861 12,467 % achieved 128% 95% 129% 100% 80% 90%

In 2012/13 OVC served was at 128%, the project surpassed the target and served additional 1,461 OVC, while in 2013/14, 95% of targeted OVC were served thus less by 5% to meet the target. In 2014/15, there was over achievement by 29% compared to 2015/16 where 100% OVC were served. From 2016 to 2018, there was a drop in meeting the targets by 10% due to delays in CBO functionality which was addressed. OVC Services provided by Program Area Stable - The program reduced economic vulnerability of OVC Households and empowered them to provide for the essential needs of the children in their care. This was achieved through supporting 262 VSLA model and this improved livelihoods and increased household incomes among the OVC households since most VSLA members borrowed funds for agricultural production and also boosting their small income generating activities. Relatedly, a total of 206,000,000 UGX was saved out of which 144,000,000 UGX was loaned out to the members.

Figure 39: VSLA group meeting-Kabarole PAs a best practice, VSLAs have been used as a fora for health, HIV education and awareness which led to awareness building campaigns and education on maternal health issues, drug adherence sessions, Infant mortality, nutrition, and health related matters. Additionally, SINOVUYO sessions were integrated in the VSLA groups to improve parent-child relationship. Furthermore, 524 out of school youth and adolescent OVC attained apprenticeship skills in different courses. Start-up kits were provided to the youth and this enabled opening up of business thus the youth making money and able to support their families.

Figure 40: Follow up of apprenticeship in Kamwenge Additionally, 950 OVC households have been served with agricultural inputs of beans, groundnuts, maize etc. The inputs increased agricultural production for OVC households, strengthened their food security and incomes. In Karusandara Sub County, in Kasese District, 24 OVC households received 76 goats for livelihood improvement thus strengthened their economic security.

Figure 41 Left: LC III handing over seedlings to OVC caregivers -Kamwenge .Right OVC caregiver watering onion demonstration garden- Kamwenge Schooled: The project has supported 5,872 OVC in education through provision of scholastic materials and school subsidies (fees), the support reduced educational disparities and barriers to access among school-age going children. The support also ensured that OVC access, retention and completion of primary and secondary levels are improved. Community structures such as of Para Social workers, CDOs, CBO staff have monitored the children in schools ensuring daily attendance and no drop outs. Also the involvement OVC caregivers in VSLA enabled provision of other basic needs to the OVC from the borrowed money. Similarly, the project also supported the establishment of 8 functional home learning Centers (ECDs) with 278 children in Kyenjojo District. The children have developed milestones such as social relations, ability to play, interact with peers and have developed cognitively. The peer children will be tracked in their primary schools to monitor their outcomes and performance.

Figure 42: OVC after receiving their scholastics materials-Kasese Left: ECD in Kyenjojo Sub County. Safe: To improve safety among OVC households, a total of 613 para social workers (PSWs) were trained and retrained child protection and case management in the region. The trained para social workers have conducted monthly OVC households visits aimed at ensuring that OVC households are provided with a service including monitoring of their safety. The monthly PSWs coordination and planning meetings have been used as fora to discuss case management, referrals and the findings feed into the SOVCC and DOVCC agenda which addresses OVC issues within the district. To strengthen safety of OVC, SINOVUYO sessions were conducted with 20 OVC caregivers groups thus 500 members in Kyegegwa hence improved parent-child relationships. Furthermore to enhance safety, 6,300 OVC were supported to access birth certificates in collaboration with NIRA. In a nutshell, the project continued supporting CBSD in the districts to prevent and respond to issues of safety of OVC within their respective districts.

Figure 43: SOVCC meetings discussing Sub county OVC issues - Kyegegwa Left: Care giver meetings aimed at improving relationship- Kabarole C5.2 Case management: The project built capacity on case management through refresher trainings and onsite mentorship to CBOs and para social workers on OVC assessment, identification, enrollment, case management and graduation using standardized Ministry of Gender, Labor and Social Development tools. 613 Para-social workers & 23 CBOs have implemented standardized case management at the OVC household level. The case management was strengthened with collaboration of the CDOs, technical Support supervision to CBOs and monitoring of case action plans and ensure case closure through the monthly case conferences conducted at the sub county. Relatedly, quarterly review meetings provided a platform to track progress, share challenges and as also check quality issues aimed at improving the quality of services to OVC. In summary, more three quarter of the OVC households during the period received more than two core program area services.; C5.3 Health: The project supported all OVC served during the five years to access HTS services, adherence counseling and follow up. For instance, in 2012/13, all the 6,761 OVC served accessed HTS services, likewise in 2013/14, 5,032 OVC were supported to access HTS service, same with 2015 till 2018. Relatedly in 2016, of 678 Children tested in dwelling homes, 158 positive and were enrolled into care and follow up for further support.

Figure 44: Pictures showing HIV testing at community level for OVC in Kamwenge

C6 Community facility framework Baylor Uganda launched the Community Facility bidirectional referral in February 2017, this aimed at strengthening of community-health facility bilateral referral and linkage framework. In order to achieve the Community Facility bidirectional referrals, 25 community based organizations (CBOs) were selected and sub-granted to partners with 141health facilities within the region. The strengthened collaboration between CBOs and health facilities to support HIV/TB care and prevention services has led to remarkable improvement in detecting positives through contact tracing, targeted community testing, community Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 45 of 82 mobilization and demand creation through linking communities to quality HIV care contributing to improved yield of 4.1% in 2018 compared 2.7% in 2018. Harnessing the strength of CBOs and other community structures, the project was able to improve linkage of newly identified HIV positive clients from 94% in 2017 to 97% in 2018. Adherence of clients on ART improved from 91% in 2017 to 95% in 2018 following intensified psychosocial and adherence support by community resource persons including CBO staff, CHWs, VHTs and expert clients.

C6.1 Facility-Community referrals, linkages and service delivery: Progressively, 51,210 referrals were made from the community to health facilities in 2018, out of which 49,674 received the services they were referred for, giving a referral success rate of 97%. In 2018, referrals made from the health facility to the community were 6,947 out of which 6,599 received the services they were referred for, giving a success rate of 95%. The surge in the number of referrals and referral success rate is illustrated in the graph below, comparing Q3 and Q4. This is attributed to the engagement of 27 CBOs that strengthened the bilateral referral system.

Figure 45: Graph Community-Facility Bidirectional referrals from 2017 -2018 Community -Facility bidirectional referrals-Rwenzori Region 60000 51,210 50000 40,430 40000 31,635 30000 20000 6,947 10000 4,7465,223 86 91 97 80 90 95 0 Community -Facility referals % complete referral Facility -Community referral % of complete referral

Jul- Sep 2017 Oct- Dec 2017 Jan- Mar 2018

Table 8: showing bidirectional community-facility referrals between 2017-2018 Quarters No of No. of % of No. of Facility No. of complete % of complete Communit Complete complete -Community referral from referral y -Facility referrals from referral referrals Facility- Community to Community Facility Jul- Sep 2017 40,430 34,770 86 4,746 3,797 80 Oct- Dec 2017 31,635 28,788 91 5,223 4,701 90 Jan- Mar 2018 51,210 49,674 97 6,947 6,600 95 Total 123,275 113,231 91 16,916 15,097 88 From the table above 123, 275 clients were referred from the Community to the health facility between 2017 and 2018 for different services. Of these, 113,231 received the services that they were referred for in the health facility thus 91% completion rate. The services referred for included amongst others, HIV testing services, ART initiation, Adherence and disclosure counselling, Viral Load test, ANC, Post GBV care. While, 16,916 referral were from the facility to the community and 15,097 were complete thus 88% success rate. At the community referral were made for services such as risk reduction counselling, Psychosocial Support and Orphans and other Vulnerable Child among others. This was possible because

C7. Objective 2.1: Scale up access to comprehensive HIV care and treatment services at Fort Portal Regional Referral Hospital. C7.1 HTS Performance SNAPS-West Project Support to the FPRRH- In the implementation period of SNAPs-West, HTS policy was disseminated, as well as the HTS screening for eligibility tools. Lay testers received refresher training, and 5S was implemented in testing points to improve client flow and provide privacy. The number of HIV tests conducted declined over the quarters from 8252 to 5734, as the yield improved from 3.0% to 3.5%. The number of positives averaged 208 each quarter, over the one year period of the project at FPRRH. Test kit stock outs and testing for KP conducted by multiple stakeholders were some of the challenges, which were addressed through joint planning meetings with MARPI, proper documentation of testing, and redistribution of test kits. Figure 46: HTS Yield trend in FPRRH

10000 HTS yield trend in FPRRH 4.0 8252 7606 3.5 8000 3.0 6929 3.0 2.8 5734 6000 2.6 2.0 4000 1.0 2000 249 194 191 201 0 0.0 Apr-Jun 17 NumberJul-Sept Tested 17 Tested PositiveOct-Dec 17 YEILD Jan-Mar 18

C7.2 PMTCT: Lay testers were stationed in ANC to support HTS among women attending ANC1. Testing kits were prioritized for pregnant women, and weekly review of the option B plus indicators for improvement was conducted. The proportion of women who knew their HIV status improved from 85% at the start of the project, to 97% by March 2018. The results are as in the table below.

Table 9: PMTCT Indicator Cascade-Project Performance PMTCT indicator Apr-Jun 17 Jul-Sept 17 Oct-Dec17 Jan-Mar 18 1st ANC attendance 820 828 635 810 known HIV status at ANC1 701 801 616 789 Proportion known status 85% 97% 97% 97% New +ves 22 17 16 34 positivity women 3% 2% 3% 5% partners tested 43 111 81 49 proportion with partners tested 6% 14% 13% 6% positives 0 1 1 0 positivity men 0% 1% 1% 0% TRRK 96 76 54 102 ART STAT 21 16 16 34 % started on ART 95% 94% 100% 100%

Challenges included low proportion of males testing with their partners. Male peer has been attached to MBCP, and flexi hours for ANC are being implemented to encourage male participation. AT FPRRH, HIV exposed newborn babies are born to mothers enrolled in PMTCT program at other facilities. A volunteer escorted these mothers to MBCP for a service package including a 6-week referral to the parent facility while peer mothers made reminders to mothers to have DNA-PCR conducted within 6 weeks. As a result, 1st PCR taken under 2 months of age remained above 80% in the reporting period, as shown below. Table 10: Early infant diagnosis Apr 17-Mar 18 FPRRH. Indicator Apr-Jun 17 Jul-Sept 17 Oct-Dec 17 Jan-Mar 18

1st PCR 90 112 97 100 PCR by 2 months 87 106 79 86 % PCR by 2 months 97% 95% 81% 86% The project supported printing of results at the hubs, which shortened the turnaround time for DNA-PCR results to under 2 weeks. More than 95% of caretakers therefore received results and prevention messages. Figure 47: EID Cascade Jan – March 2018

Total Positive 1

5 Given to Caregiver 191 Gap

Returned from Lab 196 Totals

5 Total PCR done 201

0 50 100 150 200 250

Table 11: showing final outcomes of HEI Apr 17-Mar 18. Apr-Jun 17 Jul-Sept 17 Oct-Dec 17 Jan-Mar 18

HEI enrolled 24 months back 115 41 44 92 HIV + linked to care 5 0 1 0 positivity 4.3% 0 2.3% 0 Discharged negative 98 (85%) 33(80%) 38(86%) 83(90%) lost to follow up 2 0 0 1 transfer out 9 6 4 8 died 1 2 0 0 Not evaluated 0 0 1 0 To improve final outcomes of HEI, FSG meetings were held regularly at the facility, appointments were tracked by peers, and phone call reminders improved clinic attendance on appointment. ART clinic team provided coaching to MCH staff, on viral load monitoring, and adherence support. The proportion of HEI who were discharged as HIV negative improved from 85% at the start of the project, to 90% by March 2018.

C7.3: Care and Treatment: At the start of the project at FPRRH, the facility implemented “test and treat” for all clients in care. All clients on pre-ART were prepared and supported to initiate on ART, with task shifting of ART initiation to trained nurses. A comprehensive package of ART preparedness, psychosocial assessment, GBV and STI screening, CD4 testing, TB screening, nutrition assessment were provided at a designated space in ART clinic. Clients experiencing challenges while initiating ART reported back to the enrollment and desk, were linked for appropriate management by the nurse. Linkage to HIV care improved from 62% to 100%, and a total of 945 (60%) of the expected 1580 clients were initiated on ART Apr 17-Mar 18. Eight thousand and seventeen (8017) clients were active in care by March 2018. The main challenge to enrollment on ART, was the low identification of clients. Providing PITC to eligible clients both at facility and community will be scaled up to improve identification of new cases.

Table 12: Trends of ART enrollment in FPRRH April 2017 – March 2018 Trends of ART enrollment in FRRH, Apr 17-Mar 18 Indicator Apr-Jun 17 Jul-Sept 17 Oct-Dec 17 Jan-Mar 18 Positives Identified 249 194 191 201 New Care 154 152 167 203 Linkage 62% 78% 87% 101% New ART 378 188 176 203 Tx new target 395 395 395 395 Active ART 7782 7981 7987 8017 Retention in HIV care services was improved by appointment reminders, and follow up by community experts. In the reporting period, the facility experiences stock out of 2nd line ARV medication, which led to clients reporting to other facilities for refills between Oct-Dec 2017. Documentation of these temporary referrals was also poor, and it affected reporting on the cohort. Redistribution of ARVs and accurate reporting and quantification in the next quarter improved stocks, and contributed to better retention in March 2018. Figure 48: Retention at FPRRH Performance 200 150% 150 94% 95% 98% 100% 100 78% 50% 50 143 134 180 171 123 96 99 97 0 0% Apr-June 17 Jul-Sept 17 Oct-Dec 17 Jan-Mar 18

Net current Cohort Alive and Tx % age

C7.4 FPRRH Viral load Monitoring: To increase coverage of viral load services, the project supported viral load camps between Aug 17 and Sept 17. Sorting of clients files, categorization as “stable” or “unstable” and flagging these improved client identification and flow with such clients being linked for VL testing before provision of other services. Staff were trained on the new VL algorithm with <1000c/ml as the cut-off for suppression. Weekly switch meetings were conducted to discuss clients failing on their current regimen. Demand creation through health talks, and dissemination of the SOP/client flow for on VL testing also improved uptake. As a result, viral load uptake improved from 59% in Apr-June 17, to 97% in March 2018. Viral suppression rates remained above 90%. Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 49 of 82

Table 13: Viral Load Monitoring performance-FPRRH Baseline March 2019 Number eligible for VL test 7291 7037 Number screened 4540 6813 VL uptake 59% 97% Number suppressed 4085 6245 Suppression rate 90% 92% Challenges were achieving suppression above 90 for children and adolescents, to which the facility implemented child and adolescent friendly clinic days during which caregivers and clients can be provided with a tailored message to support adherence. Management of non-suppressed.: Management of non-suppressed was supported by a multidisciplinary team, including community health workers. Documentation was improved by the introduction of the non- suppressed register in December 2016, and mentorship to improve documentation. 132 (39%) of the 334 non suppressed clients by March 2018, had a favorable outcome documented in the NS register. Challenges include complete documentation, provision of quality counseling, supporting adherence among clients with drug and substance abuse, and provision of adherence within community. Figure 49: Non-suppressed client management at FPRRH (Jan-March 2018) 400 300 21 129 200 334 313 131 100 184 131 52

0 53 79

enrolled NS wit 3 wit NS repeatVL Suppresse repeatVL switched

repeatVL

NS with NS

NS on NS

IAC

NS don

indicator gap

C7.5 TB/HIV: TB/HIV services were partially integrated for better outcomes, considering the complexities of FPRRH. A volunteer was supported to conduct cough monitoring at HIV clinic, as well as HIV testing on TB ward. The cough monitor also supported linkages between the two service points. ICF guides were provided to community health workers and staff conducting outreaches. A well aerated cougher’s corner, where cough etiquette and sample collection was done, reduced the risk of TB infection. A clinician from ART clinic provided refills at the TB ward for HIV positive clients. As a result, 100% of the PLHIV reporting to the facility were screened for TB. The proportion of clients with negative TB screen starting IPT was affected by low stocks of INH in the facility.

Table 14: TB/HIV services performance at the FPRRH

HIV/TB Co-infected HIV Non TB TB/ Co-HIV infection

No. PLH 106a No. 106a PLHIV PLH # of PLHIV No. of Kno Ne HIV PLH PL activ IV active on No. with IV ART who new & wn wly Positivi IV/T HIV e on with ART active negativ curre patients complet relaps HIV test ty yield B /TB ART presu diagnose on ART e nt on started/ ed IPT ed TB positi ed cases case asses mpti d with started sympto IPT continui during cases ve at HI Newl s sed ve TB on TB m TB ng on the servi V y Alre for TB during treatme screen IPT reportin ce +Ve start ady TB the nt New g period entry ed on quarter TB ART AR cases) T APR- 7865 66 20 20 7831 347 347 3 54 30 24 4% 20 30 SEPT 17 Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 50 of 82

OCT 17- 8017 174 11 9 7833 12 12 4 MAR 18

C7.6 TB treatment outcomes: To support favorable TB treatment outcomes, the project supported follow up of clients for drug refills. Treatment success rates were at 69%, with mortality among TB/HIV co-infected clients. Table 15: TB Treatment Outcome Performance-SNAPS West Project Support TREATMENT OUTCOME Apr-Jun 2017 July-sept 2017 Oct – Dec 2017 Jan-Mar 2018

Total Registered 36 100 77 94 COMPLETED TX 0 34 30 34 CURED 32 43 32 31 DIED 4 14 14 15 FAILURE 0 0 1 0 LOST 0 6 0 0 Total Evaluated 36 94 77 80 Not Evaluated 0 6 0 9 TSR 89% 77% 81% 69%

C8. Objective 3: Support MOH and its partners Strengthen National Pediatric/adolescent HIV/AIDS Care and provide training, mentorship and technical support supervision to RRHs and lower health facilities providing HIV care and ART services over the project period. Table 16: Key MOH National Paediatric and Adolescent HIV/AIDS Care and Treatment Performance Yr1: 2012/13 Yr2: 2013/14 Yr3: 2014/15 Y4: 2015/16 Y5: 2016/17 (Oct16- Y6: 2017/18 Indicator (Oct 12-Sep13) (Oct13-Sep14) (oct14-Sep15) (Oct15-Sep16) Sep17) (Oct17 - march18) Target Result Target Result Target Result Target Result Target Result Target Result

Number of health professionals trained in 120 25 100 25 120 100 120 1,170 120 1,170 120 0 pediatric HIV/AIDS care and management

Number of mentorship teams established to support lower level facilities in provision 22 20 20 20 22 20 22 20 22 20 22 20 of pediatric HIV care and treatment at regional level Number of RRH’s providing HIV/AIDS 11 nd 11 11 11 11 13 13 13 13 13 13 pediatric support to lower level facilities Proportion of Hospitals and HC IV mentored in provision of pediatric 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% HIV/AIDS care and treatment services Total number of children active in care 65721 67590 65674 64956 Total number of children active on ART 58778 63988 65350 64863 % of children active on ART 60% 60% 100% 89% 100% 95% 100% 100% 100% 100% Proportion of sites providing peadiatric services in Uganda 80% 54% 80% 70% 80% 70% 80% 80% 80% 80% 80% 80% Peadiatric treatment coverage 80% 22% 80% 37% 80% 55% 80% 64% 80% 67% 80% 67%

The goal of the pediatric and adolescent HIV unit is to improve survival and quality of life forchildren and adolescents infected and affected by HIV/AIDS through increasing access to HIV testing, care and treatment services. Over the project period,the project supported the MOH to conduct the following activities; Formation and functionalization of a national Technical Working Group for Paediatric and Adolscent HIV/AIIDs care and treatment program. The role of the TWG was to provide technical oversight and guide development of MOH policy guidelines. The TWG conducted a series of quarterly meetings each year to achieve this objective in addition to other relevant interventions meetings to share updates on the status of the paediatric and adolescent HIV program in the country. The MOH-TWG supported national training of health professionals in pediatric HIV/AIDS care and management with support from the project. Over the period, a cumulative total of 2490 health workers were trained in pediatric and adolescent Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 52 of 82

HIV nationally. The MOH team supported formation of national mentorship teams to support lower level facilities in provision of pediatric HIV care and treatment at regional level. Over the period, a cumulative total of 20 mentorship teams were formed and these supported different regions with partners. Additionally the MOH TWG was tasked to develop key guidance on care and treatment for adaptation in the 2014 consolidated HIV/AIDS/TB prevention, care and treatment. The TWG also supported development and adaptation to the addendum to the 2016 consolidated guidelines such Use of DTG in children and adolescents and implementation of DSD for children and adolescents. Furthermore the team at MO participated in the full development of Addendum to Consolidated guidelines for prevention and treatment of HIV/AIDS 2018. The team conducted regional orientation meetings on HIV drug resistance testing and third line ART. The orientation targeted key stakeholders that will be involved in conducting the resistance test for eligible patients and how those in need will access the third line ART; Over the period the TWG and UAC collaboration supported annual pediatric HIV/AIDS care and treatment conference with support from implementing partners and NTLP. The team conducted periodic (quarterly) national integrated support supervision covering all 14 regions in the country. As a result, the number of RRH’s providing HIV/AIDS pediatric support to lower level facilities increased from 11 hospitals to 13 hospitals across the country. 100% Hospitals and HC IV mentored in provision of pediatric HIV/AIDS care and treatment services annually over the project period.The total number of children in care by the end of the project reached 65,956 with improvement in the number of HIV positive children and adolescent from 60% to 100% active on ART. The number of ART accredited health facilities providing Paediatric HIV/AIDS treatment increased to 80% by March 2018.Paediatric HIV/AIDS service coverage across the supported regions improved from 22% to 67% by the end of the project.

C9. Objective 4: Strengthen implementation of district based programming approach and support integration of GHI principles into comprehensive HIV/AIDS care and treatment and other health services over the project period.

C9.1 Leadership and governance In line with strengthening Leadership and Governance for better healthcare, Baylor-Uganda is proud to have implemented the Caring Together Project at 147 health facilities across the 7 districts of Rwenzori regions from 2015-2018. The unique Caring Together approach, which was based around a comprehensive district-led mentorship scheme, empowered frontline health workers to deliver high quality services. Health workers, and all support staff, are critical to the successful running of health facilities and it is vital that they are provided with the tools to drive quality improvement in the delivery of care. Caring Together recognized that everyone is capable of being a leader, no matter their cadre, and that each individual should take ownership of the care that they provide, Thus creating a culture of responsibility and accountability at all levels. This intervention was implemented with support from PEPAL UK, Janssen Pharmaceutica NV and COMIC Relief, to improve healthcare for patients through sustainable change, was achieved through bringing together diverse skills and expertise in this unique collaboration that benefited the district leaders and frontline health workers. The objectives of the intervention focused on: Improvement in health worker motivation and leadership skills, Improvement in basic functionality and quality of care provided to patients and clients at health facility, Increase in utilization of health services among pregnant women and outpatients who have access to health facility, Evidence of leadership training intervention scale-up within Uganda. The SNAPS-West project benefited from the flagship leadership and governance intervention, the project was able to achieve on the above objectives through the following indicators. Each of the 147 supported sites received 6 rounds of follow up visits from the project mentors, with the initial being a training visit. Other follow ups focused on delivery leadership modules, review of improvement action plans and data collection on progress. Emphasis on the use of “Red line” to tack lateness was promoted at all sites at part of the government standing orders, there was an improvement in % of facilities tacking lateness from 23% at baseline to 80% by December 2017. This contributed to a reduction in late arrivals, hence a decrease in the patient waiting time from 61 to 32 minutes on average. Facilities were supported on data use through regular monthly meetings and use of the TPMT, 81% of the facilities were able to hold 2 or more meetings in the last 3 months as of Dec 2017 up from 47%. Feedback from health workers and patients showed an improvements in working as teams and satisfaction/willingness to recommend the received services respectively. Established a strong cadre of 49 mentors; When the project commenced, 49 ‘mentors’ were selected by their DHOs for participation in Caring Together. All practicing health workers, these individuals were chosen because of their strong interpersonal skills: a positive attitude towards work and change; honesty; diligence; approachability; and enthusiasm. They were equipped with leadership skills and tools and assigned three to four health facilities each, mentors conducted peer-to-peer training over the next three years at the 147 health facilities and over 2600 front line healthcare workers reached on site. A series of leadership TOTs and executive trainings that brought in international participants were conducted in the region, reaching 52 District leaders, 70 health facilities receiving World AIDS Day Awards, 147 facility In-charges equipped with in-charge leadership guides and 1052 VHT leaders.

Figure 50: Examples of A Team Performance Monitoring Tool (TPMT) and Employee of the Quarter Certificate

Developed 9 leadership Modules and 7 leadership Tools, The development of the leadership modules and tools was a result of the effective collaboration and exchange of knowledge and expertise between Janssen Pharmaceutica NV, Baylor-Uganda and Pepal. The modules and tools can be easily rolled out and scaled up in various different contexts and have been scaled up in the new ACE Fort project. The modules are easy-to- follow interactive lessons focused on core leadership competencies whilst tools are practical resources that enable and support more effective service delivery and better team performance at facilities. The nine modules are: Communication Skills, Teamwork, Time Management and Action Planning, Situational Leadership, Conflict Management, TPMT Data for Decision-Making, Influencing Skills, Resilience and Constructive Conversations. The seven tools are: Red Line, Monthly Meetings Book, Patient Waiting Cards, Employee of the Quarter Awards, World AIDS Day Awards, Stock Inventory Management Tool and Caring Together Ambassadors.

C9.2 Strategic Information (I/M&E)

Reporting in DHIS2 and OVCMIS Technical assistance was provided through training and mentorship to strengthen the district health management information systems to ensure timely and accurate reporting in DHIS2 and OVCMIS. In partnership with METS, HMIS and OVCMIS tools were provided to supported districts in the region. Key interventions implemented to improve reporting rates and timeliness include provision of internet data bundles, use of SMS reminders, provision of reporting tools and supervision. The figure below shows the trends of HMIS reporting rates over time.

Figure 51: Trend of HMIS Reporting rates in Rwenzori Region Trend of HMIS Reporting rates in DHIS2 Rwenzori region 91 96 88 92 94 99 100 75 54 0 2012 2013 2014 2015 2016 2017 2018

Outpatient Report (HMIS105) Quarterly Report (HMIS106a) Inpatient Report (HMIS108) Target

Electronic Medical Records System (OPENMRS) Baylor Uganda support implementation of electronic medical records systems to improve patient health management and quality reporting. The project target was to functionalise OPENMRS in all supported ART sites (130). Over time, the number of ART sites supported to use OPENMRS increased from 14 (11%) in 2012 to 82 sites (63%) by end of the project in March 2018. OPENMRS coverage was highest in Bunyangabu and Kabarole districts because the two districts were piloting the case-based surveillance system implemented by Baylor Uganda, METS and MOH. The increase in OPENMRS coverage was attributed to provision of computers, solars for power back-up, recruitment of MRAs and technical assistance in forma of training, mentorship and supervision. The key barriers to scale up OPENMRS system in the region were lack of power, Human resource gaps and equipment safety.

Figure 52: Number of sited using OPENMRS in Rwenzori Region

Figure 53: OPENMRS coverage by district by March 2018 OPENMRS coverage by district by March 2018 92% 40 87% 36 100% 75% 70% 64% 80% 30 23 60% 55% 20 20 60% 36% 20 12 14 14 13 11 9 10 11 40% 6 6 10 4 3 20% 0 0% Bunyangabu Kabarole Ntoroko Kyenjojo Kamwenge Bundibugyo Kyegegwa Kasese

# ART sites # ART sites using OPENMRS OPNMRS Coverage (%)

The project also supported CBOs (25) to implement an electronic system to improve data management and reporting. Data management trainings and integrated mentorships for community health management systems were conducted to streamline data flow systems, data quality, reporting and use. Data Use Initiatives: Technical assistance through trainings, mentorship and supervision were conducted to empower Biostaticians, MRAs, CDOs, DCDOs, Probation officers, health workers and project staff with skills and knowledge to analyze and use data for planning. Data management trainings conducted included GIS mapping, Advanced Ms Excel, DHIS2 and OVCMIS. The project used dashboards to provide timely data to monitor project performance including; Weekly SMS tracer, weekly PMTCT SMS dashboard, VL dashboard and Surge. In addition, the project used GIS (Geo-mapping technologies) to analyse data and identify under-served areas/populations which required interventions. Monthly and Quarterly performance review meetings were conducted at site level, district level and regional level targeting all stakeholders i.e. health workers, DHT, district leadership and implementing partners. By end of the project, all districts were conducting quarterly review meetings. At site level, 87% of supported sites were conducting monthly meetings up from 35% sites in 2012.

Data Quality Assurance The project conducted quality data quality assurance, on-spot checks, site level data validation meetings, mentorship and trainings to ensure quality data is generated and used for reporting. OPENMRS, DHIS2 and OVCMIS systems were used to generate data quality queries which were shared with responsible persons to address. Monthly district level, quarterly regional/national level data cleaning meetings were conducted involving the DHTs and project M&E teams. All actions developed from the DQAs and data cleaning meetings were monitored and tracked by the project. The project provided Metallic filing shelves and Patient file folders to improve records management systems. The challenges encountered by the project include; inadequate stock of essential data capture and reporting tools; lack of patient identifiers for unique tracking of patient receiving various services; M&E Capacity gaps in some facilities.

C9.3 Strengthened capacity of Laboratory services to enhance comprehensive care, treatment and TB/HIV services.

C9.3.1 Laboratory Quality Management System (LQMS) The project strengthened the capacity of laboratory services to enhance comprehensive care, treatment and TB services. All supported health facilities were supported to provide services commensurate to their level through direct delivery or referral system. The project supported training, viral load support and district hub reviews of laboratory quality assurance data as well as follow up mentorships working with 21 Laboratory Technical Assistance Teams (TATs). More support was given to the lab hub system in quality monitoring of tests, logistic support, equipment placement and service, and provision of supplies to support hub functionality and administration. Laboratory personnel were mentored in comprehensive Laboratory Quality Management Systems (LQMS) in all supported sites. The Laboratory Technical Assistance Teams supported quality improvement, accurate reporting, quantification and ordering of laboratory supplies from the national warehouses (NMS/MAUL) as per the order schedules.

Table 17: Laboratory Star Score Status Laboratory Hub Baselines Star Score (2012) Current Star Score (2018) Fort Portal RRH 0 3 Kilembe Mines Hospital 0 3 Kyenjojo Hospital 0 2 Bundibugyo Hospital 0 3 Rukunyu HCIV 0 3 Kyegegwa HCIV 0 2

C9.3.2 Laboratory Accreditation Technical Support The project supported establishment of additional laboratory hubs from one hub (baseline) to six hubs to implement SLMTA with a target of each laboratory achieving and maintaining at least star 3 based on the WHO-SLIPTA checklist. This was attributed to MOH site assessment and mentorship in SLMTA, logistic support, recruitment of critical laboratory staff and refurbishment of the lab hubs. By the close of project, 2 lab hubs (Fort Portal RRH and Kilembe Mines Hospital lab) were earmarked for international accreditation by South African National Accreditation System (SANAS). The table above shows the star ratings conducted by ASLM auditors of all supported hub labs by the end of the project.

C9.3.3 Strengthen Specimen Referral Systems and Hub Support The project established sample/results referral mechanism to cover all supported health units in the region over period. The system supported transportation of the following samples; CD4, viral load, sputum, DBS and HIV-EQA panels to the hub system for analysis and return of results back to the referring facilities. The system was supported by 12 hub riders who visit all health units twice a week. The project supported mentorship in utilization & documentation of viral load monitoring with reduction of viral load sample rejection rate to < 1% by March 2018. Additionally, the project supported buffer stocks of some reagents and laboratory supplies across the region to avert stock-outs as well as administrative and logistic support to the hubs. The project supported quarterly hub review meetings at the 6 laboratory hubs to review performance and utilize data to improve performance.

C9.3.4 EQA Outcomes The project continued supporting improvement in monitoring the quality of laboratory tests through strengthening internal and external quality controls of tests especially for HIV, TB and CD4. Further support was given to the 6 laboratory hubs and 2 other main district laboratories (Kibiito HCIV and Ntara HCIV) to participate in quarterly EQA for CD4 (UKNEQAS) program. Response rates increased from 50% in 2013 to 90-100% in 2018 and results average satisfactory rates increased from 25% in early 2013 to more than 85% by all the 8 participating labs quarterly. This performance was attributed to targeted EQA mentorship and participation in inter- laboratory comparability of CD4 tests. The project enrolled all

C9.3.5 Laboratory Logistic support The project procured;50 Olympus binocular microscopes, fridges to 5 laboratory hubs, 5 Computer sets to 5 lab hubs, 8 Internet Routers for VL/EID results download and communication, 7 centrifuges, 6 roller mixers to 5 Lab hubs and 1 district lab (Bwera), 6 automated biometric control access systems, and 5 eye wash equipment for infection control practices. In addition, lab automation chairs and other regular chairs, patient waiting benches and tables to improve lab services and HCT testing points in HFs were procured. Two backup hub generators were procured for Kyegegwa HCIV and Kilembe Mines Hospital. The key challenges that affected delivery of quality laboratory services include: Stock outs of some critical laboratory supplies due to non-delivery, irregular pattern or inadequate quantities delivered such CD4 reagents and controls at most hubs, sputum smear reagents for TB diagnosis, sputum mugs, slides, Stat-pak (short expiry in stock).

C9.4 Strengthening system of Logistics & supply chain management To improve medical commodities availability as a critical outcome, the project adopted a health system strengthening support model that included; Capacity building for health workers (through didactic trainings and onsite mentorships), tracking of stock levels, redistribution of medical commodities, follow up on periodic reporting/ordering of medical commodities. The support model was designed to address causative factors such as; poor quantification methods, lack of trained pharmaceutical staff or lack of appropriate skills, poor ordering practices (timing and accuracy), irrational medicine use, especially antibiotics and injections (major contributing factor to medicine wastage in health facilities). Capacity building through classroom trainings were followed up by onsite mentorships which were part of the comprehensive mentorship. Some placements/attachments were organized for some health facility staff, mainly to bring those in best performing HFs to support weak facilities, this mainly focused on targeted interventions. Additionally, over the period, the project provided technical assistance regularly on quantification and ordering of commodities during bimonthly ordering cycles and continuous quality improvements of supply chain processes.Continuous technical assistance had been also given to have the different supportive electronic systems fully functional i.e. WAOS, TWOS, Rx-solution, Pharmacovigilance tools.The support provided helped realize improved availability of essential medical commodities and minimized wastage of medicines in supported Health Facilities. Baylor Uganda has also supported implementation of national interventions like roll out of a Web-based ARV Ordering System (WAOS) to improve Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 59 of 82 quantification/ordering of ARVs and eMTCT medicines. The project in collaboration with Ministry of Health/Pharmacy Division and the then USAID/SURE (Securing Ugandans’ Right to Essential Medicines) project from 2013 to 2014 rolled out WAOS in all our supported units in the region. All high volume health centers were provided with modems to have internet available for online reporting. Project staff worked with Medicines Management Supervisors (MMS) to support ordering of other medical commodities that are not on the WAOS online platform. Ordering rate for ARVs/eMTCT medicines in all their supported regions has improved from 60% in 2013 to 95% by August 2018. TB medicines ordering rate was not tracked being a manual process, the region experienced frequent stock out and frequent expiries of TB medicines due to under-fulfillment of health facility orders by NMS , However by bringing TB medicines on web-based ordering platform, reporting rate is expected to reach 100%.The project relied on redistribution mechanisms to address the gap in units and continued to lobby MOH/CDC to exert pressure on NMS to fulfill health facility orders for TB medicines.

Figure 54: ARV stock out rate Rwenzori Region 2014 – March 2018

14% ARV stock out rate-Rwenzori Region 2014-March 2018 12% 12% 10% 8% 7% 8% 6% 6% 6% 6% 6% 4% 3% 3% 4% 2% 2% 2% 1% 1% 0% 0% 0% 0% Q.3 Q.4 Q.1 Q.2 Q.3 Q.4 Q.1 Q.2 Q.3 Q.4 Q.1 Q.2 Q.3 Q.4 Q.1 Q.2 Q.3 2014 2014 2015 2015 2015 2015 2016 2016 2016 2016 2017 2017 2017 2017 2018 2018 2018

The project conducted quarterly monitoring and evaluation of the supply chain performances to track progress on stock availability, quantification accuracy, adverse drug reaction reporting and minimized wastage on expiration. Following the support provided there was marked decline in stock out of HIV commodities as from 2014 till 2017 when stock outs began to rise, explained by the “Test and Treat” strategy due to challenges with the national supply grid to support increased number of clients on ART. This crisis in shortage was however managed by vigorous redistribution minimizing treatment interruptions to less than 2 days.

Figure 55: HIV Test kits stock out rate-Rwenzori Region 2014- March 2018 HIV Test kits stock out rate-Rwenzori Region 2014- March 2018

30% 25% 23% 25% 20% 16% 15% 13% 13% 14% 10% 8% 9% 6% 5% 5% 4% 3% 4% 2% 3% 3% 0% 0% Q.3 Q.4 Q.1 Q.2 Q.3 Q.4 Q.1 Q.2 Q.3 Q.4 Q.1 Q.2 Q.3 Q.4 Q.1 Q.2 Q.3 2014 2014 2015 2015 2015 2015 2016 2016 2016 2016 2017 2017 2017 2017 2018 2018 2018

The same trend was reflected with HIV test kits, due to increased demand for test kits with increasing testing targets, however as stocks continued to get depleted frequently, we adopted the targeted testing strategy to use limited supplies for only those who need the test.

Figure 56: Quantification accuracy Rwenzori Region 80.0% QUANTIFICATION ACCURACY -RWENZORI REGION70.3% 60.0% 50.7% 60.4% 61.8% 53.8% 49.6% 50.0% 40.0% 40.6% 27.1%37.7% 32.4% 30.0% 20.0% 31.7% 18.3% 30.8%

0.0% Cycle-4 (2016 Cycle-3 (2017 Cycle-4 (2017 Cycle-5 (2018 Cycle-6 (2018 Nov-Dec) Sep-Oct) Nov-Dec) Jan-Feb) Mar-Apr) Ordering accuracy 40.6% 50.7% 60.4% 61.8% 70.3% Matched Paed regimen needs 27.1% 32.4% 18.3% 30.8% 30.0% Consumption And Patients data tally 37.7% 31.7% 53.8% 49.6% 50.0% Using a quality improvement approach, project set to reduce commodity redistribution and costs involved. It was realized as a major factor to minimize frequent redistributions was to ensure Health Facilities quantify accurately and submit/order in time to the central warehouses, therefore a campaigns of tracking quantification accuracy was started in 2017, where quality of ARV orders were assessed using ARV Order Quality Assessment tool of MOH developed by Clinton Health Access Initiative (available on link http://arvorderquality.health.go.ug/reports/). With routine monitoring and support to health facilities, ordering quality was improved from 40% in 2016 to 70%. Matching consumption data with number of patient served had not improved because of manual tracking of client served that risks reporting errors on numbers actually served.

Figure 57: District SPARS performance-Rwenzori Region- March 2018 District_SPARS performance-Rwenzori Region- March 2018

21.4 21.2 20.5 25.0 19.8 19.1 18.9 18.3 19.2 19.8 20.0 10.8 10.1 11.1 10.2 11.8 11.5 10.7 15.0 10.1 9.6 10.0 5.0 0.0

First visit-Baseline Last visit-March 2018

Overall supply chain and pharmacy activities in general have been strengthened as reflected on SPARS (Supervision, Performance, Assessment, and Recognition Strategy) scores. Though the project did not directly implement SPARS however, the routine mentorships in the Health Facilities addressed all performance gaps reported by Medicines Management Supervisors whenever they conducted SPARS visits. There has been general improvement in quality of Pharmaceutical services including medicine logistics from score of 10.7 out of 25 (42.8%) in visit 1 to 19.8 out of 25 (79.2%) latest visit tracked. Inventory management has been strengthened by introducing, Rx-solution into 22 high volume Health facilities in Rwenzori region. Capacity of Health workers to use the application, to post routine stores transactions and generate reports (tracking expiries and monitor stock levels) had been built. To improve storage management, the project procured pallets and shelves to supplement on facilities supplied by UHSC/MSH. Quality in storage management has been improved with 78 out of 130 Health facilities with noticeable 5S quality systems in place.

Figure 58: 5S reflected for stores at Bwera Hospital stores in Kasese District Key achievements under Medical Logistics/Supply Chain Strengthening; 1. Health facilities were able to improve on storage management with the support of the Hygrometers, Pallets and Shelves procured during the SNAPS west project

2. During the SNAPS West project, the health facility teams were able to transition from the paper based stock management to the electronic logistics management by use of the Rx Solution system, WAOs and TWOs systems used in the bimonthly ordering and reporting to their respective warehouses. 3. Health facilities were oriented on the need to capture, report and document on the Adverse drug events at health facility level and pharmacovigilance teams were set up at health facility level. 4. Stock outs of HIV Commodities, EMHS and reproductive health were greatly reduced through enhanced mentorships to health workers on stock management, and the redistributions conducted. 5. The bimonthly stock status analysis from the order and reporting tools helped to identify stocking gaps in health facilities and also guide on the redistributions. This also offered guidance for emergency ordering. 6. Continuous stake holder engagement through the district review meetings to discuss logistics and supply chain issues enabled us build capacity of district teams to take lead in addressing supply chain gaps. 7. Trainings on Logistics management and information systems e.g.(Rx Solution, WAOS, TWOS) helped build skills of health workers to operate efficiently. Challenges faced by the project in Logistics Strengthening 1. Warehouse partial order fulfillments which affected stock levels of HIV commodities and hence stock outs of HIV commodities especially Second line treatment during Year 5 of the Project. 2. Rotation of health workers from one duty station to another affected the performance of the stores. 3. Inaccurate and inconsistent data submitted by health workers in the bimonthly order and report forms leading to poor decision making by the technical officers. 4. Lack of supportive tool to send alert for pending stock outs of HIV Commodities. 5. Implementation of national policies that affect supply chain e.g. test and treat with limited planning for commodity sustainability. Rxsolution did not provide us real-time stock levels because health facilities/health workers could not post all transactions in real time

C9.5 Strengthened capacity of district and health facilities to implement CQI initiatives Quality Improvement (QI) is one of the components of Quality Assurance (the others being Quality Design and Quality Control). It identifies where gaps exist between services actually provided and the expectation for the service, and serves to lessen these gaps not only to meet client needs and expectations but to exceed them and attain unprecedented levels of performance. At the beginning of the project implementation period, the region had only isolated incidents of QI application, and this was based on the interest of the stakeholder involved. There were no QI structures, and QI was only implemented in a few units sporadically with no sustainability agenda. We sought to institutionalize QI and build a culture of quality practice by incorporating it into routine district and health facility activities.

Methods: Baylor-Uganda generated and implemented a Quality Management Plan (QMP) aligned to the Uganda Healthcare Quality Improvement Framework and Strategic Plan. The QMP was applied through a Baylor-Uganda QI management structure that provided technical assistance to supported districts and health facilities in partnership with the Quality Assurance Department of the Uganda MOH. The activities engaged in were centred around: Formation, maintenance and scale up of QI structures at Regional, District and health facility levels (QI Focal Persons and QI Committees); Building capacity of health workers in QI competencies through trainings, mentorships and coaching; Ensuring functionality of the QI structures through follow up supportive supervisory visits and provision of QI implementation and reporting Tools; and Encouraging sharing of “Best Practices” through collaborative learning sessions and other for a, and Recognition/ Reward of “Best Performers”. QI was integrated into comprehensive HIV/AIDS technical support visits and mentorships, and these were carried out by joint MOH, district and Baylor-Uganda staff using SIMS and MOH Clinical Systems Mentorship tools. Standard Operating Procedures (SOP) were developed based on MOH policy guidance and compiled into an SOP manual to ensure adherence to set standards. These were adopted or customized to health facility context. We also leveraged on the work planning for the Baylor-Uganda districts sub-granting to ensure that all the 8 districts and 100% of HC IIIs, HC IVs and hospitals have Quality Improvement activities incorporated into their general work plans and budgets. We supported generation of District HIV Strategic Plans in January 2016. We developed a QI e-database to track progress of QI activities implementation, and supported focused and responsive technical assistance for improved functionality of district and facility QI teams. SIMS Assessments of SNAPS-West Sites 150 100 50 0

ANECCA Aug 2015 CDC 2017 CDC Aug 2015 CDC 2017 assessed

COE % Score Score % areas all of Red Yellow Light Green Dark Green

Figure 59: SIMS performance –Rwenzori Region By March 2018, the scale up for QI had ensured that all the 8 districts, 5 hospitals, 12 HC IVs and 95 HC IIIs of the Rwenzori Region had been trained in QI, identified QI Focal Point Persons and formed QI Committees. This constituted 86% (n=139) of health facilities, and these hosted the highest burden of disease. QI tools and methodologies were applied at 124 supported health facilities, the Centre of Excellence at Mulago Hospital and 8 District Health Offices. A total of 246 QI projects were implemented to address performance and quality of care gaps, successfully completing 118 of them and causing improvements in the selected indicators. 390 staff benefited from CMEs on CQI and 5S during health facility visits. 94% of health facilities subjected to internal and external assessments for quality of care by joint CDC, district and Baylor-Uganda teams met or surpassed expectations compared to 26% in 2015. Best Practices and Success Stories were shared at 4 region-based and 1 national learning exchange meetings where best performers were recognized, while 19 abstracts from completed QI projects were presented at 4 local and 3 international conferences (JASH, IAS, BIPAI), with 2 manuscripts published in international scientific journals.

Discussion: The results above depict competent functional QI teams in the health facilities, improved quality of care provided to clients, and data use established at the facilities. We learnt that involving clients and managers in healthcare decisions and improvement work results in better care, and that building capacity of district staff to monitor and supervise services ensures sustainability of QI. Successful and Promising Practices included introduction and support to weekly health facility data days, creating a district and regional league table, recognizing and rewarding best-performers and sharing of improvement work at regional, national and international platforms. Challenges however persisted despite all the above efforts and investments. The measure of success for each of these interventions remained varied, right from health facility level, to district to the region. QI structures were unstable, both in availability and functionality, and continued to be dependent on QI mentors and coaches. QI was also still largely perceived as a project of its own and considered additional work by a large section of health workers, and so we continued to see characteristics of resistance in facility teams to adopt and integrate QI into routine activities of the health facilities. Conclusion and Recommendations: Overall, there was resultant effective and efficient utilization of resources accruing from improved quality of care that enhanced client satisfaction and uptake of services, while members of the QI implementing teams expressed improved job satisfaction and were better motivated to continue with improvement work. We recommend continued support to capacity building efforts of the regional, district and health facility teams to implement QI; scaling up of QI structures at the regional, district and health facility levels with emphasis on their functionality; greater involvement of communities and clients in healthcare provision and decision making; Enhancing Peer- to-Peer Learning, Scaling up Best and Promising Practices, supporting HWs to present QI project- based Operational Research Abstracts at national and international conferences, and establishing model sites to act as QI learning centres. These will provide regional and district QI-competent coaches that will support district and facility QI teams and further address sustainability concerns

C9.6 Human Resources for Health (HRH) The Launch of Comprehensive Integrated Strategy towards addressing Human Resources for Health issues to include but not limited to Medical Education, Partnership Initiative, among others kicked off with the recruitment of health workers to achieve the strategy in Rwenzori Region. Human Resource for Health Primary role in HIV Care thus being the reason why PEPFAR through the project Invested UGX 200,260,521 between 2013 and 2015. The strategy of developing a skilled HIV Care work force kicked off with the recruitment of 83 critical staff in the Categories of Pharmacy, Nurses, Midwives, Clinical Officers, and Medical Officers among others in the Districts of Kasese (36) Kyegegwa (14), Bundibugyo (17), and Ntoroko (16). In comparison with the PEPFAR allocations for COP12, this was a great achievement as all the critical positions were filled as required. With the main objective of training and transforming the critical cadres into the government main stream, we achieved absorption rate of 81% (Kasese), 59% (Bundibugyo), 71% Kyegegwa and 0% Ntoroko district. Absorption was a success in Kasese, Bundibugyo and Kyegegwa districts however, with the population that Ntoroko district had then, there was no motivation for staff absorption after studying patient health worker ratio. So the overall performance of 59%. As per PEPFAR allocations in 2015; critical cadres were recruited in the districts of Kabarole (29), Kasese (11), Kamwenge (13), Kyenjojo (18) and Fort Portal Regional Referral Hospital (13). This was again tremendous success as the PEPFAR allocation for critical cadres are achieved. With a lot focus on preparing these critical cadres for absorption in the government structure, Fort Portal Regional Referral Hospital was at 8%, Kamwenge 85%, Kabarole 0%, Kasese 0%, and Kyenjojo 0% so an average rate of 14%.

Figure 60: HRH-Support performance: PEPFAR ALLOCATION / RECRUITMENTS / ABSORPTIONS 200 167167 150 100 47 47 61 50 29 29 29 17 17 16 16 18 18 0 13 13 1 13 13 11 10 0 0 14 14 10 0 Kabarole FRRH Kasese Kamwenge Bundibugyo Ntoroko Kyenjojo Kegegwa Total

PEPFAR Allocation NO. Recruited No. Absorbed

A minimal percentage was noted to have left the support to PFP facilities with major reasons of such as not having positions in the government structure which posed as a risk of not being absorbed in the government structure. These included Pharmacy and Laboratory Technologists, positions which were not provided for in the health structure of Uganda Government. Positions like Laboratory technologists added meaning to the quality of care due to the noted expertise in improving the quality tests done as well as the knowledge to able to operate highly specialized laboratory equipment such as the gene x- pert. Ultimately, at the end of the project, the staff absorption average rating was at 37%, with Kabarole (0%) FRRH (8%), Kasese (65%), Kamwenge (85%), Bundibugyo (59%) and Kyenjojo (71%). % HRH ABSORPTION PER DISTRICT Kabarole, 0% FRRH, 8% Kegegwa, 71% Kasese, 62%

Ntoroko, 0% Kyenjojo, 0%

Bundibugyo, 59% Kamwenge, 85%

Figure 61: HRH absorption per district Partnership and advocacy as one of the valued mechanisms, played a great role towards the good performance in the PEPFAR Staff absorption. Utilization and Functionalization of Human Resource Information Systems By 2016, PEPFAR through the project had invested much in critical staff that were good enough to spear head the initiatives for HIV Care Services in Rwenzori Region.The PEPFAR focus was to improve HRH information Systems through HRIS update and data use. Using the human resources information system, Baylor Uganda supported all the Rwenzori region districts to ensure that the critical information regarding health workers was well maintained and managed with easy access for critical analysis and strategic decision making. All the bio data regarding health workers were captured in the HRIS. As PEPFAR supported training of health workers, all the training records were as well captured in the HRIS. The HRIS was as well used to monitor the attendance to duty for all health workers across the region. He project HR team worked hard to ensure that attendance reports were submitted to the respective district through the in-charges in a timely manner for in putting in the HRIS. By the end of the project, the rate of absenteeism had reduced to less than 10% across the

C9.7 Strengthened organizational and technical capacities of target districts to plan and manage a sustainable program for comprehensive HIV/AIDS services

C9.7.1 Financing One of the strategy under this project was the provision of quarterly performance based sub grants to health facilities, District Health Offices (DHOs), District Community Development Offices (DCDOs), District Associations of People Living with HIV/AIDS (PLHAs) and Community Based Organisations (CBOs/CSOs). An input based sub granting mechanism was used where funds were disbursed directly to the mentioned implementing sub grant partners named above. Baylor Uganda provided these sub grants to its partners as a fulfilment of one of the six building blocks of Health Systems Strengthening (HSS) – Financing for Health.

Table 18: Sub grant Disbursements from April 2012 – March 2018. District Amount disbursed Amount accounted % accounted Kasese 1,744,022,183 1,733,824,900 99 Kabarole 1,670,222,500 1,666,404,168 100 Kamwenge 1,092,831,500 1,092,360,153 100 Kyenjojo 1,321,034,000 1,309,027,406 99 Kyegegwa 840,067,500 838,672,891 100 Bundibugyo 781,076,500 769,638,291 99 Ntoroko 532,961,500 521,840,734 98 CBOs 3,808,688,994 3,791,492,994 100 FRRH 636,000,000 636,000,000 100 Grand Total 12,426,904,677 12,359,261,537 99 Sub grant achievements; A number of achievements were registered as a results of Baylor Uganda sub granting its partners and these directly and indirectly contributed to the attainment of the project indicators. Tidying up was introduced as a component of tiding up health facilities, District Health Offices (DHOs), District Associations of People Living with HIV (PLHAs) within the sub grant. These (health facilities, DHOs and PLHAs) were requested to identify one or two priority needs every quarter to improve the working environment of staff and facility ambience. A provisional list of eligible activities was provided to each of the supported health facilities and included activities such as; replacement of broken window and door glasses, Painting of health facility blocks, Repair of broken floors and leaking roofs, Demarcation of working space, installing of signage around the facility e.t.c. Each facility was requested to identify their priority area to fix or improve. A standard operating procedure (SoP) was developed to guide health facility in charges in tidying up. The SOP required local procurement of goods and services by a committee constituted by the facility staff and HUMC members with eventual accountability of the funds. Results. A total of 125 health facilities, 7 District Health Offices (DHOs) and 7 District Forums of People Living with HIV/IADS (PLHAs) across the seven programme district of Kyegegwa, Kyenjojo, Kamwenge, Kabarole, Kasese, Ntoroko and Bundibugyo received the funds and each undertook activities of their choice. 70% were able to cause visible impact mainly through facelifts of the buildings and working environment improvements.  Activities were executed at an average cost of 110% lower than the usual cost of doing similar activities through the district procurement units.

 Turnaround time was reduced by 200% as health facilities were able to procure and have services executed within a record period of three months or less (One quarter).  72% of the health facilities registered an increase in number of clients accessing services as a result of the improved environment.

Figure 62: Tidying up pictorial

Kaswa HCIII in Kabarole.Before tidying up Kaswa HC III After tidying up

Placenta pit at Kabonero HCIII Bunyangabo District Water tank at Nyabugando HCIII in Kasese

Kidubuli HCIII in Kabarole Before Kidubuli HCIII in Kabarole After Challenges faced during the implementation period. Delayed accountability by the sub grantees which used to lead to delayed review and liquidation of accountabilities by Baylor Uganda. This led to delayed release of sub grant funds for the subsequent quarters.There were also cases of misuse of funds by the sub grantees. This resulted into disengagement with some partners especially Community Based Organisations (CBOs/CSOs). Conclusion. The first sub grant disbursements had a number of issues but as time went on, both Baylor Uganda and its partners learnt lessons. By the end of the project, the mechanism had stabilised and so many achievements were registered. It’s on those that the new project ACE – Fort is building.

C9.8 Capacity Building

C9.8.1 Trainings C9.8.2 Pre-service training: With support from the Supporting and Improving National Training Systems (SAINTS) project, 235 beneficiaries from the Rwenzori region received training from selected accredited national training Acknowledgement and Disclaimer: “This publication was supported by cooperative agreement number “insert co-operative agreement numbers” 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.” Page 68 of 82 institutions. Under this arrangement, the beneficiaries were bonded to serve in hard-to-reach and under- served districts for 2.5 - 3 years after they completed training. The bonding was to improve the staffing levels in the hard-to-reach and under-served districts in Uganda and to reduce staff attrition. The table below summarizes the beneficiaries from Rwenzori region that benefited from the bursary scheme.

Table 19: Scholarship recipients under SAINTS Project in Rwenzori region (Pre-service training) Certificate Certificate Medical Diploma Medical Medical Lab Degree/Post-graduate District Midwifery Lab Techniques Lab Technology Degree Medical Education 1. Bundibugyo 47 4 3 0 0 2. Kasese 58 9 10 1 1 3. Kabarole 24 2 3 4 1 4. Kyegegwa 7 3 2 0 0 5. Kyenjojo 16 8 5 0 0

6. Kamwenge 9 0 2 1 0

7. Ntoroko 14 0 1 0 0 Total 175 26 26 6 2

C9.8.3 In-service training: In order to meet the project objectives, Baylor-Uganda in partnership with the Ministry of Health and the District Local Governments built the capacity of various cadres of in health services’ delivery sector in order to improve their skills and knowledge. One of the methods used included in-service trainings in order to enable participants to effectively implement project-supported activities. Under the project, a variety of important topical areas were covered and were attended by 8,056 participants (see details in the table below). In addition, during the lifespan of the project, through other funding mechanisms i.e. AFCA, ELMA, SAINTS, SMGL and PEPAL, an additional 2,010 participants attended trainings as reflected in the table below.

C9.8.4 Mentorships To complement the in-service training initiatives, quarterly comprehensive mentorships in clinical systems and post-training mentorships were conducted across all 127 health facilities during the project period in order to farther build the service providers’ capacity to provide quality HIV prevention, care and treatment services. The mentorships focused on pediatric, adolescent and adult HIV care, viral load monitoring, TB/HIV services, laboratory screening and monitoring, supply chain ordering and storage, psychosocial support with counselling, and nutrition care services. The mentorships targeted health workers in the different health care departments including facilities’ ART clinic, laboratory, pharmacy/stores, records/data, OPD, labour and maternity, and the mother-baby care points. The health workers who benefitted from the mentorships were Clinical Officers, Nurses, mid-wives, Laboratory personnel, data officers and Community Health Workers. Mentorships were conducted in partnership with the district teams as the team leads; the cluster teams of Baylor-Uganda participated in the planning and coordination of the mentorship activities. These mentorships greatly contributed to the provision of quality services to clients leading and to the positive outcomes realized under the project’s support.

C10 Infrastructural Improvement Table 20: showing Major Refurbishments done during the project period District Facility refurbished (completed)

Attach asample of photos (before and after)

Table 21:Refurbishment costs and status Status of Costs Project Name/Facility type COP Year (FY) Start Date End Date district the (UGX) renovation

C11.Success stories Case study I: FROM GRASS TO GRACE WITH PRIDE Niwagaba Imelda (Second left, not real names) is an orphan born in 2002 to a single mother that passed away immediately after delivering her. She grew under hardships with her two sisters and a brother. Imeldah used to fall sick frequently not knowing what the cause was. When she was 14 years old she went to live with her elder sister who had gotten married in Lyengoma Village, Nyakasura Parish Mahyoro Sub County, Kamwenge District in Western Uganda. During one of the home visits by a Community Healthy Worker (CHW) and COSIL a CBO supported by Baylor- Uganda, Imelda was found very ill and was referred for care at Mahyoro H/C III where she tested HIV positive. She was counselled and started on medication (ART). With regular home visits by the CHW, she was enrolled in the OVC program to benefit from apprenticeship training for out of school OVC. Imelda like other disadvantaged girls was offered life skills training that enabled her to select and chose hair dressing amongst other vocational courses. Imelda narrates that ……“during my free time, I have managed to make weave and repair customers’ hair earning close to 120,000/= a month. I have now invested part of this money in 2 piglets. Having adhered to my medication and the constant follow- up from CHWs, the virus is now suppressed. Additionally I was selected to be a peer educator at Mahyoro Health center III to support other young people like me.”

Case study II: THE POWER OF REFERRAL SYSTEM.

Ndungutse John (Not real names) is a 7 year old boy born with HIV and residing in Kakinga parish Kamwenge sub county in Kamwenge district. Upon marriage dissolution between his parents, John at 3 years then was deserted by his own mother, who dumped him at her elderly grandparents’ home after getting married to another man. From frequent illnesses John suffered, his grandparents took him to Rukunyu HCIV for medical checkup, only to be told that John was HIV positive. Though started on ART, John’s health kept on deteriorating because his grandparents never gave him good care as they believed he would never survive. John’s father too never provided any support. As luck would have it, during the home visits by a Para social worker (PSW)-Ms. Kakyo Margaret, John was found in a poor health condition. His ears were swollen and pus was flowing out of them. His fingers had gotten wasted away because of jiggers. He was severely malnourished. He had no medicine and his grandparents had resorted to making him sleep in the kitchen with goats and chicken instead of the living house, where everybody stayed. Margaret the PSW then linked up with Child Initiative Agency (CIA) a Baylor- Uganda supported CBO as well as the Community Development Officer of the Sub County and a Baylor-Uganda OVC officer who immediately followed up the case. During their visit, the grandparents and John’s father were provided with psychosocial support. They were sensitized on child rights and the importance of ART adherence.

A house hold case plan was drawn with the family and followed up by the PSW on a weekly basis. John and father have been linked to Kabuga Health Centre III for ART services and has remarkably responded to treatment. John’s life is improving, his pride and hope have been restored and his caregivers now remember to provide him his medication on time. John can now feel the father’s love who has promised to take care of him. The family is grateful to Baylor-Uganda, with funding from PEPFAR/CDC and CIA - a local CBO, many other children like John have been given hope and a new lease of life.

Case study III: FAST TRACKING LOST CLIENTS IN BAYLOR SUPPORTED FACILITIES.

Laker Kahunde (Not real names) - 20years, has been twice unfortunate; at a tender age of 14 years, she was defiled―not only getting pregnant but also contracting HIV. But she did not know until in April 2016 when her parents took her to Rukoki Health Center in Kasese district, Western Uganda―where she hails for treatment. While she presented with a bout of malaria, health workers tested her for HIV because she manifested AIDS

However, after one year of good adherence to her treatment―and good health, health workers noticed when LK did not return for her review and monthly ARV refills. The health facility, which is supported by Baylor Uganda―a local CDC partner, fervently works to keep its HIV clients in care. With an active team of expert clients that help track ‘lost to follow-up clients,’ they used a ‘locator form’ that had LK’s contacts and found her. She had relocated to Bushenyi-Mitooma (a neighboring district, also in Western Uganda) to stay with the father of her child. “Life was hard on my own,” she reveals. “I tracked the father of my child and he accepted to take us in.” Unfortunately, while she was linked to another health center close to her new home, LK stopped taking her ARVs because she feared her husband would find out that she was HIV positive. This greatly affected her health. She fell very ill and her husband chased her―back to her parents. Her support team―in another follow-up effort to ensure that she stays in care tracked her back to her parents and returned her to Rukoki HC for care. “That was in May 2017,” says Michael Isingoma, the Community Linkage Officer that supported her. “We picked her and re-initiated her on ART. We also assessed her for TB as she had a bad cough. Her Sputum tested positive and we referred her for admission to Kilembe Mines Hospital in Kasese,” he adds. LK was started on TB drugs alongside antiretroviral treatment and management of other illnesses. But because her parents were too poor to afford associated hospital costs (treatment is free but caretakers have to buy food and other basics), they abandoned her in Hospital―administrators called Rukoki HC workers, who referred her, when she had signs of malnutrition. In July 2017, with support from Baylor- Uganda, and with funding from PEPFAR through CDC―Rukoki HC provided nutritional support to LK in quantities that would take her for a minimum of three months. She resumed her TB treatment, became more stable and started to adhere well to both her ART and anti TB. Three months later (late October 2017), when Isingoma led the Baylor-Uganda Kasese cluster team to visit LK at her new home, they were surprised when they were told that she had gone to collect firewood. None of them expected LK to have recovered so fast to the extent of having strength to walk a distance to collect firewood. “We were excited when she later emerged with firewood on her head,” Isingoma narrates. “LK completed her TB treatment, she is adhering well to her clinic appointments and her treatment and is virally suppressed. She is now healthy, ably raising her five-year old son, who is HIV negative.” Summary of Key Lessons Learned during project implementation Care and treatment lessons:  Working with the district health teams leads to better achievement of care and treatment indicators.  Engaging district health officers in reviewing viral load dashboards enhances routine viral load monitoring in health facilities.  Onsite training is more efficient and effective in capacity building than class training  Training of health workers in care and treatment indicators needs to be followed up by facility- based mentorships and periodic technical support supervisions to achieve results.  Clear communication of planned activities to district leads is important in ensuring successful implementation of the activities.

Pediatric and adolescent HIV care lessons:  The use of the screening tool for HTS eligibility improves HTS yield.  Birth cohort monitoring through use of the early infant diagnosis register enabled to improve uptake of early infant diagnosis.  Testing children as well as sexual partners of index clients provides an opportunity of identification of untested children as well as adolescents who are sexual partners of index clients.  Differentiated service delivery models for adolescents enhance retention in HIV care for adolescents. Engaging adolescent peer leaders in adolescent only clinics enabled peers to provide psychosocial support to fellow peers.  Integrating ART refills during adolescent peer support meetings over the weekend and during holidays provided convenience for the adolescents to keep clinic appointments. OVC services lessons:  Involvement of government structures such as DCDO and CDOs during implementation and support supervision led to the project success.  Community structures such as Para social workers are key for the project every success hence ensuring sustainability.

Health Financing lessons:  Sub granting is key in performance improvement, increased health workforce morale and sustainability of the project objectives.  District led programming can best be implemented with timely sub granting mechanisms. Sub-grant funding enables the district structures to function and take lead/charge of the activities hence project success.

Medical Commodities and technologies Lessons:  There was need to real-time tracking of stocks available in each health facility for immediate and timely action to prevent stock outs and expiries.  Analysis of ware house order fulfillment necessary to highlight warehouse performance and improved accountability of the central warehouse to stakeholders.  Routine performance monitoring and feedback to stakeholders is both a motivator and driver for further improvement in quality of services.

Leadership and Governance Lessons  Everyone can be a leader: leadership training should be aimed at all healthcare personnel and be a mandatory part of clinical training. Peer-to-peer learning is effective as challenges are understood and strong relationships are built due to a shared background. Regular follow ups are key to maintaining progress. Facility-based training is cost effective and keeps health workers in station. Financial incentives are not always needed to cause the desired change. Small changes, big impact, e.g. red line and Monthly Meetings Book being used at health facility level.

Key Challenges Encountered during Project Implementation  Low order fulfilment or health facility orders by NMS and stock outs of key HIV commodities, STI medicines, lab reagents and nutrition therapeutic feeds.  Sub-optimal viral load suppression for children and adolescents due to poor adherence and over- representation by caregivers  Limited district level coordination, supervision and ownership of interventions and outcomes to improve performance.  Limited data usage by health workers and in some cases absenteeism and poor attitude of health- workers in ART service delivery.  Mobility of PPs/KPs while looking for money within and out of the districts and the region affected retention in this population group.  Low absorption rates of HRH supported cadres by district local governments who cited low wage bill

Recommendations to address the challenges  Scale up SURGE strategies like APN and how to reach males with HTS to all ACE-FORT project supported sites from the current 49 sites and across key program areas like TB, OVC and VMMC. Strengthen viral load collaborative activities, IAC and case conferencing across supported units.

 Districts to provide stewardship and fully embrace district led programming to address gaps. DLGs /HUMCs to do joint support supervision with project staff to underperforming sites.

 Support accurate forecasting of HIV/TB commodities, retrain and equip MMS in supported districts and strengthen redistribution mechanisms for test kits, ARVs to facilities with need.

 Strengthen the Baylor Uganda weekly tracer indicators and CDC supported weekly Hybrid reporting and monthly reviews.

 Targeted onsite mentorship will continue to address identified gaps like poor viral load suppression rates in children, low HTS yield and linkage as well as fully scale up DSDM roll out to all sites and community sites. Integrate MNCH activities (best practices) from SMGL districts to all 8 supported districts. Districts to integrate activities to improve nutrition in other sectors like agriculture.

 Partnerships with key stakeholders like cultural and religious leaders and CSOs to address teenage marriages/ male involvement and sexual partner testing. Re-organize OVC programming through capacity building and plan resources to enable graduation of more families from vulnerability.

 Scale up The Caring Together Leadership model and tools to enhance leadership and governance like Caring Together Leadership Awards, The Team Performance Monitoring Tool, The Monthly Meetings Book, Patient Waiting Cards, The Employee of the Quarter Award and Re-emphasis on use of “red line” to track attendance to duty at health facilities. “The leadership project has been of paramount importance because it takes issues that have been making service delivery fail at all levels. I would recommend that it should be scaled to other districts.”– Wilfred Natukunda, Kabarole District mentor.  The project will need continued technical assistance in SURGE by the CDC technical teams and in streamlining of Data Quality for the DHIS2, HYBRID and DATIM working. Further Engagement of MOH/NMS to avert inconsistent supply of ARVs like NVP/2nd line drugs, INH & CRAG kits.

APPENDICES:

Table B: Partner sites intervention summary

If Is it a new Indicate facility, Program Area (Refer to table 7 for the definitions of the program area acronyms and mark with an X where a site? Level specify site provides a service) owner

Ser District Site name

(HC II, HC ( GOU, III, HC IV, (Y or N) PNFP, Hosp<

HVSI CIRC

HKID PDCS

OHSS

HTXS PDTX

HMIN

HVOP HVTB HVCT HLAB

MTCT HBHC HTXD

HVAB PFP) HMBL RRH,RH

1 Bundibugyo Bubukwanga N HCIII GOU x x x x x x x x x x x

2 Bundibugyo Bukangama N HCIII GOU x x x x x x x x

3 Bundibugyo Bundibugyo N Hosp GOU x x x x x x x x x x x

4 Bundibugyo Busaru N HCIV PNFP x x x x x x x x x x x

5 Bundibugyo Kakuka N HCIII GOU x x x x x x x x x x x

6 Bundibugyo Kikyo N HCIV GOU x x x x x x x x x x x

7 Bundibugyo Kisuba N HCIII GOU x x x x x x x x x

8 Bundibugyo Ntandi N HCIII GOU x x x x x x x x

9 Bundibugyo Nyahuka N HCIV GOU x x x x x x x x x x x

10 Kabarole Bukuuku N HCIV GOU x x x x x x x x x x x x x x x x

11 Kabarole Kabenda N HCIII GOU x x x x x x x x

12 Kabarole Kabonero N HCIII GOU x x x x x x x x

13 Kabarole Kagote N HCIII GOU x x x x x x x x

14 Kabarole Kakinga N HCIII GOU x x x x x x x x

15 Kabarole Karambi N HCIII GOU x x x x x x x x x x x

16 Kabarole Kasenda N HCIII GOU x x x x x x x x

17 Kabarole Kasunganyanja N HCIII GOU x x x x x x x x x

18 Kabarole Kasusu N HCIII GOU x x x x x x x x

19 Kabarole Kaswa N HCIII GOU x x x x x x x x x x

20 Kabarole Kataraka N HCIV GOU x x x x x x x x x x x

21 Kabarole Kibiito N HCIV GOU x x x x x x x x x x x x x x x x

22 Kabarole Kichwamba N HCIII GOU x x x x x x x x x x x

23 Kabarole Kida N Hosp PNFP x x x x x x x x

24 Kabarole Kidubuli N HCIII GOU x x x x x x x x x x x

25 Kabarole Kijura N HCIII GOU x x x x x x x x x x x

26 Kabarole Kisomoro N HCIII GOU x x x x x x x x x x

27 Kabarole Kiyombya N HCIII GOU x x x x x x x x x x x

28 Kabarole Mitandi N HCIII PNFP x x x x x x x x

29 Kabarole Muchwa N HCIII GOU x x x x x x x x

30 Kabarole Mugusu N HCIII GOU x x x x x x x x x x x

31 Kabarole Nyabuswa N HCII GOU x x x x x x x x

32 Kabarole Nyantaboma N HCIII GOU x x x x x x x x x x x

33 Kabarole Rambia N HCIII PNFP x x x x x x x x

34 Kabarole Rubona Y HCII GOU x x x x x x x x

35 Kabarole Ruteete N HCIII GOU x x x x x x x x x x x

36 Kabarole Rwagimba N HCIII GOU x x x x x x x x x x x

37 Kabarole Rwimi N HCIII GOU x x x x x x x x x x x

38 Kabarole Yerya N HCIII PNFP x x x x x x x x x x x

39 Kabarole Kibiito N HCIV GOU x x x x x x x x x x x x x x x x

40 Kampala COE Clinic N NRH GOU x x x x x x x x x x x x x x x x

41 Kampala PNC Mulago N NRH GOU x x x x x x x x x x x x x x x x

42 Kamwenge Bigodi N HCIII GOU x x x x x x x x x x x

43 Kamwenge Biguli N HCII GOU x x x x x x x x

44 Kamwenge Bihanga Y HCII GOU x x x x x x x x

45 Kamwenge Bunoga N HCIII GOU x x x x x x x x

46 Kamwenge Bwizi N HCIII GOU x x x x x x x x x x x

47 Kamwenge Kabambiro N HCII GOU x x x x x x x x

48 Kamwenge Kabuga N HCIII PNFP x x x x x x x x

49 Kamwenge Kamwenge N HCIII GOU x x x x x x x x x x x

50 Kamwenge Kanara N HCII GOU x x x x x x x x

51 Kamwenge Kicheche N HCIII GOU x x x x x x x x x x x

52 Kamwenge Kyabenda N HCIII PNFP x x x x x x x x x x x

53 Kamwenge Mahyoro N HCIII GOU x x x x x x x x x x x

54 Kamwenge Malere Y HCII GOU x x x x x x x x

55 Kamwenge Ntara N HCIV GOU x x x x x x x x x x x

56 Kamwenge Nyabbani N HCIII GOU x x x x x x x x x x x

57 Kamwenge Padre pio Y HCIII PNFP x x x x x x x x x x x

58 Kamwenge Rukunyu N HCIV GOU x x x x x x x x x x x Bishop Masereka 59 Kasese N HCIV PFP x x x x x x x x x x medical centre 60 Kasese Bugoye N HCIII GOU x x x x x x x x x x x

61 Kasese Buhaghura N HCIII GOU x x x x x x x x

62 Kasese Bwera N Hosp GOU x x x x x x x x x x x

63 Kasese Hima N HCIII GOU x x x x x x x x x x x

64 Kasese Ihandiro N HCIII GOU x x x x x x x x

65 Kasese Isule N HCIII GOU x x x x x x x x

66 Kasese Kabatunda N HCIII GOU x x x x x x x x

67 Kasese Kahokya N HCII GOU x x x x x x x x x

68 Kasese Kanamba N HCIII GOU x x x x x x x x

69 Kasese Karambi N HCIII GOU x x x x x x x x x

70 Kasese Karusandara N HCIII GOU x x x x x x x x x

71 Kasese Kasese TC N HCIII GOU x x x x x x x x x x x

72 Kasese Katadoba N HCIII PNFP x x x x x x x x x

73 Kasese Katunguru N HCII GOU x x x x x x x x

74 Kasese Katwe N HCIII GOU x x x x x x x x x x x

75 Kasese Kilembe Mines N Hosp PNFP x x x x x x x x x x x

76 Kasese Kinyabwamba N HCIII GOU x x x x x x x x x

77 Kasese Kinyamaseke N HCIII PNFP x x x x x x x x x x x

78 Kasese Kitabu maternity N HCIII PNFP x x x x x x x x

79 Kasese Kitswamba N HCIII GOU x x x x x x x x x

80 Kasese Kyanya SDA N HCIII PNFP x x x x x x x x

81 Kasese Kyarumba Govt N HCIII GOU x x x x x x x x x x x

82 Kasese Kyarumba PHC N HCIII PNFP x x x x x x x x

83 Kasese Kyondo N HCIII GOU x x x x x x x x x

84 Kasese Maliba N HCIII PNFP x x x x x x x x x

85 Kasese Muhokya N HCIII GOU x x x x x x x x x x x

86 Kasese Mukathi N HCIII GOU x x x x x x x x x

87 Kasese Mushenene N HCIII PNFP x x x x x x x x x

88 Kasese Nyabirongo N HCIII GOU x x x x x x x x x

89 Kasese Nyabugando N HCIII PNFP x x x x x x x x

90 Kasese RMS N HCIII PNFP x x x x x x x x x x x

91 Kasese Rukoki N HCIII GOU x x x x x x x x x x x

92 Kyegegwa Bugogo Y HCII GOU x x x x x x x x

93 Kyegegwa Hapuyo N HCIII GOU x x x x x x x x x x x

94 Kyegegwa Kakabara N HCIII GOU x x x x x x x x x x x

95 Kyegegwa Karwenyi N HCIII GOU x x x x x x x x x x x

96 Kyegegwa Kasule N HCIII GOU x x x x x x x x x x x

97 Kyegegwa Kazinga N HCIII GOU x x x x x x x x x x x

98 Kyegegwa Kigambo N HCII GOU x x x x x x x x

99 Kyegegwa Kyegegwa N HCIV GOU x x x x x x x x x x x

100 Kyegegwa Migamba Y HCII GOU x x x x x x x x

101 Kyegegwa Mpara N HCIII GOU x x x x x x x x x x x

102 Kyegegwa Weikomere N HCIII PNFP x x x x x x x x x

103 Kyenjojo Bufunjo N HCIII GOU x x x x x x x x

104 Kyenjojo Butiiti N HCIII GOU x x x x x x x x x x x

105 Kyenjojo Butunduzi N HCIII GOU x x x x x x x x x x

106 Kyenjojo Katooke N HCIII GOU x x x x x x x x x x x

107 Kyenjojo Kigaraale N HCIII GOU x x x x x x x x x x x

108 Kyenjojo Kigoyera N HCII GOU x x x x x x x x

109 Kyenjojo Kisojo N HCIII GOU x x x x x x x x

110 Kyenjojo Kyakatara N HCIII PNFP x x x x x x x x x x x

111 Kyenjojo Kyankaramata N HCII GOU x x x x x x x x

112 Kyenjojo Kyarusozi N HCIV GOU x x x x x x x x x x x Kyembogo Holy 113 Kyenjojo N HCIII PNFP x x x x x x x x x x x Cross 114 Kyenjojo Kyenjojo N Hosp GOU x x x x x x x x x x x

115 Kyenjojo Myeri N HCII GOU x x x x x x x x

116 Kyenjojo Nyakarongo N HCII GOU x x x x x x x x

117 Kyenjojo Nyamabuga N HCIII GOU x x x x x x x x x x x

118 Kyenjojo Nyankwanzi N HCIII GOU x x x x x x x x x x x

119 Kyenjojo Rweitengya N HCII GOU x x x x x x x x

120 Kyenjojo St. Adolf Butiiti N HCIII PNFP x x x x x x x x x x x

121 Kyenjojo St. Martins Mabira N HCIII PNFP x x x x x x x x St.Theresa Lisieux 122 Kyenjojo N HCIII PNFP x x x x x x x x x x x Rwibaale 123 Ntoroko Karugutu N HCIV GOU x x x x x x x x x x x

124 Ntoroko Ntoroko N HCIII GOU x x x x x x x x x

125 Ntoroko Rwebisengo N HCIII GOU x x x x x x x x x

126 Ntoroko Stella Maris N HCII PNFP x x x x x x x x x

Table C: Number of staff trained by title of training (in-service training) (2012 -2018) Title of training Number of individuals SNAP-W Other projects 1. Adolescent HIV Care Treatment and Support 78 2. ALARM/New Born Training ToT 31 3. Basic Emergency Obstetric & Newborn Care(BEmONC) 160 4. Basic Emergency Obstetric & Newborn Care(BEmONC) for Regional Mentors 36 5. Best Practice Financial Modelling & Data Analysis Training 23 6. Best Practice Financial Modelling Training 11 7. Biosafety & Biosecurity Training 147 8. Bright Future Intervention ToT 32 9. CBO Leadership & Governance Training 124 10. Clinical Mentorship Training 74 11. Community Drug Distribution Points 13 12. Community Health Information Management System 26 13. Community Home Based Care for Volunteers 374 14. Community Training for Volunteers 212 15. Community-Facility Linkage & Referral Framework 376 16. Community-Facility Linkage & Referral Framework ToT 76 17. Competence Based Training for Health Workers in the Management of TB in 55 Children 18. Comprehensive Emergency Obstetric & Newborn Care (CEmONC) 24 19. Couple HIV Counseling & Testing For Health Promoters (CVs) 301 20. Couple HIV Counseling & Testing For Service Providers ToT 26 21. Couple HIV Counseling & Testing For Service Providers (HW) 56 22. Customer Care Training for Health Workers 1 206 23. Data Management For Research & Excel Fundamentals 21 24. Defensive Driving Training 28 25. DHIS2 Regional ToT 89 26. DHIS2 Training 31 27. Differentiated Service Delivery National ToT 47 28. Differentiated Service Delivery Regional ToT 167 29. District IPT & DHIS2 Training 326 30. EID Hubs, National Sample & Results Transport Network ToT 4 31. Emergency Management of Service Providers of Safe Male Circumcision 61 32. Family Planning 88 33. Family Support Groups for Peer Educators 52 62 34. Family Support Groups for Service Providers 50 58 35. Finance & Management Training 46 36. Financial Management Training for CBOs 42 37. Fraud Prevention Awareness Training 9

38. Gender Norms & Sexual Gender Based Violence 167 39. HBHTS Training For RCT Volunteers 40 40. Health Care Waste Management 29 41. Health Systems Strengthening Leadership Initiative ToT 52 42. HIV /AIDS Home Based Care For VHTs 222 43. HIV Exposed Infant Birth Cohort Monitoring 42 44. HIV Exposed Infant Birth Cohort Monitoring ToT 52 45. HIV Testing Services Leadership Training 93 46. HMIS Training 125 47. HR-EPMS Training 121 48. HTC Study Training 55 49. Integrated Management of Acute Malnutrition (IMAM) 61 50. Infant and Young Child Feeding & Baby Friendly Hospital Initiative 79 51. Integrated Management of Acute Malnutrition-ITC 23 52. Laboratory Quality Management System 129 53. Laboratory SPARS 16 54. Leadership & Management Training 14 55. Leadership Training for Health Facility In-charges 148 56. LEEP/Colposcopy 19 57. Logistics Management 95 31 58. Long Acting Reversible Contraceptive Family Planning Training 96 59. MTB/RIF Stool Processing 10 60. National ToT on Adolescent HIV Care & Support 212 61. National ToT on Diagnosis & Management of TB in Children 65 62. National ToT on Revised ART Guidelines 293 63. New Consolidated Guidelines for HIV Prevention & Treatment 29 64. New Consolidated Guidelines for HIV Prevention & Treatment ToT 40 65. Newborn Mortality Surveillance (VAT) 48 66. Nutrition Assessment Counseling & Support (NACS) 130 67. Onsite Differentiated Service Delivery 115 68. Onsite Paediatric & Adolescent HTS 370 69. Onsite SD Bioline Training 76 70. OpenMRS Express HIV/AIDS Training 93 71. OVC Care and Management Training 179 72. OVC Caregivers Training on Agriculture & Animal Production 9 21 73. Paediatric & Adolescent HTS ToT 39 74. Paediatric HIV/AIDS Counseling 66 75. Paediatrics TB Management Training 47 76. Peer Adolescent HIV Care Treatment and Support 96 77. Peer Educator HIV Prevention & Involvement Training for Key Populations 110 78. PIASCY Programme Teacher Training 56

79. PMTCT Option B+ 498 175 80. PMTCT Option B+ / EMTCT 60 72 81. PMTCT Option B+ ToT 30 82. PREP Training 29 83. Provider Initiated HIV Counseling and Testing for RCT Volunteers 148 16 84. QI Training For Paediatric HIV Care For Health Professionals 24 85. Quality Improvement 128 111 86. Quality Improvement Learning Session 95 53 87. RAMOS Supervision 56 88. Refresher in Proficiency HIV HCT Training 32 89. Refresher HMIS Training 56 90. Refresher on Management of Non-Suppressed Clients 201 91. Resilience Training 71 92. Rx Solution SPARS Training 21 93. Rx Solution Training 20 94. Safe Medical Male Circumcision 99 95. Safer Anaesthesia for Health Workers 20 96. Serum CrAg Training 40 97. Service Provider HIV Prevention & Involvement Training for Key Populations 148 98. Sinovuyo Teen Parenting 58 99. Sputum Collection in Children 59 100. Stepping Stones Methodology 134 101. Stepping Stones Methodology ToT 29 102. TB HIV/AIDS Training 61 103. TT Vaccination Training 19 104. Viral Load Monitoring ToT 47 Grand Total 8,056 2,010