QUARTERLY REPORT OCTOBER 1 DECEMBER 31, 2016 STRENGTHENING UGANDA S SYSTEMS FOR TREATING AIDS NATIONALLY. Submitted: January 31, 2017

Transcription

1 STRENGTHENING UGANDA S SYSTEMS FOR TREATING AIDS NATIONALLY QUARTERLY REPORT OCTOBER 1 DECEMBER 31, 2016 Submitted: January 31, 2017 This report was produced for review by the United States Agency for International Development. It was prepared by University Research Co., LLC; in partnership with Integrated Community Based Initiatives (ICOBI).

2 On the cover: Top: Moses lokol, an adolescent peer, talks about challenges adolescents are likely to face and how to overcome them during a health education session at the adolescent centre, Moroto RRH. Middle: A woman receives a tetanus vaccination shot during a circumcision camp. This is one of the services given to women who escort their husbands for circumcision at Hoima RRH. Bottom: Pregnant women and adolescents listen to tips on how to deliver a healthy baby at the antenatal care unit.

3 Quarterly Report October 1, 2016 December 31, 2016 Fiscal Year 2017 Submitted to: Dan Wamanya, USAID Agreement Officer Representative Strengthening Uganda s Systems for Treating AIDS Nationally (SUSTAIN) is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement number 617-A This report was produced for review by USAID. It was prepared by University Research Co., LLC, in partnership with Integrated Community Based Initiatives (ICOBI). DISCLAIMER The author s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

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5 Table of Contents LIST OF ACRONYMS...iv 1. INTRODUCTION A VIEW OF SUSTAIN THROUGH NUMBERS KEY STRATEGIES AND APPROACHES CHALLENGES SERVICE DELIVERY COMPONENTS... 6 A. HIV Testing and Support (HTS)... 6 B. Voluntary Medical Male Circumcision (VMMC)... 7 C. Prevention of Mother-to-Child Transmission of HIV and Early Infant Diagnosis... 7 D. HIV Care and Treatment E. Facility-Community Linkages and Client Follow-up F. Nutritional Assessment Counseling and Support (NACS) G. TB/HIV Collaborative Activities H. Strengthening the Capacity of Selected Regional Referral Hospitals for Management of Drug-Resistant Tuberculosis (DR-TB) I. Supply Chain Management Strengthening J. Laboratory Services...17 K. Quality Improvement L. Health Management Information Systems M. Human Resources for Health Strengthening Support N. Stewardship PROJECT MANAGEMENT Project Personnel Partnerships and Collaborations Communications and Knowledge Management PERFORMANCE INDICATOR SUMMARY TABLE APPENDIX October 1 December 31, 2016 Quarterly Report iii

6 List of Acronyms AE Adverse Event AFHS Adolescent Friendly Health Services ANC Antenatal Care ART Anti-retroviral Therapy ARV Anti-retroviral ASLM African Society for Clinical Laboratory Medicine ASSIST Applying Science to Strengthen and Improve Systems Project CBC Complete Blood Count CPHL Central Public Health Laboratories CPT Cotrimoxazole Preventive Therapy CQI Continuous Quality Improvement DBS Dried Blood Spot Test DOT Directly Observed Treatment DQA Data Quality Assessment DR-TB Drug-resistant Tuberculosis DST Drug Susceptibility Testing EID Early Infant Diagnosis EMTCT Elimination of Mother-to-Child Transmission of HIV FP Family Planning FSG Family Support Group GH General Hospital GOU Government of Uganda HIV Human Immunodeficiency Virus HMIS Health Management Information System HRI Health Research, Inc. HTC HIV Testing and Counseling ICF Intensified TB Case Finding ICOBI Integrated Community Based Initiatives IEC Information Education Communication JMS Joint Medical Store M&E Monitoring and Evaluation MAM Moderate Acute Malnutrition MCH Maternal and Child Health MDR-TB Multidrug-resistant Tuberculosis METS Monitoring and Evaluation Technical Support MOH Ministry of Health MUAC Mid-upper Arm Circumference NACS Nutrition Assessment Counseling and Support NCD Non Communicable Disease NMS National Medical Stores NTLP National TB & Leprosy Program NTRL National TB Reference Laboratory NVP Nevirapine OPD Out-patient Department OVC Orphans and Vulnerable Children PCR Polymerase Chain Reaction PIN Production for Improved Nutrition PITC Provider-Initiated Testing and Counseling PMTCT Prevention of Mother-to-Child Transmission of HIV PNC Prenatal Care QA/QC Quality Assurance/ Quality Control QI Quality Improvement RMEMW Regional Medical Equipment Maintenance Workshop RR Rifampicin Resistance RRH Regional Referral Hospital RUTF Ready-To-Use Therapeutic Food SAM Severe Acute Malnutrition SCMS Supply Chain Management Systems SLIPTA Stepwise Laboratory Improvement Process Towards Accreditation SLMTA Strengthening Laboratory Management Towards Accreditation SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally TASO The AIDS Support Organization TAT Turnaround Time TB Tuberculosis THALAS Targeted HIV/AIDS Laboratory Support TQM Total Quality Management TSR Treatment Success Rate UKNEQAS United Kingdom National External Quality Assessment Service URC University Research Co., LLC USAID United States Agency for International Development UVRI Uganda Virus Research Institute VL Viral Load VMMC Voluntary Male Medical Circumcision WAOS Web Based Ordering System WHO World Health Organization WM Waste Management iv USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally

7 1. Introduction The USAID-funded Strengthening Uganda s Systems for Treating AIDS Nationally (USAID/SUSTAIN) project aims to: n Support the Ugandan Ministry of Health (MOH) to scale up prevention of mother-to-child transmission of HIV (PMTCT) and voluntary medical male circumcision (VMMC) as human immunodeficiency virus (HIV) infection prevention interventions within selected public regional referral hospitals (RRHs) and general hospitals (GHs); n Ensure provision of HIV care and treatment, laboratory, and tuberculosis (TB)/HIV services within selected public RRHs, GHs and health centre IVs; n Enhance the quality of PMTCT, VMMC, HIV care and treatment, laboratory and TB/HIV services within selected public RRHs, GHs and health centre IVs; and n Increase stewardship by the MOH to provide sustainable quality HIV prevention, care and treatment, laboratory and TB/HIV services at project-supported healthcare facilities. This report covers the period from 1st October 2016 to 31st December USAID/SUSTAIN provided support to various hospitals in the following areas: n Delivery of PMTCT, care and treatment, laboratory and TB/HIV collaborative services: Eleven RRHs: Arua, Fort Portal, Gulu, Hoima, Jinja, Kabale, Lira, Mbale, Moroto, Mubende and Soroti; and One GH: Kawolo. USAID/SUSTAIN was implemented this quarter by University Research Co., LLC (URC), together with Integrated Community Based Initiatives (ICOBI). n Delivery of VMMC services: Fort Portal, Gulu, Hoima, Jinja, Lira, Masaka and Moroto RRHs (subject to change after final PEPFAR targets are communicated). n Delivery of VMMC, TB/HIV, quality improvement and laboratory services only: Masaka RRH. n Support for laboratory services only: Abim GH, Kaabong GH, Matany GH, Kotido and Tokora health centre IVs. n Support for drug-resistant TB (MD-TB) services: Arua, Fort Portal, Gulu, Kabale, Masaka, Mbale and Mubende RRHs. n Human Resources for Health (HRH): The project will continue to provide support to all the above 18 healthcare facilities through sub-grants for seconded staff critical for delivery of HIV, general healthcare and laboratory services. n Routine operational support to seven MOH Regional Medical Equipment Maintenance Workshops (RMEMWs) to improve their response to laboratory equipment repair and maintenance needs at healthcare facilities in respective regions: Arua, Fort Portal, Gulu, Hoima, Kabale, Lira and Mbale. October 1 December 31, 2016 Quarterly Report 1

8 2. A View of SUSTAIN Through Numbers 82,938 people accessed HIV testing and counseling services; 2,123 newly tested HIV-positive and 93.9% were successfully enrolled into HIV care. 843 males were circumcised; 801 were followed up at least once in the first seven days post-circumcision. 9,418 pregnant women attended antenatal services for the first time; 322 newly tested HIV-positive; 2,348 males were tested for HIV with their partners at maternal and child health (MCH) units and 49 tested HIV-positive and were linked to care. 94.5% of clients in care were active on anti-retroviral therapy (ART); 25.4% of clients on ART accessed a viral load test to monitor treatment outcomes during the quarter. Average suppression rate at 12 SUSTAIN-supported facilities was 89.3%. 46.5% of TB clients tested HIV-positive; 43 patients were confirmed with DR-TB and 22 enrolled on treatment; Overall treatment success rate for TB patients was 74%. 48,712 viral load samples were referred during the reporting period; Six project-supported labs identified for accreditation received African Society for Laboratory Medicine (ASLM) star graded certification following their first Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) audit in Nov USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally

9 3. Key Strategies and Approaches Targeting achievement: Hospitals were supported to improve access to HIV testing, ART and viral suppression for clients on ART. Targeting HIV testing and support: During the quarter, a screening tool developed by USAID/ SUSTAIN s HIV testing and counseling team was introduced and utilized at all supported hospitals. It was effectively used to screen clients for HIV testing service eligibility at Lira and Fort Portal RRHs. Integrating Quality Improvement (QI) approaches with other skills and healthcare service delivery system strengthening activities SUSTAIN uses QI approaches as an integral part of its support to strengthen routine service delivery, not only for improving clinical and laboratory interventions, but also other health systems elements, such as use of data for decision making, supply chain and infection prevention. Supporting increased hospital ownership and stewardship for HIV service delivery SUSTAIN staff supported hospitals to increase their oversight and leadership for HIV services. All USAID/SUSTAIN seconded staff continue to be directly supervised by hospital management. During the quarter, the project organized a leadership forum to support improved performance management involving all the management teams from the supported health facilities (results included in the Stewardship section). Joint planning with hospital management and central MOH to align project activities with hospital and MOH goals USAID/SUSTAIN continued to work closely with various MOH departments, divisions and hospital leadership teams in the planning and implementation of project activities with special emphasis this quarter on elimination of mother-to-child transmission of HIV (EMTCT). All activities were implemented as per MOH guidelines and strategic priorities. A couple accesses HIV testing services at Mbale antenatal care unit Utilizing a health systems strengthening approach Using a health systems strengthening perspective, USAID/ SUSTAIN supports service delivery in a sustainable way: the project supported the printing of the revised tools for the supported hospitals, a skilled and expanded health workforce, improving the commodity/supply chain management system and the quality of laboratory services within the public healthcare system for both general and HIVrelated healthcare service delivery. Improving health management information (HMIS) systems through automation of data processes and increased data utilization The project supports automation of data processes and on time data entry to support quick decision making. All hospitals that are supported are given internet access and computers to facilitate this process. The hospitals are supported to institutionalize performance reviews which has improved data utilization. October 1 December 31, 2016 Quarterly Report 3

10 4. Challenges Table 1. Challenges and approaches for addressing them Challenges Approaches for Addressing Challenges Clinical Services Staff attrition has continued to create skills gaps for both clinical and psychosocial support services in RRH Low viral suppression in children Low uptake of family planning services Incorrect client addresses, lack of contact information, delayed documentation and mobile populations cross border populations still affect client retention SUSTAIN will work with trained facility core teams to support continued systems strengthening and ensure cross-training so that services can be provided without interruption. With the recently launched revised ART guidelines, the project will emphasize use of the Lopinavir/Retonavir (LPV/r) pellets for all children below three years that are started on treatment. The pellets enhance adherence to treatment as they are palatable to children and heat stable compared to the harsh tasting LPV/r syrup requiring refrigeration. The project will strengthen referral and linkages between entry units, such as ART, young child clinic, and mother baby care point, with the family planning unit through mentorships. Family planning messaging in antenatal care (ANC) will be strengthened. Clinical file reviews will be conducted to routinely assess for uptake of family planning services and remind clinicians to provide the services. Innovations including updating patients files with treatment supporter information, attaching volunteers to particular sub counties and piloting routine data validation exercises to identify missing clients. Provision of Commodities and Supplies Stockouts of critical HIV-related commodities, Fluconazole 200 mg, Efivirenz 200mg, Isoniazid 300mg, multi-drug-resistant TB (MDR-TB) medicines, male condoms, laboratory supplies (sysmex hematology controls) in the national supply chain system Overstock of some commodities; for example, CD4 supplies attributed to change in the HIV/AIDS monitoring policy from CD4 monitoring to viral load suppression Hospitals are overstocked with AZT/3TC (60/30mg) and ABC/3TC (60/30mg), and therefore risking wastage due to expiration The project facilitated redistribution between RRH based on available stock of drugs, reagents and commodities to avoid stockouts. The facilities are encouraged to ensure all eligible clients for CD4 are able to receive the service so that the excess stocks can be reduced. USAID/SUSTAIN will further strengthen stock monitoring, appropriate ordering and support of redistribution in the next quarter. continued 4 USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally

11 Challenges Stockouts of critical VMMC supplies such as lignocaine 2%, alcohol, iodine solution, surgical and disposable gloves Approaches for Addressing Challenges The project will continue to access missing critical VMMC supplies from the supported facilities essential medicines and health supplies. Iodine and alcohol were procured by the project. Laboratory Stock out of reagents and supplies for complete blood counts (CBC) and chemistry categorized as non-core by PEPFAR Lack of a running external quality assurance (EQA) scheme for chemistry from September 2016 Continue informing the MOH of reagent status at sites to guide their lobbying and seeking alternative funding sources. Labs are being supported to develop inter-laboratory comparison systems as an alternative to EQA schemes. Human Resources for Health Most high volume clinics remain heavily reliant on project supported human resources for service delivery. While a round of training for the identified core MOH staff was conducted in Year 6, the general staffing constraints faced by the hospitals affect their ability to deploy these staff on a full time basis in the direct provision of HIV services In the interim, some hospitals have established rotations, such as for clinicians (e.g., Jinja RRH), to enable the trained staff to rotate in the HIV clinic to practice the skills gained in the training. The project will continue to monitor how the hospitals progress with this exercise using monthly status reports submitted by Clinical Care Coordinators at the HIV clinics. October 1 December 31, 2016 Quarterly Report 5

12 5. Service Delivery Components A. HIV Testing and Support (HTS) The project focused on the implementation of targeted provider-initiated HIV testing and counseling (PITC) as an approach to contribute to the achievement of the first 90 of the UNAIDS strategy. The HTS eligibility and screening tool developed by the USAID/SUSTAIN HIV testing and counseling (HTC) team (Appendix 1) was used to minimize re-testers and identify eligible clients for HTC. Best practices for successful linkage were also used to improve linkage to care for clients newly testing HIV-positive during the reporting period. Clients who tested HIV-negative received HIV risk reduction counseling and were referred to appropriate prevention care and support services. HIV Incidence The average HIV incidence for all the testing points in the 12 supported hospitals was 3.3%, a slight increase from the 3.0% registered in the previous quarter. This increase in detection of HIV-positive clients is attributed to targeted PITC enhanced by screening for HTC for clients with HIV-related risks. Focus in the next quarter will now be put on HTS service delivery at the high yield entry points. Enablers for Linkage to HIV Care n Physically escorting newly identified clients to HIV clinic for in depth post-test counseling; n Use of the triplicate referral forms to enhance documentation of linkage outcomes; n Weekly linkage data reviews and follow up of clients identified not to have been linked; n Inter- and intra-facility meetings to establish successful linkage and follow up those not yet enrolled into care; and n Using hub riders to support transportation of follow up and transfer lists across facilities. Linkages and the Continuum of Care A total of 2,642 clients were identified HIV-positive from HIV testing and counseling services (Table 2). Of the 2,280 clients who tested HIV-positive from outpatient/inpatient departments, VMMC and male partners of PMTCT clients, 2,123 (93.1%) were newly identified HIV positive and 1,993 Table 2. Individuals tested, counseled and given test results by testing point and HIV status Testing Point Clients Counseled, Tested & Received Results Tested Positive Positivity Rate Inpatient and Outpatient Departments* 67,641 2, % VMMC 1, % Male Partners of PMTCT Mothers 2, % Early Infant Diagnosis* % Prenatal Care 1, % Antenatal Care* 8, % Labor & Delivery % Total 82,938 2, % *High yield entry points 6 USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally

13 Figure 1. Number of clients tested HIV-positive in relation to those newly tested and re-testers, Oct 2015-Dec 2016 Number of HIV-positive clients ,614 2,412 2,707 2,515 2,811 2,800 2,662 2,591 2,280 2, Oct-Dec 2015 Jan-Mar 2016 Apr-Jun 2016 Jul-Sept 2016 Oct-Dec 2016 The screening tool has helped us to minimize re-testers with known HIV-positive status and provide HTC to clients exposed to HIV risks compared to routine testing. This is because it helps us sensitize clients during health education sessions on who is eligible for HIV testing. Anitha Birirwa, Clinical Care Coordinator, Fort Portal RRH Tested HIV positive Newly tested HIV positive Re-testers (93.9%) were successfully linked and enrolled into HIV care. This performance is attributed to consistent use of enablers of successful linkage. These enablers include physically escorting newly identified clients to the HIV clinic for indepth, post-test counseling to appreciate HIV care services and enhance decisions on where to access care; use of the triplicate referral forms to enhance documentation of linkage outcomes; weekly linkage data reviews and follow up of those identified not to have been linked; inter-and intrafacility meetings to establish successful linkage and use of the hub riders to support confirmation and documentation of clients referred for HIV care at other health units at four health facilities (Hoima, Lira, Jinja and Mubende RRH). One hundred and thirty newly identified HIV-positive clients from HTC at outpatient/inpatient departments and VMMC settings were not confirmed linked into any HIV care services. Of these, five (3.8%) died before reaching the referral destination, 13 (10.0%) gave wrong contacts, 15 (11.5%) were contacted but phones were not available, 60 (46.2%) were undecided and 37 (28.5%) were unaccounted for. Capacity Building of HTC Teams Mentorship and coaching support was provided to HTC teams at Mbale, Gulu and Hoima RRHs. Frontline healthcare providers at the three hospitals were oriented on the targeted PITC approach and innovations to use in order to reach clients exposed to HIV. The teams were also oriented on the use of the HTC eligibility and screening tool intended to minimize HIV re-testers. B. Voluntary Medical Male Circumcision (VMMC) During this quarter, USAID/SUSTAIN supported seven regional referral hospitals to offer the comprehensive VMMC package to males in their catchment areas. This support included distribution of supplies, data capture tools, mentorships and supportive supervision. The target was to circumcise 3,221 men aged 15 to 29 years. The project promoted the clean care concept and vaccination with tetanus toxoid as a measure to prevent postcircumcision wound infection and tetanus. Additionally, quality improvement approaches were used in seven hospitals in conjunction with the Applying Science to Strengthen and Improve Systems (ASSIST) project to ensure delivery of VMMC services according to MOH standards. Performance Trends for Service Delivery and VMMC Hospital Systems Strengthening During this quarter, VMMC performance has been modest due to delays in approval of the project s annual work plan and budget, which affected delivery of certain VMMC activities. For example, planned VMMC camps did not take place. The project followed up 95% of all circumcised clients at least once in seven days following circumcision and kept the adverse events rate low at 0.2%. October 1 December 31, 2016 Quarterly Report 7

14 Figure 2. Site specific VMMC performance, October-December Number Fort Portal Gulu Hoima Jinja Lira Masaka Moroto Mubende Soroti Arua Circumcised Followed up Adverse Events C. Prevention of Mother-to-Child Transmission of HIV and Early Infant Diagnosis In line with the Uganda national policy and implementation guidelines, the USAID/SUSTAIN project supports elimination of mother-to-child transmission of HIV (EMTCT) at 12 hospitals (Kabale, Hoima, Fort Portal, Mubende, Jinja, Mbale, Soroti, Moroto, Gulu, Lira, Kawolo and Arua). During this quarter, more effort was put on strengthening psychosocial support through family support groups and systems to track missed appointments, increase retention in care for HIVinfected pregnant and lactating women and their babies through early retention monitoring and HIV-exposed cohort analysis at 12 and 24 months. Quality improvement was used to bridge the identified gaps in service delivery. Figure 3. The continuum from HIV testing, enrollment to care and initiation on ART for HIV-infected pregnant women and their infants, October 2016 December 2016 HIV-infected infants (<18mths) enrolled in care HIV-infected infants (<18mths) identified Exposed infants started on CTX Exposed infants tested & results returned Exposed infants received NVP syrup at birth Infants born to HIV-positive women in maternity Total (ANC, MAT, PNC) HIV+ women receiving ARVs Total (ANC, MAT, PNC) women identified HIV-positive Pregnant women newly enrolled into care Pregnant women newly tested HIV-positive Pregnant women received HTC in ANC New ANC attendences ,256 1, (Option B+ = 310) 989 (New positives = 335) 8,846 9, ,000 4,000 6,000 8,000 10, % (29/1,256) of the results returned for exposed infants indicated HIV-positive findings Of the 29 HIV-positive exposed infants, 24 (82.8%) were enrolled into care by the end of the reporting period 92.5% of newly identified HIVpositive pregnant women were initiated on Option B+ in the PMTCT setting 86% of exposed infants born to HIV-positive women received NVP syrup at birth 93.9% (8,846/9,418) of ANC attendances received HTC services 335 (2.1%) newly identified as HIV-positive 98.8% were newly enrolled in HIV clinic 8 USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally

15 Early Infant Diagnosis A total of 1,562 DBS DNA PCR samples were sent to the Central Public Health Laboratory (CPHL) for testing, and 1,256 (80.4%) test results were returned to the hospitals where testing took place. The 306 results not yet at the testing facility were collected in the last month of the quarter and await processing and dispatch. Of the test results returned, 951 (75.7%) were given to caregivers, while 305 infants did not receive their results due to: n Failure to honor clinic appointment by the end of reporting period (244 or 80%); n Expected to return for results in the subsquent month after follow-up (11 or 3.6%); or n Lack of caregiver contact information (50 or 16.4%). Of those tested and results returned, 29 infants (2.3%) tested HIV-positive on DBS DNA-PCR and 24 (82.3%) of these were initiated on ART, three were referred to another facility while two died before ART could be given. The data shows that 18-month retention of the net cohort (which excludes the transfer outs) was 76.3% while the positivity rate increased from 3.8% to 4.7% on adjusting for transfer outs and lost to follow up. From Figure 4, tracking of the 18-month retention in care for HIV exposed infants enrolled in care has demonstrated Table 3. The 18-month final outcome of the exposed infants enrolled in care from October December 2015 HIV Status Known Outcome Number of Infants HIV-positive and enrolled on ART 36 (97.3%) HIV-positive and transferred to other facility 68 (6.9%) HIV-positive, in care and not on ART 1 (0.001%) HIV-negative 716 (72.7%) HIV Status Unknown Dead 22 (2.2%) Lost to follow up 120 (12.2%) No documented outcome 10 (1.0%) In care but no test done 12 (1.2%) Total 985 an increase in net retention from 69.8% in Q1 FY16 to 82% in Q1 FY17, and reduction in percentage of infants missing scheduled return appointments from 3.1% in Q1 FY16 to 1.2% in Q1 FY17. Improvement is attributed to enrolment of exposed infants in birth cohorts and continued analysis for retention at 12 months since January The approach identifies lost infants due for a final HIV test for follow up. Figure month HIV exposed infant final outcome per quarter, October 2015 December Percent Oct-Dec 2015 Jan-Mar 2016 Apr-Jun 2016 Jul-Sept 2016 Oct-Dec 2016 Net retention in care Total infants tested HIV positive Discharged HIV negative In care but no test done Transferred out (Formal & self-referrals) October 1 December 31, 2016 Quarterly Report 9

16 An increase in the number of those transferred out has been observed as some of the infants followed up were confirmed to have self-transferred to other facilities nearer to their homes. Figure 5. Male partner attendance by region, October December ,500 In addition to the achievements above, USAID/SUSTAIN has registered significant gains in the following areas: Postnatal Care and Family Planning Services. n Of the 16,003 total deliveries, 3,964 (24.8%) of mothers received postnatal care services between six days and six weeks postpartum, an improvement from 19.5% and 15.2% in the previous two quarters. The increase may be attributed to improved documentation in the postnatal register and client education on the importance of postnatal care following mentorships. Number of Male Partners 3,000 2,500 2,000 1,500 1, Central South & Mid-West North & West Nile Karamoja & East 1st ANC visit Male partners tested n 8,384 women, including 1,242 who are HIV-infected, accessed family planning services at USAID/SUSTAIN supported activities. All the 12 supported hospitals have integrated family planning services at ART clinic and mother-baby care points. The project will continue to support the hospitals to create awareness of family planning services among the clients attending these units. Linkages and Continuum of Care HIV-positive pregnant and lactating women: Of the 322 women newly identified as HIV-positive in MCH setting, 299 (92.8%) were immediately enrolled into HIV care. Among the 23 HIV-positive women not enrolled at the hospital of testing, six requested for referral to other facilities, eight were later enrolled following intensified counseling, and nine were not psychologically ready and still undergoing counseling by the end of the reporting period. Psychosocial support to the new HIV-positive pregnant women: During the quarter, the project built capacity of health workers at Hoima, Kawolo, Mbale and Moroto hospitals through mentorship on establishing and managing family support groups (FSG) which provide psychological support needed by this unique category of clients. As a result, 80 (70.1%) newly identified HIV-positive pregnant and lactating women were enrolled into FSGs at these four sites. This support will be provided to the remaining eight facilities in the next quarter. FSG registers were provided to all the 12 supported hospitals. Male engagement: A total of 2,348 (24.9% of the total pregnant women attending ANC) men were tested for HIV at the MCH units. A total of 49 (2.1%) men tested HIV-positive and were all linked for chronic care. Male partner attendance is lowest in the West and South Western regions and highest in Karamoja and Eastern region. Health worker capacity building: During the quarter, the project continued to provide virtual support to health workers to improve the quality of EMTCT service delivery. Frequent phone contact proved effective. In addition, the routine quarterly mentorship visits focused on improved documentation, retention in care and management of family support groups at Hoima, Gulu and Mbale RRH. D. HIV Care and Treatment Quarter 1 interventions focused on mitigating client loss-to-follow-up through improved facilitycommunity linkages towards meeting the targets. Other areas of focus were improving access to care for orphans and vulnerable children and key populations and strengthening facility-community linkages for client retention in care. Two facilities attained the targets while six facilities attained two of the three 90s. 10 USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally

17 n 94.5% of clients in care are on antiretroviral therapy n 89.3% of the clients who accessed a viral load test during this period had suppressed the virus Achieving the Second 90 Screening of Pre-ART Clients for ART Eligibility n Timely access to CD4 tests for pre-art clients due for eligibility assessment improved from 58% in Q4 FY2016 to 59.4% (1,403 clients) in Q1 of FY2017. Of the pre-art clients eligible for a CD4 test, 139 (5.9%) accessed CD4 tests in the recommended scheduled timeframe. Of the 1,710 clients identified as eligible for ART, 1,338 (78.2%) were enrolled on treatment. Anti-retroviral Therapy n 1,617 adults and children were newly enrolled on ART this quarter, making a total of 55,780 clients (92.5% adults and 7.3% children) on ART by end of December n 93.3% of the adult population on ART were on first-line ARV regimens, while 6.7% were on second-line regimens. Pediatric HIV testing, care and ART n A total of 9,027 children (including infants tested by the DNA PCR method) less than 15 years of age were tested for HIV, and 91 (1.3%) tested HIV-positive. Of the infected children, 98 were enrolled in HIV care. This includes children from other sources. Reasons for non-enrolment include: clients lost-to-follow-up and referral to healthcare units nearer to their homes. Table 4. Clients newly enrolled in HIV care, by gender and age group, October-December 2016 Category Number of clients enrolled in care Males (>15 years) 624 Females (>15 years) 1,144 Children (5-14 years) 40 Children (2-4 years) 26 Children (<2 years) 32 Total 1,866 (20% of annual target) n 85 (86.7% of the children enrolled in care) children were initiated on ART. This includes children under 15 years of age who had been in pre-art care but not started on treatment. Children on ART, retention and pediatric ARV regimens n The ART initiation rates across the age groups of 0 2 years, 2 5 years and 5 15 years was 100%, 69.2% and 87.5% of those enrolled in care, respectively. The use of simple improvement interventions, like putting reminder stickers on client files to aid identification of children due for ART initiation, has maintained the proportion of children on care that are on ART above 99.8% (4190/4200) for this quarter. Achieving the Third 90: Ensuring client retention in care ART cohort analysis Analysis of a cohort of 1,641 clients enrolled in ART during the October-December 2015 quarter shows that 85.8% (1,408 clients) were still alive and active on ART 12 months later. Over 27% of the clients that were not recorded as active on treatment in this cohort had self-transferred to other health units in the quarter; 9% had died and 26% could not be traced for follow up because of lack of active telephone contact information. Nine of the 12 supported facilities met the 85% target in Q1 FY2017. Three facilities (Moroto, Arua and Lira RRH) were affected by mobile clients (Arua & Morotto RRH), cross border clients (Arua RRH) and long distance clients (Lira RRH) due to challenges of access to care. Adherence assessment n On average, 82.3% of clients on ART had a good adherence (successfully took [swallowed] at least 95% of prescribed ART). Clients with fair and poor levels of adherence were given appropriate counseling support and guidance to plan for improvement. n Adherence levels at the facilities have been improved through the integration of regular psychological assessment for clients both in general care and on ART, regular morning health education talks with emphasis on adherence, availability of job aides to support adherence and counseling and use of expert clients as adherence peer supporters. October 1 December 31, 2016 Quarterly Report 11

18 Viral load monitoring n 13,834 viral load tests were completed to monitor ART treatment outcomes in clients on first- and second-line ART regimens and the average suppression rate for all age groups was 89.3%. The proportion of clients on ART that accessed viral load tests in the quarter was 24.8%. The increase in numbers of clients accessing viral load tests from 12,611 in Q4 FY2016 to 13,766 in Q1 FY2017 is attributed to the viral load monitoring training that was conducted during this quarter. n Health facilities have been trained and supported to use the electronic database to identify clients with high viral loads. All incoming viral load results are reviewed weekly to identify clients with suspected treatment failure. Case review meetings are then conducted by multidisciplinary teams to identify clients for clinical and adherence reassessment. Intensified adherence support is offered for clients with poor adherence for six months after which they are virologically reassessed. When failure is confirmed, clients on first-line treatment are switched to second-line and those on second-line are referred to centres of excellence for further management. Of the clients on ART, 147 were switched from first- to secondline treatment representing an increase in the number of clients on second-line treatment from 6.3% in Q4 FY2016 to 6.6% (115 clients) in Q1 FY2017. n Facilities are being supported to monitor early warning indicators of HIV treatment failure for which interventions will be made to support viral suppression. Monitoring of viral load for children Of the children on ART, 521 (12.4%) received a viral load test during the quarter. Of the children that accessed a viral load test, viral suppression by age group was 100% for children less than 2 years, 51.5% for children 2 to 5 years, 65.1% for children of 5 to 15 years. This was low compared to the age group of 15 years and above that had a viral suppression of 89.9%. Efforts for Year 7 will focus on supporting improved viral load monitoring and suppression in these age groups. Way Forward for the Next Quarter Significant gains have been registered in reducing client loss-to-follow-up this quarter from 1,678 to 272. Delayed dissemination of the revised consolidated HIV care and treatment guidelines affected the roll out of the Test and Treat policy but facilities are being accessed for differentiated service delivery models. The following are key areas of focus for next quarter: n Implementation for differentiated services models to improve client access to care and retention. n Rolling out the Test and Treat approaches to improve access to ART. n Continued support to reduce client loss-to-follow-up. Figure 6. Retention on ART 12 months after initiation on treatment by hospital Percent Kabale Fort Portal Mubende Gulu Hoima Mbale Jinja Soroti Kawolo Arua Lira Moroto Alive and on Tx Target 85% 12 USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally

19 E. Facility-Community Linkages and Client Follow-up Following the PEPFAR guidelines for facility-community linkages, SUSTAIN oriented staff from supported RRHs on the current framework and helped develop specific action plans. During this quarter, best practices from previous years were consolidated to ensure reduction in clients lostto-follow-up. Project technical teams together with select Community Linkages Coordinators from supported hospitals with good retention outcomes conducted client follow-up exercises at facilities with high percentage of client losses (Lira, Gulu, Arua, Kawolo, Mbale and Soroti). Facilities with lower numbers of lost clients worked with expert clients to follow up with clients using phone calls and home visits. This cross-facility technical assistance had a good outcome. As a result, 1,579 clients lost-to-follow-up at 12 facilities were tracked through phone calls (1,028) and home visits (430) for those who could not be reached on phone. The following outcomes were observed: n 587 (37.2%) clients were active in care, but information was not updated in the data system; n 180 (11.4%) had self-transferred (transfers were completed during the tracking exercise); n 35 (2.2%) had died; n 14 (0.9%) had stopped treatment; and n 89 (5.6%) were transferred out, but records were not updated. Of the 1,579 clients lost-to-follow-up, 229 (14.5%) returned to the clinic. As well, 856 (54.2%) clients were confirmed active in care at the supported facility or another lower-level facility. Lastly, 272 clients could not be tracked, including 53 from the Democratic Republic of Congo and 35 attending Lira RRH who originate from distant districts. SUSTAIN will strengthen collaboration with district implementing mechanisms (PEPFAR and non-pepfar funded projects) and lower health facilities through networking, linkages meetings and inter-facility coordination meetings. Meetings with district community development officers and community-based organizations will be organized to improve services to orphans and vulnerable children and facility-community linkages. Health workers will be trained on orphans and vulnerable children and gender mainstreaming to improve linkages between facility and community services. F. Nutritional Assessment Counseling and Support (NACS) The Ministry of Health recently revised the integrated management of acute malnutrition guidelines recommending the use of therapeutic foods, particularly ready-to-use therapeutic foods (RUTF) for all severely acutely malnourished HIV-infected clients. The USAID/SUSTAIN project has continued to support health facilities to integrate nutrition services across the continuum of care using the MOH s Nutrition Assessment Counseling and Support (NACS) framework as well as the integrated management guidelines. The health facilities have been provided with nutrition assessment equipment, including weighing scales, mid upper arm circumference (MUAC) tapes as well as information, education and communication materials to improve the quality of nutrition services. Nutrition Assessment and Categorization Of the 59,034 clients within HIV clinics at supported facilities, 52,582 (89.1%) were assessed for nutritional status using the MUAC method. In total, 851 of 921 (92.4%) HIV-infected pregnant women attending ANC at supported healthcare facilities were also assessed using the MUAC method in addition to other HIV-negative pregnant women in ANC; 1,801 (81.1%) exposed infants above six months of age were also assessed and their nutrition status categorized. Of these, 1,086 (2.1%) HIV-infected clients within the HIV clinics were identified with acute malnutrition, 17 (2.0%) of pregnant women had moderate acute malnutrition, and 68 (3.8%) exposed infants had acute malnutrition. Counseling and Support n A total of 1,480 malnourished clients were given RUTF from all the supported health facilities of which 707 (47.8%) were HIV-infected. Out these clients, 599 (84.7%) were newly identified malnourished clients within the HIV clinic; others were on RUTF before the reporting period. n Fifty (73.5%) out of 68 malnourished exposed infants were given RUTF. Of the 17 malnourished HIV-infected pregnant women, none were given RUTF because they had only moderate acute malnutrition. The integrated management of acute malnutrition guidelines recommend enrolment into supplementary feeding programs that are not available at the SUSTAIN-supported healthcare facilities, with the exception of Moroto Hospital through the World Food Program. Additionally, 823 (74.7%) of the October 1 December 31, 2016 Quarterly Report 13

20 malnourished clients within the HIV clinics were provided with nutrition counseling. Infant and Young Child Feeding Practices n 909 (90.4%) exposed infants of 1,006 were initiated on the breastfeeding within one hour after birth while 2,852 (93.8%) out of 3,042 infants below six months are exclusively breastfed. Of the exposed infants over six months of age, 1,812 (41.9%) of 4,322 are reported to be given appropriate complementary foods and 2,051 (47.5%) are no longer breastfeeding. G. TB/HIV Collaborative Activities During the quarter, USAID/SUSTAIN continued to provide technical and operational support to 12 hospitals to deliver quality TB services focusing on pediatric TB management and enhancing favorable TB treatment outcomes for all notified TB cases. TB Case Detection and Notification n 98.8% of the notified TB cases (134) had a documented HIV test result in the TB unit registers. Almost half (46.5%; 521) of TB cases were co-infected with HIV. The proportion (98.8%) of TB cases with a documented HIV test was below the 100% target as some HIV tests for TB cases were not documented in the unit TB registers by reporting time at Arua, Gulu and Mbale RRH. n Among the TB/HIV co-infected clients, Cotrimoxazole preventive therapy (CPT) was provided to 96.5% (503) of clients, while ART was initiated or continued in 89.4% (466) of clients, compared to the target of 100%. The rising trends in linkage of TB/HIV co-infected clients to ART is a result of the ongoing support to the existing TB/ HIV one stop shop model sites (Hoima, Kabale, Fort Portal, Lira, Mbale and Arua) that provides integrated TB/HIV services at both TB and HIV care points. n The incident cases (new and relapse) and new bacteriologically confirmed cases notified during the quarter were 1,097 and 588 respectively. The incident cases have been consistently maintained above the quarterly target of 694 cases as the facilities embrace intensified case finding and utilization of existing GeneXpert as a screening tool for all presumptive TB cases in line with the new MOH/National TB and Leprosy Program (NTLP) guidelines. Diagnosis has Improved Client results are returned in one day without fail, compared to the earlier seven days turnaround time, thanks to the GeneXpert machine. Before, sputum samples would get lost; clients were then required to provide another sample thus delaying treatment. Dr. Wilson Senjokyo, Clinical Care Coordinator/TB Focal Person, Arua RRH TB Treatment Monitoring USAID/SUSTAIN supported the TB sites to transition to use the GeneXpert test as the screening tool among presumptive TB cases and ensured continued utilization of sputum microscopy for TB treatment monitoring. The aggregated quarterly sputum conversion rates for new pulmonary bacteriologically confirmed that had a smear done after completion of intensive phase was 91.1%, while 8.9% cases remained positive and were appropriately linked to GeneXpert testing to rule out rifampicin resistance (RR). TB Treatment Outcome Evaluation The project supported all 12 hospital TB and data teams in conducting TB treatment outcome evaluations among new bacteriologically confirmed patients initiated on TB treatment months prior to the respective quarter. Out of the 353 evaluated patients in the cohort, 265 had a cured or treatment completed outcome. This gave the cohort a treatment success rate (TSR) of 74% (Figure 7). Linkages and Client Follow-up A total of 437 patients on TB treatment missed their appointments across all 13 hospitals. All missed appointments were followed up through telephone calls and targeted home visits. Of these patients, 42.6% (186) returned to the hospital to continue their treatment while the remaining 57.4% of clients were either well and on treatment after selftransferring, not reachable, had died or chose to stop their medication. 14 USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally

21 Figure 7. Aggregated TB treatment outcomes for new bacteriologically confirmed TB patients, months after initiation on TB treatment for patients enrolled in 2015 (Q1) Failed treatment Died Lost to follow-up 1.1% 5.4% 18.4% TSR (Cured and completed treatment) 74% TB/HIV co-management for the DR-TB cases started on MDR-TB treatment at SUSTAIN supported sites n 77.3% (17 out of 22) of the new DR-TB patients had NACS through the integrated nutritional support at SUSTAIN DR-TB initiating sites. Seven (41.2%) of the 22 patients had acute malnutrition and all were enrolled on ready-to-usetherapeutic food. n 100% (22 out of 22) of the newly registered patients had a documented HIV status, 50% (11 out of 22) patients were DR-TB/HIV co-infected and all eleven clients started or continued on ART. Numberof new DR-TB patients Arua Mbale Fort Portal Masaka Mubende Gulu Tested for HIV Tested HIV-positive H. Strengthening the Capacity of Selected Regional Referral Hospitals for Management of Drug-Resistant Tuberculosis USAID/SUSTAIN continued to support interventions to enhance and sustain the capacity of seven regional referral hospitals (Arua, Kabale, Mubende, Mbale, Fort Portal, Masaka and Gulu) to manage drug-resistant TB. The project continued to support DR-TB case surveillance among MDR-TB presumptive cases, prompt enrollment for newly diagnosed cases and retention in care for the old cohorts of patients. DR-TB Surveillance and Case Detection Started on ART Laboratory Monitoring of DR-TB Patients During the quarter, the project continued to support running of chemistry and hematology tests through the automated laboratories at the treatment initiating facilities, whereas thyroid function tests for monitoring drug toxicities for patients on treatment were accessed through a private laboratory procured by the project. National Sample Referral and Transport System to the National TB Reference Laboratory (NTRL) supported the baseline culture and drug susceptibility tests (DST) and monthly sputum smear examinations for culture conversion monitoring. The patients on Bedaquiline at SUSTAIN sites are currently receiving baseline and monitoring electrocardiogram tests through support leveraged from USAID/TRACK TB and Clinton Health Access Initiative. 106 unique TB retreatment samples from 13 SUSTAIN sites 19 newly detected DR-TB cases referred to USAID/TRACK TB and CUAMM supported sites 137 GeneXpert tests (SUSTAIN supported hubs) 43 newly detected DR-TB cases 22 newly detected DR-TB cases started on MDR-TB treatment at SUSTAIN sites 21 unique TB retreatment samples referred from peripheral sites 2 new MDR-TB cases were still being prepared for initiation by reporting time DR-TB Patient Retention and Treatment Response Six-month interim treatment outcomes: For 31 patients enrolled on DR-TB treatment during the period Jan- Mar 2016, 35.5% (11) of patients has culture conversion, 58.4% of patients were not evaluated (no culture results by reporting time) and three (9.7%) patients died. In the cohort under evaluation, no patient was lost-to-follow-up. The low conversion rate during the quarter is due to a high proportion of clients (17 out of 31) in the cohort not having results back from the NTRL by the reporting time. October 1 December 31, 2016 Quarterly Report 15

22 24-month (end of treatment) outcomes: Twenty-one patients were enrolled on DR-TB treatment in the Oct-Dec 2014 cohort. The cohort TSR was 52.4% (11), lost-to-follow-up was 24% (5), the death rate was 14.3% (3), and one patient was still on treatment and another not evaluated as the final treatment culture results were not ready in the evaluation period. All five patients lost-to-follow-up are being tracked. Efforts to trace these cases were made, but the patients have changed places of residence. Improving TB Infection Control During the quarter, all the facilities both RRH and peripheral directly observed treatment (DOT) sites were supplied with and used personal protective equipment (N95 respirators and patient face masks). Linkages and Continuum of Care n During the reporting period, USAID/SUSTAIN continued to provide technical and operational support to seven MDR-TB treatment initiation sites and 85 peripheral DOT sites to conduct panel meetings, home and DOT facility assessments, contact tracing and investigation as well as home visits for patient psychosocial support. A total of 131 household contacts of MDR-TB patients were identified, 101 found symptomatic and all investigated for MDR-TB. None of the contacts were found to have TB. n During the quarter, USAID/SUSTAIN leveraged the Global Fund for AIDS, TB and Malaria to support patient treatment adherence (food packages) and transitioned patient transport and DOT site supervision to the same funding mechanism. I. Supply Chain Management Strengthening Continued improvement of supply chain management systems focused on 14 hospitals: Kawolo GH and Arua, Fort Portal, Gulu, Hoima, Jinja, Kabale, Lira, Masaka, Mbale, Moroto, Kaabong, Mubende and Soroti RRHs. In addition, SUSTAIN supported four Karamoja facilities: Matany and Abim Hospitals, Kotido and Tokora Health Centre IVs to improve laboratory logistics systems. Most of HIV commodities were supplied by the National Medical Stores (NMS) with cases of interrupted supply for commodities such as Efavirenz 200mg, Fluconazole 200mg, Niverapine 50mg, MDR-TB medicines, male condoms and hematology sysmex internal quality controls. Supply Chain Management Systems for HIV-related and Other Commodities Reporting and Ordering The project continued to support the ordering process for five HIV-related commodity orders (TB, antiretroviral/ EMTCT, laboratory credit line, essential medicines and health supplies, and HIV test kits) while working with order focal persons. The overall timely order submission rate for all SUSTAIN-supported hospitals was 98.9%. Twelve hospitals submitted 100% of the five HIV-related commodity orders harmonized and on time. All hospitals submitted the antiretroviral orders through the webbased ordering system (WAOS). Availability of HIV Commodities n The availability rate for HIV-related commodities averaged at 94.8% during the quarter. The drop in the availability rates was a result of delays in delivery and stockouts at the National Medical Stores. All laboratory supplies were available in sufficient quantities during the quarter with the exception of hematology sysmex internal quality control materials that were also unavailable at the central medical warehouses. n The high availability of commodities was achieved through regular pipeline monitoring of key HIV commodities and thus coordinating with the central warehouses to ensure timely delivery of supplies to facilities. Over 800 doses of first line pediatric treatment formulation of Efivirenz 200mg, Cyclocerine, and Isoniazid 300mg which were centrally stocked-out at the NMS were re-distributed from Kabale, Lira and Moroto hospitals to Lira, Gulu and Arua hospitals. Stock Monitoring and Redistribution The project continued to monitor HIV commodity stock status information from the supported hospitals on a monthly basis to inform planning and support for redistribution of health supplies. As a result of the stock status monitoring, HIV commodities were redistributed from health facilities with excess stock/unusable stock to those with insufficient stocks and some with stock outs. 16 USAID SUSTAIN Strengthening Uganda s Systems for Treating AIDS Nationally