Country Spotlight: Uganda

Country Overview

EGPAF has worked in Uganda since 2000. Today, in collaboration with the Uganda National AIDS Control Program and the Ministry of Health, EGPAF is increasing access to a broad range of comprehensive quality HIV/AIDS and tuberculosis (TB) services for children, women, and families in 13 districts of the Southwestern region (Kisoro, Kanungu, Rukungiri, Kabale, Ntungamo, Ibanda, Isingiro, Kiruhura, Bushenyi, Sheema, Buhweju, Mitooma, and Rubirizi).

James Pursey/EGPAF

Our Work in Uganda

EGPAF/Uganda supports the country's national AIDS Control Program (ACP) and TB and Leprosy Control Program (NTLP). EGPAF/Uganda utilizes the PMTCT, HCT and TB programs as entry points for identification of HIV-infected and affected individuals to provide prevention, care and support, and access to HIV treatment services for families. Currently, the Uganda program supports HIV prevention, care and treatment services in 13 districts in over 200 health facilities.

EGPAF/Uganda seeks to advance EGPAF’s leadership role in public policy, and advocates with the Ministry of Health, technical committees, Uganda's Parliament, development partners, donors, local celebrities and the general public to seek the eradication of pediatric HIV and AIDS.

Recent advocacy efforts include a policy analysis report prepared for the Ministry of Health by EGPAF in partnership with George Washington University in Washington, D.C. – and with support from The Children’s Investment Fund Foundation (CIFF) and ViiV Healthcare. This project was designed to inform the Ministry’s development of a national plan for elimination of pediatric HIV while identifying areas for support. The report highlights key findings in addressing the potential legal, policy, regulatory, administrative, and financial barriers and facilitators to achieving this goal.

As of December 31, 2013, EGPAF-supported programs in Uganda had:

Key Projects in Uganda

Strengthening the TB and HIV/AIDS Response in the South-Western Region of Uganda (STAR-SW) Project (USAID/PEPFAR: 2010-2015)

The STAR-SW project works to increase utilization of, access to, and coverage of quality comprehensive HIV/AIDS and tuberculosis (TB) services in 184 health facilities in the 13 districts in South Western Uganda. EGPAF aims to integrate cost-effective, family-based HIV/AIDS care and treatment services and prevention of mother-to-child transmission of HIV (PMTCT) programs into health care facilities through a multidisciplinary program of training, infrastructure development, and technical support. To enhance the sustainability of services, EGPAF promotes local district ownership of all activities; all work planning and roll-out of new services are led by the District Ministry of Health, and mentoring and supervising includes the District Health Team as the provider of support. STAR-SW objectives are as follows:

  • Increase the uptake of comprehensive HIV/TB services within supported districts;
  • Strengthen the decentralized service delivery systems for improved uptake of quality HIV/TB services, including the institutionalization of Lot Quality Assurance Sampling (LQAS) surveys at the district level;
  • Improve the quality of HIV/TB services in all supported health facilities and community organizations/activities;
  • Establish or strengthen networks, linkages, and referral systems within and between health facilities and communities;
  • Increase demand for comprehensive HIV/AIDS, TB prevention, care, and treatment services.

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Promoting Constructive Male Engagement to Increase Use of Prevention of Mother-to-Child Transmission of HIV Services in Kabale District, Uganda (FHI360: 2012-2014)

In collaboration with FHI360, EGPAF is conducting an operations research study to test an intervention package comprising facility- and community-based components designed to support constructive male engagement in the full spectrum of prevention of mother-to-child transmission (PMTCT) services, including family planning (FP). The interventions include Care and Treatment (C&T) provider training; addition of couples FP counseling within C&T services; recruitment and training of model men known as “Emanzi,” and Emanzi-led workshops shaped after Engender Health’s Men as Partners curriculum.

The primary objective of the study is to assess the effectiveness of the overall intervention aimed at constructively engaging men in the use of PMTCT services and FP decision making, measured in terms of dual method use (condoms along with another contraceptive) by C&T clients. The study is incorporated into EGPAF’s existing program, STAR-SW (Strengthening TB and HIV/AIDS Response in the South Western Region of Uganda).

The study design is a cluster randomized controlled design, with four health centers serving as intervention sites and four health centers as comparisons in Kabale District, Uganda, a rural district where C&T services are offered in eight public sector health facilities. Pre- and post-intervention cross-sectional interviews will be conducted with 1,545 C&T clients per round to assess intervention effectiveness. Changes between pre- and post-intervention PMTCT service statistics will be compared between intervention and control sites. A survey will be conducted with 1,500 men before and after their participation in a study-sponsored workshop. In-depth interviews will be conducted with 25 male and 25 female C&T clients to explore reported condom use behaviors. Process and cost data on intervention implementation will be compiled from monthly activity reports and administrative records.

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Advancing Community-Level Action for Improving MCH/PMTCT (ACCLAIM) Program (Canadian International Development Agency: 2012-2016)

The goal of this project is to increase community demand for, uptake of, and retention in maternal and child health (MCH)/prevention of mother-to-child transmission of HIV (PMTCT) services to improve country progress toward elimination of pediatric HIV/AIDS. This will be achieved through the following objectives:

  • Improving key HIV, MCH, and gender-related health behaviors through the implementation of community-based interventions that target changes in community norms and attitudes, thereby increasing the number of pregnant women accessing and completing the sequence of PMTCT services;
  • Assessing the behavioral and operational outcomes of selected community-based interventions and determine their relative effectiveness through strategic evaluation and operations research;
  • Documenting and disseminating research results, tools developed, and lessons learned to facilitate expansion of widespread expansion of community engagement activities found to be effective.

Community-based interventions designed to complement facility-based services hold tremendous promise for improving PMTCT program outcomes by addressing entrance, adherence, and retention to the range of PMTCT services along the cascade. The three main interventions for implementation and evaluation in this proposal, which address communities on three different levels, include:

  • Engagement of Community Leaders: Through training and capacity building for community leaders, this project will begin by facilitating the development of Community Action Plans (CAP) in order to generate increased demand for MCH and PMTCT services;
  • Community Days: Semi-annual Community Days will bring entire communities together for a day of communication, information, and activities to improve awareness among key target populations of important MCH and PMTCT services.;
  • Community Peer Groups: Working at the individual level, MCH classes and men’s groups will provide comprehensive MCH/PMTCT information and skills development to crucial community sub-groups focused on increasing and improving MCH and PMTCT health behaviors.

EGPAF has chosen three countries for these interventions – Uganda, Swaziland, and Zimbabwe – that, in collaboration with their respective Ministries of Health (MOH), are all making great strides in expanding facility-based services and strengthening health systems, but that have recognized barriers and gaps in demand and follow-up. This project provides a community-based approach that will influence harmful gender norms, attitudes, and behaviors through engagement at the grassroots level to enhance the potential impact. The addition of complementary community-based services will help move these countries towards elimination of pediatric HIV/AIDS, and the demonstration of the effect of these interventions will provide other countries with evidence to inform replication and scale-up.

Building upon EGPAF’s successfully supported PMTCT programs, this project will focus on breaking down community-level barriers to uptake of and retention in PMTCT services. The activities are designed to be locally relevant, addressing multiple gaps simultaneously, across a variety of settings. The proposed project will be conducted over four years in 45 community clusters across the three selected countries in a stepped approach that will allow for comparison of the effectiveness of single and combination interventions. All clusters will benefit from the “Leadership Engagement” component of the intervention package. In 15 community clusters, “Community Days” will be added on; and in the final 15 of the community clusters, the full combination intervention package comprising “Leadership Engagement,” “Community Days,” and “Community Peer Groups” will be implemented. Through routine monitoring and evaluation and focused operations research, EGPAF will be able to provide an in-depth analysis of the implementation and outcomes of the interventions, as well as the added value of each intervention. A comprehensive dissemination plan will allow for adaptation and use of these innovations in additional settings, which will contribute to the overall learning from the experience gained through implementation.

The strategic design of this project will provide the evidence base needed for communities and program managers to make an informed choice about community activities to support. The experience and evidence gained through the proposed interventions will be important not only for the three countries in which they will occur, but also across EGPAF’s other country programs and the broader global health community.

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Call to Action (USAID/PEPFAR: 2002-2010)

With funding from the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), EGPAF implemented the eight‐year Call to Action (CTA) project in 12 countries, including Uganda (from 2002 through 2010). This project sought to improve access and expand care and support for quality prevention of mother-to-child transmission of HIV (PMTCT) services, while enhancing technical leadership and documenting successful program models. By project end, EGPAF had provided nearly four million women with access to PMTCT and antenatal care (ANC) services. In Uganda, by project end, 71% of women in country receiving antiretrovirals did so at an EGPAF-supported site.

In Uganda, the CTA project introduced a peer educator program to strengthen follow-up patient care by allowing peer educators to take over certain tasks for health care workers and provide patients with social support. 152 peer educators were trained and successfully integrated into existing patient-care services at health centers. The duties of this new cadre of support workers were streamlined into ANC clinics, well-child clinics, and antiretroviral therapy (ART) clinics. At ANCs, newly diagnosed pregnant women were assigned to peer educators with an aim of establishing bonds to enhance follow-up of these pregnant mothers, thus providing the program with direct access to newborn infants. Important to both PMTCT and ART programs, the peer educators help identify HIV-exposed infants presenting to the well-child clinics and guide the mothers/parents of these children to additional counseling and patient education for mother and baby.

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Leveraging PMTCT Services to Provide Comprehensive Care and Treatment Services in Ugandan Health Centers (Abbott Fund: 2007-2011)

In 2007, EGPAF and the Abbott Fund joined together to strengthen an existing Government of Uganda-funded HIV and AIDS care and treatment program to ensure that greater numbers of infants and young children were tested and, when appropriate, enrolled in care and treatment services. Aimed at filling key gaps in services at lower-level health units, the Uganda program initiated an innovative comprehensive care and treatment demonstration project within five health centers in Masaka, Kabale, Mayuge, Mukono, and Jinja districts. In early 2009, a sixth health center in Bushenyi district was added to the partnership. This initiative has created increased access to comprehensive HIV and AIDS services for many rural Ugandan children and their families, and has demonstrated that it is possible to provide quality comprehensive care and treatment services at the health center level.

With support from Abbott Fund, the program expanded participation of peer educators at the facility and community level, thus expanding each site’s reach and ability to provide quality care and retain patients in services. These peer educators, who are HIV-positive parents, were trained and assigned roles alongside professional health workers at care and treatment sites to help ensure that HIV-positive individuals receive supportive counseling and mentoring to help facilitate return for follow-up care.

The project also engaged in ongoing sensitization and community mobilization efforts that resulted in increases in:

  • Home visits to follow-up with newly identified HIV-positive mothers;
  • Identification of HIV-positive children through provider-initiated HIV testing and counseling (PITC);
  • Number of referrals of HIV-positive children to HIV care and treatment facilities;
  • In addition, adults attending the HIV clinic whose children were not yet tested and enrolled in care were targeted for additional counseling.

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Introduction of Rapid Syphilis Testing within Prevention of Mother-to-Child Transmission of HIV Programs in Uganda and Zambia: A field acceptability and feasibility study (WHO: 2008-2011)

Given that integration of syphilis testing into prevention of mother-to-child transmission of HIV (PMTCT) programs can prevent adverse pregnancy outcomes, this study assessed feasibility and acceptability of introducing rapid syphilis testing (RST) into PMTCT programs in Zambia and Uganda. Using a pre-post intervention design, HIV and syphilis testing and treatment rates during the RST intervention were compared with baseline.

In Uganda, 13,131/14,540 (90.3%) women were tested for syphilis during intervention, with 690/13,131 (5.3%) positive and 715/690 (103.6%) treated for syphilis. Syphilis baseline data was collected but not included in the analysis, as ANC syphilis testing before the study was not consistently practiced. Comparing baseline and intervention, 6,479/6,776 (95.6%) and 11,192/11,610 (96.4%) of ANC attendees were tested for HIV (p=.0009) and 570/726 (78.5%) and 964/1153 (83.6%) received combination or single-dose prophylaxis (p=.007). About 14% (99/690) of syphilis-positive pregnant women were HIV-positive. Overall, this study found that integrating RST in PMTCT programs increases screening and treatment for syphilis among HIV-positive pregnant women, and does not compromise HIV services.

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Publications

Country adaptation of the 2010 World Health Organization recommendations for the prevention of mother-to-child transmission of HIV (2012): Download PDF download

Sharing Tasks Among Health Care Workers in Uganda to Integrate Rapid Syphilis Testing in PMTCT Services (2011): Download PDF download

Eliminating Congenital Syphilis in Uganda (2011): Download PDF download

Quality Management Brief: Rapid Syphilis Testing Study in Zambia and Uganda (2011): Download PDF download

Providing Comprehensive HIV Prevention, Care, and Treatment for Children and Adults at Primary Care Centers (Uganda) (2010): Download PDF download

Our Program: Uganda: Working with Women, Children, and Families to Eliminate Pediatric AIDS: Download PDF download