TB AND HIV CONCEPT NOTE

Transcription

1 The single concept note details the applicant s request for Global Fund resources for a disease component for a three-year period. The concept note should articulate an ambitious, strategically focused and technically sound investment, informed by the national health strategy and the national disease strategic plan. It should represent a prioritized, full expression of demand for resources, and it should be designed and implemented in a way that maximizes the strategic impact of the investment. The single concept note for TB and HIV details the CCM s request for countries with high co-infection rates for the two diseases based on data from the World Health Organization. TB AND HIV CONCEPT NOTE Investing for impact against tuberculosis and HIV Countries with overlapping high burden of tuberculosis (TB) and HIV must submit a single concept note that presents each specific program in addition to any integrated and joint programming for the two diseases. In requiring that the funding requests be presented together in a single concept note, the Global Fund aims at maximizing the impact of its investments to make an even greater contribution towards the vision of a world free of the burden of TB and HIV. Enhanced joint HIV and TB programming will allow to better target resources, to scale-up services and to increase their effectiveness and efficiency, quality and sustainability. All concept notes should articulate an ambitious, strategically focused and technically sound investment, informed by the national health strategy and the national disease strategic plans (NSPs). The concept note for TB and HIV is divided into the following sections: Section 1: The description of the country s epidemiological and health systems context including barriers to access, the national response to date, country processes for reviewing and revising the response, and plans for further alignment of the NSPs, policies and interventions for both diseases. Section 2: Information on the national funding landscape, additionality and sustainability Section 3: The funding request to the Global Fund, including a programmatic gap analysis, rationale and description of the funding request, as presented in the modular template. Section 4: Implementation arrangements and risk assessment. IMPORTANT SUMMARY INFORMATION NOTE: Applicants should refer to the TB and HIV Concept Note Instructions to complete this template. Uganda TB and HIV Concept Note 15 October,

2 Applicant Information Country UGANDA Funding Request Start Date 01 JULY 2015 Funding Request End Date 31 DEC 2017 Principle Recipient(s) If the programs are to be managed as separate grants: Funding Request Start Date for HIV Principal Recipient(s) for HIV Funding Request Start Date for TB Principal Recipient(s) for TB 01 July 2015 Funding Request End Date for HIV 31 Dec 2017 Ministry of Finance Planning and Economic Development (MoFPED) The AIDS Support Organization (TASO) 01 July 2015 Funding Request End Date for TB 31 Dec 2017 Ministry of Finance Planning and Economic Development (MoFPED) The AIDS Support Organization (TASO) Uganda TB and HIV Concept Note 15 October,

3 FUNDING REQUEST SUMMARY TABLE A funding request summary table will be automatically generated in the online grant management platform based on the information presented in the programmatic gap table and modular templates. Module Allocated/Above Prevention Programs for General Population Prevention Programs for MSM and TGs Prevention Programs for Sex Workers and their Clients Prevention Programs for Adolescents and Youth, in and Out of School PMTCT Treatment, Care and Support TB Care and Prevention TB/HIV MDR-TB HSS-Health Information Systems and M&E Community Systems Strengthening Program Management Total (in US$) Allocation + Other Sources 11,391,918 6,567, ,959,285 Above 42,608,077 56,791,469 28,396, ,795,597 Allocation + Other Sources 146, , ,262 Above 394, , , ,516 Allocation + Other Sources 377, , ,545 Above 1,219, , ,944 1,759,906 Allocation + Other Sources 842, , ,146,128 Above 1,985,411 1,060,118 1,079,642 4,125,171 Allocation + Other Sources 234, , ,119 Above 234, , ,748 1,727,503 Allocation + Other Sources 44,890,672 53,469, ,360,185 Above 58,870,302 88,846,552 77,495, ,212,518 Allocation + Other Sources 2,318,396 3,148, ,467,237 Above 497, ,246 1,831,873 3,131,055 Allocation + Other Sources 277, , ,038 Above 228, , , ,252 Allocation + Other Sources 2,726,680 3,031, ,758,011 Above 1,194,255 1,270,582 2,238,929 4,703,766 Allocation + Other Sources 872, , ,156,787 Above 1,272,842 1,431,426 1,034,467 3,738,735 Allocation + Other Sources 150, , ,904 Above 241, , , ,145 Allocation + Other Sources Above Total Allocation + Other Sources 64,229,182 68,206, ,435,501 Above 108,747, ,830, ,627, ,205,164 Uganda TB and HIV Concept Note 15 October,

4 SECTION 1: COUNTRY CONTEXT This section requests information on the country context, including descriptions of the TB and HIV disease epidemiology and their overlaps, the health systems and community systems setting, and the human rights situation. 1.1 Country Disease, Health Systems and Community Systems Context With reference to the latest available epidemiological information for TB and HIV, and in addition to the portfolio analysis provided by the Global Fund, highlight: a. The current and evolving epidemiology of the two diseases, including trends and any significant geographic variations in incidence or prevalence of TB and HIV. Include information on the prevalence of HIV among TB patients and TB incidence among people living with HIV/AIDS. b. Key populations that may have disproportionately low access to prevention, treatment, care and support services, and the contributing factors to this inequity. c. Key human rights barriers and gender inequalities that may impede access to health services. d. The health systems and community systems context in the country, including any constraints relevant to effective implementation of the national TB and HIV programs including joint areas of both programs. a. Current and evolving epidemiology of HIV and TB in Uganda HIV Burden The HIV epidemic in Uganda has been generalized for more than two decades. The 2011 AIDS Indicator Survey (AIS) revealed an increase in HIV prevalence among adults aged years, from 6.4% in 2004/05 to 7.3% in This increase is attributed to incident HIV infections and improved survival due to increased access to HIV care and treatment services including antiretroviral therapy (ART). The increase in prevalence was noted in several regions with doubling of prevalence in some regions such as West Nile. It is estimated that by end of 2014, there will be 1,631,828 people living with HIV (PLHIV), increasing to 1,969,778 by 2018 (EPP 2013, page 1). Figure 1: HIV prevalence by Region 2004/5 and 2011 (AIS 2004/5 and AIS 2011) Across all regions of the country, women are disproportionately more affected than men with an overall HIV prevalence of 8.3% among women versus 6.1% among men. Prevalence for both women and men increases with age and peaks at age years for women (12.1%) and at age years for men (11.3%). HIV prevalence ranges from 4.1% in Mid-Eastern region to 10.6% in Central 1 region. Mid-Eastern Uganda, with the highest population coverage of circumcision (53%) had the lowest HIV prevalence at 4.1% and registered a modest decline from 5.3% in 2004/05 (Figure 1). HIV prevalence was higher among uncircumcised men (6.7%) compared to circumcised men (4.5%). However, the national coverage for male circumcision remained unchanged (25% in 2004/05 and 26% in 2011). Urban residents are more likely to be infected (8.7%) than their rural counterparts (7%); this picture is prominent among women with HIV prevalence among urban Uganda TB and HIV Concept Note 15 October,

5 women estimated at 10.7% compared to 7.7% among rural women while the rates for urban and rural men are the same (6.1%) (AIDS Indicator Survey 2011, page 101). In the younger age groups years, HIV prevalence is estimated at 3.7%; the female HIV prevalence for the age groups is two to three fold that of males within the same age category. HIV sero-discordance among couples remains a major factor in the HIV transmission dynamics in Uganda. According to the 2011 AIS, 6% of married or cohabiting couples were HIV sero-discordant (AIDS Indicator Survey 2011, Page 101). Among couples where at least one partner was HIV infected, 67% are HIV sero-discordant (i.e. in two out of three couples, the partner is uninfected). The draft 2014 Modes of Transmission (MOT) analysis also shows that transmission in long-term or stable monogamous relationships due to discordancy remains a key source of new HIV infections. In 2013 Uganda adopted the WHO 2013 guidelines, which provide for treatment of HIV-positive partners within sero-discordant relationships irrespective of their CD4 counts. There are also efforts to encourage couple testing which would help identify sero-discordant relationships, but its uptake remains low (5% of individuals tested in 2013/2014 tested as couples) (HMIS/DHIS2 July June 2014). HIV incidence: The country continues to experience a high rate of new HIV infections, at 140,000 at the end of 2013 (UNAIDS 2013 HIV Estimates for Uganda). The number of new HIV infections was consistently higher than that of individuals initiated on treatment until 2013 when the ratio of new HIV infections to the net increase in ART was <1 (Uganda HIV Investment Case 2014, page 15). This trend of new infections could be further reduced by full implementation of combination prevention interventions (especially targeting the sources of new infections) as defined in the HIV Investment Case. It is envisaged that implementation of the priority scale up plan in Uganda s Investment Case to attain critical coverage levels of key interventions could avert 2,160,000 new HIV infections and 570,000 AIDS-related deaths between 2015 and Integrated adjunctive interventions such as isoniazid preventive therapy, early detection of TB in HIV infected persons, and expanding ART coverage to all co-infected persons has obvious implications for the incidence, prevalence and mortality from the related TB epidemic in the country. TB incidence, prevalence and mortality World Health Organization (WHO) estimates of TB mortality, prevalence and incidence rates in Uganda have declined from 50,492 and 624 per 100,000 population in 1990 to 13, 175 and 179 respectively per 100,000 population in 2012 (Global TB Report 2013 page 159). However, an accurate estimate of TB prevalence or mortality is not available due to weaknesses in surveillance and vital registration limiting the certainty of firm conclusions. Accurate data on TB prevalence should be available in 2017 once the TB Prevalence Survey initiated in 2014 (funded through Phase I SSF from the Global Fund) is completed and the data analyzed. A recent paper in The Lancet analyzing the Global Burden of Disease 2013 estimated the annual rate of change (%) in TB (without HIV) in Uganda for the period to be (-1.61 to -0.94) (Murray C et al, 2014, Table 5; page 1044). The continued rapid population increase in Uganda contributes to the increase in absolute numbers of TB cases. The Uganda Bureau of Statistics (UBoS) estimates that the country s population grew annually at 3.2% during the period 1991 to 2002 (UBOS 2013, page x). The NTLP coordinated an epidemiological and impact analysis in 2011 with support from a technical expert (ToR for TB epidemiological analysis page 2-3). Key findings from this analysis, from the recently concluded Joint External Monitoring Mission (JEMM) and from the process to develop the National Strategic Plan (NSP) are summarized below to provide an overview of the evolving epidemiology of Tuberculosis (TB) in Uganda. Trends in incidence, prevalence and mortality (Fig 2) show wide confidence intervals indicating considerable uncertainty in the estimates. There is currently no national level vital registration system with standard ICD-10 (10th revision of the International Statistical Classification of Diseases and Related Health Problems) coding in place in Uganda. Vital registration data is available at some facilities but coverage is unknown. Only about 30% of children under 5 years old are registered at birth. The proportion of deaths occurring in the home is also unknown. As such, TB mortality in Uganda is based on WHO estimates. The estimated annual number of deaths due to AIDs has decreased from 100,000 in 2001 to 62,000 in 2011 (Fig 2) (WHO Global Health Observatory 2011 Web data). These limitations imply that the underlying causes of AIDs deaths, including the proportion of these who died of TB are not well known - an estimated 37% of autopsied deaths among PLHIV were attributed to TB (Cox JA et al, 2012, Page 1, 3). TB Treatment outcome in Uganda was previously not disaggregated by HIV status and therefore the proportion of TB cases that died that were co-infected with HIV is also unknown. This disaggregation has been recently introduced for the cohort beginning January 2014 and data will be available when treatment outcomes for this and subsequent cohorts are reported. Uganda TB and HIV Concept Note 15 October,

6 Analysis of notified cases (Fig 3) suggest that after a consistent decline in TB notification rates from 2004 to 2010, there was a slight increase in 2011, followed by another decrease in cases in Notification rates based on Ugandan data are slightly higher than WHO rates probably due to using population denominator data, which is closer to the true population. The population estimates used in the WHO Global Report are derived from UN, while those used by the National Tuberculosis and Leprosy Control Program (NTLP) are from the Uganda Bureau of Statistics (UBoS). Figure 2: Trends in TB incidence, prevalence and mortality; annual deaths due to AIDS (Uganda) While data show that the TB case notification rates at a national level are decreasing over time, the percentage change in TB case notification rate shows much variability by year over time. When TB notification rates were compared from 2008 to 2012 by TB reporting zone (Fig 4), data suggests that reporting is generally consistent in most zones, with most variability occurring in a few zones, e.g. North-west, North-east and Kampala. Besides a slight increase in smear positive cases during , there was very little fluctuation in the proportion of notified cases that were bacteriologically positive ( %) and extrapulmonary (11.2 to 11.5%). Kampala and the Northeast are the only two zones that have consistently notified 15% of all TB as extra-pulmonary, while it is as low as 5% of notified patients in North and Northwest zones (Uganda TB Strategic plan draft July 2014, page 33). The reasons for this variation are not clear. Figure 3: Notification rate (new and recurrent) Figure 4: TB notification rate by zone About 50% of Uganda s population is under 15 years. However, children (<15 years) account for only 3% of all notified smear positive TB cases and ~ 7% of all forms of TB notified (data for this is not directly available, and is derived from the numbers of category of treatment used for children). It Uganda TB and HIV Concept Note 15 October,

7 also appears that the proportion of children reported to have smear positive TB out of all smear positive TB cases decreased over time, but there was a larger decline between 2008 and 2009 before rising again in The program s revised recording and reporting formats disaggregate data for children below 5 years. The WHO estimates that in 2012 that there were about 1,000 (660 1,300) cases of Multi-Drug Resistant TB (MDR-TB) in Uganda and that about 19% of retreatment patients notified in 2012 were tested for Drug Sensitive TB (DST); 89 confirmed MDR-TB cases were notified to the NTLP (Global TB Report 2013Table A4.7, page 175). WHO estimates of MDR are based on a recent national survey which showed that the proportion of new and retreatment cases that were MDR-TB was 1.4% and 12.1%, respectively (Lukoye D et al, 2013 pages 1, 5). Though there has been a decline in TB HIV co-infection from 54% in 2011 to 49% in 2013, HIV infection rates remain seven times higher among TB patients (49%) than in the general population (7.3%). An estimated 1.4-7% of adults and up to 9.5% of children living with HIV had prevalent TB (NTLP: Annual Report 2012/2013, page 15 and 17). b. Key populations that may have disproportionately low access to prevention, treatment, care and support services, and the contributing factors to this inequity Uganda has several Most at Risk Populations (MARPs) that are the leading sources of new HIV infections (UAC MARPs Review 2014, page 6 and 9) and have challenges accessing HIV and TB services. The HIV Investment Case defines several MARPs populations including fishing communities, Sex workers (SWs) and partners of sex workers, Men who have Sex with Men (MSM), uniformed services, and truckers. In this application, we use MARPs to include all these groups but mention specific populations in the description of interventions, as applicable. The fishing communities around Lake Victoria in the districts of Kalangala, Mukono, Buikwe, Buvuma, Namayingo, Wakiso, Mayuge, and Kayunga have a very high HIV prevalence, between 20-42% (KMCC Fishing Community Review June 2014, Page 11). The districts/communities around Lake Kyoga (Amolatar, Apac, Buyende, Dokolo, Kaberamaido, Kayunga, Nakasongola, and Serere) have twice the national HIV prevalence (14.7%) but lower than that in the Victoria basin. A review of literature on MARPs conducted by Uganda AIDS Commission (UAC) and UNFPA in 2014 characterized risk behaviors and attempted to estimate sizes of various MARPs from existing literature in Uganda. Fisher folk featured prominently due to a high HIV sero-prevalence, incidence and large population size. Major reasons for this high HIV prevalence and incidence in fishing communities include: a booming sex work industry within fishing communities partly attributed to high income from fishing and preponderance to alcohol and drug abuse as well as high mobility of fisher folk, high proportion of individuals with concurrent multiple sexual partnerships, and non-use of condoms during high risk sex. The HIV prevalence in fishing communities, from the UAC/UNFPA review, which predominantly included surveys around Lake Victoria, varied between 23-35% and the population size was estimated at 2 million; sex workers were estimated at 54,549 with a prevalence of 33% on average; truckers were estimated at 31,588 with HIV prevalence of 25% to 32%; uniformed personnel were estimated at 650,000 with HIV prevalence of 10-18%; and MSM were estimated at 10,533 MSM with HIV prevalence of 13.7%. Because of the wide variation of size estimates for various MARPs groups, this review and the Investment Case recommended a national MARPs size estimation to harmonize estimates and guide programming (UAC MARPs Review 2014, page 7). Prevalence of TB amongst MARPs is not known since this data is not collected routinely. Since a mapping of these populations is not easily available, it is also challenging to target and prioritize HIV and TB services for these MARPs. The high mobility of these populations also makes it difficult to provide HIV and TB services to these communities, and to link and retain those who are HIV infected in care for both TB and HIV services. Access to various health services is also generally lower within fishing communities (KMCC Fishing Community Review June 2014, Page 19). Truckers have historically been associated with high HIV prevalence in Uganda, and the towns and trading centers along the transport corridor have always had a higher HIV prevalence than surrounding areas. The Knowledge Management and Communications Capacity building initiative (KMCC) 2014 Truckers literature review shows very high knowledge of HIV prevention among truckers, which does not translate into risk reduction; multiple concurrent sexual partnerships with limited condom use and underlying drivers such as alcohol and drug use with sex work hotspots along the transport corridor put the truckers at risk of HIV transmission and acquisition. Yet, access to prevention, care and treatment services along the transport corridors remains limited (KMCC Truck Drivers Synthesis Report, October 2014, Page 3). Uganda TB and HIV Concept Note 15 October,

8 Other high risk groups with low access to services The Priorities for Local AIDS Control Efforts (PLACE) methodology study, which was conducted in 30 districts in , identified several venues that were associated with high-risk sexual behaviors (acquisition of new partners, multiple partnerships and transactional sex). The most common high-risk venues included bars, nightclubs, sites for local brew, markets, and trading centers. Activities at these venues included consuming alcohol, socializing, and dancing, among others. Across all districts, the HIV prevalence among the patrons and workers in the venues was about twice the regional prevalence and highest among the female patrons and workers. Yet, access to HIV prevention information and condoms within these venues were sub-optimal and condom use was low across all districts, although some districts were worse off than others (PLACE Report 2014, Pages 9, 13, 21, 23, 37). For example, in Kalangala, a fishing community with high HIV prevalence, 36% of female workers and 38% of female patrons in these high risk venues never used condoms in the previous six months while in some districts (e.g. Arua and Dokolo in northern Uganda and Kabale and Kisoro in western Uganda) >40% of the women and men in these venues never used condoms. It is also not known what proportions of these populations with higher prevalence of HIV have access to routine TB screening as this data is also not collected. In this application, CCM proposes targeted BCC interventions and condom programming for MARPs in these locations. Uganda Prisons Service The Uganda Prisons Service (UPS) has an average population of 35,000 inmates distributed across ~ 233 prisons, with a turnover of over 100,000 annually. The burden of TB is high in UPS with an estimated prevalence of 654/100,000 population (Uganda Prisons Services Report March 2009, Page viii). Annual notification of TB from prisons services is about 500 cases of all forms. Efforts to control TB in UPS are complicated by the high HIV prevalence (11%), high HIV/TB co-morbidity, prison congestion, poor nutrition and inadequate infrastructure, limited TB awareness and a weak prison health system. With support from the Government of Uganda, Global Fund (GF) and partners, the NTLP in collaboration with UPS has implemented a range of TB strategies and interventions that include: provision of high quality directly observed treatment (DOT) and TB/HIV collaborative management at 13 TB treatment units (out of 35); strengthened the prisons health systems through recruitment of health workers and capacity building for TB management and operational research; engaged NGOs, CSOs and community TB care providers to extend TB care to prison units; empowered prisoners suffering from TB to support peer education of inmates; and promoted prison community participation in TB care. Ongoing interventions to increase access to HIV testing within prisons (supported by CDC) provide platform to integrate TB screening for HIV infected prisoners. Urban populations The rate of urbanization in Uganda, 4.8 percent, is among the highest in the world. While Uganda s urbanization level is still low, at 12 percent, by 2030 it is projected to reach 30 percent, with an urban population exceeding 20 million people. In slum areas, the informality of housing overlaps with informal employment, service provision and legal status. (CIGI May 2013, pages 3,4). Urbanization rates in Uganda are higher than official estimates if one considers an alternate measure the Agglomeration Index, which considers density, urban size and proximity to the urban center. Using this index, Uganda s urbanization moves up to 25 percent using proximity to cities of 50,000 people. (Byamugisha et al, Page 2). Kampala city alone with a population of about 1.7 million (~5% of national population) accounts for one of every five TB cases notified to the NTLP. TB treatment outcomes are also among the lowest in Kampala and speak of the challenges in accessing TB services in this urban setting. HIV prevalence is high in Kampala at 7.1% (close to the national average of 7.3%). The Global Fund (GF) has also noted in its most recent Portfolio Analysis the high burden of TB is mainly in the urban and peri-urban centers, with Kampala accounting for 7,800 cases, Wakiso for 1,300 cases and other regional towns accounting for between 1,300-1,600 cases each (Pre-Assessment Report UGD-T-MOFPED Sep 2014, page 3). c. Key human rights barriers and gender inequalities that may impede access to health services Legal context Some existing Acts (e.g. Penal Code Act on sex work and same sex relationships) make it difficult to deliver services to key populations (sex workers and MSM). The recently repealed Anti Homosexuality Act (AHA) also generated a lot of discomfort among the affected populations and interrupted service delivery (e.g. the suspended national MARPs size estimation study). However, the health policy environment and guidance on delivery of services for key populations including sex Uganda TB and HIV Concept Note 15 October,

9 workers and MSM has improved over the last one-two years, with formation of key populations technical working groups at Uganda AIDS Commission (UAC) and Ministry of Health (MoH), and development of the MARPs programming Framework by Uganda AIDS Commission (UAC) (UAC MARPs Framework 2014, Page 8,9). Building on these frameworks, CCM proposes interventions to improve access to HIV services by all, including minority groups despite the legal environment. In addition to the legal issues, there is widespread stigma and discrimination against sexual minorities. A study assessing barriers and opportunities for increasing access to HIV services among MSM and sex workers, which was conducted in November-December 2013 showed that these groups experienced stigma from the general population, their families, health providers and other patients within health facilities. Stigma and discrimination was highlighted as a major barrier to access to health services (MOH MARPs Report 2014, Pages 7, 8, 33-36). The HIV Control and Prevention Act has positive elements including establishment of the HIV Trust Fund. However, criminalization of HIV transmission (AIDS Act 2014 clause 13, 14,18(e) and 41), which places a burden on HIV infected people may discourage testing, disclosure, uptake of care and treatment services including TB services, and could fuel stigma and discrimination against PLHIV. HIV and TB, Knowledge and Behavior Data from AIS 2011 indicates that high-risk behaviors remain prevalent in Uganda. Reported condom use in high-risk encounters is low. Comprehensive knowledge combining several knowledge measures remains low. In 2011, only 36% of women and 43% of men aged had comprehensive knowledge about HIV/AIDS, with very modest increases from 2004/05 (less than 10% for both men and women). Overall, 19% of the men reported having two or more sexual partners in the previous year, compared with 3% of the women. Condom use among those engaging in higher risk sex declined from 47% in 2004/05 to 29% in 2011 among women and from 53% to 38% among men (UAIS 2011 Report, Page 79, 80). This picture was also quite evident in the PLACE study, which showed low condom use among individuals in high-risk venues (PLACE Report 2014, pages 9, 13, 21, 23, 37). A national household survey carried out in 2009/10 by UBOS showed that 17% and 52% of the urban population seek medical attention from pharmacies/drug shops and private clinics, respectively. The high TB default rate in urban settings including Kampala could be explained by the fact that the majority of people in urban settings continue to seek medical attention from Private Health providers (PHPs) yet the majority of them do not have adequate knowledge on TB and will therefore not give appropriate counseling and care to TB patients. Knowledge and information about TB continues to be inadequate at the level of the community limiting demand for TB services, fuelling stigma and discrimination and contributing to poor and delayed health-seeking behavior. Gender inequalities Women and girls are at higher risk of HIV infection and constitute the largest proportion of PLHIV in Uganda (UAIS 2011 Report, Page 104). Women face barriers in accessing HIV prevention services due to limited decision-making power, lack of control over finances, and burden of care all of which limit their economic opportunities. Gender inequality is also a key driver of the HIV epidemic and negatively impacts on the health seeking behavior. According to the 2011 UDHS, about 39-42% of married women reported that primarily the husband made decisions about their health care, major household purchases, and visits to their family or relatives. According to UNAIDS women who have experienced Intimate Partner Violence (IPV) are 50% more likely to acquire HIV than women who have not experienced violence (The Gap Report, UNAIDS 2014, Page 136). In- country evidence from the Safe Homes and Respect for Everyone (SHARE) Project also suggests that young women who have experienced intimate partner violence (IPV) are at increased risk of HIV infection than women who had not experienced violence (Wagman et al., 2012). Gender Based Violence (GBV) remains prominent and may also pose additional barriers to women s access to HIV and other health services. In Uganda, 27% of girls aged have experienced violence, 56% of married women have ever encountered domestic violence during their marital life, 51% of all women have experienced physical and/or sexual intimate partner violence, 19% had their first sexual encounter against their will, and more than 16% experience violence during pregnancy (UDHS 2011, page ). This coupled with increasing accepting attitudes of GBV among communities, high rates of defilement and early marriages and child labor undermine several health indicators including sexual and reproductive health and HIV service uptake. Evidence from the Rakai SHARE project and SASA - a project implemented in 6 suburbs of Kampala by CEDOVIP in-partnership with Raising Voices Uganda, shows that community engagement and empowerment to address GBV reduces coerced sex by 20%, partner physical violence by 20% and Uganda TB and HIV Concept Note 15 October,

10 the community incidence of HIV by 36% (Abramsky et al, 2014, page 11-14). Although there are fewer men than women in the general population (0.95:1), the majority of TB patients notified to the NTLP are men with the ratio rising from 1.38:1 in 2007 to 1.7:1 in Barriers limiting access of women to HIV services could be similar to those limiting access to TB services for women. Reproductive, Maternal, Neonatal, Child, and Adolescent Health (RMNCAH) context and linkages with HIV/TB There has been a general improvement in the majority of the maternal and child health (MCH) indicators in Uganda, based on the Uganda Demographic Health Survey (UDHS) 2011, 2006, and 2001 reports. However, the improvements are too slow and below the expected national and international targets. Under-five mortality rate is 90, down from 137 per 1,000 live births in 2006, and infant mortality is 54 down from 76 per 1,000 live births. Maternal mortality ratio is 438/100,000, not significantly different from the adjusted figure of 418 in 2006 but significantly lower than the 524 in Despite these improvements, the MCH indicators are generally still far below the Millennium Development Goal (MDG) targets: under five mortality target of 56 per 1,000 and the infant mortality of 31 per 1,000. Deliveries attended by skilled providers increased from 41% in 2006 to 57% in 2011 but this is far below the MDG target of 90%. The unmet need for family planning (FP) remains high, at 34% (a small reduction from 38% in 2006). Only 48% of women make four or more antenatal care (ANC) visits, and the median time for the first ANC visit for pregnant women is 5.1 months of gestation. These poor MCH indicators pose challenges to the scale-up of HIV and TB interventions among women and children. d. The health systems and community systems context in the country, including any constraints relevant to effective implementation of the national TB and HIV programs including joint areas of both programs Uganda follows a decentralized system of governance enshrined in the National Constitution (1995) and Local Government Act (1997). The country has 112 district local governments. Uganda follows a system of five tiers of local governance linked through political and administrative units (Uganda TB Strategic Plan draft July14, fig 1; page 10). The Central Government, through line ministries, is responsible for national affairs and services; formulation of national policies and standards. The Local government responsibilities include provision of basic social services (including health) according to national policies and priorities, recruiting and managing human resources, collection and allocation of taxes and approval of district work plans and budgets. The National Health System (NHS) is made up of the public and the private sectors. The Public sector includes the Government of Uganda (GoU) health facilities under the MoH, health services of the Ministries of Defence, Education, Internal Affairs (Police and Prisons) and Ministry of Local Government (MoLG). The MoH services are structured into: National Referral Hospitals (NRHs) which are semi-autonomous; Regional Referral Hospitals (RRHs) which are self-accounting and under MoH oversight and public general hospitals and Health Centre (HC) IVs, HC IIIs, HC IIs and Village Health Teams (VHTs, HC Is) which are under the district health system managed by the Local Governments The provision of health services in Uganda is decentralized with districts and health sub-districts (HSDs) playing a key role in the delivery and management of health services at the district level. The General, Regional and National Referral Hospitals are responsible for providing health services such as prevention, promotion, curative, maternal, in-patient health services, surgical, blood transfusion, laboratory and medical imaging services, in-service training and operational research. In addition, the Regional and National Referral Hospitals provide specialist clinical services. Under the district health system, the Local Governments (LGs) recruit, deploy, develop and manage human resources for district health services. In addition, they pass health related by-laws and monitor the health sector performance in the districts. The Health Sub-Districts (HSDs) are mandated with planning, organization, budgeting and management of the health services at the HCIV and health centers within the HSD. The health centers provide basic health services such as prevention, promotion, curative and rehabilitation health services. A Hub transport system (National Sample and Results Transport Network) was pioneered in Uganda by the MoH in 2011 in a phased manner and 19 operational Hubs reaching 616 lower health facilities had been established by 2012, with the intention to expand to another 53 hubs serving an additional 1700 health facilities in In this system, patient s samples from lower level health facilities are transported to central testing points (reference laboratories) for testing. Test results from the referral laboratories are delivered to referring health facilities through the same Uganda TB and HIV Concept Note 15 October,

11 system. Local networks at the sub district level are coordinated at health facilities that act as hubs. These Hubs could either be Regional referral hospitals, District Hospitals or health center IVs. Each Hub serves 20 to 40 health facilities located in a radius of 40km radius around it. The MoH has also installed SMS (short messaging services) printers at some of the hubs to directly print results and thus reduce turnaround time for testing as well as courier costs that would otherwise be incurred to deliver the results. Each hub has a motorbike and bike rider specifically hired to collect samples and deliver results from all health facilities in the Hub catchment area. The rider makes regular scheduled visits visiting 4 to 8 facilities per route on a daily basis and takes different routes each day. Under this arrangement, he visits each facility in the Hub s catchment area at least once a week (National Sample Transport Network, page 4-5). Both the AIDS Control Program (ACP) and the NTLP utilize this hub system to transport samples and results to and from referral laboratories. The private health sector consists of Private Not for Profit (PNFPs) providers, Private Health Practitioners (PHPs) and the Traditional and Complementary Medicine Practitioners (TCMPs). The PNFP and PHP hospitals and health centers are autonomous as granted by their respective legal proprietors. The PNFP contribute significantly to the health services provided in the country: of all the hospitals 52% are public, 41% are PNFP and 7% are Private for Profit (PHP) (HSSIP 2010/ /15, page 6-7). The PHP sector is fast growing and most facilities are concentrated in urban areas. The GoU subsidizes the PNFP and a few private hospitals as part of Public Private Partnership. The subsidies cover the minimum package of health services as stipulated in the National Health Policy and Health Sector Strategic and Investment Plan. Other than the VHT system (HCI), several other community systems exist and have been used for various HIV, TB, and other health interventions in Uganda. There are several ongoing community systems strengthening (CSS) activities including empowering of various community structures and individuals (volunteers) to support and advocate for adoption of practices that maximize community response to HIV and TB service delivery. Various community formal and informal networks for key affected populations also do exist, including networks of PLHIV (family support groups, mentor mothers and fathers, etc.), networks of MSM, transgender, and sex workers, among others (MOH MARPs Report 2014, pages 22-23, 44-45). In this application CCM proposes to further strengthen these community structures for demand creation and service delivery. CCM also proposes to establish a community recording and reporting system linked to the health system to enable CSOs and CBOs contribute to TB and HIV case finding and treatment support and adherence. Whereas a lot of HIV and TB epidemiologic data exists in Uganda, several critical data gaps exist, which may hamper fully informed investments. Some of the data gaps in relation to HIV investments include limited evaluation of outcomes and impact of some interventions (e.g. primary prevention interventions such as behavior change communication) and size estimates for key affected populations. GOU together with partners, has in the past few months conducted a series of program reviews, evaluations and special studies including: 1) development of the HIV Investment Case ( ); 2) Joint External Monitoring Mission for the NTLP (Sep 2013); 3) Development of the National Strategic Plan for TB ; 4) a recently completed mid-term review (MTR) of the HIV NSP and ongoing development of a new NSP in line with the HIV Investment Case; 5) a recently completed study assessing barriers and opportunities for accessing HIV services among sex workers and MSM; 6) an ongoing review of the primary prevention interventions, with support from the Global Fund; 7) an ongoing TB prevalence survey; 6) on going modes of transmission analysis; among others. It is anticipated that several of these studies and reviews will be completed by June 2016 /17 and will inform the implementation of the proposed activities. The HIV primary prevention review and new NSP are all in advanced stages and will inform the grant making process. Opportunities for operational research to analyze and study program data to inform policy and planning also exist; these will be leveraged through this application to build capacity for OR within programs and implementing partners that translate to published evidence that the program can use. Staff recruitment improved in financial year due to a major recruitment undertaking for HCIV and HCIII. According to the Annual Health Sector Review Report (AHSR), the percentage of approved posts filled by health workers in Public facilities increased from 58% in 2011/12 to 63% in 2012/13. However the staffing at General hospitals and specialized facilities (national and regional referral hospitals) remained unfilled. The VHT concept is promoted through training of VHTs of which 75% have been established and only 55% villages have trained VHTs. The VHTs have also not been fully utilized; in a few instances where they have been engaged their impact is yet to be realized. The recent JEMM for TB (NTLP MTR 2013, Page 5-6) identified several constraints in the context of health and community systems with respect to TB control. These included underfunding and understaffing at central, regional and district levels; gaps in recording and reporting skills of facility Uganda TB and HIV Concept Note 15 October,

12 level staff; limitations in M & E and in data management; the discontinuation of the community based care model so successfully modeled in Uganda due to limited support from the district health offices; limited scale-up of Programmatic Management of Drug resistant TB (PMDT) in the face of an emerging epidemic of MDR-TB; poor or no budgetary support to TB control from the district health office in several districts; limited collaboration and leveraging of the Uganda Stop TB Partnership despite its expanding network of CSO members; limited or no involvement of the community in DOT; over-stocking and stock-outs at different facilities due to limitations in procurement and supply chain management within the National Medical Stores (NMS); low index of suspicion among health care workers and poorly performing laboratory support systems at the periphery contributing to suboptimal case notification; limited leverage of the HIV system to transport sputum samples for testing and centralized external quality assurance (EQA) overloading the national TB reference laboratory (NTRL); poor coordination between peripheral labs and treatment facilities compromising treatment initiation for patients with initial loss to follow-up; very little infection control compromising patients and health workers in facilities; little or no implementation of contact tracing of children in contact with adults with TB; limited capacity to suspect and diagnose TB in children and absence of data quality assurance protocols and limited quality assessments of data contributing to data uncertainties. 1.2 National Disease Strategic Plans With clear references to the current TB and HIV national disease strategic plan(s) and supporting documentation (including the name of the annexed documents and specific page reference), briefly summarize: a. The key goals, objectives and priority program areas under each of the TB and HIV programs including those that address joint areas. b. Implementation to date, including the main outcomes and impact achieved under the HIV and TB programs. In your response, also include the current implementation of TB/HIV collaborative activities under the national programs. c. Limitations to implementation and any lessons learned that will inform future implementation. In particular, highlight how the inequalities and key constraints and barriers described in question 1.1 are currently being addressed. d. The main areas of linkage with the national health strategy, including how implementation of this strategy impacts the relevant disease outcomes. e. Country processes for reviewing and revising the national disease strategic plan(s). Explain the process and timeline for the development of a new plan and describe how key populations will be meaningfully engaged. Uganda s HIV Investment Case for aims at scaling up evidence based HIV interventions. The Investment Case aims to rapidly scale up selected combination prevention interventions in the first three years (between ) and thereafter sustain the coverage at these recommended levels, in order to achieve the desired impact (averting 2,160,00 HIV infections and 570,000 deaths by 2025). The selected interventions include: 1) Anti Retroviral Therapy (ART) (80% coverage) with treatment irrespective of CD4 count for several MARPs; 2) emtct (95% coverage of ARVs among HIV infected pregnant women); 3) safe male circumcision (SMC) (80% coverage); 4) access to and use of condoms in high-risk sexual encounters (80%); 5) HIV testing and counseling (50%); and 6) behavior communication interventions focusing on the most affected populations including sex workers, MSM, fishing communities, truckers and uniformed personnel as well as young people in and out of school (Uganda Investment Case 2014, Page 14).The investment case also emphasizes addressing underlying structural drivers of the HIV epidemic and integration of HIV with TB and RMNCAH programs as well as enhancements of relevant health and community systems to ensure effective and efficient programming. Uganda is also in advanced stages of developing a new National HIV Strategic Plan (NSP) for 2014/ /20. The NSP development started after the 7 th Annual Joint AIDS Review (JAR), which was held September 11 th to 12 th, The MTR and JAR as well as the NSP development are done through multi-stakeholder consultations and efforts. The National TB and Leprosy Control Program-Strategic Plan (NTLP-SP) 2010/ /15 was revised (2012) to align it to new evidence and guidance in TB control that was provided by the Uganda TB and HIV Concept Note 15 October,

13 World Health Organization (WHO), most especially in the area of TB/HIV collaboration and the need to scale up new diagnostics. In July 2014, the NTLP concluded an exercise to develop a renewed national strategic plan (NSP) that will take into account the Post-2015 Global TB Strategy, acknowledge the achievements of the NTLP and the challenges it currently faces and advise the planning, implementation, monitoring and funding of TB control for the period 2015 to 2020 (Uganda TB Strategic Plan draft July14, Pages 41-42). Specifically, this renewed strategic plan will also inform the direction and funding request of the NTLP under the New Funding Model of the Global Fund through a Joint TB HIV Concept Note. This most recent document includes a monitoring and evaluation plan, operational narrative, budget and a technical assistance component and is the reference strategic planning document for the NTLP in this Joint application. a. The key goals, objectives and priority program areas under each of the TB and HIV programs including those that address joint areas. Uganda National HIV Strategic Plan (NSP) for 2015/ /20 The draft NSP has four thematic service areas: Prevention, Care and Treatment, Social Support and protection, and systems strengthening, and is aligned to the Investment Case in terms of the selected interventions and targets. Similarly, the proposed investments in this application are fully aligned with the HIV investment case, the TB and HIV NSPs, and address the key challenges highlighted in the HIV and TB program reviews. Goal: The goal of this application is to contribute to the following Investment Case goals: a) 77% reduction in new HIV infections by 2025; (b) reduction of new infections in children from 14,200 to 4,040 between 2014 and 2025; and (c) avoid 570,000 deaths by Uganda National Tuberculosis and Leprosy Control Program. Strategic Plan 2015/ /20 (version July 2014) The Vision guiding the current strategic plan is A Uganda Free of Tuberculosis. The Goal of the current plan is To reach a reduction of 34% in TB prevalence by 2020 (113/100,000). (Uganda TB Strategic Plan draft July14, Page 55). The plan includes four operational (strategic) objectives. Each operational (strategic) objective is further broken down into comprehensive strategic intervention areas for the national program as detailed below (Uganda TB Strategic Plan draft July14, Pages 56 to 59): Objective 1: To detect 85% of estimated TB cases and successfully treat 90% of them by 2020 Increase the capacity of health workers to diagnose TB, especially childhood and clinically diagnosed TB Ensure treatment initiation and adherence in all diagnosed TB patients Improve access to and utilization of quality laboratory network and radiology services for TB diagnosis Empower patients, their families and communities in TB care through referral of presumptive TB patients to diagnostic facilities, supporting treatment adherence and conducting contract tracing (each patient will lead to activities in the family/community where the patient comes from) Strengthen TB care and prevention in congregate settings Strengthen and expand Public Private Mix in line with national policy framework Implement an urban TB care and prevention strategy for cities and municipalities Integrate TB care and prevention services into NCD and MCH services Objective 2: Provide TB/HIV integration to co-infected patients and enroll >90% of co-infected patients on ART Strengthen collaboration and monitoring mechanisms Scale-up implementation of the one-stop model for co-infected TB patients in ART accredited facilities Implement TB/HIV interventions to decrease the burden of HIV among patients with presumptive and diagnosed TB Support the provision of ICF and IPT services in HIV care settings Implement TB infection control practices in all DTUs Objective 3: To detect 80% of estimated MDR-TB cases and treat successfully 80% of them by 2020 Ensure early detection and improve MDR-TB patient management Uganda TB and HIV Concept Note 15 October,

14 Expand access and improve MDR-TB treatment (including home based care pilot) Implement Infection Control practices in MDR-TB facilities including follow up facilities Objective 4: To strengthen systems for effective management of Tuberculosis & Leprosy services to meet the NSP targets Advocate for increased financial resources from domestic sources and ensure maximum use of available finances Improve the quality of TB care and ensure patient safety at all levels Engage communities and stakeholders in TB and leprosy prevention and care Improve human resource capacity at all levels to effectively deliver TB and leprosy services To improve availability of quality assured TB and Leprosy medicines, supplies and equipment for prevention and treatment at all diagnostic and treatment health facilities To strengthen M&E systems for tracking performance and measuring outcomes/ impacts to guide decision making Implement the research agenda through collaboration of NTLP and the Uganda TB research community Ensure availability of logistics for NTLP general office operations b. Implementation to date, including the main outcomes and impact achieved under the HIV and TB programs. In your response, also include the current implementation of TB/HIV collaborative activities under the national programs HIV Program There is significant progress towards achieving some of the Investment Case and NSP targets including HIV counseling and testing, expanding ARV coverage within PMTCT as well as ART for adults (including adolescents) and children (<14 years). However, for some areas e.g. male circumcision and condom programming, progress has been slower. Behavior change communication According to the MTR prevention review, several achievements have been registered in behavior interventions. Achievements included development of a BCC message book which was distributed to all districts by UAC; a pastoral letter distributed by the Inter-Religious Council of Uganda (IRCU); and interventions targeting cultural leaders. UAC also established a message clearing committee and launched a new campaign Zip-up 256. However, it is estimated that only 1,639,649 individuals were reached with BCC, representing 7.9% of the targeted number. Also, HIV risk behaviors persisted. The districts of Kalangala, Bududa and Kyenjojo had the highest proportion of adults reporting non-marital partners ( % of adults surveyed) while the proportion reporting condom use at last non-marital sex was lowest in Apac, Atuke, Alebtong, Pallisa, Budaka, Ntungamo and Kisoro (range: %) (HIV Prevention MTR Report, Sept , Page ix). The KMCC BCC review of 2013 indicates that consistent, targeted messages that are grounded in the realities of the communities, promoted by multiple sectors and multiple channels such as mass media and telecommunications are valuable but should be used strategically and targeted to communities. The review notes that the ABC campaign was previously successful but overlooked the influence of gender, coercion and socioeconomics of decision-making dynamics and did not target MARPs such as sex workers and fishermen as well as the risk compensation due to new technologies like SMC and ART (KMCC BCC Synthesis Report 2013, Pages 7, 8). Inconsistencies in messages were also cited as a challenge (e.g. mixed messages around use and non-use of condom). Thus the current BCC models and messages may require adjustments to align with the current environment. HIV counseling and testing (HCT) Scale-up of HCT is a critical element in accessing HIV prevention and care and treatment. Access to HCT services by the general population increased from 25% of women and 23% of men in 2006 to 66% among women and 45% among men in 2011 (AIS 2011). HIV testing among men increased four-fold, from 11% in but remains far below the uptake among women. The higher coverage among females is attributed to HCT opportunities during MCH and PMTCT services. HCT has expanded over the last three years with expansion of Provider Initiated Testing and Counseling (PITC), community models, and couples HIV counseling and testing. The Investment Case targets to test 50% of individuals years annually. A total of 5,524,327 adults (15 years and above) out of an estimated 15,152,308 were tested and received their HIV test results in 2011; representing 36.4% HCT uptake in This proportion increased to 58.2% by the end of 2013 (6,982,715 of 12,000,450) (HIV Prevention MTR Report, Sept , Page vii). In FY 2013/ million people received HCT from 4,401 sites, including PMTCT sites (HMIS/DHIS 2 July Uganda TB and HIV Concept Note 15 October,

15 June 2014). However, access to testing by some population groups (e.g. men) is still low. Couple testing is also low; only 5% of testers received couple HCT in 2013/2014. This application includes activities to strengthen PITC and scale-up community testing for selected high-risk groups including fisher folk, uniformed personnel truckers, among other groups. Male circumcision SMC prevalence was 26% in 2011, according to the AIS. The annual target for the national SMC program is 1,001,875 circumcisions, to contribute to the previous NSP target of 5 million circumcisions by SMC scale-up was initially slow but has significantly increased due to improved capacity. Training capacity has been built countrywide through recruitment of dedicated teams for SMC. A mixed model approach has been adopted; using roving teams to conduct SMC outreaches and camps, in addition to static sites at facilities. A few implementers/sites have introduced new SMC technologies (Prepex); currently 10 sites use both Prepex and the surgical method. In 2012/2013, 400,000 out of 1,000,000 targeted circumcisions were done (40%) compared to 1,023,357 (at 1295 sites) in 2013/2014 (HMIS/DHIS 2 July 2013-June 2014). The increased number of circumcisions in the past year is a clear indication of the increased demand and capacity to provide SMC, and the coverage should continue to increase if the momentum and inputs for SMC are sustained. In this application, CCM requests support to further scale-up SMC including use of Prepex non-surgical devices. Condom programing The MoH is implementing the national Condom Strategy that guides implementation of comprehensive Condom Programming. The strategy is aimed at increasing demand for male and female condoms, improving access to and utilization, strengthening the condom supply chain management, and monitoring and evaluation. Leadership at all levels (MoH Condom Coordination Unit, District Condom Focal Persons and UAC) has been strengthened to oversee coordination of strategic condom activities. Both male and female condoms (FC2) are procured and distributed. The country has recently strengthened capacity for the Condom Post-shipment testing policy, and this has greatly improved the condom throughput. However, the number of condoms procured annually has been declining since 2010 and the numbers are significantly below the projected national need (Figure 5). The supply and commitments for 2014 are less than a half of the projected need (Condom Strategy 2013, Pages 6, 7). Distribution channels for the condoms also require enhancement to make condoms more available to high-risk populations. Yet, the alternative distribution mechanisms (outside health facilities are not well developed) (Condom Strategy 2013, Page 7). This application includes strategies to enhance community distribution of condoms especially targeting high-risk and vulnerable populations (sex workers, MSM, fisher folk, truckers and uniformed personnel), among other groups. Condom distribution at selected hotspots will be enhanced (informed by PLACE Methodological Study). Figure 5: Number of condoms procured PMTCT and EID Uganda started implementing life-long ART for PMTCT in October The national PMTCT program now called the Elimination of Mother-to-Child Transmission (emtct) Program supports the holistic implementation of the four-pronged strategy (primary prevention, prevention of unintended pregnancy, provision of ARV prophylaxis, care and support). The plan includes the consolidation of services to increase uptake, male involvement, strengthening of family planning (FP) services, and improvement of comprehensive care for women living with HIV, their spouses and their exposed children through early HIV diagnosis and linkages to care. The PMTCT facility coverage has increased significantly over the past year; from 2,138 in 2013 to 3248 facilities Uganda TB and HIV Concept Note 15 October,

16 providing PMTCT services by June The proportion of pregnant women tested for HIV increased from 30% in % in 2014 (HMIS/DHIS 2 July 2013-June 2014). The proportion of pregnant women living with HIV receiving ARVs increased from 33% in 2007 to 87% in 2014 (HMIS/DHIS 2 July 2013-June 2014). There are several interventions related to community systems strengthening (e.g. mentor mothers, mentor fathers, family support groups, and VHT among others) to support mobilization, retention, adherence and psychosocial support. Whereas testing for HIV at ANC has improved, syphilis testing remains very low. In July 2013-June 2014, 95% of the women who attended first ANC were tested for HIV while only 6% had a syphilis test, a missed opportunity for eliminating congenital syphilis alongside emtct (HMIS/DHIS 2 July 2013-June 2014) In 2013, EID facility coverage was 1,696 (76% of the facilities) including 100% of referral hospitals, 100% of district hospitals and 100% of HCIVs, 84% of HCIIIs, and 5.6% of HCIIs. Coverage of EID testing among infants (first DNA PCR) in 2013 was 60,437 (51%), a steady increase from 7% in The median age at first PCR has remained fairly stagnant; at 4.2 months in 2011 and 4.8 in 2013 (EID Database; However, the percentage of exposed infants who received the first PCR at two months has increased from 45.6% in 2011 to 59.8% by June 2014, against the NSP target of 50% by Prevalence of HIV among those tested was 9% in 2012 and 4.6% in 2013, a significant decline from 19% in The prevalence among those that completed the PMTCT cascade was 4% compared to 25% among those with no PMTCT; however, only 28% had completed the PMTCT cascade. According to the MTR review, the number of new pediatric infections reduced from 28,000 in 2011 to 8000 by end of 2013 (HIV Prevention MTR Report, Sept , Page vii). ART and pre-art care The number of ART facilities increased from 475 in 2011 to 1603 by June 2014; 100% public hospitals, 91% of HC-IVs (188) are providing ART (87% of the HC IV facilities provide pediatric ART) services. This has led to a rapid scale-up of the number of individuals on treatment. Pediatric ART coverage has also increased -- tripled between 2006 and 2013 (Annex 5, pages 17 and 18). Following the 2013 ART guideline revision, 43% (588,039) eligible adults and children were receiving treatment by end of 2013 (adults constitute 92% of those on treatment), and 48% (680,514) by June 2014 (HMIS/DHIS2, July 2013-June 2014). Based on retention data reported by facilities, 83% of adults and children remain on treatment 12 months after initiation of ART as of December Over all, PLHIV are initiating ART earlier: the number of individuals initiating ART at CD4 <250 reduced from 80% in 2008 to 57% in 2013 and 48.7% by June Additionally, 100% of HC IV and HC III are performing or linked to CD4 and full blood count for patient monitoring. The increased number of facilities providing ART and the enhanced coverage for laboratory monitoring have increased the capacity to enroll and support more individuals on treatment, and is a crucial step towards the implementation of the WHO 2013 treatment guidelines. This expanded capacity explains the recent increase in the number of individuals enrolled on treatment annually. By June 2014, there were 963,272 PLHIV in care, and of these 79% were receiving cotrimoxazole prophylaxis while 73% were screened for TB, and 60% accessed the Basic Care package (safe water system, and cotrimoxazole, mosquito net, condom and education on PHDP) in The improvements in HIV care have had an impact on HIV related deaths, which are reported to have reduced over the years. HIV related deaths reduced from 120,000 in 1998 to 63,000 in 2013 (Uganda HIV Investment Case, Pages 17 and 18). Services targeting MARPs and vulnerable populations Over the past few years, Civil Society and government have initiated interventions serving key populations. The MARPs Network was established to bring together community based organizations (CBOs), and provides a platform where these organizations share experiences, contribute to program design, forming a growing forum for knowledge management, strengthening organizations, advocacy, and coordination. The MARPs network brings together several CBOs both formal and informal, which serve these communities. The Most At-Risk Populations Initiative (MARPI) clinic at the STD clinic in Mulago Hospital serves as a one-stop center providing a comprehensive package of HIV prevention services for SWs and MSM, and has introduced ART among the services provided. Several PEPFAR partners also support HIV initiatives for key populations including SWs and MSM. These existing partners and networks will provide an entry point for the scale-up and strengthening of MARPs services. The Semi-annual PEPFAR Report May 2014 shows that 132,755 MARPs received services from various partners within the previous six months. The MARPs that were reached include 15,059 sex workers, 429 MSM, truckers, 9334 incarcerated populations, and 76,710 fisher folk (PEPFAR Semi-Annual Report 2014). This application seeks to further expand the MARPI clinic model to four regional referral hospitals; a review of the access to services among sex workers and MSM in 2013 revealed more challenges Uganda TB and HIV Concept Note 15 October,

17 with access to HIV services outside Kampala. Gender based violence and social protection Generally there is a noticeable reduction in the proportion of PLHIV that report cases of SGBV from 39% to 25% between 2011 and 2013 (UAC Draft NSP, Page 36). In 2013, USG- PEPFAR supported programs reached 543,833 individuals with interventions that explicitly addressed GBV; 609,020 individuals with interventions and services that addressed legal rights and protection of women and girls impacted by HIV; and 943,964 individuals with interventions that explicitly addressed norms about masculinity related to HIV (UAC Draft NSP, Page 36). TB Program Uganda is one of seven countries in the World Health Organization s (WHO) list of 22 high-burden countries that have met all of the 2015 MDG targets for reduction in TB cases and deaths (Global Tuberculosis Report 2013 Supplement, Page 4). The summary of implementation, main outcomes and impact of TB control in Uganda include the following: Case notifications In 2012, the WHO estimated the incidence of TB (all forms) in Uganda to be between 53-79,000 (Global Tuberculosis Report 2013, Table 2.1, page 9). In 2013, 47,650 patients (all forms, new and retreatment) were notified to the NTLP, of which 44,934 were incident (new and relapses). This translates to an effort to notify between 57 to 85% of the estimated incidence and represents a slight increase over the 47,211 (all forms, new and retreatment) and 44,663 (new and relapses) notified in More men were notified than women ratio 1.7:1; and as in previous years, 89% of patients were pulmonary TB, with one smear negative being notified for every two smear positive TB patients. The NTLP aggregates district data into zones (9) which approximate to the administrative regions used by the Ministry of Health and the AIDS Control Program (ACP). The NTLP is in the process of migrating these zones into the regions defined by the MoH. Zonal contribution to national TB notification varies considerably; some zones seem to contribute the equivalent of their populations while in others, the contribution was not proportional. In 2013, two zones (South-west and Northeast) notified TB patients proportional to their populations, while two others (Kampala and the North) notified more patients than expected from the national estimates Kampala notifying 4 times more and the North zone 1.5 times more. The remaining 5 seemed to notify fewer patients in proportion to their population. It is also evident that Kampala, South-west and North zones with approximately a third (35%) of the country s population notified nearly half (48%) of the national incident notification (Uganda TB Strategic plan draft July14, Pages 30 and 31). The ratio of people with presumptive TB to notifications (all forms) in Uganda increased steadily from 2008 to 2012 (2.10 in 2008 and 3.51 in 2012). As such, it suggests that the reach of the national TB program is steadily expanding over this time. Despite an increase in the number of tests being performed with time, the number of notified cases has not increased at the same rate, and even declined in 2012 compared with It is unlikely that the number of notified cases has plateaued given their latest case detection rate (all forms) of 69% (2012), but further investigations may find a change in laboratory testing methods, a change in case definitions or some other artifact of the surveillance system. It is also possible that more cases are being diagnosed and initiated on treatment and that the slower increase in notification rate is due to under-notification. Overall, during the proportion of all notified cases (new and retreatment) that are retreatment cases has remained relatively stable (7.2% in 2008 and 8.2% in 2012), with a slight increase in retreatment cases in For the youngest age group (0-4) and for ages the rates between males and females are similar. Females aged 5-14 had consistently higher rates of TB. For the rest of the age groups, rates of TB are higher in males than females. Over time, there has been a slow increase in the rates of TB in the two oldest age groups (55-64, 65+) for both males and females, while for cases aged 45-54, there has been a recent decrease in rates in females, but the rates continue to increase in males. At a sub-national level, there was wide variation: Five zones North-east, Kampala, East, South-east and Central had a lower ratio with the North-east notifying 1.02:1 in 2007 rising to 1.23:1 in 2013; three zones North, North-west and West had far greater ratios, ranging from 1.54:1 in 2007 to 2.24 in 2010 (North-west). The current recording and reporting tools have been revised to capture sex and age group only for all forms of TB. They also capture this data for children under the age of 5 years (NTLP revised quarterly reporting Form pages 1-3). The country is in the process of changing from an eight-month first line regimen without rifampicin in the continuation phase to the standard WHO recommended six-month first line regimen with Uganda TB and HIV Concept Note 15 October,

18 rifampicin throughout. Treatment outcomes Treatment success rates declined slightly in smear positive and negative/extra-pulmonary cases between , with a slight increase observed in Treatment success rates in retreatment cases have continued to decline since In the retreatment cases this decrease may be explained by increases observed in treatment failure, loss to follow-up (default) and death. However, the large variations observed over time suggest that there may be issues with internal consistency and reporting of treatment outcome in this group. In smear negative/extra-pulmonary cases there has been an increase in the proportion of deaths. Increases in death or loss to followup (default) were not observed for smear positive cases. There were no treatment failures recorded for smear negative/extra-pulmonary cases, which may suggest that there are inaccuracies in reporting. At the sub-national level, with the exception of 2007, Kampala that notifies close to a fifth of the national TB notification continues to have the lowest treatment success rates (35% in 2006 and 68% in 2012). The North zone has better treatment success rates at 85% or more for the last four years; 46/112 (37%) of districts had achieved treatment success of 85% for the 2012 cohort, while 6/112 (5%) had cure rates of over 80%. Most of the districts with good treatment success rates tended to implement community based treatment support to patients. MDR-TB and PMDT Program guidelines require drug susceptibility testing to be routinely carried out on high-risk groups for MDR-TB; treatment failures, relapses, retreatment cases, cases who are contacts of an MDR- TB case, and health care workers (NTLP MDR Guidelines page 15-16). DST results are collected in the TB register. However, to date, there is virtually no systematic process in place to successfully capture, monitor and track all MDR-TB suspects, cases and treatment nationally. From , the number of confirmed MDR-TB cases detected nationally was 57 (2009), 93 (2010), 71 (2011) and 89 (2012). The NTLP started implementing Programmatic Management of Drug Resistant TB (PMDT) in 2012 using a mixed model of care approach (initial admission with discharge to 100% ambulatory care). The first cohort of patients will complete treatment in PMDT has been expanded to include 14 sites country-wide (12 Regional Referral Hospitals and 2 general hospitals), about 52 operational XpertMTB/Rif machines linked to a HUB system transporting sputum samples, a full-time national PMDT Coordinator (supported through GF) and an MDR-TB Technical Working Group within the NTLP. The cumulative enrollment into PMDT is 348 patients, with 260 currently on treatment (The vast majority of these patients are treated at one hospital Mulago, in Kampala). While there is considerable partner support to PMDT rollout, there is also the inherent risk to sustaining the program due to its dependence on donor funding (Uganda TB Strategic plan draft July pages 44, 47). TB HIV co-infection In recent years, Uganda has made significant strides in diagnosing and treating patients with TB and HIV co-infection. NTLP data show that while the number and proportion of all registered TB cases with a known HIV status, a proxy for HIV testing, has increased, the overall proportion of cases that are HIV positive has declined. The use of CPT (91% in 2013) and ART for co-infected TB patients while on TB treatment have both increased over time, although the number and overall proportion of cases receiving ART remains low (65% in 2013). The number of HIV positive people screened for TB also increased between 2006 and 2012 (27% in 2006 to >90% in 2012). The number of TB patients diagnosed through this screening however remains very low (1.5% of those screened versus the expected 5-7%) (Uganda Investment Case 2014, page 20). In its current approved SSF Phase II grant, Uganda has embraced the need to implement an integrated model for TB-HIV services. The National Policy for TB/HIV collaborative activities has been revised to include a policy recommendation on an integrated model for TB-HIV services. With support from partners, the MoH has taken early steps to implement an integrated model starting with the 14 regional referral hospitals and the general district hospitals. Successful implementation will require development and dissemination of implementation guidelines together with training, mentoring, and supervision of health workers. The HIV program will support TB clinics to get accredited for provision of ART and will support the accredited TB clinics to access ART and medicines for treatment of opportunistic infections. This will also be expanded to the 136 general hospitals in this application. c. Limitations to implementation and any lessons learned that will inform future implementation. In particular, highlight how the inequalities and key constraints and barriers described in question 1.1 are currently being addressed Uganda TB and HIV Concept Note 15 October,

19 Inequitable access to services and inadequate targeting of interventions to high-risk groups Widespread inequities in access to HIV and TB services and uptake across geographical regions, gender, and high-risk groups have persisted over the years. Targeting of MARPs has particularly been a major gap. The Investment case cites the limited targeting of risk groups and population segments such as MARPs and vulnerable groups as a major gap of the current HIV response (Annex 5, page 16). Feedback from the GF and from the Joint Mission (TB) also emphasized this limitation. In this application CCM intends to address this gap through interventions that are targeted to groups that are most at risk of HIV and therefore TB, including fishing communities, sex workers and their clients, and MSM. These interventions will address barriers to service uptake among high risk groups and gender norms and practices that put women and men at risk of HIV and therefore TB and that limit access to services. The NTLP has very recently mobilized an XpertMTB/Rif machine exclusively for the fishing communities to increase access to quicker TB / MDR-TB diagnosis and through this investment application expand access to TB screening and diagnosis prioritizing high-risk groups already under HIV care. Inadequate attention to primary interventions The 2014 Joint Annual AIDS Review (JAR) and other previous reviews have highlighted limited attention to behavioral interventions and drivers of the epidemic including GBV, alcohol, substance abuse, and multiple sexual partnerships, and decline in condom use (Uganda Investment Case 2014, Page 9, 24, 31). There has also been a decline in condom procurement and weaknesses in the distribution channels (Condom Strategy 2013, page 6, 7), which were for a long time, largely facility based and may partly explain the decline in condom use in high-risk sexual encounters. Additionally, there is limited coverage of SMC and HCT. The Investment Case and the new NSP emphasize scale-up of all these interventions in tandem with biomedical interventions and scale-up HIV treatment. This application specifically includes a scale-up of SMC specifically targeting younger men and high prevalence districts with low SMC coverage. The primary prevention interventions will also target youth in and out of school and high-risk populations such as key affected populations and fishing communities. In this application there are several primary prevention interventions targeting MARPs including MSM, sex workers, fisher folk, uniformed personnel, truckers, and youth in and out of Schools as well as enhancement of alternative condom distribution mechanisms and condom promotion to improve access to condoms. The application specifically includes scaling up the Most At Risk Populations Initiative (MARPI) clinic model to four regional referral hospital in addition to support for CSOs and CBOs working with MARPs such as sex workers and MSM. Despite the legal environment and challenges, there are several implementers of MARPs interventions in Uganda as evidenced by the numbers reached by ongoing programs. The health policy and guidance environment has further improved with the two newly established MARPs technical working groups (TWGs) at MOH and UAC, and the MARPs framework, with provision of services for all MARPs including SWs and MSM. The proposed expansion of the MARPI model, which has thrived despite this environment will further enhance services for SWs, MSM, and TG. This application will also seek to implement and expand IPT for eligible PLHIV based on the revised and approved national IPT guidelines thus protecting them from TB. ART scale-up constitutes the mainstay for the prevention of HIV-associated TB, and must be done in the context of intensified case finding (ICF) and infection control (IC) to minimize the risk of TB transmission in HIV care settings. The earlier ART is started during the progression of HIV infection, the greater the cumulative preventive effect (Lawn SD et al 2010 page 489, 490; Lawn SD et al 2011 page 571, 575, 576). However, although ART is necessary, it is not sufficient. People currently living with HIV are likely to need life-long ART and, even if treated effectively, these will constitute a large and expanding reservoir of people with heightened TB susceptibility for decades to come (Lawn SD et al, 2014 page 1136). As Uganda scales up ART coverage, it is imperative that IPT is also scaled up as an adjunctive intervention for those within ART care. The national IPT guidelines have been finalized and provide the opportunity to implement and scale up IPT for HIV infected people under care and as part of the 3 I s through this joint grant application. Currently IPT is available only in three centers of excellence operated by private not for profit (PNFP). The ACP will procure the isoniazid required for this effort (incentive funding) in this investment application to promote integration across programs. Additionally, this application will implement contact tracing to identify children at risk of increased transmission from smear positive adult TB patients and provide them also with IPT. The majority of Uganda s population is young and children under 5 are at increased risk for TB through exposure to smear positive adult contacts. Contact tracing has already been established as a program imperative, but is implemented weakly and is not tracked for effectiveness. It is essential that all children (under 5) contacts of smear positive patients be protected through routine contact tracing, Uganda TB and HIV Concept Note 15 October,

20 screening for TB and protection through IPT. There are limited studies on the nosocomial transmission of TB within the country. While rates of MDR-TB are low among new patients according to a national survey conducted recently, the survey also pointed out the need to enforce infection control measures within health facilities and protection for health workers including screening them regularly and monitoring them for TB (Lukoye D et al, 2013 page 7). A recent Joint External Monitoring Mission for the NTLP (Sep 2013) observed that IC was not implemented in health facilities visited posing risk for patients and health care workers. Limitations in data management systems and surveillance for MDR-TB further compound these challenges. This application seeks investments in protecting patients and health care workers from TB / MDR-TB in health facilities. The application also links with the HSS Concept Note in this intervention area (procurement of N 95 respirators for health care workers). Sub-optimal coverage of effective HIV interventions and access to TB services Coverage of HIV testing and linkage to care and prevention services, coverage of SMC and some components of the PMTCT has remained very low for a long time, while condom use at high risk encounters declined, partly due to gaps in the demand creation and inappropriate distribution mechanisms. To realize the goals of the HIV Investments Case, CCM proposes to increase and sustain the high coverage of a combination of effective HIV prevention, care and treatment interventions. Adjustments to the existing strategies for demand creation and service delivery are proposed to enhance access to quality effective interventions. Access to TB screening and diagnosis, and treatment support will be nested within these interventions in this application. Limited integration of HIV, TB, and RMNCAH Uganda developed policies and guidelines for integration of TB and HIV and has similarly developed guidelines for integration of RMNCAH and HIV programs. However, these linkages have remained weak, with resultant missed opportunities for enhancing TB and HIV as well as RMNCAH outcomes. For example EID for children remains low, yet, immunization coverage is much high, indicating a missed opportunity for management of exposed infants. Considering the high HIV prevalence among women and girls, integration is critical to ensuring improved outcomes for RMNCAH and HIV. To enhance access to HIV and RMNCAH services, this application includes activities to integrate HIV testing and other prevention services into MNCAH settings as well as MNCAH services into HIV care and prevention services. In this application CCM also proposes interventions to ensure TB/HIV integration at various levels as well as RMNCAH integration. This application seeks investments to strengthen this integration at multiple levels including a cross cutting module on program management. Inadequate capacity for quality data management and data use The Investment Case highlights inadequate data management and use among the major gaps in the response. This issue has also been highlighted in the recently completed HIV NSP mid-term review and Joint Annual AIDS Review as well as in multiple communications from the GF Country Team. Strengthening of data management and use is one of the key interventions that have been included in this application and the HSS concept note. Weaknesses within the NTLP in recording and reporting, data management, analysis and M & E have been repeatedly identified; by the Global Fund Country team and more recently by the Joint Monitoring Mission. These data uncertainties also contribute to the wide confidence intervals observed in the estimates provided by WHO with respect to prevalence, incidence and mortality and compromise the program s effectiveness and impact. This application will seek investments in strengthening the systems for health information, data management and M & E through a cross cutting module developed jointly by the NTLP and ACP and further strengthened by a broader investment in this area through the HSS concept note that will also integrate program specific information systems into the country s DHIS-2. Important lessons learned for TB control A situational analysis carried in 2009 before the implementation of the WHO funded TB Reach Project (SPARK-TB) showed that of 1,003 private facilities assessed in Kampala, only 5% provided TB treatment services routinely. Private facilities had inadequate knowledge and skills to diagnose and treat TB. Key outcomes of the successful model SPARK-TB project implemented in just 100 clinics over one year in Kampala included: Significant increase in case notification - 12% of all smear positive, bacteriologically confirmed TB patients notified to the NTLP from Kampala came from these 100 clinics, which accounted for just 7% of all private clinics in the city. Significant improvement in treatment outcomes - the treatment success rate for new smear positive TB patients diagnosed and treated in private health facilities was 80% Significant improvement in local knowledge - the local community s knowledge about TB Uganda TB and HIV Concept Note 15 October,

21 improved Significant demand creation for TB services - 14 private facilities were accredited to receive anti-tb medicines directly from the NMS and distribute them to an additional 57 private facilities more patients received free anti-tb medications of high quality. Significant collaboration with and leverage of local communities - the community network for supporting TB patients was strengthened through training of 56 Village Health Teams (VHT) and peer educators Significant potential for scale-up - the project was expanded to a further 12 municipalities and town councils in four districts This investment application will further scale up this model through consolidating activities in five districts and scaling this up to an additional ten municipalities in ten districts. The TB Specimen Referral System (TSRS) was established to facilitate transportation of sputum samples from peripheral Diagnostic and Treatment Units (DTUs) to the National TB Reference Laboratory (NTRL) for drug susceptibility testing (DST). The TSRS network expanded from 264 DTUs in 2010 to 325 in 2011 and 400 by end of June In this investment application, the TSRS will be strengthened and linked with the HUB system (already described in section 1.1 (d)) and the NTRL supported with the requisite human resources to monitor, supervise and technically support the process working closely with the Central Public Health Laboratory (CPHL). This will further decentralize the lab network and improve diagnosis and access to new technology as well as make it sustainable. The HUB system is also being strengthened through the investment application via the HSS Concept Note An important constraint for TB programming is the limited engagement of communities in all aspects of planning, implementation, monitoring, and advocacy among others unlike the ACP where communities contribute significantly in all areas of program implementation. To address this issue, communities including HIV affected communities got together and coordinated a series of consultations over the last two weeks resulting in the development of a charter of engagement to inform programming for both the TB HIV Joint application as well as the CSS priority module within the stand alone HSS concept note that will be submitted simultaneously by the CCM. This charter creates space for communities to participate in the development of priorities for this concept note, contribute to and inform the writing process and highlights interventions to upscale the community s role in the response to TB HIV (TB Charter pages 1-6). The strengths of the Uganda Stop TB Partnership (USTP), especially in supporting community based DOT will be leveraged through this investment application. Districts with poor treatment outcomes will be identified in consultation with the NTLP and investments are planned through the CSS cross cutting module to work with local grass root NGOs, CBOs and FBOs including key affected populations to expand the model community based DOT recognized and appreciated by the Joint Monitoring Mission. These investments will be further strengthened through additional investments to the UTSP via the HSS concept note of which they are a part. Support to the USTP through the SSF Phase II grant will be consolidated and expanded in this investment application to leverage their support to TB control in Uganda. d. The main areas of linkage with the national health strategy, including how implementation of this strategy impacts the relevant disease outcomes In the Health Sector there are two levels of planning, National and District. At the national level, the Ministry of Health draws the Health Sector Strategic Investment Plan (HSSIP) every five years, in close consultation with development partners. The HSSIP is linked to the National Health Policy and the National Development Plan (NDP). At the district level, local governments draw strategic plans, which include health related activities. This is then followed by development of annual works plans. The HSSIP is used to guide district health planning and implementation of health services in the country. The Ministry of Health currently has a Health Sector Strategic and Investment Plan (HSSIP) 2010/11 to 2014/15. The HSSIP aims to promote people s health to enhance socioeconomic development. The HSSIP strategically focuses on five core areas outlined below (HSSIP page xvi-xvii): Scale up critical interventions for health, and health related services, with emphasis on vulnerable populations; Improve the levels, and equity in access and demand to defined services needed for health; Accelerate quality and safety improvements for health and health services through implementation of identified interventions; Improve on the efficiency, and effectiveness of resource management for service delivery in the sector; Uganda TB and HIV Concept Note 15 October,

22 Deepen stewardship of the health agenda, by the Ministry of Health. The Ministry of Health currently has a Health Sector Strategic and Investment Plan (HSSIP) 2010/11 to 2014/15 which has been reviewed in depth through the Joint Assessment of National Strategies (JANS) process in 2011 (HSSIP Assessment report 2011 pages). The national public health response to HIV/AIDS is guided by the HSSIP and various national policies and guidelines for key interventions including the Integrated National Guidelines on Antiretroviral Therapy, Safe Male Circumcision Policy, Prevention of Mother to Child Transmission of HIV, HIV Counseling and Testing Policy (HCT), and TB-HIV collaborative Strategy, among others. The country has also developed a scale-up plan for emtct The Uganda National Plan for Elimination of Mother to child Transmission of HIV which aims to reduce the risk of MTCT to less than 5% by 2015/16. The HSSIP is reviewed annually (including the TB and HIV related indicators). The HIV and TB NSPs are also reviewed annually for more detailed program specific performance tracking. The Guiding Principles of the National Health Policy and the HSSP III are leveraged by the National Strategic Plan for Tuberculosis Control to maximize program impact and outcomes as follows (Uganda TB Strategic plan draft July 2014/, Table 4, page 51): NTLP guidelines are evidenced based and incorporate the most recent global recommendations including the Post-2015 Global TB Strategy; that TB services are provided free of cost to all Ugandans; that the NTLP fosters and works through partnerships; that diagnosis and treatment for TB is integrated into primary health care and is almost universally available; that TB control, including the control of MDR-TB is a part of the Uganda National Minimum Health Care Package (UNMHCP); that TB services are increasingly integrated with HIV services through the One Stop Shop Model of care; that TB services continue to be gender sensitive; that TB services are delivered through a multisectoral response that includes other public sector (prisons, army, police), private for profit and private not for profit; that TB services take into context international issues such as cross border migration and that TB services are fully decentralized. e. Country processes for reviewing and revising the national disease strategic plan(s). Explain the process and timeline for the development of a new plan and describe how key populations will be meaningfully engaged Uganda has had two national HIV strategic plans (for the periods 2007/ /11 and 2011/ /15) and before then a national strategic framework for HIV/AIDS. Every year a Joint Annual AIDS Review of the NSP is conducted by multiple stakeholders (public, civil society, private sector etc.). Following every annual review, an Aid Memoire is developed to highlight achievements, challenges, recommendations (for the year under review) and key priority activities for the following year. The current NSP, which is scheduled to run till 2014/2015, has recently been reviewed (midterm review conducted in 2014) and development of a new NSP for the period 2015/ /20 is ongoing, scheduled to be completed in October-November The reviews of the NSP are highly participatory and consultative (Uganda HIV NSP October 15 draft, Page 17). Thematic technical working groups (TWG) comprising of key national stakeholders from various government sectors and various self-coordinating entities including public sector, AIDS development partners, National NGOs, International NGOs, the youth, key affected populations (PLHIV), key populations, and the media among others participates in the review of each thematic area. All these stakeholders are also represented at the JAR and during revisions and development of new NSPs. The health sector also conducts annual health sector reviews that feed into the revision/development of health sector plans. This further captures HIV health related priorities for implementation during the health sector review process. Key populations are represented and actively participate in the various TWGs of the NSP review and development processes. In the recent reviews various key populations including sex workers, transgender, and men who have sex with men (MSM) were represented and participated in the generation of the NSP priorities through TWGs and key respondents. Key population consultative meetings have been held for example, a joint meeting was held in Dar es salaam (July 30-31st, 2014). Separate consultative meetings were held with each community of the key populations including sex workers, fisher folks, MSM and transgender. The Ministry of Health technical working group on MARPs also convened consultative meetings to identify priorities for key population communities. The current TB NSP has been developed for the period through a consultative process that included all program partners, donor agencies and importantly key affected populations and civil society (TB Stakeholder Engagement Report 2014 pages 1-8). The preparation for this NSP was initiated in 2013 and developed in 2014, one year ahead of the proposed plan period. The NTLP coordinated a full Joint External Monitoring Mission to review the national program in September 2013 and an epidemiological impact assessment earlier that year to Uganda TB and HIV Concept Note 15 October,

23 inform the planning process for the NSP full reports attached as annex 28. Such Joint external reviews are routinely coordinated to assist the program to assess progress against the national strategic plan and consider revisions. These are further assisted by the on-going quarterly program reviews as well as the considerations of the various technical working groups set up by the program to specifically support intervention areas. All of these, in combination with the support of international partners and global agencies such as the World Health Organization advise the review and the revision of the NSP during its term of implementation. With respect to this particular plan period, the opportunity provided by this Joint TB HIV application will support the integration of planning and policy for the TB and the HIV/AIDS program and will lead to joint planning, joint program reviews and synergy in delivery of services as well as impact for affected populations and communities. 1.3 Joint planning and alignment of TB and HIV Strategies, Policies and Interventions In order to understand the future plans for joint TB and HIV planning and programming, briefly describe: a. Plans for further alignment of the TB and HIV strategies, policies and interventions at different levels of the health systems and community systems. This should include a description of i) steps for the improvement of coverage and quality of services, ii) opportunities for joint implementation of cross-cutting activities, and iii) expected efficiencies that will result from this joint implementation. b. The barriers that need to be addressed in this alignment process. a. Plans for further alignment of the TB and HIV strategies, policies and interventions at different levels of the health systems and community systems. This should include a description of i) steps for the improvement of coverage and quality of services, ii) opportunities for joint implementation of cross-cutting activities, and iii) expected efficiencies that will result from this joint implementation The NTLP and the AIDS Control Program (ACP) are disease control programs under the department of the National Disease Control of the MOH headed by a Commissioner of Health Services. A national level Coordination Committee has been created for both programs this is chaired by the Commissioner and co-chaired by both the NTLP and the ACP Program Managers and provides a platform to integrate planning and implementation of services provided by both programs at the policy and research levels. It also assists coordination across stakeholders, donors, key affected populations and civil society to align with national priorities and needs. At the district level, the District Health Officer (DHO) is responsible for the management of health service delivery including TB and HIV/AIDS care and prevention services as part of the primary care package described in the national health policy. The DHO assigns a district health team member the responsibility of overseeing TB and HIV/AIDS care and prevention services in the district. At the HSD, the in-charge of the Health Sub-district level (HSD), usually a Medical Officer, is responsible for the management of health service delivery including TB and HIV/AIDS care and prevention services. A health worker is assigned the responsibility of overseeing TB and HIV/AIDS care and prevention services at the HSD level and this person is referred to as the Health Sub-district Focal Person. At the district, HSD and health facility level, TB and HIV/AIDS care and prevention services/services are integrated into the general health services. Both NTLP and ACP have elaborated national strategic plans that are valid up to 2015 these plans have guided their strategic investments in planning and implementation over the last several years. Over the period of their implementation, both program plans have been subject to regular and rigorous review and adaptation that has involved all stakeholders including key affected populations, international partners and global technical agencies. This process has led to the introduction of the WHO recommended TB HIV Collaborative activities early in the program cycles and performance indices reveal high coverage of HIV testing in TB cohorts and a similarly high coverage of TB screening in the HIV infected population. Scale up of CPT within co-infected populations while on TB treatment is also very high demonstrating the close linkages with the program. ART coverage for co-infected patients has also improved from 34.2% in 2011 to 53.5% in 2012 and 65% in Both programs are in an advanced stage of finalizing their strategic plans for the next 5-years. These processes have included several steps joint reviews, stakeholder consultations among Uganda TB and HIV Concept Note 15 October,

24 others. This joint TB HIV application provides an exceptional opportunity for both the programs to review their upcoming strategic plans and incorporate key administrative and policy reforms that could be reviewed mid-term with the consideration to integrate these strategic plans at a later time. i) Steps for the improvement of coverage and quality of services This joint TB HIV concept note has already initiated several processes to integrate planning and interventions within the proposed grant. A two-day stakeholder consultation was organized by the CCM jointly with both the AIDS Control Program and the NTLP and included representation from key affected populations as well as NGOs working in TB and HIV. This consultation identified key priorities to guide the preparation of the Joint TB HIV Concept Note. These priorities were summarized into a presentation that was then presented to the CCM for endorsement (TB_HIV Joint Priorities slides 1-10). The presentation already captured the priorities across both programs under the key intervention areas namely diagnosis, prevention, treatment and care, PMDT, operational research, strategic information and crosscutting issues (including HSS, CSS, Program Management). The need to focus on key affected populations, gender and other barriers including human rights barriers under-wrote these priorities and is further described in the modular template. Additionally, interventions such as increasing access to IPT for the HIV infected, increasing availability and access to new diagnostic tools such as XpertMTB/Rif for key populations at risk for TB such as children and HIV infected, improving infection control, protecting children and homes through contact tracing and IPT for child contacts of smear positive TB, expanding early infant diagnosis are among several interventions that will increase coverage of both programs, ensuring quality of services. A dedicated module for CSS that includes an intervention area to introduce and develop community monitoring of program services will also add to the quality and the efficiency of both programs. This module also includes interventions to build institutional capacity in civil society and key affected populations to contribute to and hold accountable national efforts to control TB and HIV. Significantly, the CCM has also submitted a separate Concept Note to the Global Fund for HSS that prioritizes investments in three important health system areas namely, health management information systems, procurement and supply chain management and community systems strengthening. Key additions under these areas will further strengthen the programs to assure quality in planning, programming, implementation and service delivery. ii) Opportunities for joint implementation of cross-cutting activities These areas were agreed upon through a joint meeting of the two program managers during the writing process for this application and include: The National Coordination Committee can be further strengthened to address policy issues through the setting up of TWGs in identified areas Introduce biannual joint TB-HIV programme reviews that will feed into the annual MOH Joint Review Mission (JRM) and the UAC Joint AIDS Review (JAR) Coordinate regional review meetings targeting TB/HIV, DHOs, health facilities Organize implementation review meetings Introduce Joint mentorships Expand One Stop Shop model over the grant period - at lower facilities - one health worker for both diseases creating integration of services for the patient At larger facilities this will also translate to same day services, same roof, but with either health worker with capacity to treat both diseases Accreditation and training of both TB and HIV HW in ART and TB respectively coordinate and organize training within the new grant period to build cross learning and integration of skills across health workers Prioritize HR - one person from each program assigned to TB/HIV integration for close coordination Integrated advocacy and awareness for HIV and TB with prevention Officers at RPMTs Ensure program management issues are clearly prioritized in each program to ensure program functionality (transport, fuel, stationary, communication, teas) M & E Programs to agree on indicators which are shared so that favorable programs to each program are reported etc. The NTLP and the ACP will also progressively implement the integrated model for TB HIV services approved in the TB SSF Phase II grant through the One Stop Shop model. The model includes the following elements: All TB standalone clinics will be transformed into TB-HIV clinics and will provide the Uganda TB and HIV Concept Note 15 October,

25 following services. o TB diagnosis and treatment o Rapid HIV testing o Initiation of ART and follow up o Treatment of opportunistic infection. o On completion of TB treatment, the patient will be referred to the HIV clinic to continue chronic HIV care. The HIV clinics will continue to provide the HIV testing, care and treatment services. In addition, they will provide the following TB related services. o o o Active TB screening among HIV clients (Intensified TB case finding) Provide isoniazid preventive therapy to eligible HIV clients Refer HIV clients confirmed to have active TB disease to the TB-HIV clinic to start and continue TB treatment. This will also help to reduce the risk of transmission of TB within HIV clinics given the current infrastructure challenges for airborne infection control. iii) Expected efficiencies that will result from this joint implementation Multiple efficiencies are expected from the investment proposed in this Joint Concept Note and the simultaneous submission of the HSS Concept Note. These include the following: Progressive planned integration of recording and reporting from both the ACP and the NTLP into the District Health Management Information System (DHIS-2) that is computerized and supported by highly trained personnel in data management (Biostatisticians). This will increase efficiency in management and utilization of health information at all levels, improve data quality, build capacity for M & E and guide better programming. Progressive planned integration of procurement and management of the supply chain for TB and HIV medicines and commodities into the national essential medicines procurement and supply chain. This improves efficiency and guarantees sustainability since the Government / partners do not have to fund and manage multiple supply chains. There are still gaps in the management of the supply chain at the health facility level that need to be addressed through training, mentoring and supervision. This will also avoid stock-outs and overstocking at different levels. Alignments in recording and reporting of integrated program events (will be identified over the grant implementation period) will reduce duplication, translate into health system efficiencies and improve data quality Joint supervision and joint program reviews planned in this application will reduce costs, increase information sharing, promote joint ownership and translate into improvements in the quality of services delivered to patients who suffer from one or both of these diseases. Strengthening laboratory support to both the ACP and the NTLP through leveraging the HUB system established by the MoH (described in earlier section 1.1 (d) (Uganda National Sample Transport Network Page 1-8). Optimum use of this system will translate to strengthening health systems, cost efficiencies as multiple samples can be transported at the same time, end-user (patient) efficiencies and importantly to informed decision making in the clinic and in the program leading to better case management for patients and improved public health in the country. Careful deployment of the new technology for diagnosing TB and MDR-TB across the health services will improve access to these services for MARPs and key populations, especially children, and people at risk of MDR-TB, including health workers. This translates to savings and costs averted for people suffering with illness, savings and costs averted to the country s health budget and importantly into DALYs saved and deaths averted. Alignment of priorities within the concept note as well as alignment later in joint implementation are facilitated significantly through the Community Engagement Charter that has been developed by communities including representation from Key affected populations of both diseases. This charter details interventions of importance to communities from both programs and outlines pathways and processes for both programs to efficiently link with communities inviting their contribution and partnership in creating impact. (TB Charter pages 1-6)) Health systems strengthening improvements in the recent past Although still a challenge to HIV programming, several advancements have been registered in health systems strengthening. Some of the improvements include: 1) Rationalization of HIV and TB commodity supply chain management which has significantly reduced stock out of ARVs and TB Uganda TB and HIV Concept Note 15 October,

26 drugs and consumables; 2) Improved coverage of laboratory services nationally (HIV NSP MTR 2014, page 19); Labs performing smear microscopy for TB have increased from 303 in 2006 to 1091 in 2011 (one for every 25, -30,000 population); 98 facilities (all RRH, district hospitals and some HC IVs) received iled fluorescent microscopes in June 2012; introduction and expansion of rapid TB diagnostic technology such as XpertMTB/Rif there are currently close to 60 sites delivering this service; 3) Capacity building and accreditation of health centers to provide TB diagnosis and treatment, HCT, PMTCT, and ART services with a rapid expansion of ART and PMTCT services; 4) M&E systems enhancement including rolling out DHIS2 countrywide; ARV web-based ordering and reporting on commodities; 5) Establishment of the Regional Performance Monitoring Teams to enhance data integrity, support supervision, and reporting as well as quality improvement initiatives (although not yet fully operational); 6) Human resource improvements: recruitments and training of additional health workers for HCIV and HCIII; and 7) MoH Implementing Partner rationalization to improve efficiency and coordination within the districts and facilities. All these health system improvements will support the implementation of the proposed interventions and specifically the proposed implementation of the WHO 2013 HIV treatment guidelines. TB/ HIV collaborative activities Challenges to implementation of TB-HIV collaborative activities include low ART coverage among TB clients (65%), delays in the implementation of IPT, low case detection rates for TB especially among the HIV-infected, weak TB infection control, and fragmented integrated delivery of TB and HIV services. However, various opportunities exist for integrating TB and HIV services and reversing the current trends. A TB-HIV National Coordination Committee (NCC) has been in place for several years. The expansion of accredited ART facilities with the rapid rollout of ART and PMTCT Option B+ addresses the challenges of differential decentralization of TB and HIV services and thus provides an opportunity to ensure quick and sustained ART for TB-HIV co-infected patients. MOH has developed IPT guidelines to support the scale-up of IPT in PLHIV. Expanded provider-initiated HIV testing to the lower level facilities provides an opportunity for increased HIV testing of TB patients. The momentum that has been generated through joint stakeholder consultations and planning for this TB-HIV joint application has generated renewed effort and commitments towards further strengthening and synergies between the TB and HIV programs in Uganda. b. The barriers that need to be addressed in this alignment process The HIV/AIDS epidemic continues to be the most important risk factor for TB incidence and mortality in Uganda. The HIV prevalence in the general population increased from 6.4% in 2004/05 to 7.3% in 2011 (Uganda Sero-Behavioral Survey 2004/5 page 107/UAIS 2011 report page 104). The increasing trend in HIV prevalence is likely to reverse the current declining trend in incidence and prevalence of TB as well as mortality attributed to it, if efforts to prevent new HIV infections are not stepped up. The prevalence of HIV among TB patients notified to the national TB program has stabilized around 50% since (Global Tuberculosis Reports, 2009 page 153, 2011 page 107,2012 page 125 /, 2013 page 159) A few studies conducted in limited settings in Uganda, showed that the prevalence of TB among people living with HIV ranged between 5.5%-7.2%. (Moor D et al page ; Worodria W, et al page 1, 5-7) A meta-analysis conducted by Masja et al in 2011 showed that TB related deaths among people living with HIV were three times more than those in non-hiv infected persons (Straetemans M page 1, 3-7). Challenge areas that both programs will address through this application include Improving TB screening in HIV infected although the proportion screened is high, this has not translated to identified TB patients (1.5% vs expected 5-7%). There continues to be a high risk of MDR-TB in this population. (HIV Investment Case page 20) This application will bring in and promote access to additional new TB diagnostic technology with increased sensitivity and the capacity to simultaneously detect R resistance so that presumptive TB in this population is able to access quality assured TB diagnosis and that TB / MDR-TB is diagnosed early and treated promptly and completely. The revised version of the diagnostic algorithm and the Intensified TB Case Finding Guide provides a pathway for HIV infected persons to access TB testing with XpertMTB/Rif early (Combined GENEXPERT ALGORITHM page 1, TB ICF Guide page 1/). The HIV grant will also be used to support procurement (incentive funding) of XpertMTB/Rif cartridges for this purpose contributing to expanding access jointly for this important technology. Improving ART coverage in the TB HIV co-infected population during TB treatment. This is currently low and compromises TB treatment outcomes and increases AIDS mortality and morbidity. Patient pathways to access treatments for TB and HIV need to be reviewed so that co-infected patients are able to access TB treatment and ART easily and conveniently. This application proposes an Uganda TB and HIV Concept Note 15 October,

27 integrated model of TB HIV services and care through the One Stop Shop, which will be expanded to 14 RRHs, 2 NRHs and 136 general hospitals across the country. Protecting HIV infected people from TB is another challenge that will be addressed within this grant. While IPT is now within the national guidelines, this is not routinely available to eligible HIV infected population. Access to this involves alignment across the two programs at the policy and procurement levels as well as service delivery, tracking and support to patients receiving IPT, recording and reporting and routine monitoring. The HIV grant will support procurement of isoniazid that will be used to protect PLHIV under care from TB based on screening and eligibility criteria already established. Protecting patients and the community, especially HIV infected populations, and health care workers from TB and MDR-TB. This involves implementing infection control across health facilities amongst others and will require support from the general health systems as well as coordination across the two programs so that patients and presumptive TB patients are rapidly screened and moved into treatment programs as appropriate. Health care workers must also be protected and regularly screened, monitored and supported as appropriate. HIV infected health care workers must be provided the option to serve in clinics not handling TB / MDR-TB patients routinely. The Intensified TB Case Finding Guide and the revised diagnostic algorithm for access to XpertMTB/Rif provides pathways for presumptive patients and health workers to be triaged and fast tracked for screening and diagnosis of TB in health facilities and congregate settings. Increasing detection of TB among children this is currently very low and this application articulates actions to improve detection of TB among children. The procurement of new technology (XpertMTB/Rif) in addition to the existing technology, the prioritization of increasing EID of HIV amongst children are opportunities to coordinate across programs for the benefit of children. In addition, data collection on children with TB will be disaggregated by relevant age group (<5 years, 5-14) to determine the burden of diseases and modify interventions accordingly. The prioritization of women and children within HIV specific interventions and the clarity around key affected populations within the HIV infected community is also the opportunity to increase access for TB screening and diagnosis in these important populations requiring program coordination and alignment of services across the two programs. Increase engagement with the community in all areas of programming including planning, development of priorities, writing of the concept note, ensuring that community engagement is a priority intervention in each of the disease specific priority modules, identification and elaboration of priority interventions within the priority module (engaging communities), developing a broader framework to engage communities across the health system through the HSS concept note and leveraging the Community Engagement Charter developed during the process of writing this concept note (TB Charter pages 1-6). SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND SUSTAINABILITY To achieve lasting impact against the diseases, financial commitments from domestic sources must play a key role in a national strategy. Global Fund allocates resources that are insufficient to address the full cost of a technically sound program. It is therefore critical to assess how the funding requested fits within the overall funding landscape and how the national government plans to commit increased resources to the national disease program and health sector each year. 2.1 Overall Funding Landscape for Upcoming Implementation Period In order to understand the overall funding landscape of the TB and HIV national programs and how this funding request fits within these, briefly describe: a. The availability of funds for each program area and the source of such funding (government and/or donor). Highlight any program areas that are adequately resourced (and are therefore not included in the request to the Global Fund). b. How the proposed Global Fund investment has leveraged other donor resources. c. For program areas that have significant funding gaps, planned actions to address Uganda TB and HIV Concept Note 15 October,

28 these gaps. a. The availability of funds for each program area and the source of such funding (government and/or donor). Highlight any program areas that are adequately resourced (and are therefore not included in the request to the Global Fund) The annual health budget allocation has averaged around 7.5% - 9.0% of the total national budget for the last 5 years, which is well below the African Union s Abuja declaration of 15% allocation for health (Abuja Declaration 2001/page 5). Health sector finances come from domestically generated revenue from the central government and local governments and from development assistance. Over 95% of financing to the district health system is from the central government. Development assistance plays a major role in financing health services though a bigger proportion of this is off budget. The MoH has a big challenge tracking donor off-budget support (Joint HSSIP Assessment report pages 48-50). From FY2007/08 to FY2011/12, the total health expenditure per capita averaged US $ 10 and increased to US $ 11 in FY2012/13 which is less than a quarter of US $ 48, WHO recommends as the minimum required to fund the Minimum Health Care Package (Abuja Declaration page 5 World Health Organization, Macroeconomics and Health page 16). Donors, NGOs and individuals shoulder the rest of the health expenditure. Out of pocket expenditure has increased from 42% in FY 2012/13 to 54% in 2013/14. The HIV and TB programs are funded by two major funding mechanisms: 1) The Government of Uganda (GOU) budget support to the Health sector through the Ministry of Finance Planning and economic development; 2) Support from the development partners under a project mode funding. The GOU finances both the recurrent and non-recurrent expenditures of the health sector. The recurrent expenditures include the wage and the non-wage bills while the non-recurrent expenditures relate to investments in the physical infrastructure, and other long-term developments. In the 2012/13 budget the GOU set the health sector as one of the priority sectors. Key investments included: recruitment of additional human resources, investments into the physical infrastructure such as constructions and refurbishment of health facilities across the country; improvements in the supply and delivery of drugs and pharmaceuticals from the central stores to the health facilities (Background to the budget 2014/Page 95-97). Additionally, GOU has increased its funding to the health sector by 52%, from Uganda shillings billion in 2010/11 to 1,127 billion in 2013/14. These investments benefit both the HIV/AIDS and TB national programs. Supplementary support from development partners for TB and HIV is received through project mode. Resources secured from the Global Fund through this concept note application will contribute towards meeting the unmet need of the government s efforts. Table 1 below shows the national need for the proposed TB-HIV interventions over the project period ( ). Table 1: National funding need for each of the proposed TB-HIV interventions Summary budget by Modules Jul 2015-Jun 2016 Jul 2016-Jun 2017 Jul Dec 2017 TOTALS Prevention: general population 44,490, ,501, ,560, ,551,844.3 Prevention: MSM and TGs 178, , , ,439.6 Prevention: Sex workers and 309, , , ,354.0 their clients Prevention: Youth, in and out 1,116, ,153, ,342, ,613,100.8 of school PMTCT 423, , , ,429,935.4 Treatment, care and support 172,078, ,109, ,169, ,357,725.4 TB care and prevention 2,616, ,645, ,625, ,888,091.2 TB/HIV 293, , , ,400.0 MDR-TB 3,401, ,318, ,275, ,995,607.8 Health information systems 672, ,123, ,252.8 and M&E 2,308,904.8 Health and community 405, , ,740.0 workforce 1,097,190.0 Community systems 388, , , ,882.7 strengthening Program management 325, , , ,194.7 Results-based Financing TOTALS 226,701, ,370, ,091, ,162,670.8 Uganda TB and HIV Concept Note 15 October,

29 Table 2 below highlights the funding estimates for TB-HIV from the partners over the proposed implementation period, with total financial gap of US $430,481,434. Table 2: TB-HIV Partner support (commitments) for Financial Year 2015/ /2017 July-Dec 2017 Totals National Need 226,701, ,370, ,091, ,162, Projected resources Government of Uganda 36,700,000 36,700,000 36,700, ,100,000 USG/PEPFAR*** 54,900,000 54,900,000 54,900, ,700,000 IRISH AID*** 8,580,000 TBD TBD 8,580,000 SIDA*** 2,600,000 TBD TBD 2,600,000 Germany Leprosy 500, , ,000 1,500,000 Foundation for Innovative New Diagnostics. 602, , ,000 1,067,000 DFID 6,800,000 TBD TBD 6,800,000 GF grants ( HIV and TB) 3,334,237-3,334,237 Total projected commitment 114,016,237 92,239,000 92,426, ,681,237 Funding Gap 112,685, ,131,330 92,665, ,481,434 *** Partner support beyond 2015/16 has not been fully ascertained. PEPFAR currently is the principle supporter of comprehensive prevention, care, and treatment services in partnership with the GOU. In the CCM meeting of 16 th October 2014, PEPFAR communicated that the PEPFAR global program was in a period of change, which will result in programmatic adjustments in all PEPFAR countries. During the next several months, PEPFAR will work in collaboration with national stakeholders to secure, validate, analyze, and use data to help identify where the burden of disease is in Uganda, and to direct resources to those areas to achieve control of the epidemic. Changes will likely occur in where and how PEPFAR programming in Uganda works. Any adjustments that will arise after submission of this concept note will be catered for during the grant making process to ensure that the Global Fund and PEPFAR resources complement and leverage each other to maximize the impact of the limited funding and work towards achievement of UNAIDS s 90:90:90 goals. The NTLP is currently funded through a SSF Phase 2 grant (UGD-T-MoFPED) that started in July 2014 and will end in December 2017 the value of this grant is US $ 15,140,487. Within the programmatic gap table in this investment application, allocation from the Government of Uganda and implementing partners (IP) is indicated as follows: approximately 30% of costs incurred for notification of TB (program gap 1); about 25% of the costs for treatment outcomes including costs of first line drugs; procurement of isoniazid for IPT for children requiring this and identified through contact tracing; about 19% of the costs for PMDT including costs of second-line drugs. While there is significant investment in almost all areas of programming within the NTLP through Implementing Partners (IPs), this investment is not nationwide and is strategically targeted, geographically as well as at different levels of the health services including communities, patients and program processes. These investments from IPs bring additionality to the Global Fund grants that support the NTLP countrywide and across all populations (with prioritization as appropriate). They also leverage the health sector allocations of GOU that aims to build sustainability into these investments over the medium and long term. b. How the proposed Global Fund investment has leveraged other donor resources The concept note development process included a programmatic and financial gap analysis for the HIV and TB national programs to derive the national need and also map out interventions that would be funded by the GoU and other in-country partner support for the period of the concept note. The total need for funding the HIV and TB from 2015/16 to 2017/18 is estimated to be US$ - Uganda TB and HIV Concept Note 15 October,

30 729,162, The contributions from the GOU and developments partners is estimated to be US $ 298,681,237. The GF funds will supplement the current resources to consolidate gains and contribute to closing the gaps in program implementation. GF resources requested under this Concept note will be invested in key areas of TB-HIV, including HIV and TB prevention, care and treatment, and the critical systems for delivery of these services. While continuing investment by IPs in these areas is not certain, it is very likely and the Global Fund investment provides a national platform for strategic investments by IPs in important program areas. c. For program areas that have significant funding gaps, planned actions to address these gaps A total of US $ 8.7 billion will be required over the investments period 2015 to The returns from the investment include (a) aversion of 2,160,000 new infections between 2015 and 2025 (a 77% reduction, (b) reduction of new infections in children from 14,200 to 4,040 between 2014 and 2025 (c) Uganda will avert 570,000 deaths by 2025 and (d) the lives of 42,620 children will be saved from AIDS related death by Recent records show that although Government has been increasing its contribution to the epidemic, more than 80% of spending for the national HIV and AIDS response comes from AIDS Development Partners, thus revealing a significant resource gap for financing the investment needed for the period. The most grossly under-funded programs in HIV include HIV prevention in the general population and HIV treatment; an estimated US$ 568,357,725.4 is required to achieve the 80% target of HIV treatment for eligible individuals by The requested funding through this application (within allocation) only covers about half of the required funds for treatment. Additional needs are captured under the above allocation request. Additionally, GOU plans to increase its contribution to HIV and is in the process of establishing the HIV Trust Fund to raise funds for scaling up the national HIV response towards the epidemic. The HIV Control and Prevention Act has set the stage for establishment of the HIV Trust Fund, which has been under discussion in recent years. This Fund will augment the resources required to Implement Uganda s Investment Case and contribute to reduction of new HIV infections and mortality in the long-term. GOU will also continue with efforts to ensure resource mobilization and efficient use of resources for TB and HIV, from other partners. The proposed integration of TB and HIV in this application is one such effort that will enhance synergies and efficiencies in implementation of programs for the two diseases. Government will also ensure practices that improve accountability and management of resources are in place (Uganda HIV Investment Case, page ix). The Uganda AIDS Commission and AIDS Control Program have engaged with Senior Top Management (STM) of the MOH to leverage additional domestic funding. As part of this process, following a meeting with STM, a Cabinet information paper is being developed to be discussed with Cabinet and Ministry of Finance to explore mechanisms for additional funding to the HIV response. The NTLP continues to be underfunded from the MoH and understaffed and this has been documented as a key challenge by both the external review as well as multiple Global Fund Portfolio briefs communicated to the CCM. The financial commitment to TB control is not commensurate to the burden of TB disease in the country and has led to the NTLP s high donor dependence. Another major concern is that the yearly allocation of funds is based on historical expenditure rather than on actual needs. Because of the perception of a significant (and traditional) external support to control the TB epidemic, several District Administrations, whose budget must include funding of district health services operations, make often available a very limited (if any) budget for TB related, resulting mainly in poor support to the field community work required by the community care model. A specific area in need of urgent response is support for the scale up and quality of care for the Programmatic Management of Drug Resistant TB (PMDT). As compared to regular TB, deficiencies in quality of care for drug resistant TB can have heightened consequences, with potential for more severe adverse reactions and acquired resistance, including the development of extensive drug resistant (XDR) disease. Uganda TB and HIV Concept Note 15 October,

31 2.2 Counterpart Financing Requirements Complete the Financial Gap Analysis and Counterpart Financing Table (Table 1). The counterpart financing requirements are set forth in the Global Fund Eligibility and Counterpart Financing Policy. a. For TB and HIV, indicate below whether the counterpart financing requirements have been met. If not, provide a justification that includes actions planned during implementation to reach compliance. Counterpart Financing Requirements Compliant? If not, provide a brief justification and planned actions i. Availability of reliable data to assess compliance Yes No The country has not yet carried out a resource tracking study to establish actual spending and specific disease spending. National health accounts 2010/11 did not capture disease specific spending. Earmarked funds for TB support are for purchase of drugs committed by the government. Accessibility to partner s databases remains a major challenge. Data submitted from partners implementing TB programs outside government systems seem to portray a lower picture of their expenditures. Annual budgetary performance framework reports have been used. Data system Limitation: 1. Insufficient existing mechanisms of sharing information between the TB program and partners implementing TB programs outside the government funding mechanisms. 2. Lack of established database at the NTLP. 3. Budget support spending not earmarked by diseases ii. Minimum threshold government contribution to disease program (low income-5%, lower lowermiddle income-20%, upper lowermiddle income-40%, upper middle income-60%) Yes No The Gap analysis indicates Counterpart Financing is 29%, which is greater than 5% requirement for a country like Uganda. This is due to government commitment to purchase Malaria, TB drugs and ARVs up to $101million over the 3 Uganda TB and HIV Concept Note 15 October,

32 years of the grant. iii. Increasing government contribution to disease program Yes No As indicated in the gap analysis, government contribution to the NTLP is expected to grow and the growth will depend on continued government commitment to earmark funds for purchase of drugs and overall annual increment in the health budget. The health budget is expected to continue to grow in absolute terms based on national budget increases in values. Below is the expected increase in government contribution to national TB program and the contribution is expected to double in 2017/18 as compared to 2012/13 financial year (see details below) b. Compared to previous years, what additional government investments are committed to the national programs in the next implementation period that counts towards accessing the willingness-to-pay allocation from the Global Fund. Clearly specify the interventions or activities that are expected to be financed by the additional government resources and indicate how realization of these commitments will be tracked and reported. c. Provide an assessment of the completeness and reliability of financial data reported, including any assumptions and caveats associated with the figures. b. Compared to previous years, what additional government investments are committed to the national programs in the next implementation period that counts towards accessing the willingness-to-pay allocation from the Global Fund. Clearly specify the interventions or activities that are expected to be financed by the additional government resources and indicate how realization of these commitments will be tracked and reported The period 2010/11 to 2013/14 has shown an increase in the GOU releases to the health sector. The sector funding is the major source of resources for the health care service delivery. The GOU provides resources for both recurrent and non-recurrent expenditures. The recurrent expenditures cover the payment for wages and non-wage bills while the non-recurrent largely covers developments expenditures. The two disease programs benefit directly from the sector resources as these are integrated into the Health sector. In addition GOU allocates funds specifically for the two disease programs to support the procurement of drugs and pharmaceutical products, the costs of multi-sectoral coordination for the HIV response and research and innovations for the HIV and TB programs. In fiscal year 2012/13, GOU with support from partners recruited additional health workers for the lower level health facilities. The growing trend in GOU releases to the Health sector is an indication of increasing commitments to the attributions to the disease programs in general. The GOU contributions to the health sector as a proportion of the total budget stands at 8.4% for period 2013/14. While this is still below the 15% Abuja declaration target, there is a positive outlook on GOU nominal allocations to the Health sector that is projected to grow to about 47.2% in the year 2017/18 compared to the year 2011/12-health budget (See Figure 6). It is projected that as the economy grows, the overall national budget will increase and therefore all sector budgets will increase in nominal terms accordingly. Figure 6: Annual Health Expenditure and cumulative Nominal Growth Uganda TB and HIV Concept Note 15 October,

33 Minimum threshold for counterpart financing The willingness to pay refers to the government s direct contributions as proportion of the total government and the Global Fund contributions to the disease programs. Uganda is classified as low Income country and is required to fulfill a 5% counterpart-funding threshold for the willingness to pay. Uganda has met the minimum threshold for the willingness to pay for the HIV/TB programs. The Gap analysis indicates Counterpart Financing is 29%, which is greater than 5% requirement for a country like Uganda. The government has put a credit line for procurement of TB, HIV (ARVs), and Malaria drugs to the tune of 100 billion Uganda shillings (US $37 million; $34.5 for TB and HIV drugs). This translates into US$111 million in three years. This is over and above the GOU programmatic financing to UAC and MOH. Table 3 below shows the GOU willingness to pay. Table3: Government of Uganda Willingness to pay Government Spending and Commitments by Program Y-2 Y-1 Y0 Y1 Y2 Y HIV 37,629,340 35,290,739 34,932,231 34,661,924 33,296,881 32,847,839 Tuberculosis 11,117,936 9,017,744 5,615,133 3,743,916 3,669,725 3,598,028 Malaria 3,693,131 3,533,110 4,617,443 3,376,498 3,309,587 3,244,927 HSS* 33,505,324 43,237,650 70,847,111 94,451,142 29,215,413 12,593,099 HSS* Total Wage bill for the Health sector 96,216, ,146, ,818, ,162,486 Table 4 below is the expected increase in government contribution to NTLP and the contribution is expected to double in 2017/18 as compared to financial year 2012/13. Out turn 2012/13 Projected 2013/14 Projection 2014/15 Projection 2015/16 Projection 2016/17 Projection 2017/18 Estimates for GOU funding to TB in US $ 2,111, ,469, ,744, ,155, ,617, ,227,212.7 Annual Increase in GOU funding to TB 0% 17% 11% 15% 15% 17% Increase in GOU funding to TB (base year 2013/14) 0% 17% 30% 49% 71% % Evidence of the counterpart funding from GOU include; a. Funds for procurement of drugs and pharmaceuticals specifically for the HIV and TB programs, ARVs and the anti TB medicines through the National Medical stores. b. Staff emoluments for addition staff recruited as part of GOU HR interventions for HIV program Uganda TB and HIV Concept Note 15 October,