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USAID StrengtheningTB and HIV & AIDS
Responses in East Central Uganda (STAR-EC):
An Eight-Year Journey
End-of-Project Conf...
What We’ll Cover Today:
STAR-EC’s Eight-Year Journey
1. Where we started
2. STAR-EC goal and objectives
3. What we achieve...
Where we started
in 2009
STAR-EC covered
3.1 million
people, roughly
11% of Uganda’s
population.
Our region had a large presence
of high risk populations:
 Female sex workers
 Sero-discordant couples
 Fishermen
 Tru...
1 in 4 men engaged in
multiple concurrent sexual partnerships.
Weaknesses in the health system complicated
an already challenging epidemic.
Only four health facilities were
accredited t...
Testing and counseling rates were below 50%.
And only 59% of adults could name
3 ways to prevent HIV transmission.
HIV infection was
high, particularly in
the lake shore
communities.
And 1 in 8 infants exposed
to HIV tested positive.
pre...
1 in 5 TB patients were lost to follow up.
Tuberculosis was a persistent challenge.
STAR-EC goal and
objectives
Goal: Increase access, coverage, and use of
quality comprehensive TB and HIV and AIDS
prevention, care, and treatment serv...
STAR-EC worked across 3 areas to improve
HIV and AIDS and TB service delivery
system
strengthening
demand
creation
quality...
Game changing interventions at each level
along the continuum of care
facility
family/individual
community
identification ...
What we achieved
2009-2016
Our TB and HIV and
AIDS achievements
over eight years have
been remarkable.
HIV and AIDS
3.6%
5.4%
1.9%
0.0
1.0
2.0
3.0
4.0
5.0
6.0
200000
400000
600000
800000
1000000
2009 2010 2011 2012 2013 2014 2015 2016
Ove...
fisher folk
23%
4%
FSWs
20%
7%
2010 2011 2012 2013 2014 2015 2016
And in key and priority populations such as
fisher folk ...
And priority populations like pregnant and
lactating women.
2.7%
1.3%
2010 2011 2012 2013 2014 2015 2016
** Source: CPHL (inclusive of confirmatory tests for newly enrolled HIV positive babies)
5%
12%
6.5%
2010 2011 2012 2013 2...
4.7%
0.7% of
discordants
identified
4.2%
0.4% of
concordants
identified2010 2011 2012 2013 2014 2015 2016
We also saw a do...
The MOVE Strategy
was used to increase
uptake of VMMC
services.
IncreasedVMMC coverage
37% 58%
The HIV-related knowledge, attitudes, and
practices of female sex workers improved
between 2012 and 2016.
Uptake of HIV te...
We profiled and followed up 1,670 female sex
workers.
99 percent of female sex workers (FSWs) were
tested for HIV and 19 p...
Improved access to HIV testing
48% 92%
The number of health facilities accredited to
provide ART sites increased dramatically during
the life of the project.
93 ...
372
40,116
2009 2010 2011 2012 2013 2014 2015 2016
And in turn, we saw an increasing number of
clients on treatment.
7,041
in care
43,378
in care
3,119
on ART
40,116
on ART
2010 2011 2012 2013 2014 2015 2016
And for every 10 patients in ca...
Including a steady increase
in the number of children
(0-14 years) on treatment.
20
3027
2009 2010 2011 2012 2013 2014 201...
Mentor mothers
provide peer
support and link
HIV+ pregnant
mothers and
mother-baby pairs to
services.
Which supported ARV uptake among
HIV positive ‘mother-baby’ pairs.
222
3,329
60%
83%
2010 2011 2012 2013 2014 2015 2016
Original cohort on ART
Active after 12 months
(% of original cohort)
...
92%
88%
91%
87%
91%
87%
92%
89% 90% 90%
Bugiri Buyende Iganga Kaliro Kamuli Luuka Mayuge Namayingo Namutumba Region
And fo...
TB
Mobile laboratory
services made tests
accessible in hard-
to-reach areas.
We saw a steady increase in TB
case notification and detection.
62.6% 63%
81%
2014 2015 2016
STAR-EC started measuringTB c...
Services for multi-drug resistant TB
became available in the region.
40
2
38
1
22
13
2
Notified cases
Death after notifica...
67%
TSR
90%
30%
Cure
Rate
74%
20%
LTFU
4%
2010 2011 2012 2013 2014 2015 2016
TSR >85%
Cure rate
>50%
Loss to
follow up
<10...
84% tested for HIV
37% HIV positive
32%
84% CPT uptake
100%
18% ART
uptake
96%
2010 2011 2012 2013 2014 2015 2016
Through ...
Improved quality of
services
Quality improvement approaches
were data-driven.
Linkag
e
Retentio
n
QI
team
matu
rity
Linkag
e
Retentio
n
QI
team
matu
rity
Linkag
e
Retentio
n
QI
tea
m
mat
urity
Village...
STAR-EC worked to strengthen the
Ugandan health system for lasting change.
Provided essential equipment such as
microscopes and CD4 machines.
Installed power back-up systems in 3
hospital laborator...
14 clinicians seconded to island health
facilities.
Installed solar systems in 18 health facilities.
Transitioned from pap...
And rehabilitated infrastructure.
Before
The Bugiri lab work top had a
dilapidated sink that did
not work.
After
The Bugir...
Our team
strengthened
M&E systems.
We conducted DQAs
and improvement
through CQI and SIMS.
And supported TB/HIV
district-led performance
reviews and HMIS
register triangulation.
Challenges and
opportunities
• Understaffing: regional average 68%
• Stock outs of supplies and drugs
• Limited space at facilities to treat increasing...
• Integrated outreach model
• Use of ICT, e.g., mobile health
• District operational plans and district
management committ...
Legacy
Rapid scale-up of
evidence-based
interventions is possible.
 VMMC
 Option B+ Providing prevention and
treatment services...
Acknowledgements
• USAID
• MOH
• District leadership and health workers
• Implementing partners, e.g., ASSIST, SDS
• Sub-p...
Sub-Partners
• AHF Uganda Cares
• Communications for
Development Foundation
Uganda (CDFU)
• Mothers to Mothers (m2m)
• Wor...
• AIDS Information Centre (AIC)
• Integrated Development Activities
& AIDS Concern (IDAAC)
• Multi Community Based
Develop...
Uganda JSI/STAR-EC Project end-of-project conference presentation
Uganda JSI/STAR-EC Project end-of-project conference presentation
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Uganda JSI/STAR-EC Project end-of-project conference presentation

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Highlights of the USAID Uganda STAR-EC project. STAR-EC worked to increase access, coverage, and use of quality comprehensive TB and HIV and AIDS services in east and central Uganda.

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Uganda JSI/STAR-EC Project end-of-project conference presentation

  1. 1. USAID StrengtheningTB and HIV & AIDS Responses in East Central Uganda (STAR-EC): An Eight-Year Journey End-of-Project Conference August 11, 2016
  2. 2. What We’ll Cover Today: STAR-EC’s Eight-Year Journey 1. Where we started 2. STAR-EC goal and objectives 3. What we achieved a. HIV b. TB c. Health system strengthening 4. Challenges and opportunities 5. Legacy Photo: USAID
  3. 3. Where we started in 2009
  4. 4. STAR-EC covered 3.1 million people, roughly 11% of Uganda’s population.
  5. 5. Our region had a large presence of high risk populations:  Female sex workers  Sero-discordant couples  Fishermen  Truckers  Sugar plantation workers  Boda boda riders
  6. 6. 1 in 4 men engaged in multiple concurrent sexual partnerships.
  7. 7. Weaknesses in the health system complicated an already challenging epidemic. Only four health facilities were accredited to provide ART. And only 372 clients were on treatment in 2009. 59%of health worker positions in the region were filled.
  8. 8. Testing and counseling rates were below 50%. And only 59% of adults could name 3 ways to prevent HIV transmission.
  9. 9. HIV infection was high, particularly in the lake shore communities. And 1 in 8 infants exposed to HIV tested positive. prevalence* positivity** positivity** * AIS (2005); ** HMIS
  10. 10. 1 in 5 TB patients were lost to follow up. Tuberculosis was a persistent challenge.
  11. 11. STAR-EC goal and objectives
  12. 12. Goal: Increase access, coverage, and use of quality comprehensive TB and HIV and AIDS prevention, care, and treatment services Objective 1: Increase uptake of HIV and AIDS and TB services in supported districts Objective 2: Strengthen decentralized service delivery systems to improve uptake Objective 3: Quality HIV and AIDS and TB services delivered in all supported health facilities, community organizations, and activities Objective 4: Networks, linkages, and referral systems established or strengthened between health facilities and communities Objective 5: Increase demand for HIV and AIDS and TB prevention, care, and treatment services
  13. 13. STAR-EC worked across 3 areas to improve HIV and AIDS and TB service delivery system strengthening demand creation quality improvement Community mobilization BCC IEC Networks, referrals, linkages Meaningful involvement of PLHIV Training and capacity building HF accreditation Improving lab capacity Quality control Support supervision Data quality assessment Leadership and management Coordination M&E Drug logistics management HR for health Infrastructure renovation Providing key equipment
  14. 14. Game changing interventions at each level along the continuum of care facility family/individual community identification adherencetreatmentenrollment Adherence support groups Know your viral load campaigns Programs to prevent gender-based violence Monthly data triangulation Active client follow up by phone Female sex worker support clubs Active client follow up by linkage facilitators Active client referral using linkage facilitators Same day enrollment using integrated home outreach TB and HIV services Mother-baby care and cohort analysis Provider initiated testing and counseling Integrated outreach to hotspots and islands (PPs, KPs) Index client HIV testing and counseling continuum of care
  15. 15. What we achieved 2009-2016
  16. 16. Our TB and HIV and AIDS achievements over eight years have been remarkable.
  17. 17. HIV and AIDS
  18. 18. 3.6% 5.4% 1.9% 0.0 1.0 2.0 3.0 4.0 5.0 6.0 200000 400000 600000 800000 1000000 2009 2010 2011 2012 2013 2014 2015 2016 Overall HIV positivity declined. Targeted HTC outreaches among KP and PP # of people tested PITC campaigns HIV positive
  19. 19. fisher folk 23% 4% FSWs 20% 7% 2010 2011 2012 2013 2014 2015 2016 And in key and priority populations such as fisher folk and female sex workers.
  20. 20. And priority populations like pregnant and lactating women. 2.7% 1.3% 2010 2011 2012 2013 2014 2015 2016
  21. 21. ** Source: CPHL (inclusive of confirmatory tests for newly enrolled HIV positive babies) 5% 12% 6.5% 2010 2011 2012 2013 2014 2015 2016 And in HIV exposed infants. EID strengthening program
  22. 22. 4.7% 0.7% of discordants identified 4.2% 0.4% of concordants identified2010 2011 2012 2013 2014 2015 2016 We also saw a downward trend in HIV discordants and concordants identified.
  23. 23. The MOVE Strategy was used to increase uptake of VMMC services.
  24. 24. IncreasedVMMC coverage 37% 58%
  25. 25. The HIV-related knowledge, attitudes, and practices of female sex workers improved between 2012 and 2016. Uptake of HIV testing and counseling increased from 70 to 97 percent. Consistent condom use with every sexual encounter improved from 44 to 73 percent. Use of contraceptives to control pregnancy by HIV positive FSWs increased from 70 to 76 percent. 51 percent of HIV positive FSWs belong to an adherence network.
  26. 26. We profiled and followed up 1,670 female sex workers. 99 percent of female sex workers (FSWs) were tested for HIV and 19 percent were HIV positive. 90 percent of HIV positive FSWs are enrolled and active on ART. 74 percent of FSWs on ART have viral suppression.
  27. 27. Improved access to HIV testing 48% 92%
  28. 28. The number of health facilities accredited to provide ART sites increased dramatically during the life of the project. 93 health facilities 4 health facilities 2009 2016
  29. 29. 372 40,116 2009 2010 2011 2012 2013 2014 2015 2016 And in turn, we saw an increasing number of clients on treatment.
  30. 30. 7,041 in care 43,378 in care 3,119 on ART 40,116 on ART 2010 2011 2012 2013 2014 2015 2016 And for every 10 patients in care, 9 are on treatment, up from four out of ten in 2009.
  31. 31. Including a steady increase in the number of children (0-14 years) on treatment. 20 3027 2009 2010 2011 2012 2013 2014 2015 2016
  32. 32. Mentor mothers provide peer support and link HIV+ pregnant mothers and mother-baby pairs to services.
  33. 33. Which supported ARV uptake among HIV positive ‘mother-baby’ pairs.
  34. 34. 222 3,329 60% 83% 2010 2011 2012 2013 2014 2015 2016 Original cohort on ART Active after 12 months (% of original cohort) Improved retention on ART reflects strengthened quality of care in HIV services.
  35. 35. 92% 88% 91% 87% 91% 87% 92% 89% 90% 90% Bugiri Buyende Iganga Kaliro Kamuli Luuka Mayuge Namayingo Namutumba Region And for those in treatment, 90 percent have viral suppression. Target 90%
  36. 36. TB
  37. 37. Mobile laboratory services made tests accessible in hard- to-reach areas.
  38. 38. We saw a steady increase in TB case notification and detection. 62.6% 63% 81% 2014 2015 2016 STAR-EC started measuringTB case notification in 2014
  39. 39. Services for multi-drug resistant TB became available in the region. 40 2 38 1 22 13 2 Notified cases Death after notification Enrolled on MDR treatment Death on treatment Completed Still on treatment Lost to follow up
  40. 40. 67% TSR 90% 30% Cure Rate 74% 20% LTFU 4% 2010 2011 2012 2013 2014 2015 2016 TSR >85% Cure rate >50% Loss to follow up <10% National Benchmarks We exceeded national benchmarks on TB treatment outcomes.
  41. 41. 84% tested for HIV 37% HIV positive 32% 84% CPT uptake 100% 18% ART uptake 96% 2010 2011 2012 2013 2014 2015 2016 Through collaborative counseling sessions, STAR-EC addressed TB and HIV together. Increased ART uptake was one of the most significant results.
  42. 42. Improved quality of services
  43. 43. Quality improvement approaches were data-driven.
  44. 44. Linkag e Retentio n QI team matu rity Linkag e Retentio n QI team matu rity Linkag e Retentio n QI tea m mat urity Village District IP % linked to comm unity % kept appoint ment 2.5 on TMI % linked to comm unity % kept appoint ment 2.5 on TMI % linked to comm unity % kept appoint ment 2.5 on TMI 1 Busanzi Bugiri STAR EC ND 41% 99 82 55 92 2 Busowa Bugiri STAR EC ND 52% 92 77 59 83 3 Butambula Bugiri STAR EC ND 48 89 77 56 77 4 Bwole Bugiri STAR EC ND 52% 92 64 73 84 5 Mukuba Bugiri STAR EC ND 64 86 75 90 92 6 Ndifakulya Bugiri STAR EC ND 49 92 73 96 98 7 Nkusi Bugiri STAR EC ND 58 93 83 68 67 8 Busoigo Kamuli STAR EC ND ND 100 100 100 47 9 Butekanga Kamuli STAR EC ND ND 73 67 98 72 10 Buwanzu Kamuli STAR EC ND ND 74 45 100 84 11 Kananage Kamuli STAR EC ND ND 74 49 82 68 12 Kulingo Kamuli STAR EC ND ND 93 82 90 74 13 Mandwa Kamuli STAR EC ND ND 100 60 92 72 KEY MOH standard met (>85%) Good 3.0- Good ≥90% Good >60 (but below MOH standard) Fair 2.0-2.5 Fair 89%-80% Fair <60% poor 1.0-1.5 Poor ≤79% Poor ND No Data ND No Data ND No Data JULY - SEPT 2013 OCTOBER-DECEMBER 2013 JANUARY-MARCH 2014 Follow up Follow up Follow up % complete follow up % complet e follow up % complete follow up ND 34 81 ND 51 79 ND 28 85 ND 31 91 ND 58 88 ND 41 62 ND 71 90 ND 44 40 ND 74 66 ND 59 55 ND 75 72 ND 76 73 Linkage ND 20 60 Appointment keeping/follow up Team Maturity Linkage Retentio n QI team maturity Linkag e Retentio n QI team maturity Linkage Retentio n QI team maturity % linked to communi ty % kept appoint ment 3.0on TMI % linked to comm unity % kept appoint ment 3.0on TMI % linked to communi ty % kept appoint ment 3.0on TMI 97 90 96 87 95 94 92 85 91 92 90 93 84 90 95 87 91 98 84 89 93 82 93 99 88 92 96 83 87 95 90 96 93 97 95 100 88 97 100 100 100 98 93 86 95 86 94 91 96 86 90 83 96 100 94 96 96 89 95 95 97 85 97 93 88 81 100 93 95 93 96 96 100 96 100 92 97 95 Follow up OCTOBER-DECEMBER 2014 JANUARY-MARCH 2015 % complet e follow up % complet e follow up APRIL-JUNE 2015 Follow up Follow up % complete follow up 93 78** 98 93 94 91 100 100 100 93 98 100 100 93 81 96 100 100 100 99 100 88 100 95 88 93 100 92 95 100 88 89 88 90 100 92 88 9894 Before (2013) After (2015) STAR-EC strengthened quality improvement both at the facility and community levels. Green shows where MOH standards were met for linkages, follow up, and retention
  45. 45. STAR-EC worked to strengthen the Ugandan health system for lasting change.
  46. 46. Provided essential equipment such as microscopes and CD4 machines. Installed power back-up systems in 3 hospital laboratories. Operationalized 7 laboratory hub networks to scale up viral load and early infant diagnosis, serving more than 130 health centers. We improved the capacity of laboratories.
  47. 47. 14 clinicians seconded to island health facilities. Installed solar systems in 18 health facilities. Transitioned from paper-based medical logistics to a web-based ordering system. Provided delivery beds and related equipment to 10 island facilities. And improved the capacity of health facilities.
  48. 48. And rehabilitated infrastructure. Before The Bugiri lab work top had a dilapidated sink that did not work. After The Bugiri lab work top got a newly fitted sink with elbow tap and a new refrigerator.
  49. 49. Our team strengthened M&E systems.
  50. 50. We conducted DQAs and improvement through CQI and SIMS.
  51. 51. And supported TB/HIV district-led performance reviews and HMIS register triangulation.
  52. 52. Challenges and opportunities
  53. 53. • Understaffing: regional average 68% • Stock outs of supplies and drugs • Limited space at facilities to treat increasing numbers of clients • Manual handling of records, making compilation of reports difficult, especially at high volume sites • Government underfunding for supervision, mentorship, and QI activities • Loss to follow up, due to many KPs and PPs Challenges pose a threat to sustainability.
  54. 54. • Integrated outreach model • Use of ICT, e.g., mobile health • District operational plans and district management committees as good platforms for integrated health activities • Functional community structures linked to health services • A well-skilled workforce, using HMIS data to inform programming • District-led programming and implementation Opportunities can be leveraged for continued improvement.
  55. 55. Legacy
  56. 56. Rapid scale-up of evidence-based interventions is possible.  VMMC  Option B+ Providing prevention and treatment services at multiple levels (facility, community, individual) can bring the HIV epidemic under control. Tailoring outreach and services to the unique needs of key and priority populations using a family centered approach can lower HIV prevalence. Over 8 years, STAR-EC has proven:
  57. 57. Acknowledgements • USAID • MOH • District leadership and health workers • Implementing partners, e.g., ASSIST, SDS • Sub-partners • CSOs • Communities
  58. 58. Sub-Partners • AHF Uganda Cares • Communications for Development Foundation Uganda (CDFU) • Mothers to Mothers (m2m) • World Education, Inc./Bantwana Initiative Pre-Qualified CSOs • Family Life Education Programme (FLEP) • National Community of Women Living with HIV&AIDS in Uganda (NACWOLA) • Uganda Reproductive Health Bureau (URHB) • Youth Alive Acknowledgements
  59. 59. • AIDS Information Centre (AIC) • Integrated Development Activities & AIDS Concern (IDAAC) • Multi Community Based Development Initiatives, Ltd. (MUCOBADI) • Uganda Development Health Initiative (UDHA) • UgandaWomen andYouth Development Initiative (UWYDI) • Youth andWomen in Action (YAWIA) • Bukooli Initiative forWomen in HIV&AIDS (BIWIHI) • Friends of Christ Revival Ministries (FOCREV) • Jinja Diocese Health Office (JDHO) • National Forum of People Living with HIV&AIDS Network in Uganda (NAFOPHANU) • SiguluWomen AIDS Awareness Organization (SIWAAO) Acknowledgements Additional Collaborating CSOs

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