UGANDA NATIONAL ADVOCACY ACTION PLAN by tdl18804

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    UGANDA NATIONAL
    ADVOCACY ACTION
         PLAN




 CAMPAIGN TO END
PAEDIATRIC HIV&AIDS
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                                                   TABLE OF CONTENTS


Contents
    ABBREVIATIONS........................................................................................................................ 2 

SECTION 1: INTRODUCTION AND OVERVIEW OF COUNTRY CONTEXT........................ 3 

    Trends of the HIV epidemic in Uganda....................................................................................... 3 

       Drivers of the Epidemic in Uganda ......................................................................................... 4 
    Overview of Paediatric HIV&AIDS in Uganda ............................................................................ 5 

SECTION 2: .................................................................................................................................... 6 

    OBJECTIVE 1; FAMILY CENTRED CARE AND NUTRITION; ................................................ 6 

    Policy and strategy guidelines in Uganda: .................................................................................... 6 

    Progress and gaps in PMTCT service delivery to mothers and babies....................................... 7 

    Growth in PMTCT service coverage .......................................................................................... 8 

    Beneficiary outcome of objective 1:............................................................................................ 9 

OBJECTIVE 2: EARLY INFANT DIAGNOSIS AND TREATMENT............................................ 13 

    Policy and Strategy provisions in Uganda.................................................................................. 13 

    Beneficiary outcome.................................................................................................................. 14 

OBJECTIVE 3; ACCESS TO APPROPRIATE MEDICATIONS..................................................... 18 

    Policy and strategy provisions in Uganda .................................................................................. 18 

OBJECTIVE 4: FULL FUNDING TO ELIMINATE PAEDIATRIC AIDS. ...................................... 23 

    Policy and strategy provisions. .................................................................................................. 23 




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ABBREVIATIONS
AIDS            Acquired Immune Deficiency Syndrome
ART             Anti Retroviral Therapy
CEPA            Campaign to End Paediatric HIV/AIDS
CSOs            Civil Society Organizations
EID             Early Infant Diagnosis
EIT             Early Infant treatment
HEPS            Coalition for Health Promotion and Social
                Development
HIV             Human Immunodeficiency Virus
MOH             Ministry of Health
NAAP            National Advocacy Action Plan
PMTCT           Prevention of Mother to Child Transmission
TMAP            Treatment Monitoring and Advocacy Project
UNAIDS          Joint United Nations for AIDS
UNICEF          United Nations Children’s Fund
WHO             World Health Organizations




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SECTION 1: INTRODUCTION AND OVERVIEW OF COUNTRY CONTEXT.

Trends of the HIV epidemic in Uganda
The approximately 25 year old epidemic in Uganda started in the 1980’s on the shores of Lake
Victoria in Rakai spreading quickly, initially in major urban areas and along major road network
highway 1 with heterosexual contact being the major infection route. The first National AIDS
Control Programme was set-up in Uganda at the Ministry of Health (MoH) to sensitise and
educate the public for prevention of HIV infection using the Abstinence, Be Faithful, Condom
use (ABC) strategy, ensure safe blood for transfusion, surveillance and initiate programmes for
care and treatment. By the early 1990s a large part of the population had succumbed to
opportunistic infections with a higher prevalence in urban relative to rural areas. It is estimated
that the epidemic had its peak during this period with the average antenatal HIV prevalence of
18 %, 25%-30% in major urban areas. It was realised that addressing the epidemic needed a
collective effort from all stakeholders in their different mandates and areas on comparative
advantage and capabilities. Political leadership, political commitment and openness about the
epidemic were identified as key in controlling the epidemic. The second phase of the epidemic
was between 1992 and 2000 reflecting a nationwide decline in prevalence 2 .

The third stage of the epidemic as revealed by the Uganda HIV/AIDS Sero-Behavioural Survey
2004-2005 (UNSBS 04/05) reflects a HIV prevalence of 6.4 % for the age group 15-49 both
sexes; urban 10.1 %, rural 5.7 %, female 7.5 % and male 5.0 %. Prevalence as shown in Figure 1-1
below is highest in the 30 – 34 age groups.

Figure 0-1 : HIV prevalence between age 15-59 years by age and sex




                                                            
1
    Uganda HIV/AIDS Sero-Behavioural Survey 2004-2005
2
    Uganda UNGASS Progress report of January 2008
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It is estimated that a total of 2.6 million people have been infected by HIV in the last 25 years of
whom 1.6 million 3 have passed on. Most of these were from productive age groups thus
affecting the nation’s productivity. It is also estimated that currently there are about 100,000
new infections 4 every year.

Drivers of the Epidemic in Uganda
Factors driving the epidemic include behavioural factors, social–cultural, socio-behavioural,
economic and geographic factors among others. These include 5 higher risk sex (which include
non-marital, extra-marital, non-consensual, commercial, transactional, intergenerational, sex for
survival), mother to child transmission, HIV discordance and non-disclosure, poverty, early
marriages, glorifying of non-marital sex, multiple sexual partners, stigma, discrimination and STI
prevalence.

New infections are found highest among the cohabiting/married/widowed group at 42% as
shown in figure 1-3 below.

Distribution of new infections by sources




                                                            
3
  Policy Recommendations Based on the Major Findings of the 2004-05 Uganda HIV/AIDS Sero-Behavioural Study
4
  Ministry of Health records
5
  The Road Map towards Universal Access to HIV Prevention in Uganda August 2006.
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Overview of Paediatric HIV&AIDS in Uganda
Of the 1.I Million HIV infected individuals in Uganda, an estimated 110,000 are children. Of these
children 50,000 are in need of life saving antiretroviral therapy. (ART)Only 16,000(8.8%) of the
180,000 individuals receiving are children. Most of the children who receive ART in Uganda are
located in urban setting 6 . If Uganda attained full coverage and utilization of PMTCT it would save
25, 000 babies born infected each year and approximately 2083 per day. This will would also save
on the cost of lifelong treatment for these babies in addition to reducing their suffering and
allowing them to contribute to national development. Full coverage of PMTCT+ would contribute
to reduction in Infant mortality rate one of the MDG indicators, where Uganda. For example
Uganda has under-5 mortality rate of 130 children out of 1000 and Infant mortality rate (under 1),
of 82 children out of 1000 (UNICEF, 2007). It is against this background that CEPA Uganda will
aim at addressing bottlenecks that lead to the above situation and help reverse the trend and save
25,000+ children that currently get infected annually in Uganda. Like in other countries the four
core CEPA objectives provide ground for developing the NAAP. These are:

       1. Family-Centered Care and Nutrition. Expand access to PPTCT+ and pediatric
          treatment, care, and support, including nutrition services, and integrate child and family
          services with other health services in order to improve survival rates and health
          outcomes for children, HIV-positive mothers, and their families.
       2. Early Infant Diagnosis and Treatment. Expand access to early infant diagnosis and
          earlier and improved pediatric treatment in order to improve survival rates and health
          outcomes for children.
       3. Access to Appropriate Medications. Reduce distribution barriers and increase the
          global supply of high-quality, low-cost lifesaving medicines for children and their families,
          including ARVs, drugs to treat opportunistic infections, and first and second-line
          regimens to ease dosing and administration.
       4. Full Funding to Eliminate Pediatric AIDS. Secure the financial resources needed
          to facilitate country-level scale-up of PPTCT+ and pediatric and maternal treatment
          programs.




                                                            
6
    National HIV&AIDS Strategic Plan 2007/8- 2011/12. Uganda AIDS Commission
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SECTION 2:
OBJECTIVE 1; FAMILY CENTRED CARE AND NUTRITION;
Expand access to PMTCT+ and paediatric treatment, care and support including nutrition
services; integrate child and family services with other health services in order to improve
survival rates and health outcomes for children, HIV-positive mothers and their families. This
campaign aims at influencing the government, development partners and implementing
organisations to prioritise family wide prevention, treatment and care. It’s aimed at influencing
service providers and policy makers to adopt WHO guidelines endorsing highly active
antiretroviral therapy (HAART) as best practice for PMTCT.

Policy and strategy guidelines in Uganda:
The 2006 Policy Guidelines for PMTCT in Uganda 7 provide for a comprehensive strategic
approach for preventing HIV infection among infants and children that includes four elements, in
line with global WHO/UNICEF and UNAIDS guidelines:

       Primary prevention of HIV infection among women of childbearing age
       Preventing unintended pregnancies among women living with HIV
       Preventing HIV transmission from women living with HIV to their infants
       Providing appropriate treatment, care and support to mothers living with HIV and their
        children and families.


The Health Sector Strategic Plan (HSSP) II 2005/06 – 2009/10 8 aims to make PMTCT services
available at all health facilities of HC level III or higher. In addition, the 2006 PMTCT policy
guidelines provide that Health Centre II should provide a basic PMTCT package comprised of:

       Counselling the mothers to promote uptake of HIV testing,
       Providing support to mothers and their families to make appropriate infant feeding choices,
        and where infrastructural and human resources capacities permit,
       Providing ARVs for the mother and infant at the time of labour and birth.


The assumptions in the PMTCT Policy guidelines with respect to ARV regimens in PMTCT are
that:

       20% of all the HIV+ mothers will be on single dose Nevirapine, primarily those attending
        late or at lower health centres.
       20% of all the HIV+ mothers will be on AZT+3TC+sdN; in cases of late attendance at
        Health Centre IV (HCIV) and hospitals
                                                            
7
    MOH (2006) Policy Guidelines for Prevention of Mother-to-Child Transmission of HIV in Uganda, Kampala
8
    MOH (2005) Health Sector Strategic Plan II 2005/06 – 2009/10, Kampala
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      40% of all the HIV+ mothers will be on AZT+ sdN; those reached before 34 weeks of
       gestation
      20% of all the HIV +mothers will be HAART; 75% on AZT+3TC+NVP


The HIV Control Bill 2007 9 provides for mandatory HIV testing for all pregnant women, and
access to medications for PMTCT by all HIV positive pregnant women as an entitlement.

      In contrast to mandatory testing for pregnant women, the bill provides for pre-test
       counselling for the spouse, to inform the decision for HIV testing (as a choice).
      The bill does not address the entitlement of HIV positive mothers to medications for HIV
       treatment, and the right of infants born to HIV positive mothers to access medications for
       HIV prevention.


Family-focused HIV treatment, care and support: The UNAIDS/UNICEF/WHO Progress
Report on Universal Access for 2008 indicates that testing pregnant women for HIV not only
provides an entry point for them to receive interventions to prevent transmission to the child
but also facilitates the enrolment of women, their families and future infants into longitudinal
HIV prevention, care and treatment.

      A recent study in Uganda observed an 81% reduction in mortality among uninfected children
       over a 31-month period if their HIV-infected parents were receiving antiretroviral therapy
       and co-trimoxazole preventive therapy 10 .


Breastfeeding and HIV prevention in infants: The 2006 national PMTCT policy guidelines
provide for the following elements with respect to infant feeding for HIV positive mothers:

      Mothers living with HIV and their partners will be counselled on infant feeding, within the
       context of HIV infection to enable them make an informed and appropriate choice.
       Adequate support will be given to them to facilitate practice of the chosen method.
      A mother should opt for replacement feeding if it is Affordable, Feasible, Acceptable,
       Sustainable, and Safe
      A mother living with HIV will continue to breastfeed the infant who tests HIV positive for as
       long as possible


Progress and gaps in PMTCT service delivery to mothers and babies
 Knowledge about the risk of MTCT and PMTCT is still low, reported in the 2006 UDHS at
   52% among women and 43% among men.



                                                            
9
 GOU (2007) The Human Immunodeficiency Virus Control Bill, 2007, Kampala
10
  Mermin J et al. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected
children: a prospective cohort study. Lancet, 2008, 371:752–759.
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      Pregnant women that attend antenatal care receive HIV prevention education as a core
       element in group health education sessions, and individual education and counselling
       sessions.

      This is reinforced by information provided during the pre and post test counselling that
       accompanies HIV testing.

      There is limited specific provision for direct and sustained follow up support to HIV negative
       mothers identified through PMTCT services, their spouses, or their family members.
      Only 6% of the pregnant women receiving PMTCT services attend with their spouses’ 11 .HIV
       prevention education emphasized in ante natal clinics receives little or no attention during
       delivery and in post natal services; which services reach only a limited section of mothers
       and their children.
      Only 41% of mothers have health facility deliveries; and only 26% receive post-natal care 12 .


Growth in PMTCT service coverage 13
Proportion of Health Facilities in Uganda with PMTCT services – by facility level

                                    Hospitals                         HC IV         HC III         HC II

2005                                                           94%            86%            9%            0%

2006                                                            94%           87%            20%           2%

2007                                                           97%            92%            29%           3%

Source: UNGASS Uganda Report for 2006 and 2007

The Uganda UNGASS Report for 2007 indicates that PMTCT coverage increased from 16% in
2005 to 34% in 2007. This exponential rate of increase can be attributed to the accelerated
PMTCT roll out at HC III level over the same period; which grew from 9% to 29% (a 200%
increase). This underscores the importance of further growth in HC III coverage, if the national
target of 90% PMTCT reach is to be realized.

While PMTCT coverage at Hospitals and HC IV is close to the HSSP II target of 100%, coverage
at HC III is far below this, and seems unlikely to be realized if progress continues at the pace
between 2005 and 2007. The above figures need to be considered in light of the fact that 91%
of all health facilities in the country are HC II and III level. This means that realistic access to
PMTCT services can only be realized if coverage at these HC levels is greatly improved.

Use of a two-drug regimen AZT-3TC (Combivir) started in Uganda in 2007; initially aiming to
reach clients at higher level health facilities (Health Centre IV, District and referral Hospitals),

                                                            
11
   Uganda PMTCT Report Card, 2007
12
   As reported in the UDHS 2006 report
13
   Uganda UNGASS Progress report of January 2008
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where the process can be directly supervised by the appropriately qualified health worker
(Medical Doctor or Clinical Officer). The reported coverage with a two-drug combination in
2007 at only 9% was much lower than the global average of 32% 14 .

It is encouraging to note that generic ARV production started in Uganda in 2009, including the
2-drug combination for PMTCT. This achievement provides a strong and valid basis for
advocacy to scale up the 2-drug combination to three for PMTCT.



Beneficiary outcome of objective 1:
Increased access to PMTCT+ and paediatric treatment, care, and support, including nutrition
services, and integrate child and family services.




                                                            
14
  UNAIDS, UNICEF, WHO (2008) Towards Universal Access: Scaling up HIV services for women and children in the health sector
Progress Report 2008
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       Family-Centred Care and Nutrition NAAP matrix


Core Objective: Family-Centred Care and Nutrition.

Expand access to PMTCT+ and paediatric treatment, care, and support, including nutrition services, and integrate child and family services with other health
services in order to improve survival rates and health outcomes for children, HIV-positive mothers, and their families.
Bottlenecks           Activities                               Advocacy Output                 Advocacy Outcome           Indicators           Target
Limited access to      Advocate and support MOH to             MOH commitment to              Setting of PMTCT          National            MOH, CSOs,
PMTCT +services          produce and disseminate guidelines        producing and                    targets by civil          PMTCT+               Development
which do not             to civil society organizations on         disseminating PMTCT+             society.                  targets set by       Partners,
reach all women                                                    guidelines.                  Dissemination of
                         PMTCT +and Paediatric HIV                                                                            stakeholders.        UAC
in need. ( 30% in                                               Commitment from civil              PMTCT+ guidelines
2007 of all              treatment.
                                                                   society on the                   to stakeholders.       Best practise
expected HIV                                                       prioritisation of            Development of
                          Hold a meeting with civil society                                                                  report.
positive pregnant                                                  PMTCT+.                          FCC protocols for
                         organisations on PMTCT + and
women receiving                                                 Stakeholders understand            health facilities.
                         incorporation in work plans.
ARVs for                                                           the Paediatric FCC
                       Convene a paediatric stakeholders
PMTCT)                                                             protocols.
                         to review and recommend
                         paediatric FCC protocols for health
                         facilities

                           Prepare a best practice report on
                            national Paediatric FCC models


   Inadequate             Lobby and support MOH on the           MOH support to               Guide on the              Guide on          MOH.
    nutritional             development of a minimum                developing minimum            minimal nutritional       minimal             MOGLSD,
    supplementati           nutritional package for children        nutritional healthcare        supplements               nutritional         UAC, CSOs.
                                                                                                  package                   package.
    on and                  exposed to or living with               package.
                                                                                                  disseminated.            Best practice
    support for



        
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    children                HIV&AIDS.                                   FCC guideline                Production and             report.
    exposed to or                                                       developed.                     distribution of IEC
    living with            Advocate and support MOH to                Best practice report on        materials.
                            develop IEC materials on the                FCC.                          Guidelines
    HIV.
                            minimum nutritional package for            National training              incorporating FCC
                            children exposed to or living with          curriculum on FCC in           and promote service
                            HIV&AIDS.                                   place.                         delivery design
                           Support MOH on the dissemination                                           changes to address
                            of minimum nutritional health care                                         continuum of care.
                            package and FCC guidelines to                                             Sharing of best
                            CSOs at national and sub national                                          practice report with
                            levels; district health offices and                                        stakeholders to
                            health care facilities at all levels.                                      improve
                           Lobby AIDS Control                                                         programming.
                            Program/MOH as well as health
                            care worker pre-service training
                            institutions to incorporate FCC
                            approaches and delivery of
                            nutritional minimum package into
                            their respective in service and pre-
                            service training curriculum.
                           Development of media brief on
                            FCC on CLWHIV.
                           Convene Uganda Paediatric
                            Association(UPA) committee
                            meeting to review and recommend
                            paediatric FCC protocols for health
                            facilities
   Widespread             Advocate and support MOH on                Commitment by                 Government and            Stigma and         MOH,
    stigma and              developing of IEC materials with            government and                 development                discriminatio       Uganda AIDS
    discrimination          information on Stigma and                   development partners to        partners roll out          n strategy          Commission,
                            discrimination reduction.                   support the Stigma and                                    adopted.            development
    against PLWA                                                                                       anti-stigma
                           Mobilise CSO to lobby for adoption          Discrimination strategy.                                                      partners.



        
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has negative        and funding of the national stigma   campaign.
impact on           and discrimination communication
PMTCT and           strategy.
paediatric
care, support
and treatment
services
seeking
behaviours,
resulting in
limited
demand for
the services.




    
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OBJECTIVE 2: EARLY INFANT DIAGNOSIS AND TREATMENT
Aimed at expanding access to early infant diagnosis and earlier improved paediatric treatment in
order to improve survival rates and health outcomes for children. This CEPA objective aims at
persuading national stakeholders to develop and implement policies and guidelines to promote
national level scale up of early infant diagnosis and treatment programs. The government,
development partners and Civil Society will enhance and expand EID and EIT programs and
support paediatric AIDS services within the National Strategic Plan and Ministry of Health
Strategic framework.

Policy and Strategy provisions in Uganda
Early infant diagnosis of HIV among HIV-exposed children and adequate follow-up are an
essential integral component in PMTCT, to effectively identify infants living with HIV and ensure
the timely initiation of care and treatment. The PMTCT policy guidelines, 2006 state that all
children born to mothers living with HIV should be tested for HIV from 10-14 weeks of age and
offered follow up care and support. It also states that all children born to mother living with HIV
should be started on prophylaxis using Cotrimoxazole, 6-8mg/kg body weight daily from 6
weeks of age until he or she is confirmed to be HIV negative. The global WHO guidelines on
care for infants born to HIV positive mothers, 2008 provide for;

       HIV antibody testing at birth, and again at 6, 12 and 18 months of age,
       HIV/PCR at 4 weeks and again at 4 months
       ART (TMP+SMX) from 4 weeks until there is confirmation of HIV negative status
       Vitamin A 100,000 IU at 9 months, 200,000 IU every 6 months until the age of 5 years


The importance of early infant diagnosis in enabling timely access to AIDS care is well illustrated
by the experience from Kenya, which reported a 66% increase in the number of children on
ART between 2006 and 2007, following introduction of PCR for all exposed children at 6 weeks
of age and older, followed by HIV antibody test at 18 months 15 .

The common approach for diagnosis of HIV/AIDS in children is use of a combination of clinical
signs and symptoms among sick children based on WHO guidelines for clinical staging, and HIV
antibody testing. The circumstances mentioned for HIV testing in children were;

       When a child is sick and is taken to a health facility, or through child health clinics such as
        EPI and growth monitoring
       When a child is suspected to have been exposed to HIV (e.g., born to an HIV positive
        mother, defiled/raped) and is taken for testing
       During HIV counselling and testing sessions for families – as may be done during home-
        based, VCT, or family visits to health facilities (outreach that encourages testing for all;
        media based-promotion)


                                                            
15
     WHO, UNAIDS, UNICEF (2008) Towards Universal access: scaling up priority HIV/AIDS interventions in the health sector

 
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The WHO guidelines for clinical diagnosis of HIV/AIDS in children are often not available at
some of the health facilities expected to provide this service. It is important that all health
facilities have the necessary guidelines, not only for clinical diagnosis and staging of HIV/AIDS in
children, but also for provider-initiated testing and counselling for children, a strategy already in
use in some African countries 16 . In countries such as Malawi and Zambia, provider-initiated
testing and counselling of sick children has helped to substantially increase the numbers of HIV-
infected infants and children who are detected.

A number of countries in Africa have integrated HIV status information in routine child and
maternal health records (e.g., the Child Health Card) to facilitate the identification of HIV-
exposed infants and provide appropriate diagnostic and follow-up services 17 . However, Uganda
is yet to adopt this important strategy to enhance timely and consistent paediatric AIDS care.

Beneficiary outcome
    Reduction in early child and maternal mortality due to HIV&AIDS.



Bottlenecks to achieving the above;

      Disparity in the 2006 PMTCT policy and the National Guidelines of 2008.
      Testing of mothers during pregnancy is not a law, so opt out is encouraged.
      Limited awareness of the revised National Infant feeding policy and guidelines of 2009
      Inadequate access to ART for children(including specialized formulations and dozing).
      Long turnaround time (Upto 3 months in some Centres) to receive HIV DNA PCR results
       for infants tested (Yet to come up with activities for this).




                                                            
16
   UNAIDS, UNICEF, WHO (2008) Towards Universal Access: Scaling up HIV services for women and children in the health sector
Progress Report 2008
17
   Examples include: Cameroon, Malawi, Rwanda, Swaziland, United Republic of Tanzania and Zimbabwe

 
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        Early Infant Diagnosis and Treatment NAAP matrix


Core Objective: Early Infant Diagnosis and Treatment.

Expand access to early infant diagnosis and earlier and improved paediatric treatment in order to improve survival rates and health outcomes for children.
Bottleneck          Activities                               Advocacy Output           Advocacy        Indicators                    Target
                                                                                       Outcome
 Limited            Develop and produce fact sheets  Presentation of                 Awarenes  Briefs on early infant  MOH,                   
   awareness of          and briefs on infant feeding to         factsheets and            s creation      feeding.                     Referral
   the revised           policy makers and CSOs.                 briefs to policy          and more  MOH                               and
   National          Hold a consultative meeting with           makers.                   children        recommendations for          district
   Infant feeding        Members of Parliament of the         Civil society and           tested for      roll-out on EID/EIT in       health
   policy and            HIV&AIDS Committee to                   government                HIV&AIDS        health centres.              centres,
   guidelines of         champion EID and EIT.                   commitment on             .            IEC materials                  Parliame
   2009              Production and dissemination of            the dissemination                         promoting adherence          nt of
                         IEC materials promoting                 of the infant                             linking EID with             Uganda.
                         adherence linking EID with              feeding policy.                           testing.                   MOES.
                         testing for all children.            Education and
                     Support and participation in               awareness of
                         national consultative forums like       National infant
                         Paediatric Day, World AIDS Day          feeding policy.
                         promoting EID and Treatment.

   Disparity in                                               Government                 MOH            Revised PMTCT           MOH,
    the 2006            Hold and support stakeholder           commitment on               impleme         comprehensive           Uganda AIDS
    PMTCT policy         meetings with government to            harmonizing                 ntation         policy.                 Commission.
    and the              lobby for the revision of PMTCT        paediatric care                            Government              Uganda Law
                                                                                            of
    National             policy in alignment with the           policy and                                  hospitals receiving     Reform
    Guidelines of        National Guidelines.                   guidelines.                 national                                Commission,
                                                                                                            PMTCT policy.
    2008.               Hold a meeting among policy           EID/EIT guidelines          paediatri      Media reporting on      UNICEF
                         and stakeholders to agree on the       (diagnosing and             c               EID and EIT.



         
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                         dissemination of the PMTCT              treatment regimens       EID/EIT       National paediatric
                         policy and National Guidelines.         shared among             standard       curriculum in place.
                        Develop and share a brief to the        partners.                s.
                         media on the PMTCT policy and          Commitment by
                         National Guidelines.                    government and          MOH
                        Dialogue with government and            stakeholders on          health
                         development partners to                 the disseminations
                                                                                          worker
                         strengthening training for pre-         of PMTCT policy.
                         service and in-service providers.                                training
                        Support the government on the                                    program
                         completion of the National                                       s
                         Paediatric Curriculum.
                                                                                         Compre
                                                                                          hensive
                                                                                          PMTCT
                                                                                          policy
                                                                                          develope
                                                                                          d by
                                                                                          MOH.

   Inadequate          Hold lobby meetings with                Agreement by           Increased                            MOH,
    access to ART        government and development              government and           commitme                              PEPFAR,
    for                  partners to scale up support to         development              nt                                    UAC, Civil
    children(inclu       Paediatric ART.                         partners on              towards                               Society Fund
    ding                                                         support to ART.          Paediatric
    specialized                                                                           ART.
    formulations
    and dozing)
   Testing of          Participate in the development of      HIV bill including      Compreh       Comprehensive HIV      Uganda AIDS
    mothers              the HIV&AIDS prevention bill            comprehensive            ensive         bill.                  Commission,
    during               while advocating for mandatory          EID/T.                   HIV&AIDS                              Uganda Law
    pregnancy is         and available provider-initiated                                 bill                                  Reform



         
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not a law, so        counselling and testing            developed   Commission.
opt out is           (mandatory HIV testing for every   .
encouraged.          pregnant woman).
                    Mobilise the involvement of
                     treatment organisations in
                     review of the HIV bill.




     
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OBJECTIVE 3; ACCESS TO APPROPRIATE MEDICATIONS
Reduce distribution barriers and increase the global supply of high quality, low cost lifesaving
medicines for children and their families including ARVs, drugs to treat opportunistic infections
and first and second line regimens to ease dosing and administration. It’s aimed at influencing the
government, development partners and drug manufacturers to revise policies and procedures to
reduce country level barriers and increase the supply and availability of paediatric medications
including ARVs and drugs to treat opportunistic infections.

Policy and strategy provisions in Uganda
Despite international commitments to achieve universal access to HIV/AIDS services by 2010,
including 80% coverage for PMTCT+ services, progress toward these goals remains too slow,
and paediatric HIV transmission remains high. It is estimated that 17% of new infection in
children occur primarily because pregnant HIV positive women lack access to PMTCT services.

   Globally of the nearly 3 million people on treatment globally, only 200,000, or 6.7% are
    children.
   In Uganda, according to MOH, AIDS Control Program (2008), there are about 150,000
    children living with HIV/AIDS. Of these 50,000 are in need of ART but only 26% are
    receiving it.
   Out of about 1.2 million women who become pregnant each year in Uganda, only about
    38% deliver at formal health centres, yet an estimated 78,000 are living with HIV/AIDS,
    meaning that many cases go undiagnosed and untreated
   Annual paediatric HIV/AIDS infection rate remains unacceptably high at about 25,000
    children per year.
   Studies carried out by HEPS Uganda on availability of HIV and TB medicines and diagnostics
    have shown poor availability of paediatric formulations. Nevirapine for PMTCT was found in
    only 41% of surveyed facilities




 
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              Availability of Paediatric Antiretroviral: Essential AIDS and TB Medicines and
              Diagnostics in Uganda; an Assessment of Availability and Management (May 2009)



                               Percentage availability

                               Public                             Private                  Mission

                               Overall     Urban         Rural    Overall   Urban    Rur   Overall   Urban    Rural (n=5)
                                           (n=15)                 (n=13)    (n=13)   al    (n=20)    (n=15)
                               (n=32)                    (n=17)                      (n=
                                                                                     0)

Didanosine powder for          3%          7%            0        0         0        -     0         0        0
oral solution 2g/100ml

Efavirenz cap 50mg             41%         60%           24%      15%       15%      -     45%       53%      20%

Lamivudine oral solution       16%         7%            24       8%        8%       -     50%       40%      80%
50mg/5ml

Lamivudine oral solution       25%         27%           24%      0         0        -     20%       20%      20%
10mg/ml

Nevirapine oral suspension     56%         53%           59%      15%       15%      -     60%       53%      80%
50mg/5ml

Ritonavir oral solution        0           0             0        0         0        -     0         0        0
80mg/ml

Stavudine cap 15mg             22%         33%           12%      8%        8%       -     40%       47%      20%

Stavudine cap 20mg             19%         20%           18%      0         0        -     45%       40%      60%

Zidovudine cap 100mg           19%         275           12%      0         0        -     40%       47%      20%

Zidovudine oral solution       34%         40%           29%      0         0        -     70%       60%      100%
10mg/ml




               
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Beneficiary outcomes

   Increased access to Paediatric HIV treatment


Bottlenecks

   Disparity in the 2006 PMTCT Policy and the National Treatment Guidelines. The Essential
    Medicine List does not provide for Pediatric ARVs and the National Pharmaceutical Plan is
    silent on
   Inadequate access to ART for children(including specialized formulations and dozing)
   Inefficiencies in the Procurement & supply chain systems: these include the Procurement and
    Disposal of Assets Law that is not conducive to assess to medicines, supply challenges at the
    National Medical Stores as well as lack of human resource and capacity at health facilities
   Registration of new formulations is slow and prohibitive




 
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                        Access to Appropriate Medications Nutrition NAAP matrix



Bottlenecks               Activities                           Advocacy                Advocacy                  Key Performance       Targets           Responsible
                                                               Outputs                 Outcomes                  Indicators                              Partners
   National               Analyze and make 500 copies         Relevant               PMTCT Policy and         Analysis report     MOH officials,     Consultant/H
    PMTCT policy,           report of existing gaps in           authorities utilize      Treatment                                    ACP, AIC,            EPS
    National                policies                             these findings in        Guidelines    that        Fact-sheets,      LRC,               All
    Treatment              Produce 500 copies each of           their meetings                                      policy briefs     Parliamentaria       stakeholders
                                                                                          spell issues of
    Guidelines,             fact sheets, policy briefs on       Parliamentarians                                                      ns
    EML, NSSP are                                                                         paediatric ART
                            gaps and present to the policy       and key officials
    silent on infant        makers                               understand issues
    HIV/AIDS               Have 10 lobby meetings with          in report
    treatment.              policy makers and key
                            government officials


   Stock out of           Conduct bi-annual monitoring          Increased              MOH, NMS,                Monitoring        MOH officials,       HEPS
    drugs at the            studies on availability of             awareness of            Health facility in-       reports, media    ACP, AIC,
    health facilities       Paediatric ARVs and                    availability of         charges commit to         coverage          LRC,
                            commodities                            paediatric ARVs         stop stock outs          Increased         Parliamentarian      All
                           Press conferences                     Improved                                          availability of   s                     stakeholders
                                                                   delivery of                                       Paediatric ARVs
                                                                   paediatric ARVs

   Inefficiency in          Tracking study of lead time of      MOH officials,         Government               Tracking report   MOH officials,       HEPS/UYP/U
    the                       paediatric ARVs                      media use               commits to               Report of         ACP, AIC,             PA
    Procurement &                                                  reports in their        creating                  meetings          LRC,
    supply chain           Holding meetings with health                                   Information                                 Parliamentarian
                                                                   meetings and for
    systems                 workers and NMS to identify                                    management                                  s                    All
                                                                   planning                system to control
                            supply chain bottlenecks and                                                                                                     stakeholders
                            forge solutions                                                stock outs



            
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   Registration of    Study time it takes to register      NDA uses              NDA discusses         Study report   NDA, MOH      All
    new                new formulation                       report to inform       consideration of                                     stakeholders
    formulations is                                          its drug               improving
    slow and                                                 registration           registration
    prohibitive                                              process                guidelines for
                                                                                    ARVs




            
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OBJECTIVE 4: FULL FUNDING TO ELIMINATE PAEDIATRIC AIDS.

Aimed at securing financial resources needed to facilitate country level scale up of PMTCT+ and
paediatric and maternal treatment programs. It will persuade both government and development
partners commit the increased finical resources needed to effectively scale up PMTCT+ and
paediatric treatment programs and eliminate paediatric AIDS and mortality.

Policy and strategy provisions.

Although public spending on health has increased from about $8 (sh16,000) per person in 2001 to $11
(sh22,000) per person in 2007, the Government still not reached its own target of $28 (sh56,000) per
person needed to cover the Uganda National Minimum Healthcare Package. Neither has it come close to
meeting the $40(sh80, 000) per person recommended by the World Health Organisation as minimum
needed to fund health care in developing countries. Practically, Uganda’s health sector is under-funded,
relying heavily on private sources of financing, especially out-of-pocket spending. The budgetary allocation
stands at 10%, contrary to the Abuja declaration threshold of 15%. Consequently, due to insufficient
funding, the package of health services at public health facilities is inadequate to meet people healthcare
needs.

The sector is heavily donor dependant, with donors providing about half of the budget. According to the
Ministry of Finance, donors contribute UGX 253 billion to the sector and off budget, the donors provide
300 billion. The U.S. alone through the President’s Emergency Fund for HIV/AIDS Relief (PEPFAR),
contributes up to US$ 283 million for HIV/AIDS alone. The sector consequently incurs high levels of
inefficiency within “volatile and unpredictable” external funding. Since donors provide around 75% of the
funding, the government is left with little ability to dictate the way in which money for the sector is
spent.

Another policy and implementation issue on funding is that decentralization has continued, but has not
resulted in a significant improvement in delivery of services. The vast majority of spending at the
decentralized level has gone toward employee costs and arrears – not toward drugs, equipment, and
other infrastructural costs. Thus, while allocation of money to decentralized facilities was meant to
improve service provision, the transfer of money has not translated into the expected improvement in
services. In such a situation paediatric HIV/AIDS has been one of the victims of funding challenges.




 
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            Full funding Nutrition NAAP matrix

Full Funding to Eliminate Paediatric AIDS.

Secure the financial resources needed to facilitate country-level scale-up of PMTCT+ and paediatric and maternal treatment programs.
Objective             Activities                                 Out put            Outcome                    KPI                Target         Partners
                                                                                                                                                 Responsible
Bottleneck

Under budgetary           Advocate for increased budgetary      Paediatric         Budget Funding levels in   -Budget            MoFPED,        HEPS-Uganda,
allocations for            allocations for MoH (I5% Abuja        HIV/AIDS and       respect to Paediatric      Advocacy           LGs, MoH       ANECCA,
paediatric                 Declaration ): Specific activities:   PMTCT budget       HIV/AIDS and PMTCT                                           Development
                      -Under take national Annual budget
                                                                                                               Report for
HIV/AIDS by                                                      funding briefing   revealed to stakeholders   increased                         Research
government            reviews to determine the per capita        paper              for action                                                   Centre,
                      paediatric HIV/AIDS allocations and                                                      funding for
                                                                                                                                                 GHA……….
                      develop a CEPA Budget Threshold –                                                        Paediatric
                      briefing paper                                                                           HIV/AIDS and
                                                                                    -Recommendations to        PMTCT
                      -1 national budget advocacy meeting                           government for
                      to demand for budget prioritization of                        actions on paediatric
                      Paediatric HIV/AIDS and PMTCT
                                                                                    HIV/AIDS and PMTCT
                      -4 regional budget advocacy meeting                           budget prioritization
                      to demand for budget prioritization of
                      Paediatric HIV/AIDS and PMTCT

Inadequate funding        Advocate for increased support for    Briefing paper     Recommendations to         -Advocacy          Global Fund,   HEPS-Uganda,
for paediatric             paediatric HIV/AIDS and PMTCT         on state of        donors on how to fill      Report on          USAID,         ANECCA,
HIV/AIDS and               from development partners. The        development        gaps on paediatric                                           Development
                           specific activities:
                                                                                                               levels of          WHO,
PMTCT by                                                         partners funding   HIV/AIDS and PMTCT         donors support     UNAIDS,        Research
                      -Under take national donor PMTCT
development                                                      for HIV/AIDS       and meet their                                               Centre,
                      and Paediatric HIV/AIDS support                                                          for paediatric     DFID ,
partners                                                         and PMTCT          obligations                                                  GHA……….
                      analysis and develop a CEPA donor                                                        HIV/AIDS and       DANIDA
                      Threshold matrix                           - Development                                 PMTCT
                                                                 Partners’


    
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                    - 1 PMTCT and Paediatric HIV/AIDS       PMTCT and
                    donor funding Appraisal workshop        Paediatric
                                                            HIV/AIDS -
                    - Media and CSOs advocacy policy        funding levels
                    briefs to use to pressure development   matrix
                    partners to increase funding for
                    paediatric HIV/AIDS and PMTCT



                                                            - Annual press
                                                            briefs on funding
                                                            for HIV/AIDS
                                                            and PMTCT

Lack of                Conduct tracking studies on         -1 PET report on    Empowered media and   Empowered         Partners in   HEPS-Uganda,
transparency and        paediatric HIV/AIDS and PMTCT       PMTCT and           CSO partners to       media and CSO     CEPA          ANECCA,
accountability          funding                             Paediatric          monitor the use of    partners to                     Development
                                                                                                                        Uganda and
                       Develop HIV/AIDS funding            HIV/AIDS            HIV/AIDS Funds        monitor the use                 Research
                        monitoring matrix for media and                                                                 media
                                                            funding                                   of HIV/AIDS                     Centre,
                        CSOs                                                                                            fraternity
                                                                                                      Funds                           GHA……….
                                                            -Media and
                                                            CSOs HIV funds
                                                            monitoring
                                                            matrix




    

								
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