1. Strengthening TB and HIV&AIDS Responses in East Central Uganda There is no Conflict of Interest for this presentation

2. Strengthening TB and HIV&AIDS Responses in East Central Uganda Responding appropriately to the complex health needs of most-at-risk populations in hard-to-reach areas: Improving HIV outcomes through integrated service delivery to fishing communities of the Sigulu Islands in Uganda 20 th International AIDS Conference 21 st July, 2014 Dr. Samson Kironde

3. Strengthening TB and HIV&AIDS Responses in East Central Uganda Presentation Layout Background and DescriptionIllustrative ResultsLessons learned and Conclusion

4. Strengthening TB and HIV&AIDS Responses in East Central Uganda The Sigulu Islands are located in Lake Victoria in Uganda Commercial fishing is the main economic activity on these islands

5. Strengthening TB and HIV&AIDS Responses in East Central Uganda Background to the Sigulu Islands  Fishing communities have been noted to be at high risk of acquiring HIV infection in many countries in sub-Saharan Africa  The Sigulu archipelago in Namayingo District, Uganda comprises of 11 inhabited islands (out of 19) with over 42,000 people most of whom are fishing families  The lucrative fishing business attracts many different nationalities to the islands and the migrant nature of commercial fishing makes populations mobile  Daily access to disposable income leads to high risk behaviours such as transactional sex with CSWs, alcoholism and drug usage  A baseline survey done in 2010 showed high STI prevalence with HIV prevalence ranging from 17-30%

6. Strengthening TB and HIV&AIDS Responses in East Central Uganda Healthcare infrastructure is poor and low level…  Access to healthcare remains a major bottleneck islands are hard-to-reach and up to 8 hours from mainland by motor boat)  Due to their migrant nature, islanders have poor health seeking behaviour  STAR-EC, a USAID funded project managed by JSI Research & Training Institute, Inc., conducts quarterly outreaches to the islands in order to provide integrated service delivery  Due to poor infrastructure, services are provided mainly in outreach mode in tents

7. Strengthening TB and HIV&AIDS Responses in East Central Uganda A range of services are provided during an outreach Integrated services provided include:  HIV testing and counseling  Voluntary medical male circumcision  STI management  Family Planning  Malaria diagnosis and treatment  TB diagnosis and treatment  HIV care and support, including opportunistic infection treatment  Risk reduction initiatives and community dialogue to promote structural HIV prevention  Antiretroviral therapy  Dissemination of IEC materials For those diagnosed HIV positive, a ‘continuum of response’ is emphasized to enable them to be linked to relevant services

8. Integrated Service Delivery Client Flow during a typical outreach Tent Registration General Population Pregnant mothers Mothers with Infants VMMC Clients etc. General Health Education HIV&AIDS TB STIs VMMC service delivery using MOVE HTC point for VMMC Clients VMMC Health Education Condom distribution Analgesics provision Day 2 Review ART initiation Chronic Care ART Refills Antenatal Care Postnatal Care Family Planning Pills Depo Provera Implants Vasectomy Sputum testing for TB General Laboratory HTC EID CD4 STIs Malaria Supplies Store ‘Mentor mothers’ for counseling adherence and psychosocial support HTC results distribution and post test counseling Immunization Health Education Family Planning advice Data processing General IEC Condom promotion Social marketing Edutainment * Couple counseling and other individualized counseling done at secluded spots wherever these are available on the outreach site Tent Health Facility (HC II) Improvised Reed structure

9. Strengthening TB and HIV&AIDS Responses in East Central Uganda Limited infrastructure calls for improvised service delivery… Whatever space available is used by the visiting health teams!

10. Strengthening TB and HIV&AIDS Responses in East Central Uganda Illustrative Results: April 2011-June 2014 HIV Testing and Counseling (HTC) ‘Continuum of response’ emphasized Other integrated services provided included: 22,450 individuals received HTC 11% (1,950) HIV positive 1,096 (45%) enrolled on ART 77% of all HIV+ linked to care 100% of all HIV+ pregnant women linked to PMTCT 100% of all circumcised received HTC 100% of all eligible for ART received it 100% TB cases put on treatment 82 patients put on TB treatment 1,444 clients received STI treatment 1,022 received Family Planning 611,077 condom pieces distributed

11. Strengthening TB and HIV&AIDS Responses in East Central Uganda HIV prevalence has continued to drop in newly tested islanders… Sigulu Islands significantly contribute to HIV prevalence in East Central Uganda

12. Strengthening TB and HIV&AIDS Responses in East Central Uganda Uptake of most services provided is commendable… VMMC uptake has steadily risen ~40% of eligible males >10 years have been circumcised for HIV prevention to-date

13. Strengthening TB and HIV&AIDS Responses in East Central Uganda Lessons learned and conclusion  The integrated outreach model has increased access to and uptake of services in a very hard-to-reach but high HIV prevalence area  Even with poor infrastructure, improvisation does allow delivery of much needed services  Directing resources where new HIV infections are likely to emerge contributes to controlling the spread of the epidemic Combating HIV in the Sigulu Islands through multiple approaches will contribute to markedly controlling the HIV epidemic in East Central Uganda

14. Strengthening TB and HIV&AIDS Responses in East Central Uganda Acknowledgements I would like to thank the following for their contribution towards service delivery to the highly vulnerable population of the Sigulu Islands:  The Government of the Republic of Uganda notably the Ministry of Health  Namayingo District Local Government and District Health Office  PEPFAR and USAID for providing funding  JSI Research & Training Institute and its consortium partners on STAR-EC  The beneficiaries who reside in the Sigulu archipelago