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Empowering community systems to return clients to care

When Anita Nalule (not real name) tested positive for HIV, she was distraught. “I wondered if I could hang myself. I returned home and went to bed because my head was not working properly.”

It was a difficult and painful period for Anita and she took a long time to start taking the anti-retroviral treatment she was given as she battled with her acceptance of the diagnosis combined with a fear of taking medication. At the clinic after getting her diagnosis, Anita had put the drugs in her bag and left them. Eventually, Anita retrieved them and started her treatment course.

“It was a nightmare. The side effects from the medication were unbearable,” she says. Anita was vomiting, dizzy and had what she called “unbearable nausea”. She stopped taking the drugs and decided not to return to the ART clinic.

“My health deteriorated and I was later admitted to hospital. At this point, my CD4 count had reduced to below 250.” But even still, after getting discharged, she would not take the medication.

The hospital where Anita was initiated though is within the network of facilities in the Mubende region that are supported by the CDC-funded Accelerating HIV Epidemic Control project. This 5-year project is implemented by Mildmay Uganda in partnership with Program for Accessible health, Communication and Education (PACE).

When Anita had only made one encounter within a period of 6 months after her initiation on treatment, she was recorded at the facility as a lost-to-follow-up (LTFU) client. The list of these lost clients is generated and given to community resource persons under the project who in turn go into the communities, to follow up and find out what happened to the people who are not coming for treatment.

When the community owned resource person tracked Anita, he found when she was unwell. The two of them talked through her health and the importance of adhering to treatment. They discussed side effects of medication, their management and the possibility of changing treatment course. Anita is now back on treatment and adhering.

Many HIV-positive clients, like Anita, fail to adhere to their treatment for one reason or another, and often extra effort is required to return them to care. The project has worked to identify different ways to support clients who have been lost to the healthcare system. The Community System Strengthening model has community members referred to as community owned resource persons (CORPs) who track patients who have not been to the ART (and TB, for TB patients) clinic for at least 3 months. This is combined with e-referral systems that allow for reminder messaging and follow-up so that clients remember to go to the health facility for their appointments and refills whenever required.

With better adherence and retention of clients, there can be less AIDS-related deaths. To achieve the UNAIDS 95-95-95 goal, this project is making sure that for all those people that have been tested positive, there are immediately linked to ART and when they are linked, they are able to adhere to treatment. Community linkages can play a crucial role in making sure that Uganda reaches the 95-95-95 global goal.

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Giving birth to my third child was not a nightmare

After giving birth to each of her first two children, 23-year-old Margaret Nabiddo would bleed uncontrollably. “I would bleed every day, for almost a month,” she says.

Her third delivery was different. While she was pregnant with her third child, Margaret was given a comprehensive clean delivery kit during her last trimester. This maama kit, distributed in communities in a pilot project under the Maverick Collective Project, included misoprostol and chlorhexidine. The two were added to the Ministry of Health – recommended maama kit to reduce on unpreventable maternal health deaths.

Misoprostol, taken after the delivery of the baby (with confirmation that there is no other baby), helps to control postpartum bleeding while the chlorhexidine is used for the care of the newborn’s umbilical cord.

“I got my maama kit from Deo [Village Health Team] who spoke to me about the importance of going for antenatal visits and delivering in a health facility,” the resident of Lwemivubo Village in Kiyuni sub-county, Mubende says. Margaret received her antenatal care from Kiyuni Health Center III.

“When I got into labour, I knew there was no way I could reach the hospital so I decided to carry my kit to the nearer Kakigando Health Center II. After I delivered my baby and the placenta, the midwife gave me the three tablets to put under my tongue.”

Margaret’s bleeding stopped after one week. It was a different experience from her earlier deliveries where she bled for almost a month.

Globally, postpartum haemorrhage (excessive bleeding after childbirth) is the leading cause of maternal deaths. In Uganda, over 24% of maternal deaths are due to uncontrolled bleeding after childbirth. It is recommended that mothers be given oxytocin which helps to limit bleeding by stimulating uterine contractions.

However, oxytocin is difficult to store as it requires refrigeration and therefore near impossible to have available in resource-limited areas. Misoprostol on the other hand, can be stored at room temperature with a shelf life of up to two years, and therefore easy to distribute in remote areas that are less likely to have refrigerators and reliable electricity supply.

The Maverick Collective project in Uganda focused on the availability of the misoprostol to mothers in these settings in order to reduce preventable maternal deaths. The project distributed the pilot comprehensive clean delivery kits in five districts of Uganda, identified alongside Ministry of Health, as those where maternal mortality was relatively higher than national average.

For women like Margaret, the addition of misoprostol made their postpartum experience a more enjoyable and safer period.

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ULINZI: A condom for the Military

The Directorate for HIV and AIDS under the Uganda People’s Defense Force (UPDF) alongside the Program for Accessible health, Communication and Education (PACE) officially launched the Ulinzi condom this month.

Ulinzi, which means “protection”, is a condom branded specifically for the soldiers in order to scale up HIV prevention amongst the military. The idea, conceived in 2013, was to get a condom with which the military related and therefore was more likely to use consistently. PACE, a health organisation that uses social marketing approaches to measurably improve the health of Ugandans, undertook pre-testing activities that included key informant interviews and focus group discussions before deciding on Ulinzi.

Condoms remain a key intervention in the prevention of HIV, but condom use across the continent has continually gone down.

Following the Presidential Fast-track Initiative on Ending HIV&AIDS in Uganda by 2030, the UPDF has taken additional measures to make sure there are no new infections.

“One of the challenges of the UPDF when it took power in 1986 was HIV. The NRA (as it was known then) were heroes, and money did not matter. There was a lot of excitement and constant celebration but no structured interventions to mitigate the spread of the virus,” Brig. Leo Kyanda, the Chief of Staff for the UPDF Land Forces said at the double launch of the condom and the UPDF HIV Prevention Strategy in Bombo Military Barracks on October 2nd, 2018.

Brig Kyanda speaking at the launch

The PEPFAR-funded project has worked with other partners to enhance the already existing efforts in the army to increase prevention behaviour for soldiers and the military communities. Often, these communities are affected by the mobility of the work, separation from family and the sometimes remoteness of their assigned posts. Constant interface with life-and-death situations may also affect health behaviour.

“We don’t hide,” Brig Kyanda said, complimenting the openness with which the soldiers have dealt with the virus and how it has ensured the ART adherence within the force.

“PACE has joined hands with UPDF to amplify and complement already existing efforts. (…) The Ulinzi condom is not going to be a magic bullet for HIV prevention, of course and should be used alongside other proven strategies,” Phyellister Nakamya, the Executive Director for PACE said.

The condom will be distributed, for free, amongst the military populations and communities around military bases across the country.

As with the rest of the Ugandan population, the force is increasingly young and innovation must be at the center of health solutions to ensure that the country registers no new infections.

Ulinzi in the News:

NTV Uganda: http://www.ntv.co.ug/news/national/UPDF-launches-new-condom-brand/4522324-4788808-li7ax3z/index.html

BBC Africa: https://www.bbc.com/news/world-africa-45746092

Business Focus: http://businessfocus.co.ug/updf-launches-ulinzi-condom-brand/

Standard Media: https://www.standardmedia.co.ke/article/2001297884/uganda-s-army-launches-ulinzi-condoms-for-use-by-its-soldiers

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Uganda: Pace Throws Fete for Outgoing Country Head

24th October, 2016. PACE bid farewell to its outgoing Executive Director, Mr Zacch Akinyemi, who has been at the helm of PACE for the last three and a half years, during a farewell party held on 21st October 2016 at the Sheraton Hotel in Kampala.

A Nigerian native, Mr Akinyemi’s time as the chief decision-maker at PACE has enabled PACE to evolve and adapt to the needs of the Ugandan population, enabling PACE to better serve and contribute greatly to the health of Ugandans.

Mr Akinyemi handed over the position to Dr Dorothy Balaba, who has been the Director of Programmes at PACE.

Dr Balaba is the first Ugandan to head the organisation.

To know more about what happened at the farewell fete, read more here 

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PACE brings the MSD for Ugandan Mothers (MUM) project to a close

October 21st 2016 

More than 53,000 mothers have delivered safely in small, private-sector facilities over the last four years since the launch of the MSD for Ugandan Mothers (MUM) project. Through the MUM project, providers work to ensure that pregnant women—particularly those in remote and low-income communities—have access to affordable, quality maternal health products and services through the ProFam network of privately-owned franchise clinics.

This comprehensive project also works beyond the clinic setting by helping women overcome common barriers to care, such as cost, transportation and limited supplies. The MUM project includes 142 health facilities in 42 districts in Uganda—covering more than one-third of the country—and access to quality care which has impacted an estimated 130,000 women.

Recognizing the opportunity to improve maternal health in Uganda, the MUM project worked with small midwife-owned facilities that are often closest and therefore, the first facilities that mothers reach when in labor. The Programme for Accessible health, Communication and Education (PACE), the lead implementing partner of the MUM project, worked with many of these facilities since 2008 through its social franchise network, ProFam. The ProFam franchise is a network of private sector healthcare providers that provide high quality health services at affordable prices under a common brand.

To learn more about the impact of the MUM project, read here

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PACE closes out the Positive Living Project (PLP)

26 September, 2016 The Ministry of Health in partnership with Programme for Accessible Health, Communication and Education (PACE) and the US Centers for Disease Control and Prevention (CDC) implemented a ten-year Positive Living Project (PLP), which has proven that adoption of such positive lifestyles can greatly reduce opportunistic infections, delay HIV disease progression and improve quality of life among PLHIV.

With total funding amounting to US$ 19.783 million from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through CDC, the project distributed a Basic Care Package (BCP)-a simple health kit that included Cotrimoxazole, which is prescribed by clinicians upon confirmation of a positive HIV test; an insecticide-treated mosquito net; a safe water vessel with water treatment for disinfection; condoms and information on how to lead a positive lifestyle. It also integrated screening and management of sexually transmitted infections, family planning, partner testing and supported disclosure, partner discordance counselling, PMTCT, and safer sex practices, including abstinence and fidelity with correct and consistent use of condoms.

PACE on 20th September, 2016, held a national PLP impact dissemination and close out meeting for the project that ends this month, at Hotel Africana in Kampala to share best practices and lessons learned. This follows an independent end of project evaluation by Makerere University School of Public Health.

“Our aim was to reduce opportunistic diseases like malaria, diarrhoea, pneumonia and partner re-infection which take advantage of the compromised immunity of HIV-infected individuals. Findings from the end of project evaluation report show a significantly low incidence of these diseases among individuals that used the BCP kit along with their ART compared to those who used ART only, or the BCP only, especially in the first six months of treatment. Further still the incidence of the diseases dropped significantly in the same period among clients with the BCP only, compared to clients that did not have the BCP at all” says Dr. Dorothy Balaba, Director of Programs at PACE.

The report also showed that adoption of the positive living lifestyle behaviours was higher among PLHIV who had the BCP than those who did not even if they all nearly had equal knowledge about the lifestyle.

To learn more about the impact of the PLP project, read here

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