Namulaba Proposal To Avert 9 Jan 2007

Namulaba Proposal to Avert 9 Jan 2007
Namulaba Community HIV/AIDS Project

Towards a sustained community response to HIV/AIDS
A proposal from:
Namulaba Community Health Centre
Contact person:
Dr Samuel Kalibala, Project Director.
P.O. Box 2598 Kampala
Cellphone 254 722 514 371
skalibala@hotmail.com
Project location:
Namulaba Village near Namataba (one hour from Kampala, towards Jinja)
Budget
Year 1
US $ 19795
Executive Summary
Why this project?
HIV knowledge without behavior change is not enough
Behavior change needs HIV services such as VCT in order to be effective
But HIV services are not accessible to rural people
And where they are provided they are in separate vertical programs that do not
strengthen primary health care
Hence, the health needs of the individual and the family are not addressed
holistically
Therefore there is no synergy of care and prevention
We propose to conduct community education linked to key services such as
VCT, PMTCT and ARV care, around a nucleus of primary health care at a village
health centre easily accessed by the rural community
We also propose to emphasize ongoing counseling as a means to continually
support individuals as they address factors affecting their response
Experiences gained in this project will be shared with other villages using this
site as a centre of excellence
HIV knowledge by a community is worthless without the ability to respond to the
epidemic. While education messages promote ABC (Abstinence, Being-faithful and
Condom-use), if people in a community do not have access to some key intervention such
as Voluntary Counseling and Testing (VCT) to know their HIV status, it may be near
impossible to attain an optimal response to the epidemic except by a select few who can
abstain. Being faithful may be limited in its implementation due to the fact that it requires
mutual knowledge of HIV status by the two partners. Therefore, in order for faithfulness
to work, it is necessary for people to have easy access to VCT. But disclosure of HIV
status takes time and VCT as a one time intervention may not be enough to enable
effective disclosure and sharing of knowledge of HIV status to occur. It may be possible
to use additional counseling sessions as a means to enable effective sharing of HIV status
and thus facilitate faithfulness. This project will explore using ongoing counseling as a
follow up to VCT. It will also explore using ongoing counseling to address marital
problems to strengthen the marriage bond in order to strengthen the being-faithful
intervention.
In an ideal Ugandan village, there should be a local health centre that provides basic
health care for common illnesses. In the same ideal situation, new public health programs
designed to address problems in the community are supposed to be provided to the
community using this existing health centre. However, not all basic health care is
available to villages such as Namulaba, and not all the new public health programs
especially those dealing with HIV/AIDS are available in this community. These services
are distantly located and transportation money is scarce especially in situations where it is
the bread winner who is living with and weakened by HIV/AIDS. Given the lack of
money and lack of easy access to services families might choose to save their meager
resources rather than enabling the person living with HIV to access life saving ARVs.
ARV may be provided free of charge but can only be accessed after spending a fortune in
travel costs. ARV care that costs a fortune in travel costs is not free and is not
accessible. Alternative approaches must be explored to enable the majority in
villages to access these vital life saving drugs.
How was the idea conceived?
The director of this project Dr Samuel Kalibala is a medical doctor who has worked on
HIV/AIDS since 1988 when he started work with TASO (The AIDS Support
Organization) in Uganda. He has since worked internationally based at WHO and
UNAIDS in Geneva and with the Population Councils Horizons Program based in
Nairobi and is currently working for the International AIDS Vaccine Initiative (IAVI). In
2004, when he started a farm at Namulaba village people from the surrounding
community begun approaching him with HIV/AIDS problems. The underlying problem
was that this village, like many other villages elsewhere, has limited access to basic
HIV/AIDS interventions and health care in general. Since it was not sustainable to
transport individual people to the nearest hospital, the idea of a community health centre
that would be the nucleus for comprehensive HIV/AIDS programming was conceived.
The proposed project is to be housed in an eight-room community health centre located in
an under-served rural community of 28,000 people, one hour away from Kampala, the
capital city of Uganda. The goal of this three-year project is to enhance community
access to key HIV/AIDS services and strengthen community capacity for a sustained
response to HIV/AIDS and its social impact. It is also aimed to develop this as a centre of
excellence that can enable village to village sharing of best practices in true community
response to HIV/AIDS. The goal will be achieved through three main objectives. One
objective is to mobilize a sustained community response to HIV/AIDS. Mobilization
strategies will include song/drama as well as sports competitions linked to HIV
education. A sustained response will be through the strengthening of Community Based
Organizations (CBO) capacity and skills. Another objective is to provide and promote
HIV prevention interventions. The strategy will be to use VCT as an entry point to
providing ongoing counseling to individuals and couples thus enabling them to make
decisions about HIV prevention. The third objective is to use primary health care as a
nucleus for HIV/AIDS care including on-going counseling, treatment of opportunistic
infections, Prevention of Mother to Child Transmission (PMTCT) and Antiretroviral
(ARV) care.
Expected outcomes:
a) In-depth knowledge of HIV/AIDS.
b) Wide spread knowledge of HIV status by individuals.
c) Accessible services for people living with HIV/AIDS including on-going
counseling, treatment of opportunistic infections, ARVs and PMTCT.
d) Responsible sexual decision making by individuals.
e) CBOs with programmatic and administrative skills to plan and implement
programs responding to HIV/AIDS and its social impact.
f) A centre of excellence in community based HIV/AIDS programming.
The project will support the functioning of a rural health center and use it as a point of
access to vital HIV/AIDS services namely VCT, PMTCT and ARVs combined with
ongoing counseling. To do this, the health centre building provided by the Project
Director will be furnished, equipped and staffed to provide basic care. Using links with
agencies providing VCT, PMTCT and ARVs elsewhere, these services will first be made
available at this health centre as outreach services available on designated days in a
month. Thereafter, systems will be established to provide these services routinely. These
services will be promoted using a community sensitization campaign about HIV using
song/drama and football/netball competitions which have already began. The impact of
this project will be evaluated using annual surveys which begun in December 2005 with a
baseline.
This project will entail working with existing CBO structures in conjunction with
agencies providing the vital services of VCT, PMTCT and ARVs that currently exist only
outside the intervention area. CBOs are a means for these impoverished communities to
express their desire to respond to their problems but they are usually minimally
functional and have no physical infrastructure nor the capacity or skills to address the
problems they were formed for. In this situation the identified CBOs have formed a
network and this network will be hosted at the health centre. The network will be used for
sharing information as well as strengthening of skills in project design, proposal writing
and project implementation including reporting and accountability. An expected output of
the project is the generation of a number of new projects by some CBOs. Such projects
could address vital issues such as poverty, care of orphans, education and others that are
beyond the scope of this proposal. In addition the leaders of the CBOs will receive
training and get to work in various capacities in this project thus getting hands on
training. Hence at the end of this project the community will have more skilled providers
of vital services such as ongoing counseling and home based care.
In summary this is a proposal for a project that will sensitize the community about
HIV/AIDS using information and entertainment. The project will also provide HIV/AIDS
services integrated in primary health care so as to enable individuals to act on their HIV
risk as well as seek and receive health care as appropriate. The community structures will
be strengthened thus allowing a sustained response and a sharing of best practice as a
centre of excellence.
Much preparatory work took place in 2005 and 2006. The period Feb-Dec 2007 will be
used to procure equipment and supplies and to slowly start-up a number of services. This
phase is the subject of this proposal which is hereby submitted to AVERT for
consideration of funding.
Table of contents
A.
INTRODUCTION
Background
Rationale and History of Project
HIV related knowledge, attitudes and practices (KAP)
B.
HIV INTERVENTIONS PROPOSED BY THE COMMUNITY12
Community Education
Abstinence
Being-faithful
Being-sexually responsible
Condom-use
Voluntary Counseling and Testing (VCT)
Caring for the sick
Prayers and the role of religion
Counseling
6
7
8
C.
PROJECT OBJECTIVES AND ACTIVITIES
1.0 To mobilize a sustained community response to HIV/AIDS.
15
15
2.0 To provide and promote HIV prevention interventions.
19
3.0 To provide comprehensive care for people living with HIV/AIDS

including on-going counseling, treatment of opportunistic infections
and referral for PMTCT and ARV care.
22
D.
25
WORK PLAN, TIMELINES AND BUDGETS
A.
INTRODUCTION
Fighting the HIV epidemic is a war that requires community engagement and
involvement as well as access to vital services that enable individuals to implement their
prevention and care decisions effectively. Such services include Voluntary Counseling
and Testing (VCT), Prevention of Mother to Child Transmission (PMTCT) and
Antiretroviral (ARV) drugs. Without a motivated community that accepts HIV/AIDS as
their own problem and responds to it, education campaigns only impart knowledge but no
action is taken. When individuals in a community make a resolve to address the HIV
situation in their lives they often need to know their HIV status as a starting point which
is the gateway to prevention and care.
Uganda as a country is well known for having mounted an effective response and reduced
the HIV prevalence from over 15% in the 1990s to 6.3% as per the 2005 sero-survey
results. But according to UNAIDS, data on behavior suggest that the past declining
prevalence trends may not continue in the future without a renewed focus on prevention.
A countrywide household survey done in 2004-2005 found that men were much more
likely to have multiple partners than were women29% of men and only 4% of women
said they had had more than one sexual partner in the previous 12 months. Condom use
was not all that widespread: of the women and men who said they had slept with a casual
partner in the previous year, roughly half used a condom the last time they had sex with
that person.
Knowledge about HIV/AIDS is quite high in most communities and people are aware
that in order to prevent the spread of HIV they need to practice either: Abstinence, Beingfaithful or Condom-use, the famous ABC strategy. However, unlike Abstinence which
does not require any technology to implement, Condoms are a technology which should
be accessed continuously and Being-faithful requires mutual knowledge of HIV status by
both partners for it to be effective in prevention. Without knowledge of status through
couple VCT, for example, Being-faithful to an infected partner without using condoms
will result in HIV transmission. But learning ones HIV status brings to surface the need
to access ARVs and PMTCT for those who learn that they are HIV infected. In some
communities these services have been provided based at existing health facilities that
were designed to provide basic health services. Individuals, who can access these
facilities have benefited in terms of knowing their HIV status, making personal decisions
about prevention and seeking ARVs and PMTCT as appropriate.
Hence, when one engages a community to discuss and respond to the HIV/AIDS
epidemic one soon faces the reality that there is only so much the community can do with
their bare hands so to say. This is the reality which faced the Project Director when he
tried to engage the community near his farm at Namulaba to respond to HIV/AIDS
through the Namulaba church development committee which he chairs. Eventually he
made a decision to build a private, not for profit health centre on his land and the
community decided to start a network of CBOs to begin mobilizing the community. This
proposal seeks support to provide HIV prevention and care services based at the
Namulaba Community Health Centre together with community education events of the
CBO network.
At the 11th International Conference for PLHAs, Kampala, 26th-30th Oct.2003 it was
recommended that in order to lower HIV prevalence below the current levels there is
need to intensify consistent dissemination of information to demystify HIV/AIDS
especially through outreaches in schools, home visits, seminars, workshops, media and
religious leaders. Further, it was recommended that VCT and other related health care
services be available at community levels (J Mwirumubi et al 2004).
Background
The Namulaba Community HIV/AIDS Project is based at a little village called Namulaba
located in Nagojje sub-county. When moving from Kampala towards Jinja, on reaching a
township called Namataba (about 30 Km from Kampala), one turns off northwards on an
earth road and moves for about 8 Km inland to reach Namulaba. The intervention area of
the project is the Nagojje sub-county.
Nagojje
2 Km
10 Km
Namulaba
8 Km
Intervention Area
Kampala
30 Km
Namataba
Kawolo
35 Km
Jinja
Nagojje sub-county is in Mukono district, one of the 69 districts in the country.

According to a June 2005 estimate based on the last national census of 2001 Nagojje subcounty has a total population of 28,429 living in 6981 households. Hence, on average
each household is occupied by about 4 people. Nagojje sub-county comprises the
following parishes: Nakibano, Namataba, Nagojje, Waggala, Kyajja and Namagunga, see
table 1. Apart from a few large tea and sugarcane plantations belonging to commercial
farmers, the population is comprised largely of subsistence peasants. Each household has
a small plot of land on which they grow crops for food some of which they sell to earn
cash.
Table 1: Nagojje Sub-county Population Distribution by Parish June 2005
Parish
Number of Households Population
Nagojje Parish
971
4145
Kyajja Parish
631
2508
Nakibano Parish
930
3981
Namataba Parish
1503
6223
Waggala Parish
1582
6151
Namagunga Parish
1364
5421
Total for Nagojje Sub-county
6981
28429
Rationale and history of project

This project is located on farm land purchased by the Project Director in March 2004.
The impetus to start the HIV project emerged when he was repeatedly approached by
people from the neighborhood with needs related to HIV/AIDS care. Having worked on
AIDS since 1988 in The AIDS Support Organization (TASO) it was logical for
community members to expect help from him. He was eventually appointed by the local
church to lead the churchs community development committee. Based on the expressed
need for health services and specifically HIV/AIDS prevention and care activities he
made a decision to construct a community health centre on his land.
What has been done?
June 2005, an inventory was done of community based organizations (CBOs)
engaged in community development and social services. Over 20 CBOs were
identified in Nagojje sub-county.
Nov 2005, a one-day HIV/AIDS sensitization seminar was conducted for 121
leaders of CBOs (about 6 per CBO). A decision was made to prepare and conduct
song and drama competitions on HIV/AIDS among CBOs.
Dec 2005, a baseline of HIV knowledge, attitudes and practices (KAP) was
carried out. An abstract was submitted and accepted for publication in the Toronto
International HIV/AIDS conference in August 20061.
May-June 2006, four detailed one-day seminars on HIV/AIDS were conducted by
two HIV counselors. Each seminar was attended by about 40 participants.
Participants of the seminars were also asked to generate community concerns and
proposals for action regarding HIV/AIDS.
June 2006, a one-day HIV/AIDS sensitization seminar was held for 48 youth
leaders. A decision was made to prepare for football and netball competition
linked to HIV/AIDS education among youths.
July 2006, decision was made to form Nagojje Network of CBOs.
Music, dance and drama competitions carried out and finals conducted in
December 2006 as part of World AIDS Day celebrations.
Boys football and Girls netball competitions begun in some parishes, finals to be
conducted in 2007.
Follow-up survey of HIV Knowledge, Attitudes and Practices (KAP) conducted
in December 2006 and completed January 2007. Results to be available February
2007.
HIV related knowledge, attitudes and practices (KAP) at baseline.
1
The prevalence of ABC (abstinence, being faithful and condom use) and factors
influencing abstinence in a rural community: baseline survey of Namulaba church of
Uganda AIDS project
(IAS Conference Abstract)

By Sebyayi Muwanga D., Kalibala S.
AIDS 2006 - XVI International AIDS Conference, 2006
Abstract no. CDC1983.
Quantitative survey: A baseline survey was carried out in the community in December
2005. From each of the six parishes 20 men and 20 women aged 15 years were
interviewed totaling 240 respondents.
Qualitative data gathered in seminars: In addition to the quantitative survey a number of
seminars attended by four groups of about 40 community leaders each were carried out as
well as one for youth leaders attended by 48 of them. These sharing seminars were a
two-way communication with the community. On the one hand the HIV counselors
shared HIV/AIDS knowledge with the community leaders and in return the community
leaders shared the community views and perceptions about HIV in the community. This
information was carefully recorded in verbatim for each seminar and was used to inform
program development as is evident in the text below.
Knowledge: As expected, the population was knowledgeable about HIV. For example
87% were aware that HIV can be transmitted from mother to baby. And 95% said there is
something one can do to avoid AIDS. Asked an open ended question about what can be
done to reduce risk of HIV 76.3% said use condoms, 57.1% said abstain from sex,
29.6% said one faithful sexual partner, 6.3% said limit number of sexual partners and
5.8% said go for a test.
Risk perception and attitudes: In the Namulaba community the baseline data further
showed that there was poor risk perception. Regarding the last sex act only 16.3% were
very concerned that they might catch AIDS; 20.8% were somewhat concerned and 56.3%
were not concerned. Regarding care for PLHAs, many had a positive attitude in that 95%
said they were willing to care for a friend or relative who has HIV/AIDS.
Abstinence: There were varying levels of abstinence depending on age and sex of
respondent. Primary abstinence (never had sex) was reported by 25.5% of people aged
16-19 years. Secondary abstinence of > 12 months was reported by 16.0% of men and
23.1% of women. During the seminars of community leaders it emerged that not many
people were abstaining and that those saying so were probably lying except for the
sexually inactive elders. Indeed, even the youth leaders in their seminar noted that not all
youth were practising abstinence. No and its evident especially among the school goers
who do get pregnant.
While it was apparent that these community leaders, young and old, believed that sex was
inevitable the youth leaders mentioned some conditions for youth to have sex These
included age, consent and knowledge of HIV status. Its also important to have sexual
relations after consent and at a right age. In Uganda the acceptable age is 18 years for
boys and girls. However, before you engage in sexual relations you are supposed to go
for a blood test and always remain faithful to each other. Community leaders also said
that there were factors such as alcohol, pornographic videos, provocative clothes,
deteriorated morals and peer pressure that prevent people from abstaining from sex. It
was also mentioned that many engage in sex to get money and gifts and as such can not
abstain. But it was also felt that overall lack of awareness or concern about the epidemic
might be a factor in preventing abstinence. The liberal nature of todays society was
blamed as the main cause of early sex among teenagers. There was also mention of a
form of dilemma which some parents face in terms of instilling discipline and moral
values in their children versus the need to observe childrens rights. Some parents are
very relaxed towards their childrens behaviour because they claim that the childs rights
law overshadows them.
These observations have also been made in other communities in Uganda.
The innate characteristics of individuals are usually overwhelmed by societal pressures
such as coercion by sugar daddies and sugar mummies forcing young people into sex in
order to get food or money or school fees. Bombardment with pornography is also a
problem. Mwaka-Mbasaalaki CL et al 2004
Being-faithful: Being faithful was not that well practiced either since 31.8% of males and
5.2% of females reported two or more sexual partners in the past six months. In the
seminars the community leaders were of the view that only a minority of people were
faithful to their partners. Factors leading to breach of faithfulness included failure by one
partner to sexually satisfy another, usually the female failing to meet the sexual demands
of the male. But also if one partner, usually the male, failed to meet the material needs of
the other then again faithfulness would be put at risk. Another issue raised was that a
person could seek sex outside the relationship in order to revenge on a spouse who
appears to have an affair. It was also mentioned that if a person has shortcomings like
being unkempt, drunk, quarrelsome or just uncouth there was a tendency for their spouse
to seek a more decent person for an affair. Lack of love, affection and care in a
relationship may also lead one to seek love elsewhere.
Condom-use: When asked if they were able to do something to reduce risk at the last
sexual act of the 226 who were sexually active 49 people (21.7%) said they did
something. And of these 41 people (or 18.1% of the sexually active) said they used a
condom: 23.6% of males and 12.9% of females. In the community seminars it was the
feeling that there was low condom use. Indeed one shopkeeper said he used to stock
condoms but not many people were buying them, so he gave up. A number of reasons for
low condom use were given such as claims by some women that condoms give them
lower abdominal pain and that condoms can tear and parts of them remain inside the
woman thus causing pain. Others even said that condoms can cause cancer. Other
comments were that the condoms were sometimes too small or expired and can easily
break or tear. Others did not like condoms because they reduced sensitivity. It was also
mentioned that it is inappropriate to use condoms since in many marriages there is a
desire for pregnancy. It was also felt inappropriate to use condoms once a couple tests
HIV negative. There was also an age issue as condoms were considered to be something
for the young and not for mature people. It was also felt that people under the influence
of alcohol were not likely to properly use condoms. It was further suggested that there
was limited awareness of condoms and their use in the community.
There are high knowledge levels but many gaps in behavior. About 90% of the
respondents had heard of HIV/AIDS but the high knowledge levels did not always match
individual beliefs, attitudes and perceptions towards HIV/AIDS prevention.
Kasasa S et al 2004 reported from that in one community in Kampala
10
Effects of HIV/AIDS on the community: Participants in the community seminars were

aware of negative reactions that can happen to a person suspected of having AIDS. They
highlighted the fact that when one is suspected of having AIDS some people could
discuss him/her as a topic in the community and point fingers at him as well as label
him/her as being promiscuous or a prostitute. Sometimes the person may be isolated and
even not provided basic needs like food. Regarding negative effects of HIV/AIDS on the
community they mentioned the loss of productive people sometimes the person affected
might be providing a vital service such as being a teacher or a shopkeeper and when they
die the service is lost. On this issue however, it was felt that unfortunately some
employers lay off people from work just because they seem to have AIDS even though
they are still strong enough to work. Thinking that a person infected with AIDS can not
perform his/her normal duties thus chasing him/her away from employment or even
denying this person the chance to prove his/her worth They emphasized the devastating
effects of the loss of a bread winner in a family and how the dependents are left without
help.
It was also mentioned that the suffering and pain of a person with AIDS is felt as a pain
by those who love them in the community. In the seminar of youth leaders there was also
a feeling that some family members of PLHAs may be stigmatized too. The youths who
do have people infected and caring for them in their homesteads are sometimes isolated
from their fellow youth because they consider them also being with the infection.
Consequences of not caring for people living with HIV/IADS (PLHAs): Participants in
community seminars highlighted the need for care for those suffering with AIDS. It was
mentioned that if people are isolated and not provided care they lose hope and may die
sooner. The person may become depressed, withdraw from the public and reject food and
treatment or even contemplate suicide. The youth leaders echoed this too. If this person
was still of school going age they will be forced to abandon school due to the hostile
environment he/she is living in. Others may become delinquent and sale their properties
and squander the money and become alcoholic. It was also feared that when a person is
not cared for they may become hostile and do negative actions to hurt society such as
promiscuity and rape to spread the virus.
Advantages of caring for PLHAs: Community seminar participants were appreciative of
the societal benefits of caring for a person with AIDS. It was felt that when one is cared
for they can seek and receive information about HIV which can help them to use
preventive measures to avoid spreading the virus. They can also come out and become
good community educators about HIV/AIDS care and prevention. It was also highlighted
that when a person receives good care they develop a positive attitude, participate in
developmental activities and begin planning for the future of their family as well as write
a will. Participants also noted that the treatment of some of the infections that a person
gets, such as Tuberculosis (TB) and Sexually Transmitted Diseases (STD), can limit their
spread thus having a public health benefit. And a caring attitude was said to enhance
adherence to treatment, probably referring to ARVs. Caring for the sick will help to
make the sick person aware of drug adherence and compliance.
11
B.
HIV INTERVENTIONS PROPOSED BY THE COMMUN ITY
Community education: From the community seminars it emerged that priority

interventions revolved around the need for intense mobilization of communities and
sensitization about HIV/AIDS. This would include education about risk factors for
transmission, how it can be prevented as well as the need to care for those living with
HIV/AIDS. Suggested methods included newspapers such as Straight Talk, community
seminars, formation of clubs, seminars at schools, as well as testimonies by people living
with HIV/AIDS. Receiving seminars on HIV/AIDS, emphasising the coming out of
people to talk about AIDS in abroad day light.
One other issue which was stressed was the need for parents to be made more aware of
their role to educate their children about the dangers of irresponsible sexual behavior.
Abstinence: Participants of the community seminars agreed that abstinence should be
promoted as a means to prevent the spread of HIV among young people. Some proposed
that young people should abstain until marriage while others proposed abstinence up to
age 18. For others it was felt important that one should abstain until they have a partner
with whom they have had HIV testing and know each others results.
They proposed that seminars should be conducted to educate people especially the youth
about the dangers of sex such as HIV, STDs and unwanted pregnancy. Those who have
had bad experience of not avoiding sex should come out to tell others the side effects of
such phenomenon. At the same time promotion of good values such as school education
was proposed as a means to encourage abstinence.
Admiring those who have
succeeded after postponing sex like focusing on education then one finally graduates and
gets a good job than engaging into sex. There was also a call for a return to cultural
values and a strengthening of religious teachings as a means to encourage young people
to abstain. In the youth leaders seminars parents were called upon to play their role. Its
important to sensitise the youth by their parents in order to know the relevance of
delaying sex. Parents were also asked to pay attention to how their youngsters are
dressed. The dress codes of some youth especially girls is not good so its important that
the parents or guardians of these youth should advise them accordingly.
During the seminar for youth leaders, it was also proposed that certain forms of
entertainments were not good for young people. Places likes discos should be
discouraged as these sometimes do lure many youth to engage in sexual practices.
Instead of such entertainment it was proposed that sports activities be promoted. Its also
important to advise the youth to engage in extracurricular activities like sports in order to
put to use the extra energies. Indeed, football and netball were proposed as one of the
best ways to mobilize young people and educate them about HIV/AIDS. Organising
activities like football and netball matches and HIV awareness be made either before
these activities start or at the end. This was deemed highly feasible since each local area
already had some kind of team. Almost every local council has a football or netball team
but the problem is many of these groups are not active because they dont have balls to
play
12
Being-faithful: The community seminars also proposed faithfulness to ones sexual partner
as a means to reduce HIV risk. However, many felt that faithfulness would only work if
both partners were tested and they shared knowledge of their HIV status. Another
condition for faithfulness to work was the need for both partners to be faithful and not
just one. Again there was a call for the strengthening religious values. Go for an HIV
test then remain faithful to each other as well as having Gods intervention.
Being-sexually responsible: Participants also brought up the issue of being responsible
with ones sexual life. Have sex at a right time, place, with the right person (your
spouse) and at the right age. Have sexual relations after consent. They called upon
people to always have in mind the suffering which can be caused to others by barbaric
sex such as rape.
Condom-use: Condoms were largely suggested as a temporary measure to be used by
people before they get someone with whom they can receive HIV testing and thereafter
be faithful to each other. Use condoms each time you are having sexual relation to
someone you are not sure of the sero-status. Condoms were also suggested for those
who could not control themselves to abstain and also for situations where one was not
sure of the integrity of or not in love with the partner. Use condoms if you believe that
your sexual partner doesnt have genuine love. Use condoms for one night stands.
However, it was felt that within a mutually faithful relationship condoms could come to
use as a means of family planning or when one or both partners are known to be infected
with HIV. But some were of the view that many young people who get HIV/STD and
unwanted pregnancies could have avoided these calamities had they used condoms.
Indeed it was considered to be a responsible thing to do for young people to use
condoms. The teenagers or youth also use these condoms and mostly those who have
been attending various HIV/AIDS seminars because they are aware of the importance of
using condoms. In the youth leaders seminar one identified barrier to condom use was
the unpredictable nature of youth sex. Some youth dont use condoms because one can
get a chance to have sexual intercourse and is not with any condom thus many are caught
unaware
Regarding sources of condoms shops, hospitals, clinics as well as community distributors
were mentioned. Some said they had also obtained condoms during HIV/AIDS seminars
and workshops.
Voluntary Counseling and Testing (VCT): To a large extent VCT was discussed as a prerequisite for engaging in a sexual relationship. Checking sero-status in AIDS
Information Centre before engaging in a relationship For this reason it was mentioned
that those who had not yet known their HIV status should always use condoms. But it
was also identified as a way of knowing the truth so that people who are sick with AIDS
can stop imagining that they were bewitched. There was a call to mobilize people to go
for HIV testing. Indeed it was suggested that during home visits to care for the sick,
people in that home should be encouraged to go for testing.
Caring for the sick: Participants in the community seminars were quick to highlight care
for the sick as a major intervention in the response to the epidemic in that community.
Elements of care which they felt they could undertake included visiting and helping with
13
chores such as cleaning up; providing medicines and assisting or encouraging a person to
take medicines as recommended; providing food and helping cultivate vegetables; and
advising a person to always seek medical care. A number of organizations were
mentioned as providing support in the care area. These included TASO (The AIDS
Support Organization), Hospice Uganda, BUKADEFU and the Holy Army of Mary
(Abegye lya Bikira Maria).
A number of constraints in the area of care were however highlighted. These included the
lack of time to give sufficient care to fellow community members and the lack of enough
money to provide for the needs of the sick. High transport costs to take patients to
facilities where ARVs are provided were reported as a major hindrance to ARV use.
Another issue was the fact that many of the sick are in denial and are reluctant to go seek
HIV testing which would enable them to seek better care including ARVs. Furthermore,
some of the sick people are in a state of anger, are hostile and refuse medicines and even
food; and sometimes those who are ill even cut off communication with their care
providers making it difficult to provide care for them. An overwhelming belief in
witchcraft by the patient and their immediate family could also make them reject care.
There was also the danger of getting too involved in the affairs of the sick person and
being blamed for exploiting them especially in the case of sale of property. In case the
sick person once had property and was sold, its the care taker who will be held
responsible and blamed for the selling of the property. The care provider is sometimes
viewed as someone who wants to benefit from the resources of the sick.
Prayers and the role of religion: Religious values encouraging abstinence, faithfulness
and holy matrimony and discouraging fornication were considered vital for instilling
sexual responsibility in the community and as such helping with HIV prevention. There
was also great emphasis put on praying for and with the sick. Asking the person whether
s/he could be interested in praying, if not to contact a religious person s/he is comfortable
with.In addition there was a call for divine intervention to reduce worldly desires which
tended to tempt people to have sex outside marriage.
Counseling: Participants in the community seminars identified the role they could play
through counseling. They mentioned that counseling included visiting the infected person
and their family telling them not to lose hope by giving examples of those on ARVs who
had regained life; helping them not to blame themselves and be angry with themselves;
encouraging them to talk to someone they trusted and educating them how to live
positively for example by eating well. Counselling the patient and strengthening this
person not to give up, may be one day a vaccine or cure will be found. Along with this
was the need to engage people living with HIV/AIDS into gainful employment which
would indeed help them to regain self-esteem.
Creating an environment to show this person that he/she is still important or resourceful
to the community
Counselling was also proposed as a way to educate individuals about HIV transmission
and how to prevent it. It was highlighted that counseling means showing them love, being
kind, friendly and approachable and understanding the person in need.
In terms of who can counsel, it was mentioned that this was being done by community
volunteers of whom only few had been trained in counseling.
14
C.
PROJECT OBJECTIVES AND ACTIVITIES
The above information shows that the community is quite knowledgeable about HIV and
its prevention. It is also clear that the community is aware of its HIV programming needs
and is able to propose a number of tangible and potentially effective interventions.
However, it is apparent that the community has gaps in terms of motivation, skills and
resources to respond effectively to the epidemic. The community also has limited or no
access to key HIV services such as VCT, ARV care and PMTCT that are vital for an
effective response. To address these concerns and gaps a project is proposed to sensitize
the community about AIDS and elicit a sustained community response. This community
response will be linked to increased access to vital HIV services based out of the
community health centre. Such a link will ensure that individuals who make up their
minds to address HIV in their lives do not find a vacuum when they search for the
necessary technology such as VCT or ARVs.
Goal
The goal of this project is therefore to enhance community access to key HIV services
and strengthen community capacity for a sustained response to HIV/AIDS and its social
impact.
Objectives
1. To mobilize a sustained community response to HIV/AIDS.
2. To provide and promote HIV prevention interventions.
3. To provide comprehensive care for people living with HIV/AIDS including ongoing counseling, treatment of opportunistic infections and referral for PMTCT
and ARV care.
1.0 To mobilize a sustained community response to HIV/AIDS.
The ultimate responsibility to address an issue such as AIDS in a community lies in the
hands of the community members themselves. They are most versed with the factors
facilitating the epidemic and factors hindering an effective response. The community in
this project clearly knows these factors and has articulated them as shown above.
However, they have highlighted the fact that their members do not perceive the gravity of
the problem and are certainly not motivated enough to mount an effective response.
Therefore, this project has, as one of its objectives, the aim to sensitize the community
members about the HIV/AIDS problem and mobilize them to respond. Further to this the
project aims to enhance sustainability of this response by developing skills and technical
capacity among leaders of CBOs.
1.1. To sensitize the general community about HIV/AIDS and mobilize them to
undertake prevention measures, promote health care seeking behaviors and reduce
stigma.
The main means of sensitization as proposed by the community leaders is entertainment.
To this effect the following activities are proposed.
1.11. Prepare and conduct songs and drama competitions by CBOs.
15
Much preparatory work has already taken place during the formative phases of this
project. A number of CBOs have formed song and drama groups and preliminary
competitions have begun. The plan is to conduct competitions that climax in a final show
on World AIDS Day. Each group is required to present a song and a drama about
HIV/AIDS. They however, are encouraged to produce other entertainment pieces. The
project will provide HIV/AIDS sensitization to the team members during rehearsal
periods to ensure that the HIV knowledge used for the productions is accurate. In addition
the project will provide cash gifts to the teams. Each team will receive an award, even the
worst performers. The competitions will be arranged to start with preliminaries attended
by large crowds each time and culminating in finals that will be attended by even larger
crowds. Hence, the competitions will be an exciting way to communicate the HIV/AIDS
messages, to the community, by the community using means that are entertaining and
appropriate to the community. Following the final competition, the project aims to
support the top team(s) to traverse the villages putting up shows. In addition, mobile VCT
services will be made available at these events.
1.12. Prepare and conduct football and netball competitions
As stated above the youth leaders identified games as a responsible form of entertainment
that can be used to sensitize young people about HIV/AIDS and mobilize them to mount
an effective response. Each of the six parishes will have a boys team for football and a
girls team for netball. The rehearsals will be preceded by an HIV/AIDS discussion
facilitated by two HIV counselors. In the case of girls, the facilitators will include a lady
from the community to be referred to as Ssenga or Auntie. This aims to exploit an
existing culture of sexual education that is supposed to be given to girls before they get
married. This indeed is an acceptable way to talk to young girls about sex and sexuality.
Prior to playing this role the auntie will undergo training in HIV counseling skills. The
discussions will be a form of group counseling and those with personal issues will be
encouraged to see the counselors at the end of the match or to make an appointment to
see the counselors at the clinic on another day. This same principle will be followed
during the preliminary competitions where a large number of counseling aides will be
available to take on small groups of young people and have a discussion about HIV/AIDS
before kick off. In addition, mobile VCT services will be made available at these events.
The tournament is planned to take place every year culminating in a World AIDS Day
finals.
1.2. To build community capacity for sustainable responses to HIV/AIDS and its
social impact.
While the project can not aim to create a self-sustaining response it is designed to
enhance sustainability of the community response to HIV/AIDS. It is planned to use its
inputs to leverage the untapped resources and potential in the community. The basic
untapped resource in the community is its people. While people need to work on their
gardens to grow food, not every body works all day in the gardens. There is a certain
amount of free time and, one dare say, redundancy which not only needs to be exploited
for useful work on HIV/AIDS but also needs to be addressed because it may have a role
to play in HIV transmission especially if it leads to consumption of illicit alcohol.
16
Therefore, the guiding principle of this project is to build the capacity of community
members by giving them skills which they can use on an ongoing basis to identify their
problems and seek help to address them.
1.21. Provide skills training to CBOs staff
Specifically, the project will work through the Namulaba Network of CBOs to provide
member CBOs with a number of key skills necessary for HIV/AIDS programming. These
will include project management skills such as proposal writing and accountability for
funds and resources. In addition technical skills will be imparted such as how to organize
and conduct a training workshop or how to monitor and evaluate programs using lowtech tools such as a pencil and an exercise book.
1.22 Provide a resource centre and administrative support to CBOs
The project will avail its office to operate as a CBO network office and resource centre.
In addition the conference room at the health centre will be made available to training
workshops and meetings of CBOs. The office will have a full set of office equipment
including a computer, printer, photocopier and a mobile phone. The office will also have
a small library of relevant books. CBOs will be assisted with word processing and other
aspects of document preparation. This assistance will extend to other activities of these
CBOs, not related to this project, as long as they are in the general area of community
development and social services.
1.3. To monitor the growth and nature of community responses to HIV/AIDS and its
social impact.
As shown above, as part of the formative work for this project, an inventory of existing
community responses was carried out. It revealed about 20 CBOs struggling to address a
variety of community needs relating to development and social services. It is a stated
objective of this project to enhance capacity of the community to respond to its problems
by strengthening CBOs. Hence, a systematic effort will be undertaken to monitor and
document achievements in this area by carrying out the following activities. These
activities will be carried out by various members of the CBO network based on their
skills but they will be housed in the CBO office provided and supported by this project.
1.31 Formalize a CBO network and conduct regular meetings.
CBO network meetings will be organized once a month at the Community Health Centre.
During these CBO network meetings information will be shared about CBO activities
within and without the HIV/AIDS area. Minutes of these meetings will be written and
circulated among members as a record of new events reported that month.
1.32 Develop and publish a quarterly newsletter of the CBO network in Luganda and
English
CBO network members will be encouraged to write articles in a language they are
comfortable with and these will be compiled in a loose-leaf newsletter. This will enable
members to report and learn about activities. The newsletter will be circulated to district
authorities as well as donor NGOs in order to publicize the activities taking place in this
community and solicit support in cash and in kind.
1.33 Develop and maintain an updated referral directory of social services
This directory will indicate the available services, the organizations providing them,
location, contact person, opening hours and requirements such as fees etc
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1.4. To monitor changes in HIV/AIDS knowledge, attitudes and practices

As part of the formative activities of this project a quantitative baseline survey of
HIV/AIDS knowledge, attitudes and practices (KAP) was carried out in Dec 2005. In
addition, qualitative information was obtained during community seminars held to
sensitize the community about HIV/AIDS. During this project both these two data
gathering processes will be formalized into an annual survey to monitor changes in
HIV/AIDS knowledge, attitudes and practices in the community. The following activities
will be carried out.
1.41. Develop a study plan for the annual evaluation of HIV/AIDS knowledge, attitudes
and practices (KAP).
The Project Director will develop a detailed proposal indicating the target population, the
sample size, recruitment plan, consent method, data collection methods (quantitative and
qualitative), questionnaires, how interviewers are trained and supervised, data
management, analysis and dissemination.
1.42. Conduct the annual KAP survey
In November preparations will be made for the KAP survey including recruiting and
training data collection staff and field guides, preparing of questionnaires, developing a
data collection schedule and informing community leaders. In the first week of December
soon after the World AIDS Day events the survey will be conducted.
1.43 Finalize the KAP survey and disseminate findings
In December-January the data is entered and analyzed by a temporary data manager.
Preliminary data is disseminated to the larger family of the project including project staff
and CBO network members. In addition appointments will be made to disseminate the
findings to community members in each parish. During these dissemination meetings
issues will be identified and recommendations for action made. A plan to implement these
recommendations will be made and used as a launch for the new programming cycle. The
report of that annual KAP survey will be finalized and disseminated widely at the district
level, national level and abroad electronically. In addition, conference abstracts as well as
journal articles will be written.
1.5 To develop a centre of excellence for learning best practices in sustained
community responses to HIV/AIDS
1.51 Document service delivery as well as social cultural and behavioral lessons learnt
The philosophy of this project is two-way learning between the community and the
external agents. For this reason, the staff of the project will be very observant and note
any emerging lessons about the culture and behavior of people as they interact with them.
The staff will also listen to perceptions, feedback as well as advice about the information
and services provided by the project. To document these insights, discussions during
education sessions shall be documented in a manner similar to focus group discussions.
This method was used during the formative stages of the project and it was successful in
yielding valuable information which has been used to inform the development of this
proposal. Secondly, service providers especially those providing counseling will be
required to take notes and report emerging issues or difficult cases during meetings of
counselors when they meet to support each other. These reports will be collated
anonymously and disseminated in conferences and journals. Funds have been set aside in
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the budget to occasionally pay consultants to help out with these tasks as well as the tasks
in 1.52 and 1.53.
1.52 Systematically test and evaluate innovative service delivery approaches
Service delivery models will have to be invented as more and more services are added.
There will therefore be a need to systematically observe the efficiency of these models in
terms of client flow, provider-contact time, waiting time as well as client satisfaction.
These observations will be important for informing management decisions to make
necessary changes but also important as lessons learnt to be disseminated to a wider
audience.
1.53 Develop Namulaba as a centre of excellence for learning how to develop and
implements interventions for a sustained community response to HIV/AIDS.
This is a project which is engaging the community and not leaving them to act in a
vacuum but providing them with key HIV services that make their response meaningful.
This situation will be unlike many communities where they are engaged to think about
AIDS but not given the means to respond effectively. Also, the HIV services are not
provided in one well managed corner of a health facility that is functioning sub-optimally
to provide the rest of health care to the community. But instead this project is taking
primary health care as the nucleus around which the new HIV services revolve. These
characteristics make this project not only of benefit to the Namulaba community but a
best practice of a true community response to the epidemic. Many community responses
abort because people are stimulated to respond but feel impotent because they lack the
very basics for response such as knowing ones HIV status. For this reason the project
will evolve into a centre of excellence that will provide technical support for developing
similar comprehensive responses to HIV/AIDS in other Ugandan and African villages.
Collaboration will be established with organizations such as the Ministry of Health, the
Uganda AIDS commission and UNAIDS to replicate this project to other places in a
village to village approach.
2.0 To provide and promote HIV prevention interventions.
A major output from the above mobilization efforts will be the desire by individuals to
take charge of their lives by seeking specialized advice, counseling as well as VCT. The
project will promote and provide counseling as a tool to enable individuals make
decisions about their sexual life. For this reason, a number of counseling aides will be
trained and made available to provide confidential one to one discussions at the health
center and during home visits. To differentiate it from the counseling during VCT which
is specific for HIV testing, this other counseling will be referred to as ongoing
counseling. VCT counselors will refer clients for ongoing counseling as needed. And the
providers of ongoing counseling will refer clients to VCT. In addition to the general
counseling aides, the project will also have specially designated religious counselors
representing four to five common faiths. Those clients requiring or desiring religious
counselors will be referred according to the faith they confess.
2.1 To provide and promote VCT, ongoing counseling and sexual abstinence among
young people.
Formative work with community leaders including youth leaders clearly identified
abstinence and restoration of moral values as the key interventions for young people. The
19
project proposes to meet these needs by using VCT as an entry point to discuss sexual
and reproductive issues. Following this, confidential ongoing counseling will be used to
promote primary abstinence for those who have not started sex and secondary abstinence
for those who have started sex. A crucial issue with youth services is the youth friendly
nature of the service providers and the site infrastructure. To this effect the following
activities will be undertaken to ensure youth friendly services.
2.11 Recruit and train peer-educators to provide client care for youth seeking services.
The concept of using peer educators as service providers is borrowed from Naguru
Teenage Information and Health Centre (NTIHC) in Kampala. Youths who have been
keen in the youth games will be identified and screened for responsible behavior as well
as integrity. Those selected will undergo a two-day training in client care as well as
adolescent sexual and reproductive health services. This cadre of staff will function as the
main organizers of services for youths including directing client traffic at the clinic and
providing them some of the services such as IEC materials.
2.12 Establish a youth corner
One of the clinical rooms will be set aside as a youth corner where young people can go
without having to wait at the reception. This room will be used for group discussions and
health education of young people. Peer educators will be the staff in this room and will
arrange for those requiring medical care, VCT or confidential counseling to go to a
neighboring counseling room once the provider is ready for them.
2.13 Provide Youth Friendly Services
The nurse and VCT counselor will be sent to Naguru Teenage Information and Health
Centre (NTIHC) in Kampala to be oriented in the provision of youth friendly sexual and
reproductive health services. Back at Namulaba once the peer educators identify a young
person who needs a medical service, VCT or counseling they will alert either the nurse or
the VCT counselor, depending on whether it is a medical need or counseling need. The
relevant provider will then make themselves available in the counseling room next to the
youth corner and provide the service to the young client as arranged by the peer educator.
Ongoing counseling will be provided as a follow-up service on referral by the VCT
counselor.
2.2. To provide and promote pre-marital couple VCT, pre-marital ongoing
counseling and mutual faithfulness among un-married lovers.
A major gap that exists in HIV programming at a community level, is the lack of advice
for people who are courting. And yet this is a time in peoples lives when they need a lot
of support in terms of deciding what to do with the desire to have sex before marriage.
The project will address this need by recognizing un-married lovers as people who can
seek ongoing counseling even before they make a decision to get married. Couple VCT
will be used as an entry point to discuss sexuality issues. Ongoing counseling will use
this chance to begin inculcating the principle of mutual faithfulness. Ongoing counseling
will be provided as a follow-up service on referral by the VCT counselor.
2.21 Promote the concept of Couple VCT for un-married lovers
In many societies, people who are not married and have not declared themselves ready
for official or religious marriages are considered somehow illegal and are not
recognized as a couple. Hence, it will be important that the project shows that this
concept is a vital part of society since it is what leads to marriages. One of the ways to do
20
this will be to encourage unmarried people who have come for VCT to bring along their
lovers, next time for couple VCT and ongoing counseling as lovers even though they are
not ready for marriage. The provision of this service will be no different from the others
but the crucial issues will be in how it is promoted and the comfort level that is created by
the staff at the clinic, in receiving these two lovers who are neither married nor intending
to get married.
2.23 Provide premarital VCT and religious counseling
Some of the lovers mentioned above will, however, have made up their mind to get
married in which case they will need premarital VCT and counseling. In places where
this service is being provided it is largely provided in two parts. The VCT is provided at a
health facility and the couple is supposed to take their results to the religious leader who
is going to officiate at their marriage. In this project there will be a continuum from the
VCT counselor who will hand over the couple to the religious counselor at the centre. It
will then be the responsibility of the religious counselor to ensure that the counseling is
continued up to when the couple is handed over to the religious leader who is going to
wed them.
2.3 To provide and promote couple VCT, marital ongoing counseling and mutual
faithfulness among married people.
The community seminars recommended faithfulness as the major intervention for married
people. However, they called for VCT followed by mutual faithfulness hence the need to
encourage married people to seek VCT as a couple. Another need raised by the
community was that of enhancing moral values in the sacred union of marriage. The
project aims to address these two needs by promoting VCT among married couples
through songs and drama.
2.31 Provide VCT to married couples followed by ongoing marital counseling
VCT will be used as an entry point to discuss sexual matters within the couple and then
the couple will be referred to a religious counselor to provide ongoing marital counseling.
Designated sessions of marital counseling will enable the couple to bring up other issues
in their marriage which may have been considered irrelevant in the VCT session.
2.32 Make available ongoing marital counseling at the health centre
In addition, religious leaders will be encouraged to inform their congregation of the
availability of religious marriage counseling at the health centre, with or without VCT, on
given days. People, especially women, needing help in their marriages can visit the
religious counselors at the health centre without worrying that they will be required to be
tested for HIV when they are not ready. The religious counselors can then request the
spouse to come together with the index case for counseling. Religious counselors will
make themselves available to provide ongoing counseling sessions as and when required
by the couple. Religious counselors can then bring up the issue of VCT as and when
appropriate.
2.4 To provide and promote VCT, ongoing counseling and condom use among
people living with HIV and discordant couples.
In most communities perhaps the only groups for which condoms are unanimously
proposed are discordant couples or people living with HIV/AIDS. For this matter
21
therefore, the project is going to focus its condom promotion campaign in counseling
sessions as follows.
2.41 Encourage disclosure of HIV status and involvement of sexual partner
During all VCT counseling sessions and in all interactions with people living with HIV,
disclosure to sexual partners will be discussed. Counseling Aides will be made available
to provide ongoing counseling to assist individuals to disclose to their partners. Once the
partners are engaged couple VCT will be provided and if discordant or concordant
HIV+ve, condom use shall be promoted and emphasized as the best intervention in the
circumstances.
2.42 Encourage condom use before disclosure of HIV status and involvement of sexual
partner
Disclosure is not easy and may not take place immediately after VCT. Furthermore, there
is a very high risk of transmission of HIV in discordant couples. For these reasons the
project intends to use post-test counseling sessions of VCT to recommend condom use
for every sexually active person who has received VCT but who does not know the HIV
status of the partner. Condoms will be demonstrated during post-test counseling and
offered to clients to use until their partner tests and share knowledge of their HIV status.
2.5 To provide and promote VCT, ongoing counseling and condom use among single
adults.
A general sensible recommendation is that single adults should abstain until they have
pre-martial VCT and get married. However, the project will make use of the opportunity
when a single person presents for VCT to counsel them about the choice between
abstinence or condom use for any further sex before they find the right person to get
married to. To meet this objective the following activities are proposed.
2.51 Refer to ongoing counseling single adults after VCT
The VCT counselor will at the end of post-test counseling suggest ongoing counseling
and refer the client if desired. During sessions of ongoing counseling the client will be
supported to make choices between abstinence and condoms, depending on confidential
discussions of the clients sexual life, as interim measures until the client finds someone
to get married to.
2.52 Promote ongoing counseling to single adults
The project will also inform the general public of availability of counselors to provide
ongoing counseling to single adults even if they do not desire to receive VCT. Indeed
ongoing counseling will also be provided at events such as songs and drama competitions
as an outreach service side by side with VCT. Again the client will be supported to make
choices between abstinence and condoms, depending on confidential discussions of the
clients sexual life, as interim measures until the client finds someone to get married to.
3.0 To provide comprehensive care for people living with HIV/AIDS including ongoing counseling, treatment of opportunistic infections, home-based care and
referral for PMTCT and ARV care.
Formative work has clearly indicated that in this community there is limited access to
certain vital HIV/AIDS services such as PMTCT. At the moment most HIV/AIDS
services are located either at Kawolo Hospital, Nagalama Health Center or Jinja Hospital
22
or in Kampala, all of which are long distances away. While commendable efforts have
been made to bring some of these services such as PMTCT to Nagojje Health Centre on
an outreach basis, there is still a need to increase frequency, regularity and volume of
services.
To begin with, the Project Director will visit the health partners and authorities in the
district and in Kampala as well as Jinja. The aim of these visits will be to develop a list of
potential referral links and collaboration with regard to the delivery of PMTCT and ARV
care. Priority will be given to setting up links which enable the current service providers
to conduct outreaches at Namulaba Community Health Centre. After this a satellite
service delivery point will be developed at Namulaba Community Health Centre for these
agencies. This satellite will for example be operated by the Namulaba staff while
receiving training, supplies, supervision and quality assurance from the given agency. For
example, TASO or the Joint Clinical Research Centre (JCRC) could provide such support
for ARV care. Having established these services or links to these services the project
aims to target specific populations with specifics services as below.
3.1 To ensure access to PMTCT services for all pregnant women
Based on an assessment of existing accessibility to PMTCT services and on negotiations
with agencies providing PMTCT a decision will be made to carry out one of the
following activities.
3.11 Establish referral links with PMTCT services
Messages will be included in HIV education campaigns to encourage pregnant women to
seek Ante Natal Care (ANC) early in their pregnancy and be advised about PMTCT
services. The community will be made aware of the health facilities with PMTCT
services, their operating days and hours as well as what is done there as part of PMTCT.
In addition staff at Namulaba will inform clients about the PMTCT services.
3.12 Provide Outreach PMTCT services at Namulaba
Offer a room and a designated day for a PMTCT agency to visit Namulaba and provide
PMTCT services. As above, messages will be passed onto the community about the
service and the specific days it is delivered.
3.2 To ensure access to free ARV care to people living with AIDS.
As for PMTCT a decision will be made to carry out one or more of the following
activities based on an assessment of existing accessibility to ARV services and on
negotiations with agencies providing ARVs.
3.21 Establish referral links with ARV services
The community will be made aware of the health facilities with ARV services, their
operating days and hours as well as what is required to receive ARVs. In addition staff at
Namulaba will inform clients about the ARV services.
3.22 Provide Outreach ARV services at Namulaba
Offer a room and a designated day for a ARV agency to visit Namulaba and provide ARV
services. As above, messages will be passed onto the community about the service and
the specific days it is delivered.
3.23 Establish ARV services as a satellite centre at Namulaba.
23
Train staff and set up ARV services at Namulaba as part of the HIV clinic to be supported
in terms of supervision, supplies and quality assurance by a relevant ARV organization
such as TASO or JCRC.
3.3 To provide prevention and treatment for opportunistic infections to people living
with AIDS.
The project will operate a doctors clinic once in a month . The afternoon session of this
clinic day will be devoted to seeing people living with HIV. The following activities will
be undertaken.
3.31 Establish an HIV clinic
Staff will be trained, clinical forms developed, record keeping systems established and a
room and time designated for an HIV clinic. Messages will be passed on to the
community and other health services about this clinic. In addition staff at Namulaba will
inform clients of the service. HIV positive individuals identified through VCT at
Namulaba and other health services will be encouraged to make appointments and turn
up at the designated date and time. PLHAs will be registered for ongoing care. The clinic
will provide lab diagnostic facilities for opportunistic infections (OIs) including TB;
prophylaxis using Septirn; treatment of OIs and referral or provision of ARVs. Referral
for specialized services such as TB care, cancer therapy or hospitalization will also be
provided. In addition ongoing counseling will be provided.
3.4 To provide accessible, subsidized primary health care to the general public.
As mentioned above the project will operate a doctors clinic once a month. The morning
session of this clinic day will be open for patients with general medical conditions. The
clinic will provide lab diagnostic facilities for common illnesses, treatment and referral
for specialized services or hospitalization.
3.5 To enhance access and referral for medical and social services not available in
the community.
Referral links are vital for HIV related services as well as other health and social services.
The following activities will be carried out in order to ensure a good referral system.
3.61 Develop a referral directory for health and social services
A directory will be developed to include all services provided by the different CBOs that
are part of the CBO network; private and public health facilities in the community as well
as distant secondary and tertiary referral facilities. To the extent possible the directory
will include the hours of service, the requirements to access the services such as fees or a
referral letter and the contact person.
3.62 Develop a referral network
A meeting will be convened of CBOs and health facilities providing HIV/AIDS related
services and develop a referral network. Each organization will provide a contact person.
A universal referral slip will be developed. A feedback system will be agreed. Regular
meetings of the referral network will be convened to discuss challenges and find
solutions.
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D.
WORK PLAN, TIMELINES AND BUDGET
A phased approach will be used in implementing this project.
1.Mobilization and Preparatory Phase: Starting Feb 2005 a number of activities have
been carried out regarding engaging the community, establishing the project office and
formative research to inform proposal development. Activities have included construction
of the health centre building, initial sensitization meetings with community leaders,
inventory of CBOs, baseline KAP survey, detailed community seminars with community
and youth leaders and preparation for music/dance/drama and sports competitions. The
preparatory phase is expected to end Feb 2007 when the health centre building will be
ready for use.
2. Procurement and Start-up Phase: The period Feb-Dec 2007 will be used to procure
equipment and supplies and to slowly start-up a number of services. This phase is the
subject of this proposal which is hereby submitted to AVERT for consideration of
funding. The work plan and budget for this phase are shown in Table 3 below.
a) Procurement
Recruitment of personnel
The initial personnel will be short-term and will include the Project Director who will
also be the physician in the clinic, the lab technician, the nurse in charge, the HIV
counselor, nursing aides and community health workers. The numbers will depend on the
need at a given time. Once the training courses listed below are developed, suitable
candidates will be selected and trained as nursing aides, counseling aides, peer educators
and community health workers. Those who qualify after the training will then be
recruited into these positions. The numbers recruited will be increased gradually as the
services develop.
Procurement of Equipment and Furniture
In February when the building process is completed, the Project Director will begin the
process of procurement of equipment and furniture. Delivery and installation are
expected to be completed by end of March. Testing the equipment is scheduled to take
place in April and clinical work is scheduled to start in May 2007.
b) Start-up of services
To begin with, VCT services will be delivered by a group such as the AIDS Information
Centre (AIC) which is a well-established VCT organization in Uganda and can provide
VCT on an outreach basis. About one VCT session will be scheduled every three months
to be carried out in relation to the major community education events of
music/dance/drama and sports. After six months these VCT outreaches will be
complemented by clinic-based VCT services to coincide with the doctors monthly
clinics. VCT at the clinic will be provided by the HIV counselor of the project-- a
certified HIV counselor.
The best music/dance/drama teams will be paid a small stipend to entertain while
educating the general public in scheduled events to be linked to VCT at least once in
three months. These events will each time be climaxed by a sports competition by the
youth. In the mean time the music/dance/drama teams will be rehearsing and preparing
for the annual competition on World AIDS Day, 1st Dec. The top four teams will again be
paid to inform and entertain the communities in the new year. This cycle of competitions
25
will ensure that there are new creations by artists and that one group does not dominate
the stage indefinitely.
The sports competitions will be scheduled in accordance with school holidays, starting
with rehearsals and practice as soon as holidays start and ending with competitive
matches in the last week of holidays. In Uganda, school holidays take place Dec-Jan;
April and August. Each of these competitions will be linked to the music/dance/drama
competitions and to VCT outreach.
Ongoing counseling provided by counseling aides and religious counselors will start with
the training of these cadres. A counseling skills course will be designed in collaboration
with a counseling training organization such as TASO. TASO, the AIDS Support
Organization, is the oldest AIDS care organization in Uganda started in 1987 and
currently provides HIV treatment, care and support to tens of thousands of people living
with HIV/AIDS at its twelve centers located in various parts of the country. This training
will be a sandwich course starting with a few days of in-class training, followed by a
period of counseling under supervision by the HIV counselor of the project. The course
will end with another few days of in-class training which will result in a certification.
Once qualified, these counseling aides will begin providing the service of ongoing
counseling.
Youth peer educators will be trained after their course is developed in collaboration with
an organization such as Naguru Teenage Centre which has expertise in providing
information and services to youths. It will also be a sandwich course and supervision
will be provided by the HIV counselor of the project. Once qualified, youth peer
educators will take on the role of facilitating pre-sports HIV discussions. They will also
work at the community health centre in the youth corner to provide client care to the
youth and direct them appropriately to services available at the community centre.
Another course will be developed for community health workers again in collaboration
with organizations such as TASO that have experience in this area.
A course for nursing aides will be developed and it will have a number of stages, perhaps
three. Those who pass the first stage will start working as they study for the second stage
and when they pass the second stage they will work, in a higher position, as they study
for the third stage. After the third stage they will formally graduate and continue working.
The course will be developed in collaboration with hospitals such as missionary ones that
have experience in training nursing aides.
Primary health care services will be initiated starting with monthly visits to the clinic by a
team of health workers lead by a doctor. On a scheduled day of the month the team will
come with lab equipment, medicines and other supplies in a vehicle, conduct the clinic
and leave in the evening.
c) Monitoring and Evaluation, Social behavioral studies and operations research and
annual KAP survey
One of the objectives of this project is to learn how best to support communities to
respond to the epidemic. Right from the very beginning and throughout the project the
principle of strict project monitoring and evaluation will be engrained in the project. For
this reason the project will hire the services of suitably qualified consultants to set up
systems for monitoring and reporting service delivery statistics. In addition, various
26
service delivery approaches will be systematically observed as experiments. Outcomes

from these observations will be used to modify service delivery to make it more costsaving, higher quality and more effective. Further, there will be many opportunities to
document social cultural and behavioral observations made during the course of service
delivery and community education and entertainment. This data will be carefully
collected and synthesized in reports to be disseminated in local and national meetings as
well as presented internationally at conferences and journals.
Table 3: Work Plan, Timeline and Budget for Procurement and Start-up phase. FebJuly 2007.
Activity
Timeline
Budget elements
Budget in
Budget
Uganda
in USA
Shilling
$
dollars
@
1650
Lab and other medical
8,250,000
5000
equipment as well as
furniture
Electricity generator
8,250,000
5000
General operating costs Feb-Dec
Fuel for generator,
3,300,000
2000
(Eleven
water, mobile phone
months @
charges, cleaning
300,000)
supplies, office
stationery etc)
Monthly doctors
May-Dec
Transport and
3,952,000
2395
clinics
Eight visits honorarium for
@ 494,000 Doctor/Project Director;
Nurses salary; Lab
techs salary; nursing
aides salary; HIV
counselors salary;
medicines and other
supplies
Training of nursing
Mar-July
Facilitators salaries,
1,920,000
1164
aides, counseling aides, (16
transport, meals. (two
peer educators and
workshops
days each, 20
community health
days
participants).
workers.
@ 120,000)
Information and
Feb-July
Stipend for teams;
1,000,000
606
entertainment events of (2 events @ salary for community
music/dance/drama
500,000)
health workers, cost for
and sports
mobile VCT
competitions.
Preliminary
Oct
Cash prizes, meals,
500,000
303
competitions
salaries and transport for
27
st
facilitators
Cash prizes and meals
Consultant salaries and
transport. Data
collection, data
management, report
writing
Final competitions
1 Dec
800,000
485
Consultants for
Oct-Dec
4,690,000
2842
monitoring and
evaluations, social
behavioral studies and
operations research and
annual KAP survey
Total
32,662,000 19795
Budget notes:
Doctors Medical Clinics: The money budgeted here includes transport and honorarium
for the doctor (200,000 per clinic day), salary for the lab technician (45,000 per clinic
day), salary for the Nurse (45,000 per clinic day), salary for the HIV counselor (45,000
per clinic day), salary for a senior nursing assistant (15,000 per clinic day). The budget
also includes medicines and other supplies calculated at a rate of 4,8002 per patient for 30
patients per clinic day (144,000 per clinic day).
Training activities: This refers to training of staff such as counseling aides, peer
educators etc. The cost of each training day includes salaries for two facilitators @
45,000 (90,000), stationery of 10,000 and meals for 20 people (20,000).
Information and entertainment events of music/dance/drama and sports
competitions: The costs will include a stipend for the entertaining group (50,000),
transport and salary for community health workers to facilitate the session (50,000),
transport for counseling aides and peer educators to provide one to one counseling to
those who desire (50,000). And fees for a mobile VCT team (350,000).
E.
SUSTAINABILITY AND THE WAY FORWARD
User Fees: In the first place patients receiving care at the general medical clinics operated
by the doctor will pay user fees, not to be paid for HIV services. The amount to be paid in
user fees will be determined after local consultations. This money will be saved and used
to fund services when the funded project ends. In the last three months of the funded
project, an executive service will start to be provided at which the costs will be fully
recovered. This service will be marketed among the management of the tea and sugarcane
farms and because of the good quality of care is likely to attract other working people in
the community who otherwise seek care at private clinics.
Funding of services by Government and others: All through the project, effort will be
made to solicit support from the government or from national organizations responsible
for a particular service such as VCT, ARV or PMTCT. Indeed in the long run the project
aims to be designated as an official delivery point for these services and be entitled to
receive funds and support for these services similar to government or NGO facilities.
Other Fundraising: In addition a fundraising effort will be undertaken among local
Ugandan charity organizations like the Rotary Club and the Lions club. Furthermore, the
training course of nursing aides, counselling aides, community health workers will
gradually be operated at full cost recovery. These costs will either be born by the students
2
Calculation based on actual costs observed at Naguru Teenage Centre (unpublished)
28
or by their sponsoring institutions. In addition, researchers and interns from various

institutions will be encouraged to undertake their studies or internships at the project site
and will also be asked to make a monetary contribution to the running of the services of
the project.
Charges for information and entertainment: The community HIV education and
entertainment music/dance/drama and sports groups will also begin to charge fees for
their work. The drama clubs of TASO and AIC indeed currently charge a fee whenever
they are invited by another organization to perform. The music/dance/drama groups of
Namulaba will be marketed outside of the project area and be made available to perform
for other projects for a fee. Money will also be collected at football/netball matches. The
money collected out of these events will be managed by the groups and used to sustain
their work.
New project proposals: All the same there will remain a need to seek formal funding to
continue especially the HIV services. For this reason, one of the objectives of this project
is to strengthen the capacity of CBOs to write project proposals. Indeed one of the
expected outcomes of the project is that by the end of the first year, there will be at least
three project proposals developed by CBOs and funded to deliver various elements of
HIV services as per their expertise.
c) Project review, evaluation and strategic planning
After six months of operation, a review of the achievements, challenges and lessons
learned from this project will be made. At some stage an external facilitator will be
invited as a consultant to conduct strategic planning sessions. A number of issues about
the future of the project will be addressed during these sessions. These will include the
future direction with regard to sharing country-wide the lessons learned in this project.
Issues of replication in neighbouring and distant communities will be discussed. Issues of
whether Namulaba should become a teaching centre of excellence on HIV programming
in communities and others will also be examined. Some of the outcomes of these
discussions may be implemented immediately while others may need raising new funds
in which case a new proposal will be written. Indeed, an expected outcome of these
strategic planning meetings is that a new two-year strategic plan will emerge. Based on
this new plan a number of project proposals will be developed and submitted to a variety
of donors.
29

Namulaba Proposal To Avert 9 Jan 2007

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Namulaba Community HIV/AIDS Project