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  1. There is no Conflict of Interest for this presentation

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

  3. Presentation Layout

  4. The Sigulu Islands are located in Lake Victoria in Uganda • Commercial fishing is the main economic activity on these islands

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

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

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

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

  9. Limited infrastructure calls for improvised service delivery… Whatever space available is used by the visiting health teams!

  10. Illustrative Results: April 2011-June 2014

  11. HIV prevalence has continued to drop in newly tested islanders… • Sigulu Islands significantly contribute to HIV prevalence in East Central Uganda

  12. Uptake of most services provided is commendable… • VMMC uptake has steadily risen • ~40% of eligible males >10 years have been circumcised for HIV prevention to-date

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

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