This session discussed the major challenges on decentralization of ART scale up from regional and district hospitals to health centers. Country specific programmes from Uganda, Malawi and Ukraine presented their experiences and challenges of scale up.  The epidemics have very different characteristics in these countries.  Ukraine focused very heavily on providing services through focused NGO support to government programmes. The epidemic in this country is IDU driven and the GFTAM grant, which was  temporarily suspended, was re-initiated through civil society. Around  9,000 patients are now on ART and a multidisciplinary care approach was adopted. The ART coverage that was 3% some years ago, is now reaching 35%.  Innovations, implementation standards and policy changing  with advocacy by civil society has been critical. TB rates are very high.  Now plans to get 80,000 on ART by 2013.

The two African countries had more conventional interventions. Uganda informed that  sustainability, insufficient human resources and  lack of integration  are the major challenges to decentralize the ART expansion . The improvement of  national health care service is a priority strategy. In Malawi nurses are initiating ART but  large loss to follow up (around 1/3) with high mortality rates is a concern. Few TB patients, pregnant women and children are currently on ART.