1. LIST OF RELATED ACTIVITIES ARV Services (#6945), and Palliative Care: TB/HIV (#6944). 2. ACTIVITY DESCRIPTION KEMRI has been supporting implementation of PMTCT activities in the five districts of Kisumu, Nyando, Nyamira, Gucha and Kisii in Nyanza Province with Emergency plan funding since 2004. To date, the program has supported integration of PMTCT services in 77 ANC and maternity units, provided HIV counseling and testing to 77,921 women, and given ARV prophylaxis to 7,509 HIV-positive women. In FY 2007, KEMRI will continue to support PMTCT activities in this region whose ANC HIV prevalence ranges from 5-20%. Activities include counseling and testing of pregnant women in antenatal clinics (ANC) and in maternity wards, and provision of the more efficacious PMTCT ARV regimens to HIV+ women and exposed infants. In 2007, KEMRI will counsel and test 79,169 pregnant women and provide antiretroviral prophylaxis for 10,769 HIV-positive women, 50% of these women will receive both SD Nevirapine and AZT. In addition the program will support the WHO clinical staging of all HIV positive pregnant women to identify those eligible for HAART in line with the National guidelines, and will facilitate linkage or access to HAART for 1,074 of these women. Where CD4 testing is available, this will be used as additional criteria for identification of women eligible for HAART. All HIV positive women identified through the PMTCT program will be given Cotrimoxazole for OI prophylaxis therapy. TB is one of the common opportunistic infection seen in HIV positive individuals. The program will work with the TB/HIV program to strengthen TB screening among HIV-positive pregnant women and make referrals for treatment. The program will continue to support the follow up of HIV-positive women and their infants in the postnatal period through strengthening postnatal care services at facility level. The current package of care for the mother includes regular follow up, linkage to family planning services, OI prophylaxis and counseling on correct infant feeding practices; infant additional care activities include OI prophylaxis using Cotrimoxazole starting at six weeks of age, and DBS for HIV- PCR (Early Infant HIV Diagnosis-EID). The program will target 6,660 HIV exposed infants for DBS, and will work with the HIV/AIDS treatment program to ensure linkage to pediatric HIV care services for all eligible infants. The program will also strengthen psychosocial care and support for the HIV-positive mother and her family at both the facility and community levels through the establishment of structured support groups. At the facility level, interventions will include psychosocial counseling with a focus on giving information and skills to the HIV-positive women to encourage adherence to interventions such as correct use of ARVs and optimal infant feeding practices. At the community level, the interventions will include establishment of support groups, dealing with disclosure and encouraging partner and family support. To strengthen increased male partner involvement, the program will review the current approach of male-only clinic with a view of replicating this model. KEMRI will work with the Ministry of Health to expand PMTCT services from the current 104 to 130 health facilities with the goal of achieving universal geographic coverage of services. The program will train 553 service providers on PMTCT and comprehensive HIV management for HIV-positive mothers and their families. This program will also support DBS for DNA PCR activities in Nyanza and Western Province through the purchase of the required test kits and supplies.

Significant changes in 2007 focus on the provision of a more comprehensive package of care to the HIV positive woman, her infant and family. These activities include use of the more efficacious PMTCT ARV regimen in line with WHO and Kenya National ARV guidelines, EID and strengthened linkage to pediatric HIV care services and improved TB screening among the HIV-positive pregnant women. 3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will contribute 7.8 % of the pregnant women who receive counseling and testing and 12 % of the ARV prophylaxis to the 2007 PEPFAR PMTCT target totals. This program will also contribute to the number of HIV positive women accessing TB screening and treatment services thereby contributing to the PEPFAR care and treatment goals. Finally, the program will also contribute to pediatric HIV care and treatment goal through identification of HIV-exposed and infected infants who require care and treatment. 4. LINKS TO OTHER ACTIVIES This activity relates to the KEMRI ARV Services program (#6945), and the KEMRI TB program in Nyanza Province (#6944). This activity is linked to Palliative Care and HIV/AIDS treatment/ARV services through the provision of ongoing care to the HIV-positive women in the antenatal and post natal settings, care of the HIV exposed infant in the post natal period, referral for pediatric HIV diagnosis and referral to the ART

sites for women and infants based on the national guidelines. It also linked to Palliative Care: TB/HIV through the integration of TB screening services among the HIV positive pregnant women in PMTCT settings and referral to the TB clinics. 5. POPULATIONS BEING TARGETED Targets adults, pregnant women, HIV positive pregnant women, HIV-positive infants and HIV affected families. Health care providers in the Ministry of health including doctors, nurses and other health care workers such as clinical officers, will be targeted for training. Community mobilization efforts will work with community based groups to address factors affecting uptake of PMTCT services. This activity also targets rural communities. 6. KEY LEGISLATIVE ISSUES ADDRESSED Will increase gender equity in HIV/AIDS programming by providing training on couple counseling, risk assessment, and stigma reduction, and supporting women to mitigate potential violence or other negative outcomes of disclosure. Community mobilization efforts for increasing male partner support and involvement will also address male norms and behavior thereby increasing PMTCT service uptake. 7. EMPHASIS AREAS Major emphasis on quality assurance, quality improvement and supportive supervision with minor emphasis on community mobilization/participation, Training and Development of Network/Linkages/Referral systems.

Plus-up funds will be used to support training of trainers (TOTs) on early infant diagnosis: national algorithm and DBS collection, handling and shipment. The master trainers will be used to scale up training activities and mentorship at district levels. Funds will also be used to strengthen counseling on infant nutrition, formation of exclusive breastfeeding support groups, and psychosocial support. Brochures, posters and education materials with messages on EID and infant and young child nutrition will be developed in English, translated into national and local language in HIV high prevalence areas. Funds will further be used on procurement of reagents, on logistics and policy issues. Plus up funds will also be used to procure HIV test kits to support the upscaling of partner testing. A budget total of $300,000 is earmarked for this activity and will support HIV tests for 200,000 partners. Finally, an additional plus up fund budget of $ 500,000 will be used to strengthen the diagnosis and treatment of Sexually Transmitted Infections-specifically Syphilis screening (using RPR) among pregant women attending ANC clinics as part of the comprehensive PMTCT program.This will be achieved through the purchase and distribution of reagents to all the 1,500 PMTCT sites nationally.The program will also complement the national program efforts of routine Hb tests as part of the ANC profile tests. The program will target reach 1,000,000 pregnant women within PMTCT program nationally.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Counseling and Testing (#6941), Condoms and Other Prevention (#6948), and Abstinence and Be Faithful Programs (#6903).

2. ACTIVITY DESCRIPTION The Kenya Medical Research Institute (KEMRI), through its collaboration with CDC, will participate in a study of youth interventions conducted by the Institute of Tropical Medicine (ITM) in the Asembo and Gem areas of Nyanza Province, which has the highest HIV prevalence rates in the country. KEMRI and CDC have had a long collaboration in Nyanza Province, and KEMRI implements activities through a cooperative agreement with CDC Atlanta. Although some of the activities for this youth intervention are implemented by ITM, and are described in that entry, KEMRI is also actively involved in the study, primarily through the hiring of local staff and by supporting local implementation of the project. One of the major activities being conducted by KEMRI in partnership with ITM is the implementation of a "Families Matter" curriculum which involves both the youth and their parents. This is an adaptation of the US-based "Parents Matter" curriculum which CDC has evaluated in the US. To date, parents and community and religious leaders in Asembo and Gem are very supportive of this approach of enabling parents to take a more active role in HIV prevention for their adolescent children. Staff hired by KEMRI will be involved in the continued "roll-out" of this intervention. Efforts to change the social norms which contribute to the high risk for young girls in this part of Kenya are part of this intervention. The project has also found that the lack of skills and employment opportunities contributes to high-risk behavior among girls, so one aspect of the project is the provision of vocational skills and opportunities for income-generating activities for these youth. In the past, CDC-prevention programs have been met with unexpected shortfalls in funding or supplies which require a rapid response such as supporting partner organizations to attend particularly important forums or providing essential prevention supplies. To provide a back up for this, up to $50,000 is included in this narrative to enable KEMRI, in collaboration with CDC respond favorably to such needs.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This project will contribute to the Kenya Five-Year Strategy which focuses on HIV prevention in youth, as the primary target group is young people, including children aged 10 to 14. It will primarily provide staffing and other administrative support in the implementation of the ITM project; therefore the specific targets related to this activity are listed in the CDC-AB-ITM entry and are therefore not duplicated in this entry.

4. LINKS TO OTHER ACTIVITIES This activity will be very closed linked to AB activity (#6903) implemented by the Institute of Tropical Medicine and to the KEMRI OP activity (#6948) and CT KEMRI activity (#6941) for Nyanza province. These activities serve as referral points for each other, and ITM staff provide technical assistance in the scientific adaptation of curricula that is largely implemented by KEMRI staff. Young people needing counseling and testing are served under the KEMRI CT activity.

5. POPULATIONS BEING TARGETED The primary population being targeted is rural youth, including both in-school primary and secondary students and out-of-school youth. Ages of youth targeted range from 10 to the early twenties. Different, age appropriate curricula are used with these groups. In addition, their parents and community and religious leaders are targeted by the project including religious leaders and volunteers. All of the targets relating to this study of model youth interventions are described in the ITM entry and are not duplicated here.

6. KEY LEGISLATIVE ISSUES ADDRESSED This project will have a strong gender component, including increasing young women's access to income and productive resources and addressing male norms and behaviors.

7. EMPHASIS AREAS The primary emphasis area is human resources, as the project has a large staff needed to implement and assess the impact of these interventions. Community mobilization to change social norms which encourage early sexual debut is also an important component of this project, along with IEC activities to educate the youth and their parents about abstinence and faithfulness.

1. LIST OF RELATED ACTIVITIES This activity relates to Abstinence and Be Faithful Program (#6903) and to the Condoms and Other Prevention Activity (#6904).

2. ACTIVITY DESCRIPTION The Kenya Medical Research Institute, through its collaboration with CDC, will participate in a study of youth interventions conducted by the Institute of Tropical Medicine (ITM) in the Asembo and Gem areas of Nyanza Province, which has the highest HIV prevalence rates in the country. KEMRI and CDC have had a long collaboration in Nyanza Province and KEMRI implements activities through a cooperative agreement from CDC Atlanta. Although most of the activities for this youth intervention are implemented by ITM, and are described in that entry, KEMRI is also actively involved in the study, primarily through the hiring of local staff and to support some of the local implementation of the project. In 2007, 6000 individuals will be reached with targeted HIV prevention messages. 10 condom outlets will be established. This comprehensive youth intervention study includes the following OP activities. One activity being conducted by ITM is the adaptation and implementation of a safer sex curriculum targeting youth aged 13 to17 years old. "Healthy choices for a better future" is an adaptation of "Making Proud Choices", a curriculum that was selected by CDC as an effective intervention. The curriculum is currently going through the final stages of adaptation and will be pilot tested in the coming weeks. ITM is also developing a proposal to evaluate this curriculum. Staff hired by KEMRI will be involved in the assessment and implementation of this curriculum. In addition, prevention activities are organized throughout the year at schools and in the community in close participation with local youth committees and volunteers. Efforts to change the social norms which contribute to the high risk for young girls in this part of Kenya are part of this intervention. The project has also found that the lack of skills and employment opportunities contributes to high risk behavior among girls, so one aspect of the project is the provision of vocational skills and opportunities for income generating activities for these youth.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This project will contribute to the Kenya's Five-Year Strategy which focuses on HIV prevention in youth, as the primary target group is young people, including adolescents aged 13 to 17 years. 6,000 young people will be reached with this intervention and 10 condom outlets will be established.

4. LINKS TO OTHER ACTIVITIES This activity will be very closely linked to AB activities implemented by the Institute of Tropical Medicine (#6903) and to the OP activities being implemented by ITM (#6904) in Nyanza province.

5. POPULATIONS BEING TARGETED The primary population being targeted is rural youth, including both in-school and out-of-school youth. Ages of youth targeted range from 10 to the early 20's. Different, age appropriate curricula are used with these groups. In addition, their parents and community and religious leaders and volunteers are targeted by the project. Teachers and rural communities are also targeted as well as adults through adult involvement. It also targets People Living with HIV/AIDS.

6. KEY LEGISLATIVE ISSUES ADDRESSED This project will have a strong gender component, including addressing male norms and behaviors, focusing on reducing violence and coercion and increasing gender equity in HIV/AIDS programs. Through its' livelihoods project, it will increase women's access to income and productive resources.

7. EMPHASIS AREAS The primary emphasis area is community mobilization to change social norms which encourage early sexual debut. Another emphasis is Human resources, as the project has a large staff needed to implement and assess the impact of these interventions. IEC activities to educate the youth and their parents about abstinence and faithfulness as well as conducting needs assessment are also important areas in this project.

This will be an expansion of COP 07 activities. 1. LIST OF RELATED ACTIVITIES This activity relates to activities in ARV Services (#6945), Counseling and Testing (#6941), TB/HIV (#6944), and PMTCT (#6949). Kenya Medical Research Institute (KEMRI) will expand ongoing activities at more than 50 sites mainly in Nyanza but also in Eastern, North Eastern Provinces and Kilifi district. These expanded activities include support for provision of facility based palliative care services for 56,000 people with HIV, including 3000 children, and support for training for 650 health care workers. Laboratory and clinical network centers will be supported at New Nyanza Provincial Hospital and Kilifi District Hospitals. Support for N. Eastern and Eastern Provinces will transition to Care International and TBD partner, respectively. Points of service will include all district and sub-district hospitals in the regions served by these referral hospitals, as well as many health centers and dispensaries.

2. ACTIVITY DESCRIPTION Kenya Medical Research Institute (KEMRI) will expand ongoing activities at more than 50 sites mainly in Nyanza but also in Eastern, North Eastern Provinces and Kilifi district. These expanded activities include support for provision of facility based palliative care services for 50,000 people with HIV, including 3000 children, and support for training for 650 health care workers. Laboratory and clinical network centers will be supported at New Nyanza Provincial Hospital and Kilifi District Hospitals. Support for N. Eastern and Eastern Provinces will transition to Care International and TBD partner, respectively. Points of service will include all district and sub-district hospitals in the regions served by these referral hospitals, as well as many health centers and dispensaries. At each site KEMRI provides technical assistance, equipment and supplies, infrastructure improvement, improvement of laboratory capacity, laboratory reagents, adherence counseling, assistance with monitoring and reporting, cotrimoxazole prophylaxis to prevent opportunistic infections, treatment of opportunistic infections, improved access to safe drinking water, establishment of psychosocial support groups linked to each clinic and additional community-based services. KEMRI conducts a number of activities that enhance the development of care services at the national and regional level. These include regular coordination meetings of HIV care providers in the province in collaboration with the Provincial ART Officer, regional quality assurance programs, and specimen transfer networks to optimize the availability of high quality CD4 cell count determination and national infant diagnostic HIV testing. KEMRI supports facility-based practical training during which health care workers are invited to join the functioning clinics and gain experience in all aspects of HIV treatment and clinic management. This activity's scope includes: identification and treatment of HIV-infected children and adults and provision of care in remote areas. The latter is facilitated by mobile teams that move between rural health centers and dispensaries, particularly those providing PMTCT services or TB treatment, an important step towards decentralization. KEMRI has implemented a data collection system designed to assist health facilities report national and PEPFAR indicators. Significant changes from FY 2006 to FY 2007 for this activity include decentralization of services, transitioning to new USG partners in Central, North Eastern, and Eastern Provinces, and increased emphasis on: provision of care for children, strengthening linkages with related programs, greater involvement of PLWAs and prevention with positives. In FY 2007, KEMRI will initiate support for HIV care provision to mentally ill patients at Mathari Mental Hospital, the national referral hospital for mentally ill patients in Kenya. This activity will support development of treatment guidelines for the mentally ill patients and training curriculum for the health workers in Mathari Hospital. This facility will act as a referral center for all other mental health facilities in the country.

The long-standing (>25 years) collaboration between KEMRI and CDC in Kenya was initially research-based, then expanded in 1999 to include HIV prevention and treatment activities. By the end of March 2006, this collaboration was supporting care at more than 70 facilities and was supporting palliative care services for more than 40,000 patients.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will contribute to the results of expansion of palliative care services for people with HIV, strengthened human resource capacity to deliver palliative care services, and a strengthened referral network for these services. In addition, these activities will contribute to expansion of care for HIV-infected children, in particular by supporting infant testing at sites supported both by this partner and other Emergency Plan partners.

4. LINKS TO OTHER ACTIVITIES These services link to KEMRI-supported ARV treatment services (#6945) as well as other ART and non ART services provided by other Emergency Plan Partners like University of California, San Francisco, Catholic Relief Services and Cooperative Housing Foundation in Nyanza Province. They also tie into well-established referral linkages with local VCT (#6941) and PMTCT (#6949) programs. Practical training supported by KEMRI is linked directly to classroom training supported by Mildmay International (#6992). The population level impact of the supported services is being evaluated through SI activities (#6946) conducted by KEMRI. KEMRI activity support in Central and Eastern Provinces will gradually be replaced by support from Columbia University (#6868) and TBD partner (#7043).

5. POPULATIONS BEING TARGETED The target population for this activity is people with HIV. The main geographic region served by these activities is Nyanza Province, a priority region because it has the highest prevalence of HIV in Kenya (15% compared to 7% nationally). Most of the services are provided to the general population with HIV, but special services are provided to women and children through pediatric and PMTCT-plus services, to participants in US government funded research programs and their families, and the mentally ill. Discordant couples are targeted by behavior change counseling and other prevention activities focused on HIV-infected patients.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses legislative issues related to stigma and discrimination through involvement of PLWAs in service provision and community sensitization activities.

7. EMPHASIS AREAS This activity includes minor emphasis on commodity procurement, development of network/linkages/referral systems, human resources, logistics, and quality assurance and supportive supervision, training, and strategic information.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in CT (#6941), Palliiative Care (#6942), ARV Treatment (#6945), and PMTCT (#6949).

2. ACTIVITY DESCRIPTION In FY 2007, Kenya Medical Research Institute (KEMRI) will expand collaborative TB/HIV activities in Nyanza Province, an area that is projected to register 25,000 new TB patients. All 12 districts in Nyanza Province will be supported to expand TB/HIV collaborative activities, including HIV testing of TB suspects and monitoring and treatment of HIV in TB clinics. We will strengthen active TB screening among HIV-positive clients at the PSC/CCC and medical inpatient wards. PEPFAR funds will support provincial and district TB/HIV stakeholders meetings, train workers in and implement enhanced TB screening, diagnosis, treatment, and referral, and develop and print IEC materials. Mechanisms of referral to TB clinics and back-referral to HIV care settings will be emphasized, and treatment and recording of TB in HIV care settings will be piloted.

KEMRI is also supporting TB/HIV services in Kodiaga and Kibos prisons, and will expand services to prisons in Siaya, Homa Bay and Kisii, including intensified TB case detection. In collaboration with the Kenya Association for Prevention of TB and Lung Disease (KAPTLD), KEMRI will support good clinical and laboratory practice in 10 private clinics. Activities will focus on capacity building, provision of equipment, minor renovation, and procurement of supplies including cotrimoxazole (CTX), HIV test kits and laboratory reagents. In addition 5 laboratory technicians will be recruited to improve access to AFB microscopy and investigations for HIV care. In Nairobi, in 2007, Rhodes TB Clinic will screen 10,000 TB suspects, and serve between 4000 - 5000 TB patients. In FY 07, TB/HIV activities will be coordinated by KEMRI through partnership with the National Leprosy and Tuberculosis Program (NLTP), Nairobi City Council (NCC) and the USG agencies. In both Nyanza and Nairobi, the funds requested for will be used for testing TB suspects and patients for HIV, screening for TB among HIV+ persons, providing HIV+ TB patients with referral and CTX/ART, risk reduction counseling and psycho-social support, training of health workers to deliver TB/HIV services, supporting infrastructural development, supporting supply of HIV test kits and medicines for TB prevention and other opportunistic infections and improving referral linkages. To improve community participation in DOTs delivery, 700 community health workers (CHWs) from Migori and Rachuonyo Districts will be trained. In addition, supervision of the already trained 1,460 CHWs will be strengthened through recruitment of a coordinator. Motivation of the trained community health volunteers will be maintained through regular meetings, refresher trainings, exchange visits and non-monetary incentives. In order to improve supervision of TB/HIV work, 3 motor bikes will be provided. All sites delivering collaborative TB/HIV services will use a standard TB/HIV data collection tool developed by the NLTP.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will result in strengthened delivery of integrated TB/HIV services, including strengthened referral systems, improved diagnostics and treatment of TB among HIV-positive patients and of HIV in TB patients, strengthened capacity of health workers to provide integrated TB/HIV services and strengthened systems capacity for program monitoring and evaluation and management of commodities.

There will be a special focus on screening for TB in at least 20% of the HIV-infected patients from the PSC/CCC and medical in-patient wards. The proportion of HIV-positive TB patients on ARVs will be increased from 30% to 60% with 100% CTX coverage. Quality of laboratory services will be improved through recruitment of laboratory technologist, AFBs microscopy training and improved supervision.

4. LINKS TO OTHER ACTIVITIES These activities will be linked to ongoing CT (#6941), Palliiative Care (#6942), ARV Treatment (#6945), and PMTCT (#6949) actitivites in Nyanza and Nairobi Provinces including linkages with the private sector and prisons.

5. POPULATIONS BEING TARGETTED TB suspects (adults and children), TB patients, HIV+ persons identified from PSC/CCC/medical inpatient wards, and PLWHA organizations - deliberate action will be taken to intensify TB screening and TB case finding among PLWHA.

6. KEY LEGISLATIVE ISSUES ADDRESSED Diagnostic HIV testing for all TB patients will be given on an "opt out" principle. Guidelines on HIV testing based on consent, confidentiality and counseling will be observed as part of standard practice. Increased availability of CT in clinical settings and increased access to HIV-related care for TB patients will help reduce stigma and discrimination.

7. EMPHASIS AREAS TB screening, DTC, commodity procurement, quality assurance, community mobilization, infrastructure, targeted evaluation, network/linkages/ referral systems, and training.

Provider-iniatiated diagnostic HIV counseling and testing in all health care settings including OPDs, in-patients and TB clinics is essential because this facilitates provision of comprehensive care and provides opportunity to prevent new HIV transmissions.TB clinics already test more than 60% of TB patients and plan to achieve universal coverage. Diagnostic CT in OPDs and among in-patients is still poorly provided for but has potential to complement TB activities as TB suspects will be screened for HIV and PLWHA screened for TB. It is essential that uninterrupted supply of HIV test kits is sustained in all these clinical settings and the Plus-up funds will be used to supplement supply of test kits.

1. LIST OF RELATED ACTIVITIES This activity is related to activities in AB (#6943), OP (#6948), ART (#6945), PMTCT (#6949), TB/HIV(#6944), and Lab (#6940).

2. ACTIVITY DESCRIPTION In FY 2007 Kenya Medical Research Institute (KEMRI) will strengthen and expand HIV counseling and testing (CT) services in Nyanza province, the region with the highest prevalence in the country. CT services in Nyanza include both client and provider initiated CT approaches, and is provided both in health facilities and in the community. In the past, the KEMRI CT program focused mainly on VCT. From FY 2005, KEMRI began to introduce provider-initiated CT, because of the increasing care and treatment opportunities, made possible through the President's Emergency Plan. In FY 2006, the KEMRI supported VCT program in Nyanza was handed over to Liverpool VCT. This notwithstanding, KEMRI will continue to provide oversight supervision, data management and quality assurance for the VCT program in Nyanza. In FY 2007, KEMRI will put more resources into provider-initiated and home-based CT. In provider-initiated CT, KEMRI will support dissemination of policies and guidelines, training and supervision. In the same FY 2007 KEMRI will expand the implementation of home based CT in Asembo and Gem, as part a comprehensive community HIV/AIDS program. Other components of the home care program will be PMTCT, ART, Lab and TB-HIV. Proper implementation of the home-based CT program in Nyanza will lead to many previously undiagnosed people knowing their status and being referred to care and treatment. It will also support community and client education about HIV/AIDS. Special efforts will be made to promote couples VCT and to provide prevention services for discordant couples. In FY 2007, KEMRI will provide CT services to at least 60,000 people in the region. In order to achieve this, they will train 120 counselors and health workers. Most of these will be deployed to the home-based CT program. Currently there are 12 health facilities that provide DTC in both out-patient and in-patient services in the whole of Nyanza. In FY 2007, this service will be expanded to cover 50 sites in the province. In FY 2007, KEMRI will also facilitate quality assurance for both counseling and testing.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA CT in this high prevalence area will result in identification of many previously undiagnosed HIV positive individuals and discordant couples who will benefit from prevention, care and treatment that have been made available through the President's Emergency Fund. This partner is expected to contribute 7% the total USG target for CT during FY 2007. These planned activities will contribute to the result of increased access to CT services, particularly among underserved and high risk populations. In health care settings, increased availability of diagnostic CT services will lead to identification of many HIV infected patients who are eligible for ART. The activity also contributes substantively to Kenya's 5-Year Strategy that focuses on encouraging Kenyans to learn their status and emphasizes HIV testing as standard package of care in medical settings. The strategy also emphasizes the development of strong links between CT services and care outlets and also between the community and the heath care system.

4. LINKS TO OTHER ACTIVITIES KEMRI CT activities in Nyanza province and neighboring areas will refer increased number of HIV positive patients requiring care to the Emergency fund supported Comprehensive care centers at Nyanza Provincial Hospital, AMPATH -Chulaimbo, Merlin and Mildmay. Strengthened linkages between CT centers and care outlets will improve utilization of care opportunities created through the President's Emergency Fund and other partners. This activity is linked to KEMRI AB activity (#6943), KEMRI-ART activity (#6945), KEMRI PMTCT activity (#6949), KEMRI TB/HIV activity (#6944) and KEMRI OP activity (#6948). This activity is also linked to KEMRI Lab activity (#6940).

5. POPULATIONS BEING TARGETED This activity will mainly target rural communities in the project site, working together with community and religious leaders in each community. In this area, the whole population will be targeted, including adults, youth and children (including infants). The activity will also target symptomatic individuals seeking care at health facilities especially in medical wards, STI clinics, TB clinics and other service outlets targeting conditions that are commonly associated with HIV. In addition, health care providers in both public and private medical settings will be trained to provide CT services to patients as part of routine

medical care.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity will increase gender equity through family approach to CT, during the home based CT program. The low CT service uptake by couples and low disclosure rate by partners will be addressed through vigorous campaigns to educate people of Nyanza on the benefits of couple VCT and mutual disclosure of HIV status. The much increased availability of CT services in clinical and community settings will help to reduce stigma and discrimination besides addressing people's right to access the highest standards of CT and care services.

7. EMPHASIS AREAS In FY 2007 KEMRI will implement home based CT. Major emphais areas for this activity are in the area of training. In addition, part of the implementation of this activity will involve a minor emphasis on targeted evaluation activities. But for this to succeed there will be need for other emphasis to be in the areas of human resource development, community mobilization and development of network/linkages. In some instances, there may be need for infrastructural support to facilitate referral. Apart from the home based CT program KEMRI will continue to provide oversight technical support to CT activities in the entire Nyanza region, for quality assurance and quality improvement.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in ARV Drugs (#6997, #6989, #6969) and ARV Services (#6945, #7004).

2. ACTIVITY DESCRIPTION The Kenya Medical Research Institute (KEMRI) will assist with forecasting and procurement of additional drugs needed to treat 110,000 Kenyans with ARVs. Two other major partners - Mission for Essential Drugs and Supplies, Management Systems for Health/Rational Pharmaceutical Management Plus (MSH/RPM Plus) will maintain primary responsibility for procurement and distribution of pharmaceuticals nationally and under the Emergency Plan. Together with USG staff in country, these major partners are primarily responsible for quantification and tracking for ARVs procured with Emergency Plan funds. This alternate procurement mechanism through KEMRI will allows some flexibility that will help to continue to avoid stock outs and treatment interruptions.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities are essential to maintaining a full and uninterrupted supply of HIV/AIDS related pharmaceuticals and commodities.

4. LINKS TO OTHER ACTIVITIES These activities will coordinate with other partners involved in ARV drugs, KEMSA, MEDS, MSH/RPM Plus, and complement and link with all activities listed in the ARV services program area.

5. POPULATIONS BEING TARGETED This activity targets men, women, and children with HIV.

6. EMPHASIS AREAS This activity includes a major emphasis in commodity procurement.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Palliative Care (#6942), ARV Drugs (#6947), Counseling and Testing (#6941), TB/HIV (#6944), and PMTCT (#6949).

2. ACTIVITY DESCRIPTION "This will be an expansion of the exisiting COP 07 activities.Kenya Medical Research Institute (KEMRI) will expand ongoing activities at more than 40 sites mainly in Nyanza but also in Kilifi District, Coast and Eastern, North Eastern, and Central Provinces. These expanded activities include provision of antiretroviral treatment to 15,000 HIV-positive individuals (3,000 new patients), including 1,300 children, and support for training for 400 health care workers. Laboratory and clinical network centers will be supported at the Provincial Hospitals in Kisumu and Garissa and District Hospitals in Machakos and Kilifi. The support for Garissa and Eastern South (Machakos) will transition to Care International and TBD partner. Points of service will include all District and most Sub-District Hospitals in the regions served by these referral hospitals, as well as many health centers and dispensaries. " At each site, KEMRI provides technical assistance; equipment and supplies (test kits); support to improve laboratory capacity, laboratory reagents (specifically for PCR reagents for early infant diagnosis); support for adherence counseling; assistance with monitoring and reporting and infrastructure improvement. Funds from this renewal will be used to renovate Matuu sub district hospital and Ambira health center in Eastern and Nyanza provinces respectively.KEMRI also conducts training and provides salary support for some staff in accordance with Emergency Plan guidelines. ARVs are provided at the sites through the Kenya Medical Supplies Agency (KEMSA), Mission for Essential Drugs and Supplies (MEDS), and through KEMRI procurement. KEMRI also conducts a substantial number of activities that enhance the development of treatment services at the national and regional level. KEMRI supports regular meetings of care and treatment providers in the Province in collaboration with the Provincial ART Officer, and is helping to develop regional quality assurance programs and expand specimen transfer networks to provide high quality CD4 cell count determination and diagnostic HIV testing for infants.

KEMRI program key focus areas include: identification and treatment of HIV-infected children, identification and treatment of infected patients in the in-patient setting, and provision of care in remote areas. The latter is facilitated by mobile teams that move between rural health centers and dispensaries, particularly those providing PMTCT services or providing treatment services to large numbers of patients with TB. Because the PMTCT and TB treatment programs have been effectively decentralized, the support for services at these sites is an important step toward decentralization of treatment services for people with HIV. KEMRI will continue to assist with data collection and national reporting for supported facilities. By the end of March 2006, KEMRI was contributing to ARV treatment for more than 9,000 patients in 38 facilities. In 2007, KEMRI will initiate support for ART provision to mentally ill patients at Mathari Mental Hospital, the national referral hospital for mentally ill patients in Kenya. This activity will support development of treatment guidelines for the mentally ill patients and training curriculum for the health workers in Mathari Hospital. This facility will act as a referral center for all other mental health facilities in the country. 3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will contribute to the results of expansion of ARV treatment for clinically qualified HIV-positive patients, strengthened human resource capacity to deliver ARV treatment, strengthened referral networks for provision of ART, and expansion of treatment services for children. KEMRI activities also support other programs, for example by providing training opportunities to staff from other programs and by providing infant diagnostic testing.

4. LINKS TO OTHER ACTIVITIES This activity links to CT, non-ART/BHCS, PMTCT and SI services supported by KEMRI and other Emergency Plan partners (e.g., EngenderHealth and Family Health International). Practical training supported by KEMRI links directly to classroom training supported by Mildmay International.

5. POPULATIONS BEING TARGETED

The target population for this activity is people with HIV. Nyanza is high priority because of the very high prevalence of HIV (9-41%). Most of the services are provided to the general population with HIV, but special services are provided to women and children through pediatric and PMTCT-plus services, to participants in US government funded research programs and their families, and to mentally ill patients. Discordant couples are targeted by behavior change counseling and other prevention activities focused on HIV-infected patients.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses legislative issues related to stigma and discrimination through involvement of PLWAs in service provision and community sensitization activities.

7. EMPHASIS AREAS This activity includes minor emphases on commodity procurement, development of network/linkages/referral systems, human resources, logistics, training, targeted evaluations, and quality assurance and supportive supervision.

1. LIST OF RELATED ACTIVITIES This activity relates to all activities in MTCT, HVCT (#7009) and HVTB (#7001).

2. ACTIVITY DESCRIPTION The Kenya Medical Research Institute (KEMRI) is a premier Government of Kenya (GOK) biomedical research institute and home of CDC offices and laboratories. KEMRI has highly trained laboratory staff who conduct research and assess laboratory technologies. Key KEMRI objectives include: i) Provide highly technical laboratory services to support HIV testing and treatment programs; ii) Provide laboratory services to support surveillance activities iii) Provide supportive supervision and assist with development and implementation of training materials required to expand capacity in clinical laboratories; iv) Collaborate with the National Public Health Laboratory Services (NPHLS) to strengthen NHPLS capacities including the conduct of supportive supervision, reference laboratory services, and local evaluations of laboratory tests; v) Support the NPHLS to improve and sustain the national quality assurance (QA) program for HIV testing, testing for clinical monitoring of HIV treatment, and TB testing in district and provincial/regional hospitals.

The most important example of technical lab services provided through the KEMRI labs is DNA PCR assays for early infant diagnosis. By September, 2006, the KEMRI laboratories were testing approximately 300 infant diagnostic tests per week from nearly 40 clinical sites through a courier supported network transporting filter paper samples and results. Although the capacity for infant diagnostic testing is being established/expanded at other sites, including NPHL and the MOH Coast Provincial Hospital clinical lab, KEMRI will remain a key provider of this service. KEMRI already has a working relationship with Kilifi District Hospital in areas of DNA PCR assays for early infant diagnosis. In FY 2007, KEMRI will build on this relation to strengthen Coast region's lab capacity to meet emergency targets.

During FY 2004-2006, KEMRI conducted serologic testing for sentinel surveillance and demographic surveillance surveys; these functions are gradually being transferred to NPHLS with support from KEMRI. KEMRI will continue to train the NPHLS staff on sample collection, processing, calibration and validation of instruments.

Although various training functions are also being transferred to the NPHLS, KEMRI will assist with development of training curricula and standard operating procedures and will remain an essential provider of in-service training to clinical lab staff, particularly in the areas of rapid HIV testing and collection of samples for early infant diagnosis.

For the past several years, KEMRI laboratories have conducted most local validations of new laboratory assays. During FY 2007, much of this function will be shifted to NPHLS with KEMRI support; KEMRI will continue to assist with evaluations of highly complex assays such as alternate assays for infant diagnosis (for example ultra-sensitive p24 antigen assays).

KEMRI will collaborate with NPHLS staff in the expansion of a proficiency testing program for HIV rapid and confirmatory tests and CD4 cell count determination. KEMRI roles in this expansion will include assistance in developing national CD4 cell count standards, development of proficiency panels, and assistance with supportive supervision and oversight of QA procedures.

3. CONTRIBUTION TO OVERALL PROGRAM AREA KEMRI laboratory activities play a key role in enhancing capacity of the NPHLS and point-of-service labs to support surveillance, prevention, and care and treatment of HIV/AIDS and TB. Training/capacity building focuses on the NPHL will held to build long term sustainable laboratory capacity in Kenya. These activities will support the training of 300 individuals in the provision of lab-related services and will contribute to improvement of the capacity of 60 laboratories to perform HIV and CD4 and or lymphocyte tests.

4. LINKS TO OTHER ACTIVITIES This activity relates intimately to NPHLS and APHL activities as well as to virtually all counseling and testing and care and treatment activities.

5. POPULATION BEING TARGETED This activity targets the laboratory technologists of the NPHLS throughout the country at

sub-district, district and provincial levels where ARV services are being rolled out. Technologists from institutions outside the NPHLS will also be trained.

6. EMPHASIS AREAS This activity will place major emphasis on technical training on QA/C, new and appropriate technologies. Minor emphasis areas will include procurement of specialized laboratory commodities and operationalization of laboratory QA schemes for HIV care and treatment.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in HVTB (#7001 and #6944), HVAB (#6903), HBHC (#7005), HVCT (#7009 and #6941), HVSI (#7002 and #6988) and HLAB (#6940). 2. ACTIVITY DESCRIPTION This activity will result in improved HIV surveillance and in the increased capacity for analysis, dissemination and utilization of strategic information to strengthen HIV/AIDS policies and programs.

This activity has several components: (i) Intervention Evaluation: KEMRI/CDC maintains a jointly funded Demographic Surveillance System (DSS) that monitors a population of 135,000 in Nyanza Province with HIV prevalence in adults of approximately 25%. The DSS is being used to capture individual and aggregate-level data on HIV infection, care and treatment services uptake, and HIV/AIDS-associated mortality. The DSS is also being used to evaluate both the indirect and direct impact of ARV use on a population level, including economic impact, impact on land use and impact on mortality. In addition, KEMRI is evaluating the impact of HIV on orphanhood (approximately 1/3 of children under the age of 15 are orphans). The DSS will be expanded within Siaya district and will include the Siaya District Hospital. The expanded DSS will better be able to monitor the impact of the HIV interventions on all-cause mortality, HIV-specific mortality, and the rates of opportunistic infections through population-based surveys utilizing thrice-yearly census data and once yearly individual-level data. Mortality data will be collected using verbal autopsy in collaboration with the Ministry of Health and the Central Bureau of Statistics and improve HIV/AIDS mortality surveillance.

A related sub-activity will entail setting up a microwave/radio connection of Siaya District Hospital and two selected health facilities with KEMRI/CDC Kisian. This will allow real-time connections between DSS and clinical sites, greatly increasing the utility of DSS data in demonstrating ARV penetration. This project will also evaluate the feasibility of the use of fingerprint-based ID system vs. a photo ID/barcode based system.

(ii) Training: KEMRI will continue to offer training for MOH and partners' staff in strategic information and assist in collection, data entry, management, analysis, and utilization of program information. This continually improves the local human resource capacity to carry out SI activities. KEMRI data staff will also offer technical support to the national TB program on Portable Digital Assistant (PDA) data capture.

The data management team will support the rollout of the new NASCOP registers and forms at facilities in Nyanza, Eastern and Central provinces. In addition to strengthening the national M&E system, PEPFAR reports will also be generated from these data and facility feedback provided on the scale-up of various services (HTXD, MTCT, HVCT, etc). As part of this activity, 120 individuals will be trained on data management and analysis.

(iii) TB Reporting: To enhance the HMIS at the National Leprosy and TB Program (NLTP) integrated TB/HIV case reporting system in PDAs has been piloted in Nyanza and Nairobi. Following the successful pilot, PDA use will be extended to Coast and Eastern provinces. District and Provincial TB coordinators from these provinces will be trained on the use of PDA and each supplied with the handheld device. A GPRS module will be added to enable direct submission of data from the field to a central database at the provincial level resulting in fast and secure data submission. It is expected that the level of reporting for electronic TB data will increase to about 90%. A total of 40 individuals will be trained.

(iv) Integrated AIDS Care Services Evaluation: An evaluation of an Integrated AIDS Care Services will be undertaken, with the aim of improving clinic-based HIV diagnostic testing and counseling (DTC), home-based HIV counseling and testing (HBT), and decentralized care and treatment in the KEMRI/CDC DSS.

In order to carry out this evaluation, counselors and health care workers at health facilities will be cross-trained so that they can offer HIV testing and counseling under a variety of circumstances (e.g., Home-based VCT, Diagnostic DTC, PMTCT, VCT). DTC will be implemented in health facilities following national guidelines. PLWHAs will be incorporated into the evaluation staff. Following HBT, all HIV-positive persons will be linked to a nearby health facility offering HIV services and receive an HIV "package of care". All HIV patients

will be screened for TB and care provided for those who are dually infected. All persons from the DSS area that test HIV-positive (whether through HBVCT or DTC) will be treated and managed by MOH clinical staff and/or through community-based lay health workers. Pregnant women found to be HIV+ will be referred to the closest PMTCT site, and prevention interventions for discordant couples, as well as HIV+ and HIV- individuals will be delivered.

(v) AIS Quality Assurance: Working in collaboration with the Central Bureau of Statistics and NASCOP on the AIDS Indicator Survey (AIS), KEMRI will, through its laboratory infrastructure, provide technical oversight and quality assurance for all laboratory testing using Dried Blood Spots (DBS) samples. Laboratory data will be managed by the KEMRI data management staff, who will also assist in analysis and report writing.

(vi) KEMRI Kilifi has developed a DSS covering a 240,000 population that represents an 80% catchments area for District Hospital admissions. Support for data management at the hospital level will link routine counseling and testing information with the DSS follow-up system to evaluate outcomes and impact of CT in the referral for care and treatment. 3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will contribute in numerous ways to overall program area goals, including assessing the penetration of HIV care and treatment activities, better understanding of orphanhood, TB, AIDS mortality, and home-based counseling and testing of HIV. It will strengthen the national M&E systems and reporting though the training of 160 individuals in SI and 20 organizations, including 12 MoH district programs. 4. LINKS TO OTHER ACTIVITIES This activity relates to activities in HVTB (#7001 and #6944), HVAB (#6903), HBHC (#7005), HVCT (#7009 and #6941), HVSI (#7002 and #6988) and HLAB (#6940). 5. POPULATIONS BEING TARGETED The Demographic Surveillance Site targets the general population, sentinel surveillance targets pregnant women and STI patients, the training and capacity building activities targets health workers and data managers, and the reports generated by this activity target policy makers.

Comprehensive evaluation of MC service delivery models and population level impact of MC: Leveraging the existing Demographic Surveillance System (DSS) in Nyanza Province, we will be able to evaluate the impact of MC circumcision on HIV incidence at the population level. We will also be able to document uptake, coverage and cost-effectiveness of facility-based MC service delivery and the added value of mobile approaches to MC service delivery. In addition, we will monitor adverse events as well as risk compensation and disinhibition. The existing DSS infrastructure provides a unique and excellent platform to assess operational research questions and identify the most efficient and effective models of MC service delivery. This evaluation will be conducted in partnership with NASCOP and KEMRI and the results will be used to inform GOK policy and strategy development. The evaluation will be incorporated in the comprehensive prevention, care, and treatment activity already planned for the DSS area to ensure that the population has full access to all services.

KEMRI will work closely with NASCOP, the Nyanza Circumcision Consortium and other partners to strengthen MC delivery systems in Nyanza Province. KEMRI's work will involve both Facility and Mobile approaches to MC service delivery and willl also incorporate a comprehensive evaluation of MC service delivery models and population level impact of MC: Leveraging the existing Demographic Surveillance System (DSS) in Nyanza Province, we will be able to evaluate the impact of MC circumcision on HIV incidence at the population level. We will also be able to document uptake, coverage and cost-effectiveness of facility-based MC service delivery and the added value of mobile approaches to MC service delivery. In addition, we will monitor adverse events as well as risk compensation and disinhibition. The existing DSS infrastructure provides a unique and excellent platform to assess operational research questions and identify the most efficient and effective models of MC service delivery. This evaluation will be conducted in partnership with NASCOP and KEMRI and the results will be used to inform GOK policy, implementation guidelines and strategy development.

Table 3.3.14: