1. LIST OF RELATED ACTIVITIES This activity relates to activities in Counseling and Testing (#6968), HIV/AIDS Treatment: ARV services (#6973), Palliative Care: TB/HIV (#6975), and Palliative Care: Basic Health Care and Support (#6922).

2. ACTIVITY DESCRIPTION Since August 2001, the Kenya Medical Research Institute /Department of Defense (KEMRI/DOD) has been implementing a Prevention of Mother-to-Child Transmission of HIV infection (PMTCT) program in the Kericho District of the south Rift Valley Province. The number of PMTCT sites has increased from three to over 70 and as a result 67,000 pregnant women have received PMTCT Counseling and Testing (CT). Between January and July 2006, 19,589 pregnant women presented for their first antenatal visit, of which 92% received their HIV test results. Among them, 1,009 women were diagnosed as HIV-positive and 82% and 65% of them and their HIV exposed infants received ARV prophylaxis respectively. With Emergency Plan (EP) support, KEMRI/DOD has scaled-up PMTCT services in 5 other districts of south Rift Valley Province (SRV). Male involvement has been encouraged through the development of Saturday male clinics throughout the region. Though the program has been successful, due to inadequate numbers of trained health workers, limited working space, poor infrastructure, weak logistics supply chain management, inadequate management, as well as fear of stigma and discrimination in the communities continues to limit the full utilization of PMTCT services and further access to care and treatment by the HIV-infected women and family members. Low levels of male involvement, lack of appropriate infant feeding options, and limited access to family planning information and services are further barriers. The SRV Province has 250 health facilities and fewer than 80 are currently providing PMTCT services. In 2007, KEMRI-SRV will continue to work with Provincial and District Ministry of Health (MOH) Health Management Teams (HMT) to address these barriers in an effort to scale up PMTCT services from the expected 120 health facilities at the end of FY 2006 to 160 in the six districts of south Rift Valley Province in FY 2007. The coordination with Government of Kenya in the implementation of this activity will ensure sustainability and quality of the services. CT services will be provided to 72,423 (about 80% of all pregnant women) women during the antenatal, intra-partum, and postnatal period. 2,344 HIV-infected mothers and 2,100 of their babies will receive ARV prophylaxis. The prophylaxis will include AZT to 50% of the HIV infected women from 28 weeks gestation and their exposed infants. A total of 250 health workers will be trained to address the shortage of human resources. In addition, technical assistance will be provided by four additional locally employed staff. CT within the PMTCT program area will be extended to male sexual partners of the pregnant women, their young children, the Child Welfare Clinic, and family planning clients. Presumptive Malaria Treatment, provision of mosquito nets and cotrimoxazole prophylaxis to both mother and infants will be encouraged. Dry Blood Spots (DBS) will be used for rapid HIV antibody testing quality assurance and control. DBS will also be used for Polymerase Chain Reaction (PCR) testing of the HIV exposed or infected children. HIV-infected women will be screened for comprehensive HIV care and treatment eligibility. Follow-up and referral as appropriate of the HIV-infected women, their HIV exposed children, and their sexual partners will be encouraged. Counseling regarding infant feeding practices will be provided. Family planning services will be supported through appropriate training and supervision. The KEMRI research laboratories in Kericho will provide HIV PCR diagnostic testing services.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This KEMRI/WRP activity will contribute to approximately 7.2% of the total, direct PMTCT Emergency Plan targets of 1,000,000 pregnant women offered CT in FY 2007. This will also support government efforts of ensuring that at least 80% of pregnant women have access to PMTCT services by the end of 2008. Planned activities will improve equity in access to HIV prevention and care and treatment services since the currently underserved rural communities will have better access. KEMRI will work to ensure the availability of networks and linkages among medical sites where AIDS care and treatment are provided for both adults and children.

4. LINKS TO OTHER ACTIVITIES The PMTCT activities will relate to the following KEMRI-SRV comprehensive approach to HIV/AIDS care and treatment: Palliative Care: Basic Health Care and Support (#6922), CT (#6968), Treatment: ARV services (#6973), and TB/HIV (#6975). This activity will be

linked directly to Treatment: ARV for those women who screen HIV positive during the PMTCT process and CT will be conducted on male partners and children of women in the PMTCT clinics. The women will also be screened for TB as a direct link with TB/HIV services. Linkages between PMTCT service and care outlets will be strengthened to improve utilization of care opportunities created through PEPFAR funding.

5. POPULATIONS BEING TARGETED This activity targets adults of reproductive age, pregnant women, family planning clients, infants, and People Living With HIV/AIDS (PLWHA) including HIV-positive pregnant women. Strategies to improve quality of services will target MOH staff, doctors, nurses, midwives, and other health care workers such as clinical officers and public health officers in both public and faith based facilities as well as the local communities through training, Support Supervision, and Health Education.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity will increase gender equity in programming through PMTCT services targeted towards pregnant women and their spouses. Women bear a high HIV burden through not only primary infection but also as caregivers and impact of stigma and discrimination. Identifying these women through PMTCT will provide an opportunity to access care for themselves, their spouses, and their infants - all targeting improved pregnancy outcomes. Increased availability of PMTCT and PMTCT+ services will increase access and help reduce stigma at community and facility levels. Men will be encouraged to come for CT services and male PMTCT clinics will be expanded. Psychosocial Support Groups, Mothers to Mothers To Be and Peer Counseling will be encouraged to improve on PMTCT uptake and to also reduce fear of stigma and discrimination.

7. EMPHASIS AREAS The major emphasis area in this activity is training health care workers and facilitating early infant diagnosis. Minor emphasis will be placed on infrastructure, development of networks/linkages and referral systems, and quality assurance, quality improvement and supportive supervision.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Abstinence and Being Faithful (#6891) and Counseling and Testing (#6968).

2. ACTIVITY DESCRIPTION Kenya Medical Research Institute (KEMRI) will embark on a new piloted initiative in south Rift Valley in the area of Condoms and Other Prevention in 2007 in order to bring prevention to high-risk populations in two stop-over locations along the Nariobi-Kisumu transport highway corridor within Kericho District. Both sites have been extremely underserved in the area of prevention which has fueled the prevalence rate to increase among core transmitters as well as the surrounding general communities. KEMRI south Rift Valley program has had a comprehensive HIV care program for the residents of south Rift Valley since the 2005 Emergency Plan which includes counseling and testing as well as HIV/AIDS treatment. A significant aspect of the existing KEMRI-south Rift Valley HIV comprehensive care program which has been missing is in the area of prevention, especially among high-risk populations. The reliance on conventional voluntary counseling and testing (VCT) sites to address this need has not been a sufficient prevention intervention. In FY 2007, KEMRI south Rift, will address this existing gap in HIV-AIDS prevention by targeting 5,000 individuals in Kapsoit and Chepseon in creating a sustainable prevention program which addresses the specific risk factors of commercial sex workers (CSW) as well as other high-risk adults in both locations. Kapsoit and Chepseon have an estimated HIV prevalence rate of 4-6% among the general population, but the targeted group for this activity is estimated to be higher than that. Even after personal knowledge of HIV status, there is a significant gap in prevention activities due to the lack of personal knowledge and skills that assist an individual to change behavior. KEMRI-south Rift will address this issue in these two localities with condom promotion and STI identification and management. They will also target 20 people to be trained in promoting HIV/AIDS prevention among high-risk adults.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA KEMRI-south Rift Valley's new activity in Condoms and Other Prevention will contribute to the overall objective of reducing high-risk behaviors among high-risk adults. This activity will also empower and train 20 individuals in both locations in the promotion of routine testing of STIs as well as the promotion of consistent and correct condom use. This activity will target 5000 individuals with HIV prevention messages as well as behavior change skills that significantly minimize their risk behaviors. 30 condom dispensers will also be set up throughout the two locations.

4. LINKS TO OTHER ACTIVIITES This activity is linked to Live with Hope's Abstinence/Being Faithful program (#6891) as another prevention activity occurring in Kericho District. Through coordination the two programs will work closely together in identifying populations to reach with prevention. Counseling and testing services through KEMRI-south Rift Valley (#6968) will also be linked to this activity in the promotion of gaining personal knowledge of HIV status as a key to prevention and access to care.

5. POPULATIONS BEING TARGETED This activity will target adults in the general population with prevention messages as well as the most at-risk populations of commercial sex workers and mobile populations; specifically truck drivers. Brothel owners and bar maids will also be a targeted population for this activity.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity will address adult men in educating them about the identification of male norms and behaviors which may be risk factors in HIV-AIDS transmission. The project activities with CSWs will increase gender equity in HIV-AIDS programs as well as increasing women's access to income and productive resources. Stigma reduction will also be addressed through information, education and community mobilization.

7. EMPHASIS AREAS The primary focus of KEMRI-south Rift Valley in this activity will be to mobilize the community in the participation of these prevention activities as well as reduce stigma in specific high-risk populations. This activity will also dedicate part of its time to

information, education and communication in the development of material that serves as mass media prevention campaigns as well as in training of individuals to sustain the prevention activities.

Unallocated funds for this activity will expand existing activities in the 2007 COP. Kenya Medical Research Institute (KEMRI) will embark on a new piloted initiative in south Rift Valley in the area of Condoms and Other Prevention in 2007 in order to bring prevention to high-risk populations in two stop-over locations along the Nariobi-Kisumu transport highway corridor within Kericho District. Both sites have been extremely underserved in the area of prevention which has fueled the prevalence rate to increase among core transmitters as well as the surrounding general communities. KEMRI south Rift Valley program has had a comprehensive HIV care program for the residents of south Rift Valley since the 2005 Emergency Plan which includes counseling and testing as well as HIV/AIDS treatment. A significant aspect of the existing KEMRI-south Rift Valley HIV comprehensive care program which has been missing is in the area of prevention, especially among high-risk populations. The reliance on conventional voluntary counseling and testing (VCT) sites to address this need has not been a sufficient prevention intervention. In FY 2007, KEMRI south Rift, will address this existing gap in HIV-AIDS prevention by targeting 6,000 individuals in Kapsoit and Chepseon in creating a sustainable prevention program which addresses the specific risk factors of commercial sex workers (CSW) as well as other high-risk adults in both locations. Kapsoit and Chepseon have an estimated HIV prevalence rate of 4-6% among the general population, but the targeted group for this activity is estimated to be higher than that. Even after personal knowledge of HIV status, there is a significant gap in prevention activities due to the lack of personal knowledge and skills that assist an individual to change behavior. KEMRI-south Rift will address this issue in these two localities with condom promotion and STI identification and management. They will also target 30 people to be trained in promoting HIV/AIDS prevention among high-risk adults. The additional funds will also be used to identify and implement 40 condom distribution sites in non-traditional locations where access to free condoms is limited.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in ARV Services (#6973), Palliative Care: TB/HIV (#6975), Orphans and Vulnerable Children (#6982) and Orphans and Vulnerable Children(#7035).

2. ACTIVITY DESCRIPTION The South Rift Valley basic health care and support program is a broad initiative by the Walter Reed/KEMRI HIV project in collaboration with Ministry of Health (MOH) district hospitals, two mission and two private tea estate hospitals, and a local community based organization within the South Rift Valley Province of Kenya.

The South Rift Valley has a population of approximately 2.5 million people in 6 districts within the Rift Valley Province, with a HIV prevalence ranging from 5% to as high as 19% in some congregated settings. In FY 2006, the South Rift Valley program was providing medical care and treatment to 10,471 HIV infected patients, with 5,195 patients on care (not qualifying for ART). In FY 2007, the program will increase the number of patients to 25,450 by the end of March 2008, increasing the total number of patients on care and support to 14,900.

To ensure a sustainable and quality based program this activity will continue to work with the MOH and the National AIDS/STI Control Program (NASCOP) in offering palliative care services. In FY 2007, concerted efforts will continue to support continued quality clinical care for HIV infected patients, routine patient follow-up, laboratory monitoring, prevention and treatment of opportunistic infections (OIs), nutritional support, and increasing treatment literacy and drug adherence.

In order to enable the overcrowded facilities cope with an increasing number of patients being registered at the clinical sites efforts will continue in the area of decentralizing ART care and treatment services, in accordance with the network model, which seeks to build the capacity for rural health centers to provide quality basic health care and support to HIV+ individuals. In FY 2007, this model will be further strengthened and expanded to support 75 additional rural facilities throughout the six districts in the provision of palliative care and support. By doing so, over 40% of the current patients seeking care and support will be able to access services in nearby rural facilities.

As of July 1, 2006, the South Rift Valley program was providing treatment to 1106 children, of whom 758 were on palliative care. In FY 2007 the program will focus on improving pediatric diagnosis to be able to recognize 3000 HIV positive children below 14 years of age, among whom 1,845 will be on palliative care. The South Rift Valley palliative care program will seek to support pediatric diagnostic, care and treatment programs throughout the region.

In FY 2007, the South Rift Valley basic health care and support program will also support Live with Hope Center (LWHC) in their community home based care program which has been receiving Emergency Plan funds since FY 2004. In FY 2007, the program will continue to serve and care for over 1,000 individuals in their homes in the provision of basic health care as well as psychological support and counseling through community clinical health workers as well as PLWHA community volunteers.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will contribute substantively to Kenya's 5-year strategy of providing basic health care and support to 250,000 clients, by providing services to 14,900 individuals (6% of the overall FY 2007 Emergency Plan national target). The collaboration with MOH, other GOK offices and major stakeholders ensures these services are sustainable, the goal of the collaborative efforts being provision of quality care.

4. LINKS TO OTHER ACTIVITIES This activity is linked directly to the other KEMRI-South Rift Valley HIV/AIDS program initiatives in six districts located within the Rift Valley. It is directly related to KEMRI-South Rift ARV services (#6973) in the identification and provision of palliative care for those who do not qualify for ARVs and are enrolled in the program. It is also linked to orphans and vulnerable children (OVC) programs of LWHC (#6982) and Samoei Community Response to OVC (#7035) in Kericho District to ensure that those HIV+ children in palliative care that require additional support are adequately linked to receive additional

care and support beyond basic health care and support.

5. POPULATION BEING TARGETED The KEMRI-South Rift Valley basic health care and support program will target primarily those people affected by HIV/AIDS including caregivers as well as children since the main objective of the program is to provide supplemental care to existing medical treatment. Also this activity will work collaboratively with host government workers specifically the NASCOP staff at a district level in the implementation of the program locally. Training efforts will be concentrated on health care workers both in public and private institutions throughout the South Rift Valley. The work accomplished by LWHC will be a demonstration of palliative care work with a community/faith based group in Kericho district.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity will address increasing gender equity in HIV/AIDS programs by ensuring that both men and women access palliative care and support. Traditionally, women are more receptive to the service but efforts will be made through a strong peer support network to encourage men to access services as well. Many of the palliative care and support programs actively use counselors to address male norms and behaviors as well that may contribute to the spread of HIV. This is most pertinent to this program area when it comes to issues of disclosure and discordance among partners. A lot of issues of reducing stigma and discrimination are also addressed by the delivery of services at the community level especially through the efforts of decentralizing services at the district level to local areas through the network model.

7. EMPHASIS AREAS Major emphasis for this program activity is in human resources especially in the development of capacity and sustainability for these activities in basic health care and support at the local level. Other contributing areas are in the activities of community mobilization, Development of Network/Linkages/Referral Systems, food/nutrition and infrastructure.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Treatment: ARV services (#6973), Counseling and Testing (#6968, #7038) and Prevention of Mother-to-Child Transmission (#6967).

2. ACTIVITY DESCRIPTION "Fund will be used for expansion of activity in the 2007 COP. The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed Project/Kenya Medical Research Institute (WRP/KEMRI) HIV project in collaboration with Ministry of Health (MOH) district hospitals, two mission and two private tea estate hospitals within six districts located in the SRV province of Kenya.

In FY 2005, Kericho District Hospital within the SRV adopted the tuberculosis/HIV (TB/HIV) Model which is currently providing TB and HIV care and treatment to more than 500 TB patients co-infected with HIV. The model emphasizes activities to screen all HIV infected patients for TB as well as ensures TB infection control in health care and congregate settings. " "In FY07, this model and approach to TB/HIV will be replicated in the three remaining districts in the SRV in which KEMRI-SRV is implementing comprehensive HIV/AIDS care and treatment services. Projected plans for this activity in FY 2007 are to add an additional 20 TB/HIV diagnostic sites and 32 additional TB treatment sites within the six districts. The district hospitals will be the referral units for TB patients requiring specialized diagnostic, treatment or in-patient services from the rural health facilities. Forty additional health workers will be trained on TB/HIV to support the additional health facilities supported to offer TB/HIV services. These facilities will provide health care to a targeted 4,370 TB/HIV co-infected patients.

" "All patients with TB under this program are offered HIV testing, recognition and management of STIs, and given education on safer and more responsible sexual behavior. All co-infected patients are given cotrimoxazole preventive therapy and offered comprehensive HIV/AIDS care, support and treatment (ART). Emergency Plann (EP) funds in FY 2006 were used to support the duplication of best practices in TB/HIV in two other districts within the SRV as well. Together the combination of the three districts' TB/HIV activities assisted in supporting 26 TB/HIVdiagnostic sites and 43 TB treatment sites. The program will continue to support improvement of the capacities of the laboratories in smear microscopy services and Kericho district hospital lab will continue to offer quality assurance in smear microscopy (augmented by fluorescent microscopy) in the region of the six districts. " The program, in collaboration with the NLTP program, will continue to strengthen and optimize referral of specimen for TB culture and sensitivity to the national reference laboratory. The program will also continue to support efficient and timely supply of TB drugs to all the TB treatment sites. This activity will also continue to facilitate regular support supervision and technical assistance to all the health facilities offering TB diagnosis and treatment services through direct support as well as through collaborative district level supervisory meetings.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA KEMRI-SRV will contribute towards the provision of integrated TB/HIV care by reducing TB morbidity and mortality in HIV-infected individuals and also reducing HIV-related morbidity and mortality in TB patients co-infected with HIV. Planned activities will improve equity in access to TB/HIV treatment and care services since the currently underserved rural communities will have better access.

4. LINKS TO OTHER ACTIVITIES This activity is linked to KEMRI-SRV ARV services (#6973) throughout the six districts as well as with KEMRI-SRV Counseling and Testing (#6968) activities with a primary focus on provider initiated CT. It will also be linked to Tenwek Mission Hospital CT activity (#7038). TB/HIV is also linked to SRV PMTCT program (#6967) as part of the comprehensive care and support initiative for all HIV infected pregnant women who are screened in the PMTCT program.

5. POPULATION BEING TARGETED This activity will target the general population of both adults and children but those primarily who have contracted TB and are being diagnosed or treated in the clinical setting. Trainings under this activity will focus on health care workers both in the private and public settings. All TB/HIV activity initiatives will be implemented in accordance or in collaboration with host government workers namely the National AIDS/STI Control Program (NASCOP) and the National TB and Leprosy (NLTP) program.

6. KEY LEGISLATIVE ISSUES ADDRESSED KEMRI-SRV TB/HIV activity will address increasing gender equity in HIV/AIDS programs by ensuring that equitable numbers of women including children are receiving treatment. The activities will address stigma associated with TB/HIV status through information, education, and communication materials targeted to health care providers, caregivers and communities.

7. EMPHASIS AREAS This activity includes major emphasis on commodity procurement and minor emphasis on community mobilization, human resources, infrastructure, and training. KEMRI-SRV will procure medical supplies (e.g. laboratory diagnostics and drug) as required for the diagnosis and management of HIV/TB co-morbidities. Staff training as well as obtaining additional staff will occur in order to meet the needs of the increased patient load. Finally, minor renovations will be required to prepare clinic space for this program activity.

"As pediatric treatment is scaled-up, providers increasingly report frustration with the challenge of having to educate and re-educate the caregivers of children. This primarily comes about in situations where an OVC who is infected does not have a consistent caregiver and therefore is - for example - accompanied to one visit by an aunt, to another by an older sibling, and perhaps to a third by a grandparent. This leads to longer-than-necessary clinic interactions, increased frustration for pediatric providers, and is presumed to contribute to sub-optimal care of children. Five high-volume treatment partners with significant stable adult patient populations (AMPATH, Eastern Deanery AIDS Relief Project, University of Washington/Coptic Hope Center, Kericho District Hospital and NYU/Bomu Medical Center) will receive amounts specified below for an innovation in OVC programming. " "They will be supported to establish programs where experienced adult patients (with a preference for women patients) will be screened, recruited, trained, supervised and compensated to take on a substantive role in assuring continuity of care for pediatric patients. Adult patients who are successfully managing their own treatment will be assigned a small (e.g., 5-7) cohort of pediatric patients and will be trained and supported to: 1)Make periodic (e.g., weekly) home visits to conduct medication counts and observe for signs of side effects or poor response to treatment; 2) Bring children without family caregivers to regularly scheduled medical appointments to provide continuity of contact with health workers and report on household conditions, and 3) Translate provider instructions back to individuals in the home or other setting who are responsible for the child's day-to-day care." In addition to funds to these treatment partners, funding in the amount of $200,000 is awarded to AED/Capable Partners, PEPFAR/Kenya's key ally in scaling-up community based OVC responses to design and implement a real-time evaluation of the efficacy of this approach to improving continuity of care and treatment outcomes for OVC who are HIV-positive. A technical working group representing all funded partners and the assessment partner will be formed to both assure consistency of programs and identify unique opportunities that individual partners may present for fine-tuning the model.

Table 3.3.08:

1. LIST OF RELATED ACTIVITIES This activity relates to activities in HIV/AIDS treatment/ARV services [#6973], TB/HIV [#6975], Abstinence/Being Faithful [#6981], and Condoms and Other Prevention [#8808].

2. ACTIVITY DESCRIPTION In FY 2007, Kenya Medical Research Institute (KEMRI) will continue to provide HIV counseling and testing (CT) services in partnership with the Ministry of Health (MOH) in six districts in the south Rift Valley Province. Together the six districts represent a collection of 58 district hospitals, sub-district hospitals, and health facilities that will be equipped and supported to serve as nationally registered CT sites. In FY 2007, the six districts will provide CT services to over 56,000 people in the traditional voluntary counseling and testing (VCT) sites as well as through the new provider initiated testing and counseling (PITC) strategy. Twenty individuals will be trained in voluntary counseling and testing, while 50 clinicians will be trained in PITC, to enable them provide PITC in health facilities. In implementing this, KEMRI will work closely with the district AIDS/STI coordinator (DASCO) in order to strengthen coordination and referral, especially between CT and care services. Technical assistance will be provided by 2 locally employed staff. The combination of client-initiated (VCT) and provider-initiated CT services will significantly contribute to an increased proportion of Kenyans learning their HIV status in the south Rift Valley Province, which has a population of greater than 2.2 million and a HIV prevalence rate of approximately 5-7%. KEMRI-MOH will also continue to maintain the l youth friendly stand alone site in Kericho which combines recreational services as well as CT services in this very dynamic approach to behavior change and HIV prevention among the youth. The center was established in partnership with Kericho District Hospital with support from PEPFAR in FY 2004, and has successfully assisted over 400 youth between the ages of 15-24 per month to learn their HIV status. The center also offers youth-friendly mobile VCT services in collaboration with mobile reproductive health clinics in the larger district. KEMRI will also continue to work in developing mobile VCT activities in conjunction with MOH to reach populations of the districts who have poor or no access CT services. This will be the primary method used in Transmara District, because part of the population in the district has a nomadic lifestyle and also there are parts of the district that are hard-to-reach. The prevalence rate in this district which borders Tanzania is estimated to be around 8-9% but accessibility of HIV services is extremely limited. KEMRI south Rift Valley Mobile VCT activities will reach at least 15,000 individuals in FY 2007 in the six districts served by KEMRI. This number will part of the annual CT target for KEMRI south Rift, referred to above.

3. CONTRIBUTION TO OVERALL PROGRAM AREA The south Rift Valley Province is one the areas in Kenya that have large rural populations. These rural areas will be the main target of the CT initiative in FY 2007. Together with the MOH, KEMRI will provide high quality CT services both to the Tea farming community and to the general community through mobile CT services. Currently, mobile CT services are conducted weekly and reach between 100 and 250 clients per visit. In order to meet the needs of rural Kenya, KEMRI will assist the MOH to scale up mobile CT services in these areas. These coordinated CT activities will successfully provide VCT as well as PITC to over 56,000 Kenyans in the south Rift Valley Province. This combined effort to extend quality CT services to this geographical area will successfully contribute to 4% of 2007 Emergency Plan CT targets for Kenya. KEMRI will be instrumental in contributing to the national objectives of extending CT to hospital patients and TB patients in both the inpatient and outpatient clinical settings. The youth recreational center and VCT site in Kericho will continue to consistently target out of school and in-school youth, a special population that has become a national focus in the provision of VCT services.

4. LINKS TO OTHER ACTIVITIES This activity is linked to KEMRI-south Rift Valley ARV services (#6973) by ensuring that every individual who has tested positive for HIV in the CT service is linked to care and treatment. This activity is also linked to KEMRI-south Rift Valley TB/HIV (#6975) to ensure that every person who tests positive for TB is given the opportunity to test for HIV in the PITC setting. This activity is also linked to prevention activities by Live with Hope AB (#6973) and KEMRI-south Rift Condoms and Other Prevention program (#6981).

5. POPULATIONS BEING TARGETED

KEMRI's CT services will target the general population, including children and youth. Mobile VCT services will target migratory populations in Transmara. KEMRI is working in partnership with the MOH offices in six districts and therefore will be in a position to train public health care workers in PITC in the clinical settings as well as private health care workers in AIC Litein. KEMRI, in FY 2007, will train and equip 50 public health care workers in PITC in order to support the national scale-up of CT in clinical settings within Kenya. The youth center in Kericho will also target its CT services to out-of-school youth as well as other most at risk youth like street youth. In general, VCT activities provide CT services to the most at-risk populations. CT activities are done collaboratively with National AIDS control program staff at the local level.

6. KEY LEGISLATIVE ISSUES ADDRESSED KEMRI, in partnership with the MOH, will improve gender equity in accessibility of CT services within the six districts in south Rift Valley. CT will be an important intervention strategy in challenging current sexual norms that have contributed to the risks of contracting HIV in many of the rural communities. Through information and education material stigma surrounding issues of knowing HIV status will also be addressed.

7. EMPHASIS AREAS KEMRI's efforts in CT will be divided between community mobilization/participation, human resources, information and communication, infrastructure, and training. They will improve the awareness of their CT services by focusing a part of their efforts in community mobilization and participation. Other efforts will also go towards the training of 70 health care workers in the provision of CT services in the clinical setting. Many of the health care settings do not have the existing space to provide CT services and therefore some of the efforts in FY 2007 will be to make minor renovations in the already existing infrastructure of the medical health facilities.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in HBHC (#6922), TB/HIV (#6975), and HVCT (#6968, #7038). 2. ACTIVITY DESCRIPTION The KEMRI-South Rift Valley (KEMRI-SRV) Program is a broad initiative by the Walter Reed/KEMRI HIV project in collaboration with the Ministry of Health's (MOH) district hospitals, two mission, and two private tea estate hospitals within six districts located in the south Rift Valley Province (SRV) of Kenya. The six districts collectively have a population of about 2.5 million people with a HIV prevalence between 5% and 19%, depending on the location. As of July 2006, the program was providing treatment to 10,471 HIV infected patients, with 4,109 on ART. In FY07 the program will target 25,450 HIV infected patients, and increasing the total on ART to 11,550. To ensure sustainability, the program will build the technical and management capacity of all the hospitals providing treatment by targeting 115 health care workers to be trained in ART (including pediatric AIDS treatment) in FY 2007. FY07 funds will continue to be used to encourage positive living, prevent HIV infection transmission or re-infection, enhance community mobilization, reduce stigma and discrimination, and increase treatment literacy and adherence. Funds will also be used to continue and/or initiate technical assistance from 5 locally employed staff. Kericho District and Tenwek Mission hospitals will continue to be supported as referral units for the SRV for patients requiring more specialized medical care, with Kericho District Hospital continuing to provide Quality Assurance and Control oversight for diagnostics (HIV and Opportunistic Infection (OI)), monitoring, and quality of treatment in the regional network for the rural health center facilities as well as the larger six districts in the SRV. To enable the facilities cope with the increasing number of patients and to improve accessibility of HIV treatment services in the rural underserved populations, based on the network model initiated in FY 2006, the program will continue to support the decentralization of treatment of stable patients to rural health facilities by building the capacities for these facilities to offer HIV treatment services. In FY 2007, this model will support 53 rural health centers in the delivery of ART services throughout the SRV. In FY 2006, the SRV program succeeded in providing treatment to 1106 children, of whom 348 were on ARVs. In FY 2007 the program will focus on improving pediatric diagnosis to be able to recognize 3,000 (15% of total patients) HIV positive children, and put 1,155 on ARVs. Funds will therefore be allocated for pediatric diagnosis activities for children under the age of 14 (including early infant diagnosis with use of PCR-DNA testing), training and sensitization of health care staff in pediatric ART services and improving pediatric care. 3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will contribute to the 2007 Emergency Plan result for increased number of individuals on ARV treatment, and contribute to Kenya's 5 year strategy target by providing ARV services to over 11,550 individuals throughout the six districts. It will strengthen the capacity of the health systems to offer ART and strengthen the referral network for ARV treatment provision in collaboration with host government workers, specifically with the NASCOP at the district level. 4. LINKS TO OTHER ACTIVITIES KEMRI-SRV ART activity is closely linked with KEMRI-SRV palliative care program for those individuals who qualify for basic health care and support as well as with KEMRI-SRV PMTCT program in the provision of comprehensive care for pregnant women who are HIV infected and qualify for treatment. This activity is also linked with KEMRI-SRV CT programs as an entrance point for care. It is also similarly linked to Tenwek and Live with Hope CT programs. It is also linked to KEMRI-SRV TB/HIV program, and Samoei Community Response and Live with Hope's Orphans and Vulnerable Children (OVC) programs in Kericho District. 5. POPULATION BEING TARGETED The KEMRI-South Rift Valley program will target the general population including adults, children, and family planning clients as well as people affected by HIV/AIDS through HIV/AIDS-affected families, OVC, and people living with HIV/AIDS. New rural health care facilities will increase coverage and access to all these targeted populations. Health care providers, both in the private and public sector, will also be targeted by increased ART training thus increasing the number of clients able to be served more efficiently. PLUS UP: Fund will be used for expansion of activity in the 2007 COP. The KEMRI-South Rift Valley (KEMRI-SRV) Program is a broad initiative by the Walter Reed/KEMRI HIV project in

collaboration with the Ministry of Health's (MOH) district hospitals, two mission, and two private tea estate hospitals within six districts located in the south Rift Valley Province (SRV) of Kenya. The six districts collectively have a population of about 2.5 million people with a HIV prevalence between 5% and 19%, depending on the location. As of July 2006, the program was providing treatment to 10,471 HIV infected patients, with 4,109 on ART. In FY07 the program will target 25,450 HIV infected patients, and increasing the total on ART to 11,850. "To ensure sustainability, the program will build the technical and management capacity of all the hospitals providing treatment by targeting 115 health care workers to be trained in ART (including pediatric AIDS treatment) in FY 2007. FY07 funds will continue to be used to encourage positive living, prevent HIV infection transmission or re-infection, enhance community mobilization, reduce stigma and discrimination, and increase treatment literacy and adherence. Funds will also be used to continue and/or initiate technical assistance from 5 locally employed staff. Kericho District and Tenwek Mission hospitals will continue to be supported as referral units for the SRV for patients requiring more specialized medical care, with Kericho District Hospital continuing to provide Quality Assurance and Control oversight for diagnostics (HIV and portunistic Infection (OI)), monitoring, and quality of treatment in the regional network for the rural health center facilities as well as the larger six districts in the SRV."

"To enable the facilities cope with the increasing number of patients and to improve accessibility of HIV treatment services in the rural underserved populations, based on the network model initiated in FY 2006, the program will continue to support the decentralization of treatment of stable patients to rural health facilities by building the capacities for these facilities to offer HIV treatment services. In FY 2007, this model will support 53 rural health centers in the delivery of ART services throughout the SRV. In FY 2006, the SRV program succeeded in providing treatment to 1106 children, of whom 348 were on ARVs. In FY 2007 the program will focus on improving pediatric diagnosis to be able to recognize 3,000 (15% of total patients) HIV positive children, and put 1,355 on ARVs. Funds amounting to USD250,000 will therefore be allocated for pediatric diagnosis activities for children under the age of 14 (including early infant diagnosis with use of PCR-DNA testing), training and sensitization of 60 health care staff in pediatric ART services and improving pediatric care. Secondly, $50,000 will be used to equip Kericho District Hospital's Comprehensive Care Center renovated using FY06 emergency funds.

"Evaluation of cultural role and significance of traditional circumcisers and hospital survey: KEMRI/WRP will work with traditional circumcisers in targeted divisions among 6 districts in the rural, southern Rift Valley Province where approximately 80% of men are circumcised, nearly ¾ by traditional circumcisers. A 3-faceted approach will be utilized: traditional circumcisers will be trained with regard to safe surgical techniques, HIV transmission, and importance of follow-up evaluation following circumcision; traditional circumcisers will be trained and conduct targeted surveillance for adverse events related to circumcision at both the village and hospital levels; and finally, traditional circumcisers will be trained to take prevention messages to youth following circumcision while in an approximate 1-month period following circumcision while the young men are in seclusion.

" Building on available models in Kenya, we propose to develop and disseminate Ministry of Health approved training and IEC materials to ensure that HIV prevention messages are included in the ceremonies and while the young men are in seclusion following circumcision. Since circumcision is normally conducted between the ages of 11-14 years, an important age group that can easily be influenced by peer pressure, there exists an important window of opportunity before the boys become sexually active. In addition, a the targeted surveillance will permit the ability to gather information and better understand complications and adverse events associated with the current provision of male circumcision by traditional circumcisers.

Table 3.3.14: Program Planning Overview Program Area: Other/Policy Analysis and System Strengthening Budget Code: OHPS Program Area Code: 14 Total Planned Funding for Program Area: $ 10,947,000.00

Program Area Context:

Key Result 1: Health systems management, including human resources capacity, strengthened in public and private facilities Key Result 2: Rapid, effective, and transparent use of GFATM resources improved through increased human capacity Key Result 3: Critical FBO, NGO, PLWHA, education and media networks equipped to improve the policy environment Key Result 4: Reduced stigma and discrimination among health professionals at the policy, training and health facility levels

CURRENT PROGRAM CONTEXT Kenya remains well poised to prepare and implement policies and guidelines for effective management of the HIV/AIDS epidemic. Guidelines, strategies and curricula have recently been released to advance diagnostic counseling and testing, the OVC response, as well as a unified monitoring and evaluation framework. Efforts in 2007 will focus on their effective implementation. Since the inception of PEPFAR in Kenya, the Policy and System Strengthening program area has encompassed a wide array of activities from supporting grassroots PLWHA activist networks to ensuring policy implementation across sectors at the national level.

HOST COUNTRY CAPACITY The fourth year of Emergency Plan focus in this program area reflects increased support for Government of Kenya (GOK) capacity to plan, manage, and implement HIV programs, with an emphasis on human capacity development. PEPFAR activities will provide technical assistance and other support to the Ministry of Health (MOH), including the National AIDS and STI Control Program (NASCOP), Ministry of Planning and National Development (MPND) and the National AIDS Control Council (NACC). Technical assistance to NACC focuses on strengthening monitoring and evaluation of HIV/AIDS programs, largely through the Joint AIDS Program Review, an annual assessment of government, donors and civil society responses to HIV/AIDS.

In FY 2007, the MOH will receive technical assistance to implement the recently completed three-year Human Resources Strategic Plan. PEPFAR activities to integrate the national HR information system will streamline management processes and practices including recruitment, deployment, transfers, and performance management, and linking HR and payroll data. Building upon last year's initiative, we will continue to offer critical support through seconded staff to the MPND, where the advisor engages NACC and NASCOP in the national budgeting process with the goal of increasing allocations for HIV/AIDS-related activities.

POLICY DEVELOPMENT / ADDRESSING STIGMA AND DISCRIMINATION New emphases in this program area seek to incorporate HIV/AIDS stigma reduction training across three levels of the health system: national policy, medical college curriculum, and health facility. Health worker training includes decreasing discrimination against HIV/AIDS in the health worker - patient relationship and among health worker personnel. PEPFAR funds will also support medical professionals living with HIV/AIDS to gain equitable treatment in health care facilities and to seek to establish a network of HIV health professionals. At the grassroots level, we continue to invest in strengthening networks of people living with HIV/AIDS (PLWHA), religious leaders and others to improve HIV/AIDS policies, strategies and programmatic responses.

In FY 2007, we will also advocate for mainstreaming AIDS workplace policies and AIDS awareness trainings in the private sector with a focus on small and medium-sized enterprises, and across professional and trade associations.

System strengthening initiatives are also funded under the OVC program area, where we continue to assist the Department of Children's Services (DCS) to effectively manage the OVC response through coordination of a national database. This database will track each child's access to essential services and channel the information up to the district level DCS offices and NACC.

GLOBAL FUND SUPPORT While plans, policies, and guidelines are necessary for ensuring consistent, high quality programs, they are not sufficient. Translation of plans and policies into sustained and effective action is an ongoing effort, so our 2007 COP investments in this area will have a unified focus on promoting better implementation of and adherence to policies. Like other countries, Kenya has had challenges in developing the systems to effectively utilize the large in-flows of additional resources for HIV/AIDS, particularly those of the Global Fund.

This year, we will build further upon our successful work with the Global Fund to devise the optimum structure for effective and transparent use of GFATM funds. Our budget includes funds to support active engagement of PLWHA on the Country Coordinating Mechanism (CCM) and to provide technical assistance for improved management and implementation of Global Fund grants.

BARRIERS ENCOUNTERED/STRATEGIES FOR RESOLUTION USG, other donors, the Global Fund Secretariat and key decision-makers within the host government remain concerned about the slow implementation of GFATM awards in Kenya. Many of the challenges remain based in weak administrative support to the essential architecture for fund implementation: the interagency coordinating committees, the CCM, and procurement. Our second year of funding for GFATM administrative support addresses these concerns and provides targeted assistance for a restructured CCM secretariat.

Widespread stigma and discrimination against PLWHA remains a barrier to many seeking care and treatment across Kenya. By deconstructing sources of stigma and discrimination within the medical community, we begin to improve access to care, a fundamental element of our commitment to HIV/AIDS in Kenya.

Program Area Target: Number of local organizations provided with technical assistance for 100 HIV-related policy development Number of local organizations provided with technical assistance for 460 HIV-related institutional capacity building Number of individuals trained in HIV-related policy development 950 Number of individuals trained in HIV-related institutional capacity building 13,800 Number of individuals trained in HIV-related stigma and discrimination 8,000 reduction Number of individuals trained in HIV-related community mobilization for 14,000 prevention, care and/or treatment

Table 3.3.14: