This reprograming action will provide bridge funding to the University of Manitoba to support preliminary activities for the new sex worker expanded project. These will include facilitating stakeholder and other planning meetings, surveys on population estimates, set up of office premises, advertising for staff recruitment and mapping activities. These activiites are required to support the preparation of a rapid start up when FY08 funds become available in April 2008.

Table 3.3.06: Program Planning Overview Program Area: Palliative Care: Basic Health Care and Support Budget Code: HBHC Program Area Code: 06 Total Planned Funding for Program Area: $ 23,244,297.00

Program Area Context:

Key Result 1: Provide a basic care package to 75,000 HIV+ individuals including safe water, nutritional support, and opportunistic infections medications Key Result 2: Increase integration of programs providing prevention, care and treatment to PLWHA Key Result 3: Expand community networks and develop new networks to care for PLWHA Key Result 4: Establish legal support programs for more than 2,500 individuals to support inheritance planning and the right of widows to inherit property

CURRENT PROGRAM CONTEXT Currently, an estimated 1,400,000 Kenyans are already infected with HIV, and approximately 100,000 new infections occur each year. All HIV-infected persons require HIV counseling and testing; however only 30% are identified annually (~420,000 in 2006). Each patient identified should receive at least one component of basic palliative care based upon their disease stage; 20% will require ART. Palliative care includes all clinic-based and home-/community based activities for HIV-infected persons encompassing 1) clinical and laboratory monitoring and disease management, 2) psychological, spiritual, and social support, 3) prevention information, and 4) end-of life care. In FY 2006 the anticipated number of individuals provided with USG-supported facility-based, community-based and/or home-based HIV-related palliative care is 315,000 (75%), increasing to over 360,000 in FY 2007.

In the last three years, palliative care services have been rapidly expanded throughout Kenya. As of March 2006, 230,000 persons were accessing USG-supported services at 387 sites, including non-ART HIV medical care at national referral hospitals, all 8 provincial hospitals, all 72 district hospitals, 64 mission and/or faith-based hospitals, over 70 health centers, and 13 private hospitals. USG agencies support a clinical care model focusing on patient support centers that offer a broad range of services, e.g., HIV testing, clinical monitoring, diagnosis and treatment of opportunistic infections (OI), links to support groups, and prevention of secondary transmission (Prevention with Positives). Community-based support complements these activities through nutritional supplementation, psychosocial support activities, loan programs and legal support.

NEW INITIATIVES In FY 2007, two new initiatives will strengthen palliative care services through commodity procurement to expand the availability of essential care to PLWHA. We will utilize the successful basic care package pioneered in Uganda to reach 75,000 patients in 2007, expanding to 250,000 clients within three years. By utilizing this ‘package' approach, USG anticipates reducing the commodity shortages experienced at primary care facilities and ensuring that patients receive cotrimoxazole, bednets (in malaria endemic areas), a safe water system (WaterGuard), vitamins, and condoms. Consumable items (condoms, WaterGuard, multivitamins) will be re-supplied on a continuing basis. Cotrimoxazole will be supplied through PSCMS and be distributed through patient support centers or dispensaries.

The second initiative involves utilization of a central organization for procurement and distribution of OI drugs to ensure reliable and uninterrupted supplies of these essential commodities to EP supported sites. The contractor will forecast, procure, store, and distribute a limited formulary of OI drugs for 110,000 patients.

REFERRALS AND LINKAGES The key elements of the USG-funded palliative care program embrace the full spectrum of services providing integrated and comprehensive home and basic health care to PLWHA linked to comprehensive care centers (CCC), patients support centers, and rural dispensaries. Through training of trainers programs, health workers from primary care facilities receive comprehensive and integrated care instruction, and community-based health care workers train primary care givers at home to complement facility-based services.

At health facility sites, staff will receive integrated HIV care training following Ministry of Health curricula instructing them in the prevention, identification and management of OIs, clinical monitoring of HIV-infected adults, children, and infants, coupled with appropriate counseling and education. CCCs or MCHs in rural health facilities will manage and follow the infants and children of HIV-infected women. A case manager will manage referrals to and from the community. The community-based component will include treatment literacy, basic management of OIs, ART and TB treatment adherence, adequate nutrition, home hygiene and nursing skills, malaria prevention and treatment, family planning, and identification and referral of persons suspected to be infected with HIV and TB.

Formal linkages between health facilities and community-based activities will enhance effective care, follow-up, referral tracking, and monitoring of patient satisfaction. Both professional health care workers and community and home-based care volunteer workers will be trained on effective referral. Lay treatment support volunteers will be recruited and trained, using the Catholic Relief Service training curricula, to provide psychosocial support and adherence support for ART, TB, and clinic visits. This activity will mobilize and strengthen the organizational and institutional capacity of district-level institutions to integrate, plan, lead, monitor and evaluate home and community care support programs. Quality assurance and quality improvement for both facility and community interventions will be key in ensuring that standards of care are met. Care providers will be trained on the MOH Standard Operational Procedures.

BARRIERS ENCOUNTERED/STRATEGIES FOR RESOLUTION Definitions of care have been defined in GOK policy documents but not enforced, primarily due to a lack of materials and drugs in lower-level health facilities. Secondly, fully equipped home-based care kits have been unavailable due to restrictions on drug procurement. The distribution of home-based kits and therapeutic nutrition supplements through civil society and government facilities will resolve these issues. Finally, success in palliative care depends on strong referral networks between communities and the government. To fortify these networks, Capable Partners and HPI will work with the Department of Children's Services and the National AIDS Control Council to improve their databases and to nurture the relationship between these agencies.

In Kenya, MOH severely restricts the use of opioids for palliative care, including end-of-life care. Through Mildmay International, the USG teams will advocate for policy changes to broaden access to pain medication in ways that will increase the ability of providers to alleviate suffering while maintaining safeguards against medication abuse.

WORK OF HOST GOVERNMENT AND OTHER DONORS Provision of home-based care and other social support for PLWHA through NGOs and CBOs is part of Kenya's National AIDS Strategic Plan 2005-2010 and the National AIDS and STD Control Program Home-based Care Strategy for 2004-2008. There is an effort to standardize practice to meet national guidelines. Home-based care guidelines for Kenya were finalized in 2003 with significant technical and financial contributions by USG agencies that have been further involved in guideline dissemination and use in practice. DFID provides significant support for home-based care with an emphasis on Nyanza Province.

Program Area Target: Total number of service outlets providing HIV-related palliative care (excluding 1,240 TB/HIV) Total number of individuals provided with HIV-related palliative care 389,227 (excluding TB/HIV) Total number of individuals trained to provide HIV-related palliative care 4,000 (excluding TB/HIV)

Table 3.3.06:

1. LIST OF RELATED ACTIVITIES This activity relates to activities in ARV Services (#7094) and PMTCT (#7097).

2. ACTIVITY DESCRIPTION University of Manitoba will expand provision of palliative care services at two sites in Nairobi, providing care for 700 people with HIV, including 50 children. Patients receiving care will include two cohorts of patients identified through US government funded research studies, their families, and others in the geographic area. Services will be provided at Pumwani Maternity Hospital (PMH) and a clinic in the Pumwani Majengo area of Nairobi. University of Manitoba activities will link with those conducted by other University based groups collaborating with the University of Nairobi and will be conducted in close collaboration with PMH and Nairobi City Council Clinics through the Nairobi Provincial ART Officer. The existing referral networks between the PMTCT program and other care and support centers within Nairobi will also be enhanced. Adherence to care will be supported through extensive involvement of peer groups. Funds will be used to support health care worker salaries in accordance with Emergency Plan guidance, and will support logistics (particularly pharmacy management) and dissemination of informational materials. The activity will support the training of 10 individuals to provide HIV-related palliative care (excluding TB/HIV).

University of Manitoba has an extensive history of work in Kenya with vulnerable populations including sex workers and a long standing research collaboration with the University of Nairobi with a primary focus on evaluation of risk factors for maternal to child transmission of HIV. Since 1986, they have been the main provider of health care and counseling for over 1700 mothers and their families. This long-term association has nurtured and created a very trusting environment for patients to visit. Prior to the availability of Emergency Plan funds, it had not been possible to provide antiretroviral treatment to the women and children in this cohort because of lack of resources. University of Manitoba also has a long-standing relationship with a cohort of commercial sex workers and former commercial sex workers in the Majengo area of Nairobi. Extensive community-based services have already been established that involve peers as educators and a setting that allows this very vulnerable population to receive health services that they would otherwise be unable to access. These activities will capitalize on the HIV care expertise among the University of Manitoba staff.

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will contribute to expansion of palliative care for clinically qualified HIV-positive patients, strengthened human resource capacity to deliver HIV care, and a strengthened referral network for provision of HIV care.

3. LINKS TO OTHER ACTIVITIES These activities link closely to ART services provided by University of Manitoba (#7094), PMTCT services at PMH provided by University of Nairobi (#7097) and to services provided at Kenyatta Hospital, a network center through University of Nairobi.

4. POPULATIONS BEING TARGETED Patients receiving treatment will include two cohorts of patients identified through US government funded research studies, their families, women seeking antenatal and maternity services, and others in the geographic area. These populations include vulnerable women and children, in particular sex workers and former sex workers who might not otherwise seek/access medical care and who may be high risk to transmission HIV particularly in the absence of appropriate treatment and support. Public health workers will be targeted, mainly doctors, nurses, pharmacists and laboratory workers.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses legislative issues related to stigma and discrimination through community sensitization activities.

7. EMPHASIS AREAS This activity includes minor emphasis in commodity procurement, community mobilization, development of networks/linkages/referral systems, human resources, information, education, and communication, logistics, and training.

University of Manitoba will support TB/HIV services for approximately 700 patients at 2 sites in Nairobi Province. Intensified TB screening and treatment for all HIV patients and HIV screening for all TB suspects/patients will be offered as a standard of care in all the facilities; approximately 70 patients will be identified as being infected with both TB and HIV. Funds will support refresher training of laboratory staff and improvement of basic laboratory microbiology capacity in order to meet the increased needs for TB testing. 10 health care workers will be trained to provide clinical prophylaxis and/or treatment for TB to HIV-infected individuals. Fund will support expanded and strengthened delivery of integrated HIV and TB services including strengthened referral systems. Additional activities will include community mobilization and dissemination of educational materials to patients. University of Manitoba will maintain data concerning the numbers of people served and will report both nationally and through the Emergency Plan. University of Manitoba has an extensive history of work in Kenya with vulnerable populations including sex workers and a long standing research collaboration with the University of Nairobi with a primary focus on evaluation of risk factors for maternal to child transmission of HIV. Since 1986, they have been the main provider of health care and counseling for over 1700 mothers and their families. This long-term association has nurtured and created a very trusting environment for patients to visit. Prior to the availability of Emergency Plan funds, it had not been possible to provide antiretroviral treatment to the women and children in this cohort because of lack of resources. University of Manitoba also has a long-standing relationship with a cohort of commercial sex workers and former commercial sex workers in the Majengo area of Nairobi. Extensive community-based services have already been established that involve peers as educators and a setting that allows this very vulnerable population to receive health services that they would otherwise be unable to access. These activities will capitalize on the HIV care expertise among the University of Manitoba staff. 3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will contribute towards the provision of integrated HIV/TB services for dually infected patients 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. These activities will strengthen referral systems, improve diagnostics and treatment of TB among HIV-positive patients and strengthen capacity of health workers to provide integrated HIV and TB services. 4. LINKS TO OTHER ACTIVITIES The overall program activity links closely to Palliative Care (#7093), ARV Services (#7094) currently supported by this partner, PMTCT services at PMH provided by University of Nairobi (#7097) and to services provided at Kenyatta Hospital, a network center through University of Nairobi as well as HIV/TB services supported by NLTP. 5. POPULATIONS BEING TARGETED These activities target people living with HIV/AIDS. Public health care providers, including doctors, nurses, pharmacists, laboratory workers will receive training in the diagnosis and management of TB using government guidelines. 6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses legislative issues related to stigma and discrimination through community sensitization activities. 7. EMPHASIS AREAS This activity includes minor emphasis in commodity procurement, development of networks/linkages/referral systems, community mobilization, human resources, local organization capacity development, quality assurance, quality improvement and supportive supervision, and training.

Targets

Target Target Value Not Applicable Number of service outlets providing treatment for tuberculosis (TB) 2
to HIV-infected individuals (diagnosed or presumed) in a palliative care setting Number of HIV-infected clients given TB preventive therapy  Number of HIV-infected clients attending HIV care/treatment 70
services that are receiving treatment for TB disease Number of individuals trained to provide treatment for TB to 10
HIV-infected individuals (diagnosed or presumed)

Table 3.3.07:

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Palliative Care (#7093) and PMTCT (#7097).

2. ACTIVITY DESCRIPTION University of Manitoba will expand provision of services at two sites in Nairobi, providing ART to 280 people with advanced HIV (100 new patients) , including 50 children, bringing the total ever treated to 336. Patients receiving treatment will include two cohorts of patients identified through US government funded research studies, their families, and others in the geographic area. Services will be provided at Pumwani Maternity Hospital and a clinic in the Pumwani Majengo area of Nairobi. University of Manitoba activities will link with those conducted by other University based groups collaborating with the University of Nairobi and will be conducted in close collaboration with PMH and Nairobi City Council Clinics through the Nairobi Provincial ART Officer. The existing referral networks between the PMTCT program and other care and support centers within Nairobi will also be enhanced. Adherence to care and to ART will be supported through extensive involvement of peer groups. Funds will be used to support health care worker salaries in accordance with Emergency Plan guidance, and will support logistics (particularly pharmacy management) and dissemination of informational materials.

University of Manitoba has an extensive history of work in Kenya with vulnerable populations including sex workers and a long-standing research collaboration with the University of Nairobi with a primary focus on evaluation of risk factors for maternal to child transmission of HIV. Since 1986, they have been the main provider of health care and counseling for over 1,700 mothers and their families. This long-term association has nurtured and created a very trusting environment for patients to visit. Prior to the availability of Emergency Plan funds, it had not been possible to provide antiretroviral treatment to the women and children in this cohort because of lack of resources. University of Manitoba also has a long-standing relationship with a cohort of commercial sex workers and former commercial sex workers in the Majengo area of Nairobi. Extensive community-based services have already been established that involve peers as educators and a setting that allows this very vulnerable population to receive health services that they would otherwise be unable to access. These activities will capitalize on the treatment expertise among the University of Manitoba staff and will train 20 health care workers.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will contribute to expansion of ARV treatment for clinically qualified HIV-positive patients, strengthened human resource capacity to deliver ARV treatment, and a strengthened referral network for provision of ART.

4. LINKS TO OTHER ACTIVITIES This activity relates to Pallative Care activities supported by University of Manitoba, ARV services supported by University of Nairobi at Kenyatta National Hospital, a network center, and relates closely to University of Nairobi supported PMTCT services at Pumwani Maternity Hospital.

5. POPULATIONS BEING TARGETED The populations targeted in this activity include two cohorts of patients identified through US government funded research studies, their families, women seeking antenatal and maternity services, and others in the geographic area. These populations include vulnerable women and children, in particular sex workers and former sex workers who might not otherwise seek/access medical care and who may be at high risk to transmit HIV, particularly in the absence of appropriate treatment and support.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses legislative issues related to stigma and discrimination through community sensitization activities.

7. EMPHASIS AREAS This activity includes minor emphasis in commodity procurement, community mobilization, development of networks/linkages/referral systems, human resources, information, education and communication, logistics, targeted evaluation, and training.