1. LIST OF RELATED ACTIVITIES This activity relates to counseling and testing (#8760), abstinence/be faithful (#8989), condoms and other prevention (#8942), palliative care (#8928), TB/HIV (#9059)) and ARV services (#8774).

2. ACTIVITY DESCRIPTION USAID's APHIA Nyanza project implemented by EngenderHealth began its support to PMTCT services in Nyanza Province in FY 2006. In FY 2007 this activity will continue the expansion of PMTCT services in 60 public sector and faith-based health facilities across nine districts in Nyanza Province. In these health facilities technical assistance will be provided to increase management and technical capacity of staff, and improve quality and utilization of services. This activity aims to reach 80% of ANC clients, with counseling and testing, to provide ARV prophylaxis to 90% of the expected HIV+ mothers and early infant diagnosis to 50% of exposed infants. To improve the technical capacity of health staff, 250 will receive training in PMTCT based on the national guidelines. In the eleven districts, counseling and testing will be provided to 27,624 pregnant women, antiretroviral prophylaxis to 5,043 HIV+ women, 2,520 of whom will receive the more efficacious regimen, 500 will receive HAART and 2023 will receive single dose nevirapine. Early infant diagnosis will be provided to 2,520 exposed babies. Service delivery will continue to incorporate best practices including op-out testing with same day results, maximally effective combination prophylaxis regimens, referral for partner testing and appropriate referral linkages to support post natal follow up of HIV+ mothers and exposed infants. The project will examine ways to improve infant feeding and compliance to treatment. Priority will be given to provision of integrated services ensuring effective linkages to treatment, care and support, as well as to family planning and reproductive health services. This will ensure that pregnant women receive comprehensive HIV care including OI prevention and treatment especially for TB. Support to infrastructure development, procurement of medical equipment and improved data collation will enhance service delivery. Behavior change communication (BCC) strategies will focus on stigma reduction to increase utilization of services, psychosocial support, promotion of ante natal care services and facility based deliveries.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will work in collaboration with other partners in Nyanza province to improve geographical coverage for PMTCT services and strengthen service delivery. It will contribute 2.8% of the overall PMTCT targets in 2007. This will enhance MCH service quality and encouraging rural women in underserved communities to attend ante natal care services. Referrals and linkages to care and treatment for pregnant women and infants, and referrals for partner testing will increase opportunities to provide comprehensive family care and treatment.

4. LINKS TO OTHER ACTIVITIES This activity relates to activities in counseling and testing (#8760), abstinence/be faithful (#8989), to reduce stigma and encourage women and families to know their status. It also relates to condoms and other prevention (#8942), palliative care (#8928), TB/HIV (#9059) and ARV services (#8774) encouraging healthier behaviors in HIV prevention in care and treatment settings.

5. POPULATIONS BEING TARGETED This APHIA Nyanza activity targets adults of reproductive health age, pregnant women, family planning clients, infants, and HIV positive pregnant women. BCC activities will involve community leaders and community based organizations to increase demand for services amongst community members. Strategies to improve quality of services will target faith-based and public health doctors, nurses, mid wives and other health care workers such as clinical officers and public health officers in both public and faith based facilities.

6. KEY LEGISLATIVE ISSUES ADDRESSED The behavior change communication activities for STI and HIV prevention will promote gender equity through partnering with women's organizations in the design and implementation of community activities. The activity will address male norms and behavior including multiple sexual partners through community interventions, as well as stigma and discrimination.

7. EMPHASIS AREAS This APHIA II Nyanza activity has a major emphasis on quality assurance, quality improvement and supportive supervision. Minor emphasis is put on training and community mobilization/participation.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Counseling and Testing (#8760), and Condoms and Other Prevention (#8942).

2. ACTIVITY DESCRIPTION The APHIA Nyanza project implemented by EngenderHealth initiated support to AB activities in Nyanza Province in FY 2006. This activity will continue to equip youth with skills to cope with peer pressure and help them develop positive norms and values to make appropriate and safe choices in relationships. It will target youth both in and out of school expanding abstinence-based programs for youth through child-to-child programs in Nyanza Province. In schools, 200 teachers will be trained in adolescent development, gender issues, and HIV information and facilitation skills. They will train 400 student peer educators who will then implement a child-to-child school program targeting primary school children. Further, 200 youth advocates will be trained to implement youth-to-family activities, a significant innovation in the community in FY 2007 aimed at reaching out-of-school youth. The program will promote abstinence and responsible decision making, including promotion of counseling and testing to youth out of school to reduce the risk of contracting HIV/AIDS. These abstinence and behavior change activities will reach 10,000 in-school youth and 10,000 out-of-school youth in urban and rural settings. This activity includes the involvement of church leaders and church-based youth groups to establish and reinforce norms that reduce youth risk, vulnerability and stigma. The project will utilize magnet theatre approaches and community radio to reach the general population with HIV prevention messages. Community media messages targeting men and encouraging abstinence and safer behavior will be implemented through work site activities and linkages with faith based community groups, churches and mosques. A total of 12,000 community members will be reached through these strategies. This project will work in close collaboration with the National AIDS and STI Control Programme of the Ministry of Health, ensuring that activities meet the Government of Kenya priorities and guidelines. In Nyanza Province this activity will be planned, implemented and monitored in partnership with the District Health Management Teams, District Education Officers, schoolteachers, employers, community leaders and youth. This will create a continuum of youth-focused activities in the education, health and community sectors and forge effective linkages aimed at guiding youth toward practicing safer behaviors.

This activity also includes support to the following sub-recipient for activities integral to the program: PATH $825,000.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA AB in this geographical area will contribute substantively to the Kenya 5-Year Strategy for primary prevention which puts youth first to protect them from infection. T he child-to-child program provides significant support to the strategy targeting pre-adolescents and their families with appropriate messages. Activities in the general population will include a special focus on reaching men.

4. LINKS TO OTHER ACTIVITIES This activity relates to activities in counseling and testing (#8760), and Other Prevention (#8942). This will expand prevention opportunities for youth and provide appropriate support for risk reduction.

5. POPULATIONS BEING TARGETED This activity targets girls, boys, and primary school students through peer education activities. Youth-to-family activities will target adults and out-of-school youth. Community outreach activities will target community leaders, rural communities, religious leaders and teachers, community-based organizations and faith-based organizations.

6. KEY LEGISLATIVE ISSUES ADDRESSED This APHIA II activity will address male norms and behaviors, reducing violence and coercion through peer family programs aimed at changing social norms.

7. EMPHASIS AREAS This activity primarily emphasizes community mobilization/participation through peer education with a minor emphasis on training of youth, teachers and community leaders as detailed in the activity description in Section 1 above.

PLUS UP: The program will promote abstinence and responsible decision making, including promotion of counseling and testing to youth out of school to reduce the risk of contracting HIV/AIDS. These abstinence and behavior change activities will reach in-school youth and out-of-school youth in urban and rural settings. This activity includes the involvement of church leaders and church-based youth groups to establish and reinforce norms that reduce youth risk, vulnerability and stigma. The project will utilize magnet theatre approaches and community radio to reach the general population with HIV prevention messages, including male circumcision. Community media messages targeting men and encouraging abstinence and safer behavior will be implemented through work site activities and linkages with faith-based community groups, churches and mosques.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Counseling and Testing (#8760), Abstinence and Be Faithful Programs (#8989), Prevention of Mother-to-Child Transmission (#8734), Palliative Care: TB/HIV (#9059) and HIV/AIDS Treatment: ARV Services (#8774).

2. ACTIVITY DESCRIPTION The USAID APHIA II Nyanza project implemented by EngenderHealth initiated support to condoms and other prevention activities in Nyanza Province in FY 2006. In FY 2007, this activity will continue to promote the use of condoms in high-risk encounters and support STI prevention and management in Nyanza Province but with a new focus on prevention strategies for HIV-positive persons. In 50 public and faith-based health facilities, 300 health workers will be trained to promote HIV prevention in care and treatment settings. Strengthening and expansion of STI management will include training of health service providers in syndromic management of STIs with appropriate strategies for condom promotion through the MCH, VCT, PMTCT and HIV treatment services. Utilizing the Ministry of Health's Community Strategy, 200 community resource persons (CORPS) especially from women's groups will be trained to promote health behaviors including faithfulness to their partner, knowing one's HIV status, using condoms and seeking health care for management of STI's. This activity will include a component of stigma reduction. In order to reach men,100 peer educators at informal worksites including beach communities, will be trained in HIV-prevention behaviors. The CORPS and peer educators will implement an HIV prevention program to reach 200,000 individuals in the community through community outreach and promotional activities. Community-based organizations and faith-based groups will help to train 200 youth advocates to use various BCC strategies including community radio and magnet theatre to deliver ABC messages to 40,000 youth out of school.

This activity also includes support to the primary sub-recipient for activities integral to the program: PATH at 85% of the amount requested for OP.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This APHIA II Nyanza project will contribute to the Kenya Five-Year Strategy that focuses on HIV prevention targeting high-risk groups. It will support access to condoms for those at risk for transmitting or becoming infected with HIV. In FY 2007, it includes a focus on prevention for HIV-positive individuals.

4. LINKS TO OTHER ACTIVITIES This activity relates to activities in counseling and testing (#8760), Abstinence/be faithful (#8989) to promote healthy behaviors amongst youth and reduce stigma by encouraging individuals to know their HIV status. It also relates to PMTCT (#8734), Palliative Care: TB/HIV (#9059) and ARV services (#8774) expanding HIV prevention in care and treatment settings.

5. POPULATIONS BEING TARGETED This activity targets youth, men and women living in rural communities. It targets FP clients and people living with HIV/AIDS through clinical and community interventions. Training activities target public and faith-based health care workers. Community outreach activities will target community-based organizations, faith-based organizations, community leaders, religious leaders and out-of-school youth.

6. KEY LEGISLATIVE ISSUES ADDRESSED The behavior change communication activities for STI and HIV prevention will promote gender equity through partnering with women's organizations in the design and implementation of community activities. The activity will address male norms and behavior including multiple sexual partners through community interventions, as well as stigma and discrimination.

7. EMPHASIS AREAS This APHIA II Nyanza activity has a major emphasis on community mobilization/ participation with minor emphases on training, IEC and local organization capacity development.

Plus up: APHIA II Nyanza continues to support other prevention activities in Nyanza

Province, focusing on out of school youth. Utilizing the 24 youth groups that have been trained in three districts, peer leaders will trained to provide prevention messages highlighting male circumcsion. Through community ""magnet theatre"" youth will receive information on the medical benefits of MC and get an opportunity to address msiconceptions on this prevetion strategy. Youth will be referred to APHIA II Nyanza supported sites for clinical services.

1. LIST OF RELATED ACTIVITIES The APHIA II Nyanza HBHC activities relate to HIV/AIDS Treatment Services (#8774), Counseling and Testing (#8760), Other Prevention (#8942), OVC (#9071), TB/HIV Care activities (#9059), AB (#8989), PMTCT (#8734) and Strategic Information (#8859).

2. ACTIVITY DESCRIPTION USAID's APHIA II Nyanza project implemented by EngenderHealth began its support to basic health care support services in Nyanza Province in FY 2006. In FY 2007 this activity will continue to provide basic health care support services to 10,000 PLWAs in 60 public sector and faith-based health facilities and communities across nine districts in Nyanza Province. In the rural communities 100 home based care workers will be trained in nutrition, prevention, social and spiritual support, and end-of-life care. The quality and availability of palliative services will be increased in 60 health facilities by training 200 health workers in the management of opportunistic infections and other HIV/AIDS-related complications. Linkages between health facilities and the community-based activities will be strengthened for effective care, follow-up, and tracking of referrals. Both health care workers and community and home based care volunteer workers will be trained on effective referral. This activity will work with community leaders and community based organizations to establish linkages to other sectors to improve the livelihood of people living with HIV/AIDS. This will include microfinance and agricultural organizations to enhance business skills and agricultural skills.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will help to optimize the quality of life for 10,000 PLWAs in Nyanza province and provide critical support to families affected by HIV/AIDS.

4. LINKS TO OTHER ACTIVITIES This activity relates to activities in counseling and testing (#8760), condoms and other prevention (#8942) and PMTCT (#8734),TB/HIV Care activities (#9059), and ARV (#8774) through the formation of effective referral networks for HIV prevention, treatment care and support services.

5. POPULATIONS BEING TARGETED This APHIA Nyanza activity targets adults of reproductive health age, people affected by HIV/AIDS and people living with HIV/AIDS. Linkages to other sectors including agricultural programs and microfinance will involve community leaders and community based organizations. Strategies to improve quality of services will target faith-based and public health doctors, nurses, mid wives and other health care workers such as clinical officers and public health officers in both public and faith based facilities.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses stigma and discrimination by encouraging community support for people living with HIV/AIDS.

7. EMPHASIS AREAS This APHIA II Nyanza activity has a major emphasis on training, with minor emphases on community mobilization/participation and development of networks and referral systems.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Counseling and Testing (#8760), Condoms and Other Prevention (#8942), PMTCT (#8734), Palliative care: Basic health care and support (#8928), and ARV services (#8774).

2. ACTIVITY DESCRIPTION USAID's APHIA Nyanza project implemented by EngenderHealth began its support to TB/HIV palliative care services in Nyanza Province in FY 2006. In FY 2007 this activity will continue the expansion of TB/HIV services emphasizing HIV counseling and testing for all TB patients in 10 public sector and faith-based health facilities across two districts in Nyanza Province. The districts targeted for expanded TB/HIV services are Homa- Bay and Rachuonyo Districts. In the communities this activity will encourage utilization of health facilities for TB screening and treatment through a BCC strategy supported by community based and faith-based organizations. This activity will train 90 CHWs to introduce/strengthen community DOTS and encourage stigma reduction in rural communities. An active contact tracing program will be established linking the health facility, the CHWs and home based care providers. In the health facilities technical assistance will be provided to increase management and technical capacity of staff, and improve quality and utilization of clinical and laboratory services. This will ensure quality screening and clinical monitoring of patients, treatment for TB and referral for HIV testing. This activity aims to train 100 health workers, including MOH laboratory personnel on NLTP guidelines and reporting procedures; quality laboratory services procedures and comprehensive HIV/TB management. It will provide treatment to 600 HIV-infected TB patients. It prioritizes the screening of all HIV-infected persons, linking HIV-infected TB suspects to TB diagnosis and TB treatment using DOTS, and linking all HIV-infected TB patients to HIV care and treatment including ARV and cotrimoxazole therapy. This will strengthen referral linkages between the community, VCT sites, PMTCT sites, CCCs and TB clinics.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity supports one of the high priorities of the Emergency Plan by improving geographical coverage of services that address TB among persons living with HIV/AIDS, and total of 600 HIV-infected patients will receive TB treatment. Referrals and linkages to treatment care and support for HIV-infected TB patients will be strengthened.

4. LINKS TO OTHER ACTIVITIES This activity relates to activities in Counseling and Testing (#8760), Condoms and Other Prevention (#8942), PMTCT (#8734), Palliative care: Basic health care and support (#8928), and ARV services (#8774) through the formation of effective referral networks for HIV prevention, treatment, care and support services.

5. POPULATIONS BEING TARGETED This APHIA Nyanza activity targets adults of reproductive health age, pregnant women, people living with HIV/AIDS and rural communities to increase access to TB/HIV services. BCC activities will involve community leaders, religious leaders, faith-based and community based organizations to reduce stigma and improve health seeking behavior. Strategies to improve quality of services will target faith-based and public health doctors, nurses, mid wives, laboratory workers and other health care workers such as clinical officers and public health officers in both public and faith based facilities.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses stigma and discrimination by enhancing community support for PLWHAs and increasing gender equity in HIV/AIDS programs through increasing opportunity for comprehensive health care.

7. EMPHASIS AREAS This APHIA II Nyanza activity has a major emphasis on community mobilization/participation and quality assurance, quality improvement and supportive supervision. It has a minor emphasis on training.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in TB/HIV (#9059), Palliative Care: basic health care and support (#8928), ARV services (#8774), and counseling and testing (#8760).

2. ACTIVITY DESCRIPTION APHIA Nyanza project implemented by EngenderHealth initiated support to OVC in Nyanza Province in FY 2006. It addresses OVC needs adopting the Kenya PEPFAR strategy of addressing seven essential elements of OVC support. These essential services include: Nutrition, Education, Health, Protection, Psychosocial support, Basic Material needs and Livelihood Capacity Building. This activity will continue to employ a broad range of strategies and activities to build the capacity of communities, families and orphans to meet their needs, and to build the capacity of community-based partners to deliver sustainable high quality OVC interventions. The APHIA Nyanza project will serve 35,800 orphans and vulnerable children and provide training to 8,950 caregivers. Working with trained community health workers the project will implement home based care and other support interventions suitable for the children's well being and development. A total of 1,100 household members will be trained in palliative care for HIV+ children. Linkages to food support; vocational training; educational opportunities; income generating activities; will be strengthened through appropriate community organizations. The project will also build linkages to pediatric HIV services and other relevant health services.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will reach 35,800 OVC and train 8,950 caregivers in Nyanza province. It will augment the ability of communities to provide comprehensive services including basic medical and nursing care, counseling and psychological support, relief for social needs and prevention of HIV. It will strengthen the capacities of families and communities to make informed decisions on who needs what care and how best to provide it. The project will work in close collaboration with relevant community groups and government departments to form networks that will address health improvement, capacity building and food support, vocational and micro-business training for family income support.

4. LINKS TO OTHER ACTIVITIES This activity is linked to Engender Health activities in TB/HIV (#9059), Palliative Care: basic health care and support (#8928), ARV services (#8774), and counseling and testing (#8760).

5. POPULATIONS BEING TARGETED This activity will address individuals infected and affected by HIV/AIDS by targeting caregivers of OVC, OVC - especially the girl child, as well as building the capacity of other community based and faith based organizations by working closely with community and religious leaders in the delivery of care to OVC in each community.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity will address issues in increasing gender equity in HIV/AIDS programs as well as wrap around services in food and education.

7. EMPHASIS AREAS Major emphasis area is in development of local organization capacity and minor emphasis in network/linkages/referral, community mobilization and training.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in abstinence/be faithful (#8989), condoms and other prevention (#8942), palliative Care: TB/HIV (#9059) and ARV services (#8774).

2. ACTIVITY DESCRIPTION The USAID APHIA II Nyanza project implemented by EngenderHealth initiated support to counseling and testing services in Nyanza Province in FY 2006. In FY 2007 this activity will continue to expand the geographical coverage of this service to increase access for couples and families. A total of 25 new VCT sites will be established in public and faith based health facilities. Training in VCT and DCT will be provided for 80 counselors and health care workers respectively. As a result 15,000 individuals will be counseled and tested and referred to care, treatment and other services as required. Increasing access to antiretroviral therapy dictates that CT efforts quickly transform to accommodate active case finding through provider initiated testing, PIT, in clinical settings, in addition to the more passive client initiated testing, CIT. Existing integrated VCT sites are particularly well placed to support these efforts; they will be strengthened to support DTC efforts e.g. supporting start up activities, providing testing for partners and other family members of index patients, and providing ongoing counseling. Testing in clinical settings will require support for logistics, creation and renovation of space especially at inpatient facilities, supportive supervision, ongoing monitoring, and mainstream CT reporting. Existing supported VCT sites already serve a large population of young people aged 24 and younger. In addition to existing dedicated youth VCT services, counselors at general VCT sites will be trained to work with young people. Targeted outreaches to youth centers and tertiary institutions, will also reach young people. Experiences with comprehensive counseling services at existing youth VCT centers including alcohol and substance abuse prevention counseling; gender based violence prevention and counseling, pregnancy prevention/FP; STI prevention, diagnosis and treatment; and referral to addiction treatment services; will be documented and used to scale up these efforts at existing general VCT sites. Outreach services, health action days, will require effective supervision, sessional staff, supplies, data collection and other logistics. BCC strategies supported by CBOs, FBOs, churches and mosques will encourage people to know their HIV status, and develop discordant couples support groups.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This APHIA II Nyanza project will contribute to the Kenya 5-Year Strategy that focuses on increasing access to counseling and testing clinical services. It will provide this service to 15,000 individuals in Nyanza province prioritizing youth, couples and families.

4. LINKS TO OTHER ACTIVITIES This activity relates to activities in Abstinence/be faithful (#8989) and condoms and other prevention (#8942) to promote health behaviors and reduce stigma by encouraging individuals to know their HIV status. It also relates to Palliative Care: TB/HIV (#9059) and ARV services (#8774) strengthening linkages between prevention, care and treatment settings.

5. POPULATIONS BEING TARGETED This activity targets youth and adults living in rural communities. It targets discordant couples and people living with HIV/AIDS through clinical and community interventions. Training activities target public and private based health care workers and other health workers. Community outreach activities will target community based organizations, faith based organizations, community leaders and religious leaders. At-risk populations will also be targeted with these services like commercial sex workers, discordant couples, injecting drug users, street youth, truck drivers, migrant workers, out-of-school youth and partners/clients of CSWs.

6. KEY LEGISLATIVE ISSUES ADDRESSED The activity will address stigma and discrimination by encouraging people to know their status. The behavior change communication activities for HIV prevention will promote gender equity through partnering with women's organizations in the design and implementation of community activities.

7. EMPHASIS AREAS This APHIA II Nyanza activity has a major emphasis on training and minor emphasis in

quality assurance, quality improvement and supportive supervision and development of network/linkages/referral systems. It has a minor on emphasis community mobilization/participation as well.

EngenderHealth APHIA II will provide VCT to men interested in circumcision. This will be supported by behavior change communication activities, targeting community leaders and youth. These are key components of the full package of MC services that will be supported in 30 MOH facilities and faith-based facilities where APHIA II is currently operating in Nyanza.

Table 3.3.10: Program Planning Overview Program Area: HIV/AIDS Treatment/ARV Drugs Budget Code: HTXD Program Area Code: 10 Total Planned Funding for Program Area: $ 79,180,706.00

Program Area Context:

Key Result 1: Sufficient quantities of ARV drugs procured to support treatment for 110,000 people, including 22,000 children Key Result 2: Public sector commodity forecasting, procurement and distribution systems strengthened Key Result 3: Drug quality monitoring by National Quality Control Laboratory strengthened

CURRENT PROGRAM CONTEXT Pharmaceutical logistics management in Kenya is steadily improving, but public sector drug delivery is sometimes erratic and relies on a push system where commodities are allocated to facilities from central stores. Information about stocks is kept in paper systems, reporting from Ministry of Health (MOH) sites is generally incomplete, and stock outs are common (but have been entirely avoided in the case of ARVs).

For the past three years, the majority of procurement and distribution of drugs and related supplies for Emergency Plan-supported sites has been done by the Mission for Essential Drugs and Supplies (MEDS), an FBO that supports a network of mission, NGO, public and small community facilities. MEDS maintains a large central receiving warehouse that has significantly expanded capacity for storage, sorting, and packaging operations with USG support over the last three years. It maintains a well-developed and tested quality assurance system that includes visits to pharmaceutical manufacturers and other suppliers as well as its own on-site chemical analysis capability to assess the quality of products received. MEDS also operates a zonal transportation system for product delivery, which has ensured quick turn-around time for orders from treatment sites.

In close partnership with Management Systems for Health /Rational Pharmaceutical Management Plus (MSH/RPM+) Project, MEDS has been responsible for accurate forecasting, quantification, procurement, storage and distribution of ARVS purchased by the Emergency Plan in Kenya. Due to the established supplier relationships, coupled with an elaborate distribution infrastructure, MEDS has ensured that there are no stock-outs in ARV drugs, and that the commodities are received at sites of treatment within five days of order. At the end of June 2006, MEDS was supplying ARVs directly to a total of 116 treatment sites in Kenya.

The public sector counterpart to MEDS is the Kenya Medical Supplies Agency, KEMSA, which has been another key Emergency Plan partner in HIV-related commodities. KEMSA distributes HIV test kits and laboratory reagents, as well as ARVs purchased with Global Fund and GOK resources.

Two major technical partners have collaborated with USG agency staff to support these activities in the past: JSI DELIVER and MSH/RPM+. Both work to assist government with policy development for drug procurement and distribution and strengthening of the drug registration process in Kenya; MSH/RPM+ also works with the National Quality Control Lab to strengthen capacity there. MSH/RPM+ strengthens capacity at MEDS, and supports development of patient/provider relationships at facilities. JSI strengthens capacity at KEMSA, and assists NASCOP with forecasting overall national needs and reporting from MOH facilities. JSI also supports MOH to build logistics management and planning capacity for drugs, test kits, and other essential commodities.

In FY 2006 USG Kenya purchased a number of USFDA approved generic equivalent ARVs, and achieved cost savings of up to 81% on some products (Nevirapine specifically). This cost saving enabled the purchase of drugs for 70,000 patients, and the dollar value of generic ARVs accounted for 58% of the drug budget in the contract. At the end of August 2006, there were 46,000 patients on USG-purchased ARVs nationally.

NEW INITIATIVES In FY 2007, we will purchase more USFDA-approved generic ARVs, with the majority of first-line ARVs

being USFDA-approved. As programs mature, more and more patients will move to second line ARVs and we will therefore buy more second-line drugs than we have in the past. We will also work closely with the MOH to prioritize procurement of pediatric ARVs with resources from the Global Fund, which MOH had not catered for in the initial Kenya GF work-plan.

In FY 2007, the ARV procurement contract will be competitively awarded at mission level, and bids will be solicited through an RFP process. The winner will distribute ARVs procured under the Emergency Plan, while the USG will continue to strengthen KEMSA to improve the distribution of drugs purchased by the GOK and the GFATM. A small fraction of drug procurement funds are allocated to CDC's cooperative agreement with the Kenya Medical Research Institute to provide flexibility for contingencies.

The main change in the 2007 COP is that MSH/RPM+ will work more directly with KEMSA and its staff at the Logistics Management Unit (LMU) for activities that were previously supported by JSI/DELIVER. This includes managing the LMIS system of parallel commodities. RPM+ will maintain this database and help distribute reports to relevant divisions and agencies on stock status until it is ready to be transitioned to and maintained by KEMSA. When this transition happens, it will entail: expansion of the LMIS database to include all products warehoused and distributed by KEMSA, finalization of the LMIS user manual, training KEMSA and users from MOH departments (NASCOP, KEPI, RH, NLTP and essential drug programs) on how to use the LMIS, and implementing facility-level forms and tools for recording and summarizing commodity usage data.

BARRIERS ENCOUNTERED/STRATEGIES FOR RESOLUTION Multiple drug sources continue to impose a heavy reporting burden to HIV treatment sites, as the reporting requirements tend to differ between programs. In 2007, special efforts will be made to link and coordinate these systems to minimize reporting burdens for the individual sites.

Failure to maintain timely and accurate reporting has compromised Kenya's ability to make optimal use of drug (and other commodity) donation programs. In 2007, focused assistance will be provided to NASCOP to address this problem.

The greatest challenge remains limited resources from other-than-PEPFAR sources for the purchase of ARV commodities. ART scale-up from GOK and Global fund has been temporarily capped at 42,500 patients for whom the GOK has assured ARV supply till December 2008, but we have recent and promising indications that the Government is taking steps to procure ARVs for an additional 34,000 patients from its own resources. According to the Five Year USG Kenya strategy, we had committed to purchase ARVs for 100,000 patients in FY 2007, with the expectation that the GOK/Global fund and other donors would match this target, but this has not happened. Due to the current cap on GOK/Global Fund support, USG has forecasted drug needs for 110,000 patients in FY 2007. The USG team will continue to support the efforts of GOK to allocate its own resources to purchase ARV commodities so national targets may be reached.

WORK OF HOST GOVERNMENT AND OTHER DONORS There are well-developed systems for drug registration in Kenya, however post-market surveillance is almost non-existent and the capacity of the National Quality Control Laboratory is limited by resources available. Ongoing and expanded activities proposed in the FY 2007 COP will broadly support improvement in pharmaceutical management and pharmaco-vigilance in Kenya.

The British Government, through DFID, has been a dependable partner in the purchase of ARV commodities to supplement GOK purchases. In the early part of 2006, and after the realization that due to the rapid ART scale up, there would be a shortfall in ARVs in the GOK facilities, DFID funded the purchase of ARVs amounting to 2 million pounds, and this helped prevent stock out of ARVs in public facilities. The other significant partner in ARV purchase is MSF- Doctors without Borders, who currently support ARVs for 10,000 patients in five sites in Kenya.

Table 3.3.10:

1. LIST OF RELATED ACTIVITIES This activity relates to activities in counseling and testing (#8760), PMTCT (#8734), orphans and vulnerable children (#9071), TB/HIV (#9059), basic health care and support (#8928) and ARV services (#8774).

2. ACTIVITY DESCRIPTION The APHIA II Nyanza project implemented by EngenderHealth initiated support to ART services in Nyanza Province in FY 2006. This activity will continue in FY07 to expand HIV care and treatment services in 4 districts whose selection was based on the need to augment services in districts where CDC partners are not already providing significant support. Working in 20 public sector, local sugar company worksites and faith based facilities, HIV treatment will be provided to 2,000 individuals. Activities will focus on decentralization of HIV care and treatment services resulting in initiation of services and follow up sites in health centers, and inclusion of a broad cadre of health staff to provide adherence counseling and support. To improve the technical capacity of health staff, 150 will receive training in ART and facilitative supervision. Infrastructure improvement, logistics strengthening, procurement of supplies and dissemination of materials such as standard treatment protocols, guidelines and pamphlets to address adherence will form part of the support. The network model of care will be incorporated to strengthen linkages to MCH, PMTCT, TB, and STI services to expand opportunities for ART. A behavior change communication program will be established in the rural communities surrounding the health facilities to address stigma reduction; encourage utilization of treatment services; treatment compliance as part of psychosocial support; and prevention of HIV among HIV positive individuals. Because the issue of stigma and discrimination is still high amongst health workers in Kenya this activity whilst conducting clinical training will also train workers on stigma and discrimination using a curriculum specifically produced for this purpose.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will expand ART services in Nyanza Province providing treatment to 2,000 individuals and increase availability of skilled health workers to provide care and treatment. It will enable service providers to identify and refer the large numbers of HIV infected patients who are potential candidates for ART. This activity will increase access to quality treatment services particularly among the underserved. It also contributes to Kenya's 5-year strategy emphases of developing effective linkages between prevention, care and treatment services within an integrated network.

4. LINKS TO OTHER ACTIVITIES This is linked to activities carried out by APHIA II - Nyanza across other program areas, including counseling and testing (#8760), PMTCT (#8734), orphans and vulnerable children (#9071), TB/HIV (#9059), basic health care and support (#8928) and ARV services (#8774).

5. POPULATIONS BEING TARGETED These activity targets rural community members, people living with HIV/AIDS, HIV positive infants, and children, HIV affected families, OVCs and caregivers. It also targets health care providers in public and faith based facilities, other health care workers and other MOH staff based in Nyanza Province.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity will help to reduce stigma associated with HIV status and increase gender equity by expanding the availability of comprehensive care.

7. EMPHASIS AREAS This activity includes major emphasis on training and minor emphasis on development of network/linkages/referral systems as detailed in the activity description above.

This plus up funding will be used to more rapidly scale up pediatric ART to 200 children in Nyanza province($100,000). It will strengthen and expand pediatric counselling and testing, strengthen linkages with PMTCT services at facilitesand strengthen early infant diagnosis networks using improved dried blood spot sample collection, transportation and reporting; improve community mobilization to increase community awareness and sensitise health workers on availability of pediatric testing, counselling and treatment,

provide training and mentorship to strengthen the HIV component of integrated management of childhood illnesses (IMCI). It will contribute to over 1,000 children being initiated on ART and 300 health workers trained for improved identification and care and treatment of HIV infected children.

APHIA II Nyanza will renovate and expand physical infrastructure at current or potential treatment sites particularly hospitals (district and sub-district hospitals) where an estimated 2,200 HIV positive individuals will receive care. The activitiy is expected to renovate approximately 5 district or sub-district hospitals improving their ability to provide essential ART services ($100,000).

1. LIST OF RELATED ACTIVITIES This activity is related to the strategic information activities to be carried out by University of North Carolina/MEASURE Evaluation (#7098), NASCOP (#7002) and TE/TBD (#9220).

2. ACTIVITY DESCRIPTION USAID'S APHIA II NYANZA project implemented by ENGENDERHEALTH began its service delivery activities in Nyanza province in FY 2006. In FY 2007 this activity will strengthen the provincial and district level Health Management Information Systems (HMIS) currently in use in Nyanza province MOH health facilities, and Community Based Program Activity Reporting (COBPAR) currently being rolled out at Constituency AIDS Control Committees (CACCS) levels by NACC through 3 key components. Component 1: Support APHIA II NYANZA/ENGENDERHEALTH and MOH program data collection processes for performance reporting needs (quarterly, semi-annual, annual). This component will support a participatory, coordinated and efficient data collection, analysis, use and provision of information to track achievement of APHIA II NYANZA/ENGENDERHEALTH and MOH's district level Annual Operation Plan II objectives, and inform decisions at the local, district and provincial levels, using standardized M&E/HMIS tools approved by the MOH. Component 2: Strengthen community and facility based reporting systems being rolled out by NACC and NASCOP. The component will support APHIA II NYANZA/ENGENDERHEALTH and MOH to measure progress towards its contribution to the overall country's Emergency plan, National Health Sector Strategic Plan II and Kenya National HIV/AIDS Strategic Plan goals and results frameworks. Specific activities will include building capacity of 40 local organisations and facilities to collect, report, analyse, and use both routine facility and non-facility data for planning and program improvement. Component 3: Take lead role in coordinating M&E activities in the province to meet the information needs of USAID/Kenya, the Emergency Plan, MOH, NACC and other stakeholders, in line with the "three ones" principle. APHIA II NYANZA/ENGENDERHEALTH Nyanza will organize district-level consensus building forums on M&E issues, distribute standardized data collection and reporting tools, conduct regular data quality assurance processes at all data generation points, train 110 facility based data point staff on the new data collection/reporting tools and data use for improving program performance, and hold provincial level quarterly and annual stakeholders' information dissemination meetings. APHIA II Nyanza/ENGENDERHEALTH will be held accountable for tangible results, especially in increased use of harmonized data collection and reporting tools at health facilities developed by MOH, increased data use in planning and at dissemination workshops to various stakeholders, increased supportive-supervisory visits and routine data quality assessments at all data collection points by M&E/HMIS officers, and improved coordination of M&E activities in Nyanza province. These efforts should result into demonstrated evidence in increased national level reporting by up to 60% from health facilities to NASCOP national database.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA The activity builds on the FY 2006 activities that support the national M&E systems as well as contributing to the Emergency Plan's training outputs. In overall, the activity will provide technical assistance to forty local organizations/health facilities in strategic information in addition to supporting the training of 110 SI and program managers in M&E/HMIS, reporting and data use for program management.

4. LINKS TO OTHER ACTIVITIES This activity is related to the strategic information activity to be carried out by University of North Carolina/MEASURE Evaluation (#7098), where MEASURE Evaluation will be supporting NACC in rolling out COBPAR system for community level reporting. It is also related to the strategic information to be carried out by NASCOP (#7002), where NASCOP will be rolling out Form 726, Form 727 and program specific client registers for data collection and reporting at health facilities. It is also related to SI TE/TBD (#9220) that will attempt to investigate the causes for low reporting rate by health facilities and recommend strategies for achieving 100% reporting level by health facilities.

5. POPULATIONS BEING TARGETED This activity targets host government and other health care workers like M&E and HMIS officers responsible for data collection, analysis, reporting and use at both health facilities and community level. Program managers are as well targeted for orientation on the role M&E program management.

6. EMPHASIS AREAS The major emphasis area is Health Management Information Systems (HMIS) and minor areas include Monitoring, evaluation, or reporting (or program level data collection) and Other SI Activities.

APHIA II Nyanza/EngenderHealth will help to strengthen the District Health Management Information System by building the capacity of service providers and health records information officers to prepare and submit timely and accurate reports. This will include training of 50 MOH officers in Nyanza Province to improve the utilization of registers and other reporting tools both in clinical services and prevention services. As an increasing number of clients receive male circumcision services in health facilities and counseling and testing for the prevention of HIV/AIDS, the project will support the districts to collate this information accurately in order to track the progress of the male circumcision initiatives. The project will work with the he project will conduct regular data quality assurance processes at all data generation points, and provide technical mentoring as required. APHIA II Nyanza/EngenderHealth will be held accountable for tangible results, especially in increased use of harmonized data collection and reporting tools at health facilities developed by MOH, increased data use in planning and at dissemination workshops to various stakeholders, increased supportive-supervisory visits and routine data quality assessments at all data collection points by M&E/HMIS officers, and improved coordination of M&E activities in Nyanza province. These efforts should result into demonstrated evidence in increased national level reporting by up to 60% from health facilities to NASCOP national database.

Table 3.3.13:

In collaboration with MOH, EngenderHealth APHIA II will strengthen MC service delivery capacity in 30 MOH facilities in Nyanza provinece. MC service delivery capacity-building will be strengthened in district hospitals and faith-based facilities, particularly where other PEPFAR-supported activities such as VCT, care and treatment are available. Systems strengthening will include infrastructure, equipment, and commodities provision as well as advocacy and training among service providers. This activity will also include advocacy work with community leaders, particularly the Luo Council of Elders, to increase acceptability of male circumcision as a preventive intervention.

Table 3.3.14: