1. ACTIVITY DESCRIPTION

The University of Manitoba will facilitate the development and implementation of a comprehensive sex

worker prevention package as well as implement a sex worker outreach program (SWOP) in the Central

business district of Nairobi and its environs. This package will be used by other USG partners nation-wide to

provide a network of comprehensive coverage for sex workers. The University of Manitoba will also provide

technical support to other partners implementing sex worker interventions through providing training,

practical attachment and supportive supervision in the set up and quality programming assurance in the

delivery of sex worker prevention packages. The University of Manitoba will also organize meetings and

forums to share information and best practices across a broad range of partners working in the field. The

program will reach 250,000 individuals (220,000 male clients and 3000 sex workers) and train at least 500

counselors, health workers and sex worker peer educators. In addition, 50 condom outlets will be

established. In many settings, sex workers are frequently exposed to HIV and other sexually transmitted

infections (STIs) due to their high-risk sexual behaviors. Commercial sex workers (CSWs) are among the

groups with the highest prevalence of HIV due to their high-risk sex, and their limited access (due to stigma,

discrimination, and marginalization) to services for HIV prevention, treatment, and care. The high

prevalence of HIV in CSWs is a concern both for members of these subpopulations and for the general

population, as sexual mixing can facilitate transmission of HIV from high-prevalence to low-prevalence

groups. The SWOP project will develop and implement a comprehensive prevention package for women in

sex work settings, employing an intensified approach that will help reduce the number of HIV infections that

result from commercial and transactional sex as well as restrict the overall spread of HIV from this high risk

transmitter core group to the general population. This prevention intervention package is expected to reach

at least 250,000 male customers and their partners in Year I with OP interventions. Currently, the sex

worker population in the lower socio-economic section of the Nairobi central district (River Road) is highly

characterized by an insecure environment and sex worker harassment, low education on health and HIV

prevention, and unfriendly health provision services. These have resulted in limited access to counseling

and testing, with only 20% of sex workers tested for HIV. The prices of condoms escalate with demand,

rendering them often unaffordable. Service delivery points are also fairly scattered. Incorrect condom use

including use of Vaseline jelly and use of two or more condoms and self-treatment of STIS are also chronic

problems. SWOP will establish a drop-in center within convenient locations of the sex worker network and

provide a package of services. This will include normalizing and creating a demand for HIV counseling,

testing and routine STI screening among sex workers and promoting safer sexual behaviors thereby

preventing and minimizing HIV/AIDS and other sexually transmissible infections. The project will also

provide treatment and care services for sexually transmissible infections and provide linkage to its HIV/AIDS

Care and Treatment facility. Condom information, provision, demonstration and promotion as well as

Sexual and reproductive health services will be provided. Contraception, pregnancy testing and advice will

be provided for HIV-positive individuals. Interventions to reduce alcohol and other drugs abuse in STI

infections will be provided to sex workers and their partners through the peer educator networks.

Assessment and management of general health issues and referrals will be made to friendly sites. This

comprehensive prevention package is based on scientific evidence and from the University of Manitoba's

long programmatic experience in this area. The intervention may contribute to the overall evaluation the

standard set of tools that could assist Kenya to scale up for comprehensive coverage and perhaps some

standardization of programs, and may even be used later used by other countries. 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. This long-term association has nurtured and

created a very trusting environment for patients to visit. 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 and lately, the central business district of Nairobi's River Road area. 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.

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA

These activities will contribute to expansion of comprehensive prevention services for sex workers and their

clients, strengthened human resource capacity to deliver HIV prevention and STI treatment, and a

strengthened referral network for provision of HIV care. The program will reach 250,000 individuals

(220,000 male clients and 3000 sex workers) and train at least 500 counselors, health workers and sex

worker peer educators. In addition, 50 condom outlets will be established.

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.

5. EMPHASIS AREAS/KEY LEGISLATIVE ISSUES ADDRESSED

This activity addresses legislative issues related to stigma and discrimination through community

sensitization activities. 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.

THIS IS AN ONGOING ACTIVITY. THE NARRATIVE IS UNCHANGED EXCEPT FOR UPDATED

REFERENCES TO TARGETS AND BUDGETS.

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 3000 people with HIV, including 300 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.

3. 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.

4. 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.

5. 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.

THIS IS AN ONGOING ACTIVITY. THE NARRATIVE IS UNCHANGED EXCEPT FOR UPDATED

REFERENCES TO TARGETS AND BUDGETS.

1.LIST OF RELATED ACTIVITIES

This activity relates to activities in HVCT (#), HBHC and HTXS (#).

2.ACTIVITY DESCRIPTION

University of Manitoba will support TB/HIV services at 3 sites in Nairobi Province. Intensified TB screening

and treatment for 1500 HIV patients and HIV screening for 200 TB suspects/patients will be offered as a

standard of care in all the facilities; approximately 100 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.

N/A (exempt)

PHE CONTINUING STUDY:

Project Title: A Targeted Cell Phone Intervention to Improve Patient Access to Care and Drug Adherence in

Patients Taking Antiretroviral (ARV) Medications in Kenya

Name of Local Co- Investigator: University Manitoba

Project Description:

The project is aimed at harnessing mobile telephony (cell phones) to improve health communications and

drug adherence among patients taking antiretroviral (ARV) medications for HIV/AIDS treatment. A

nurse/counselor sends weekly SMS messages to study participants who are expected to respond as to

whether they are doing ok or require assistance regarding their medications. Hypothesized benefits and

measured outcomes include self report and pill count determined drug adherence, adherence to clinical

follow-up, reporting of side effects, clinical and laboratory responses to therapy (including HIV viral load as

the most sensitive biomarker), psychosocial impact, economic impact, and clinic flow.

Timeline:

FY 2008 = Year 3 of activity

Year started: Planning in 2006, enrollment in 2007.

Expected year of completion: 2008.

Funding:

Funds received to date: $150,000USD

Funds expended to date: $35,000USD

Funds requested to complete the study:

FY 08: $201,000.

Beyond FY08: Undetermined.

Describe funds leveraged/contributed from other sources:

Safaricom technology support and funding have been requested. Mobile internet hardware, software, and

management consulting, including computer and GPRS service funding, are under consideration. If

obtained, this will provide additional support to scalability and sustainability to the program as budgeted

herein.

Status of Study:

Piloting of 12 subjects has been completed and main study enrollment has already begun at one site

(Pumwani). Ethical approval has been obtained from the hosting and collaborating institutions.

Approximately 40 participants have been enrolled (total target is 500 new ARV subjects and 500 ARV

experienced patients), and enrollment is picking up. The second site, Kajiado District CCC, has hired staff,

and will start enrolling study participants this month. Due to high patient recruitment at the Pumwani site,

urban participant targets may be met at this single urban site. The Maragua District CCC site is still under

negotiation as they have had other coincidental studies that may conflict. A third site (rural) is being

considered therefore at Tigoni sub district site in Kiambu.

Lessons Learned:

Both staff and pilot study participants were very positive about the study. The main feedback from

participants was that "it feels like somebody always cares". All piloted patients requested to continue in the

program. A challenge will be automating the SMS tracking through use of mobile internet and software in

order to be scalable. We are under discussion with the Safaricom corporate responsibility manager, who

has recently shown keen interest, in addition to efforts by our IT/data staff.

Information Dissemination Plan:

Publication of findings in reviewed medical or public health journal and presentation of findings at

international and regional conferences is the goal.

Planned FY08 Activities:

Enrollment of participants for the initial study should be completed by end 2007. Therefore follow-up will

continue until mid 2008 for the 6 month follow-up. Analysis of data and preparation for publication and

presentation will continue to end 2008. We would also like to extend the study and follow-up period to 1

year as this is a better indicator of sustained adherence benefits. Adjustments to the protocol at 6 months

would be anticipated based on lessons learned from the first 6 months, and implemented for the extended

period. Planning for integration of the initiative into scalable programs will also be undertaken.

Budget Justification for FY2008 Budget (USD):

Salaries/ fringe benefits: $80,000

Equipment: $10,000

Supplies: $10,000

Travel: $15,000

Participant Incentives: $6,000

Laboratory Testing: $78,000

Other: training and team building $5,000

Total: $201,000

Additional salary funding will ensure the program director, program coordinator, and study employees are

able to complete follow-up and engage analysis and study reporting. The equipment costs will be used

toward computer automating the protocol for scalability. Supplies costs include lab supply shortages from

the first budget and supplies for project wrap up analysis and reporting. Travel funds will cover current

shortages in local travel expenses (fuel, vehicle maintenance) as well as travel for an international

conference presentation. Participant incentives are for snacks at the clinics to provide nourishment over

clinic wait times cause by participation and data collection over three visits each. Training and team

building sessions for all staff participants will be undertaken after all staff are initially employed and at the

study wrap-up/debriefing.

Activity Narrative: PHE CONTINUING STUDY: