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 HIV/AIDS treatment/ARV services (#6945) and, TB/HIV (#6944). 2.

ACTIVITY DESCRIPTION University of California at San Francisco (UCSF) has been supporting palliative

care and treatment services in Nairobi and Nyanza provinces. The UCSF approach through its FACES

program promotes family-centered care for HIV rather than individuals with HIV. This innovative approach

has ensured equity and greater disclosure within families. Current PMTCT coverage is 28 out of 68 sites in

Migori and 4 sites in Kisumu. UCSF will implement comprehensive integrated PMTCT services in all

facilities in Migori district starting with high volume facilities offering Antenatal care, delivery and postnatal

services, and will take up some private facilities in Kisumu. Community peer support groups involving

People Living with HIV/AIDS (PLWA) will be formed and supported. In FY 2008, UCSF will implement

integrated comprehensive PMTCT service in accordance with the National Comprehensive PMTCT

guidelines. Comprehensive integrated PMTCT services include, but are not limited to counseling and testing

of pregnant women and their partners in antenatal clinics, delivery units and postnatal clinics using the opt-

out approach, clinical staging of all HIV positive women using WHO guidelines, use of appropriate

antiretroviral regimens including HAART for maternal health in accordance to the National Antiretroviral

therapy guidelines, use of zidovudine plus single dose nevirapine or use of single dose nevirapine for

women presenting late in pregnancy, postnatal follow-up for the mother and exposed infants, initiation of

cotrimoxazole prophylaxis to all exposed infants at 6 weeks, Early Infant Diagnosis (EID) at six weeks via

PCR on Dry Blood Spots (DBS) from all exposed infants and successful referral of HIV-positive mothers,

their male partners and infected infants to antiretroviral treatment centers. UCSF will provide counseling and

testing to 20,500 pregnant women and provide antiretroviral prophylaxis for 4,722 (944 on HAART, 2361 on

AZT+sdNVP and 1417 sdNVP) HIV-positive women. Early Infant Diagnosis (EID) using Dry Blood Spots

(DBS) at six weeks and cotrimoxazole prophylaxis will target 2,182 HIV exposed infants. In FY 08,180

health care providers will be trained on comprehensive PMTCT, and some health workers will be trained on

PITC, family planning and counseling (numbers trained depending on availability of funds). In total, UCSF

will train and update skills of 180 service providers in comprehensive HIV management for HIV-positive

pregnant mothers, their infants and their families.

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA

This activity will contribute to 1.9 % of the overall 2008 Emergency Plan PMTCT targets for Kenya.

Community participation and male involvement will significantly contribute to PEPFAR goals for primary

prevention, access to care and treatment, and support of those affected and infected. Technical assistance

to the Ministry of health facilities will contribute to improvement of the quality of services. UCSF will facilitate

capacity building of DHMTs for improved management of health services and set up of referral networks

and linkages for a continuum of care from facilities to Home-based care within the community and among

various programs within the district. This activity will contribute to increased awareness, demand creation

and stigma reduction leading to increased utilization of services towards the goal of universal access to

prevention, care and treatment services.

3. LINKS TO OTHER ACTIVITES

Linkages to HIV care and treatment services will be strengthened, to ensure immediate appropriate care for

the woman and exposed infants, and family members as well and thus optimize utilization of

complementary services created through Emergency Plan funding. This activity will relate to the ARV

services of KEMRI. 4.

4. POPULATIONS BEING TARGETED

This activity targets children under five years, adolescents of reproductive age 15-24, adults, pregnant

women and people living with HIV. Health care providers including doctors, nurses, and other health care

workers will be targeted for training on PMTCT using the national NASCOP CDC/WHO based curriculum.

5. KEY LEGISLATIVE ISSUES ADDRESSED

This activity will increase gender equity in HIV/AIDS programming through provision of HIV counseling and

testing services of pregnant women, and improved access to other HIV care programs for the HIV infected

woman, her infant and other family members. It will also reduce violence and coercion through stigma at the

community level. 6. EMPHASIS AREAS This activity includes emphasis on quality assurance and

supportive supervision as well as emphasis on Development of Network/Linkages/Referral Systems;

Community Mobilization/Participation, wrap around programs with Food/Nutrition, PMI through distribution

of insecticide treated nets at the MCH, safe motherhood through focused antenatal care, other Family

planning initiatives and TB screening and referral for treatment and care

PHE CONTINUING STUDY:

Project Title: INTEGRATION OF HIV CARE AND TREATMENT INTO MCH IN MIGORI DISTRICT, KENYA

Name of Local Co- Investigator: DR. ELIZABETH A. BUKUSI (UCSF, KEMRI)

Project Description:

This study seeks to determine the most effective way to provide pregnant women with high quality HIV care

and treatment. Twelve UCSF FACES-supported clinics in Migori District have been randomly assigned to

intervention or control. At intervention clinics, women receive ANC, PMTCT and HIV care (including

HAART if required) at the same visit from the ANC provider. At control clinics, women receive ANC and

PMTCT, with referral to a separate HIV unit. Outcomes, including vertical transmission, changes in CD4

count, uptake of infant HIV testing, and enrollment into HIV care, will be compared for women who attend

intervention versus control facilities.

Timeline:

FY 2008 = Year 2 of activity

Year started: Year 1 award funding cycle began April 2007

Expected year of completion: 2009

Funding:

Funds received to date: $95,944 - not yet received (pending IRB approval)

Funds expended to date: Expenses to be charged once funds are received.

Funds requested to complete the study:

FY 08: 100,000

Beyond FY08: TBD

Describe funds leveraged/contributed from other sources:

This study will benefit from funds allocated for two other studies: "The Effects of HIV/AIDS Stigma on Use of

Services by Pregnant Women in Kenya", a 5-year study (2007-2012) funded by the U.S. National Institute of

Mental Health (NIMH) (PI: Janet Turan). "The Demand for Family Planning Services Among HIV-infected

Individuals Receiving Care and Treatment in Nyanza Province", a 2-year Public Health Evaluation (2007-

2009) funded by the CDC.

Status of Study:

The FACES/research team began preparatory activities, including training to strengthen HIV services for

pregnant and postpartum women and enhancements to the patient medical record systems, in Migori

District in June 2007, but no women have yet been enrolled in the study. The study has been approved by

the UCSF Committee on Human Research, as well as the KEMRI SC and SSC. We are awaiting news

from the KEMRI ERC regarding ethical approval.

Lessons Learned:

• Strong mutual support and cooperation between program and study activities has been a great benefit to

the study progress.

• There is a need to plan separate funds for study trainings. Initially study site training was to be folded into

program training, but schedules did not overlap.

• There is a need for designated data entry staff at study sites to strengthen the system and ensure high

quality data is captured.

Information Dissemination Plan:

Throughout the study, dissemination will include monthly progress reports to each site, monthly NASCOP

reporting, and quarterly PEPFAR reporting. Upon completion of the study, results will be disseminated at

the district, provincial, national, and international levels and among local non governmental and faith-based

organizations engaged in health care. Since the results may directly influence national policies and

recommendations, results will also be shared and discussed with the PMTCT and ART technical

committees, the Nyanza Provincial ART Coordinator, NASCOP, and at the weekly CDC-sponsored

colloquium on HIV research in Kisumu. If results are promising, the fully integrated intervention will be

implemented district-wide. At study conclusion, a manuscript will be submitted to HIV/AIDS-related

publications.

Planned FY08 Activities:

Enrollment of pregnant women into the study (which entails obtaining their informed consent for abstracting

their data from their medical records and following their outcomes over time) is expected to begin at clinics

that are ready (have ARVs and have participated in "study activation trainings") in August-September 2007,

after all necessary approvals have been obtained. Activities in 2008 will include, study activation trainings

for additional sites, continued enrollment of women into the study, entry of patient medical records into

PDAs by data entry clerks hired for the study, interviews with health care providers, and data

management/quality control activities.

Budget Justification for FY2008 Budget (USD):

Salaries/ fringe benefits: $ 74,873

Equipment: $ 0

Supplies: photocopies, printing, and office supplies $ 327

Travel: for investigators to conduct study oversight visits. $ 10,000

Participant Incentives: n/a $ 0

Laboratory Testing: n/a $ 0

Other: $ 5,050

Indirect costs (26%)$9,750

Total: $100,000

1. ACTIVITY DESCRIPTION

University of California San Francisco (UCSF) has been supporting palliative care and treatment services in

Nairobi and Nyanza provinces, and PMTCT in Nyanza province. The UCSF approach through its FACES

program promotes family-centered care for HIV rather than individuals with HIV. This innovative approach

has ensured equity and greater disclosure within families. Current PMTCT coverage is 28 out of 68 sites in

Migori and 4 sites in Kisumu. In FY 2008, UCSF, in collaboration with the Kenya Ministry of Health (MOH)

will implement service delivery of male circumcision (MC) services in Migori and Rongo Districts in

accordance with the National and International Male Circumcision guidelines. FACES will roll out an

expanded pilot program to circumcise eligible men and boys, as well as neonatal infant boys. In addition to

medical service provision, MC services will include, but are not limited to linking with HIV counseling and

testing services for young men as a means to identify HIV-uninfected men who might choose male

circumcision, promotion of male circumcision at the clinic, and in the community as a means to prevent HIV

acquisition, promotion of other preventive methods for men (e.g. male condom, limiting number of sexual

partners, etc.), and promotion of infant male circumcision as a long-term strategy to decrease HIV incidence

in the population. Pregnant women presenting for ANC services will be counseled on the risk and benefits

of infant male circumcision. Printed materials will be given to expectant mothers to be shared with the

father. The materials will also outline the risk and benefits of male circumcision for the father. All men who

undergo male circumcision will be given information about the risk and benefits of having their sons undergo

the procedure, in addition to other risk reduction messages. Additional information will be available

postnatally at the MCH clinics where most children come for well-baby check-ups and vaccinations, and

male circumcision services will be provided for children whose parents consent. In FY 2008, 90 health care

providers will be trained to counsel parents about the risk and benefits of male circumcision, and 20

nurse/clinical officer teams will be trained to perform adult and infant male circumcision. 3,000 individuals

will be reached through this intervention. 10 condom outlets will be established.

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA

Community participation and male involvement will significantly contribute to PEPFAR goals for primary

prevention, access to care and treatment, and support of those affected and infected. Technical assistance

to the Ministry of Health facilities will contribute to improvement of the quality of services. UCSF will facilitate

capacity building of DHMTs for improved management of health services and set up of referral networks

and linkages to ensure integration of prevention and care services at facilities, within the community and

among various related programs within the districts. This activity will contribute to increased awareness,

demand creation and stigma reduction leading to increased utilization of services towards the goal of

universal access to prevention, care and treatment services.

3. LINKS TO OTHER ACTIVITIES

Linkages to PMTCT and VCT, in particular, and HIV care and treatment services will be strengthened, to

increase demand for male circumcision and thus optimize utilization of complementary services created

through Emergency Plan funding. This activity relates to activities in HIV/AIDS treatment/ARV services

(#6945), PMTCT (#6949) and, TB/HIV (#6944). This activity will also link closely with IMPACT Research

programs in HVAB, HVOP, HVCT, HVSI, and OPHS, and will leverage training provided by IMPACT to

complement FACES' service delivery interventions.

4. POPULATIONS BEING TARGETED

This activity targets adults, pregnant women, HIV-positive pregnant women, HIV affected families, men and

boys, with a particular focus on adolescent males, and all male infants. Health care providers including

doctors, nurses and other health care workers will be targeted for training on prevention (including male

circumcision) counseling and performance of adult and infant male circumcision using the national

guidelines.

5. EMPHASIS AREAS / KEY LEGISLATIVE ISSUES ADDRESSED

This activity will address gender equity in HIV/AIDS programs through improved prevention service delivery

at health care facilities including ANC and MCH clinics. Male norms and behaviors will be addressed by

encouraging men to take responsibility in their sexual behavior, as well as by encouraging the participation

of men in helping to make decisions regarding their infant son's health. Community Health workers will

conduct community mobilization activities regarding prevention that will help increase uptake of male

circumcision and other prevention methods as well as address issues of stigma and discrimination at

community level. Human capacity development will be addressed through training of health workers; and

local organization capacity building will occur through technical assistance to the Ministry of Health to

strengthen the quality of their service delivery.

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 (#7090, #6945), Counseling and Testing (#6941, #6907),

TB/HIV (#9054, #6944), ART training (#6991) and PMTCT (#6949).

2. ACTIVITY DESCRIPTION

The University of California at San Francisco (UCSF) will increase and strengthen its support at its existing

sites in Nairobi and Nyanza, as well as substantially expand services in 4 districts in Nyanza to include 13

sites in Kisumu, 33 in Suba and 54 in Migori. These activities will support palliative care services for 24,000

people with HIV, including 2400 children. Services will include diagnostic testing; ongoing counseling with a

particular focus on counseling for couples (including those with discordant HIV results); and prevention,

diagnosis, and management of opportunistic infections. Funds will support salaries for health care workers

and infrastructure through renovation in accordance with Emergency Plan guidance, in addition to training

50 individuals to provide HIV-related palliative care services. An area of emphasis for the UCSF supported

program is to manage families rather than individuals with HIV. The programs supported by UCSF make

extensive efforts to identify and provide treatment to family members of enrolled patients and have

structured care provision to optimize the provision of care to families. UCSF also works closely with partners

providing HIV prevention services to youth, and will provide youth-friendly HIV treatment services to

individuals referred from those programs. Other areas of focus include identification and provision of care

for children; integration of treatment with other services like TB, MCH and family planning; greater

involvement of PLWHAs as peer educators and strengthening commodity management system. UCSF is

collaborating with the National AIDS and STD Control Program (NASCOP) to develop a system for

telephone consultation that will allow care providers in rural areas to access HIV expertise. Additional

activities will include community mobilization and dissemination of informational materials to patients. UCSF

will maintain data concerning the numbers of people served and will report both nationally and through the

Emergency Plan.

Because of the geographic foci of the HIV epidemic in the United States, UCSF has vast experience

providing HIV care and has long been recognized as one of the premier institutions providing HIV care in

the United States. The faculty of UCSF also has extensive experience developing training materials and

implementing HIV care and treatment programs in resource limited settings, including Kenya. Given that

UCSF has a long-standing research presence in Kenya, these activities will capitalize on the resulting

knowledge of Kenya as well as technical expertise in care and treatment. By March 2007, the established

patient care centers in Nairobi and Nyanza were providing palliative care services to more than 15,000

people with HIV.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

These activities will contribute to the expansion of palliative care services for clinically qualified HIV-positive

patients, strengthened human resource capacity to deliver care services, and a strengthened referral

network for provision of those services. The activities will specifically support improved quality of care,

particularly for difficult to manage patients.

4. LINKS TO OTHER ACTIVITIES

This activity relates to ARV activities (#7090, #6945), Counseling and Testing (#6941, #6907), TB/HIV

(#9054, #6944), PMTCT programs (#6949) and to ART training (#6991).

5. POPULATIONS BEING TARGETED

These activities target people (adults, children, infants) living with HIV/AIDS, including participants in US

government sponsored research programs, couples with HIV, discordant couples, and families. Services for

children with HIV are being established or expanded at all sites. Public health care providers, including

doctors, nurses, pharmacists, and laboratory workers are targeted for increased HIV care and treatment

knowledge and skills.

6. KEY LEGISLATIVE ISSUES ADDRESSED

This activity addresses legislative issues related to stigma and discrimination through involvement of

PLWHAs in service provision and community sensitization activities.

7. EMPHASIS AREAS

This activity includes minor emphasis in commodity procurement, development of networks, human

resources, local organization capacity building, logistics, community mobilization, information, education,

and communication, quality assurance and supportive supervision, 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 Palliative Care (#), ARV Services (#), Counseling and Testing (#) and

PMTCT (#).

2. ACTIVITY DESCRIPTION

University of California at San Francisco (UCSF) will support TB/HIV services at 97 sites in Nairobi and

Nyanza Provinces. TB screening for 12,000 HIV patients and HIV screening for 1,600 TB suspects/patients

will be offered as a standard of care in all the facilities; approximately 800 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. 25 health care

workers will be trained to provide clinical prophylaxis and/or treatment for TB to HIV-infected individuals.

Additional activities will include community mobilization and dissemination of educational materials to

patients. UCSF will maintain data concerning the numbers of people served and will report both nationally

and through the Emergency Plan. Because of the geographic foci of the HIV epidemic in the United States,

UCSF has vast experience providing HIV care and has long been recognized as one of the premier

institutions providing HIV care in the US. The faculty of UCSF also has extensive experience developing

training materials and implementing HIV treatment programs in resource limited settings, including Kenya.

UCSF has a long-standing research presence in Kenya whose activities will capitalize on their technical

expertise in treatment.

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 service.

4. LINKS TO OTHER ACTIVITIES

The overall program activity links closely to Palliative Care (#), ARV Services (#) currently supported by this

partner, Counseling and Testing provided by KEMRI (#) and IMC (#), and PMTCT services (#).

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: The demand for family planning services among HIV-infected individuals receiving care and

treatment in Nyanza Province.

Name of Local Co- Investigator: KEMRI and UCSF-FACES

Project Description:

This study is a cluster-randomized trial comparing the effects of integrating family planning (FP) services

into HIV care and treatment programs on contraceptive uptake, contraceptive continuation, and unintended

pregnancy rates. The study will compare the integration of FP services into HIV care and treatment versus

the standard referral for FP services outside of HIV care and treatment programs. The study will be

conducted in FACES-affiliated clinics in Nyanza Province, Kenya.

Timeline:

FY 2008 = Year 2 of activity

Year started: Year 1 funding cycle began April 2007

Expected year of completion: 2009

Funding:

Funds received to date: $79,290 Awarded; not yet received (pending IRB approvals)

Funds expended to date: Expenses to be charged once funds are received.

Funds requested to complete the study:

FY 08: $100,000

Beyond FY08: TBD

Describe funds leveraged/contributed from other sources:

This study will benefit from funds allocated for a related study, "INTEGRATION OF HIV CARE AND

TREATMENT INTO MCH IN MIGORI DISTRICT, KENYA" a two-year Public Health Evaluation funded by

the CDC (2007-2009) (PI: Craig Cohen)

Status of Study:

• Developed protocol in consultation with investigators and staff from KEMRI and FACES

• Submitted the protocol to Ethical Review Committees at KEMRI and UCSF. KEMRI SSC requested

revisions and those have been submitted, approval is pending. UCSF approval is pending.

• Established contact with other researchers doing similar work in Africa (including Di Cooper in South Africa

and EngenderHealth in Uganda to get feedback on study design and validated instrument use.

• Developed comprehensive patient enrollment and patient follow-up forms. The clinical information (history,

physical exam, and laboratory data) will be inputted into a database. The new electronic database has been

built and will be used for research purposes and for patient follow-up. These new patient data forms and

database have been piloted and refined based on provider and technical feedback. The system will launch

at Lumumba Health Centre on 23 July 2007.

• Begun exploring what materials are available for provider training and client regarding family planning in

the HIV context of care (part of the intervention plans)

Lessons Learned:

• Working closely with program and other related research has been an important means to maximize

resources and streamline logistics.

• There is a need to plan separate funds for study training and to increase data entry funding allocation;

these expenses were under-budgeted in the year 1.

Information Dissemination Plan:

Upon completion of the study, results will be disseminated at the district, provincial, national, and

international levels and among local NGOs and FBOs engaged in health care. The findings will help guide

research, policy, and interventions in the area of integrating family planning into HIV care, therefore results

will also be shared and discussed with the MCH and ART technical committees, the Nyanza Provincial ART

Coordinator, NASCOP, and at the weekly CDC-sponsored colloquium on HIV research in Kisumu. At study

conclusion, a manuscript will be submitted to HIV/AIDS-related publications.

Planned FY08 Activities:

We hope to have completed the baseline data collection and implemented the intervention to train clinicians

and peer educators this year (by April 08). Next year we will be collecting and analyzing data at all sites.

Budget Justification for FY2008 Budget (USD):

Salaries/ fringe benefits: $73,000

Equipment: $ -

Supplies: $1,000

Travel: $5,000

Participant Incentives: $1,000

Laboratory Testing: $ -

Other: $10,000

Indirect costs (26%) $10,000

Total: $100,000

+Activities initiated in '07 will continue in '08, but this will be transitioned to UCSF since the UTAP

mechanism is no longer available in '08.

+Technical assistance in cost-effectiveness analyses will be an expanded component of this activity in '08,

together with the translation of evaluation findings into relevant policy.

+In addition to technical support for the comprehensive trial, this activity will involve capacity building in data

analysis, writing, and policy translation support. This activity will support current PEPFAR partners to

analyze and use existing program data to improve program quality and inform policy development. Through

a series of trainings and workshops, this activity will help to develop Kenyan professional capacity for

epidemiological analysis and translation into policy.

+In '08 this activity will also involve the translation of study instruments, particularly Standard Operating

Procedures (SOPs) into programmatic tools that implementing partners can use.

1. ACTIVITY DESCRIPTION (TECHNICAL ASSISTANCE FOR EVALUATION)

This activity will continue work initiated in '07 under the UCSF/UTAP mechanism to provide technical

assistance for several plus-up activities. To support development and implementation of the Comprehensive

Package Study, UCSF is supporting KEMRI, NASCOP and CDC-Kenya to develop a study protocol, study

instruments, and procedure manual for this important Public Health Evaluation. This evaluation, which is a

collaboration of KEMRI, NASCOP, and the USG PEPFAR team will assess the population-level impact on

HIV incidence of a prevention package that includes VCT and Male Circumcision. The evaluation will also

assess the population-level impact on mortality and morbidity of widespread provision of care and treatment

within the CDC/KEMRI Demographic Surveillance System. In addition, UCSF staff are providing technical

assistance for training and supervision of study staff and overall supervision of the project. A key

component of the technical assistance will be the training of Kenyan counterparts in all components of

epidemiological evaluation. This human capacity development is a key component of this project.

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA [

This program will provide important information needed to assess the effectiveness of the prevention

interventions on HIV incidence in the DSS area. The epidemiological data will inform the design of

prevention packages and referral mechanism to care and treatment.

3. LINKS TO OTHER ACTIVITIES

This activity will link to SI support to NASCOP and KEMRI as well as to Public Health Evaluation activities.

4. POPULATIONS BEING TARGETED

This activity will provide training for adult men and women.

5. EMPHASIS AREAS / KEY LEGISLATIVE ISSUES ADDRESSED

Emphasis areas for this national activity include human capacity development, training, in-service training,

retention strategies, local organization capacity building and strategic information strengthening.

6.TARGETS

Number of organizations offered TA- 3

Number of individuals trained on surveillance, HMIS and/or M&E - 20