1. ACTIVITY DESCRIPTION

University of Washington (UW) has been supporting palliative care and treatment services in Nairobi and

Western/Nyanza province. The UW approach through its indigenous faith-based partner, the Coptic Church,

provides services in both urban and rural sites. In FY 2008, UW, in collaboration with the Kenya Ministry of

Health (MOH) will implement service delivery of male circumcision (MC) services in its sites (particularly

Maseno Clinic—on the border between Nyanza and Western provinces in accordance with the National and

International Male Circumcision guidelines. UW 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 08, 18 health care providers will be trained to counsel

parents about the risk and benefits of male circumcision, and 5 nurse/clinical officer teams will be trained to

perform adult and infant male circumcision. 500 individuals will be reached through this intervention. Three

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. UW 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 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, palliative

care, and TB/HIV.

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.

PHE CONTINUING STUDY:

Project Title: Empiric therapy of helminth co-infection to reduce HIV-1 disease progression

Name of Local Co- Investigator: KEMRI, University of Washington

Project Description:

Many individuals in areas of the world hardest hit by the HIV/AIDS epidemic are also infected with soil-

transmitted helminths. It is important to determine whether routine treatment of helminth co-infection should

be considered standard practice in the treatment of HIV-1 infected individuals in helminth endemic areas.

We are conducting an evaluation to determine the effect of an intensive, empiric deworming regimen on

changes in markers of HIV-1 disease progression, namely CD4 decline and plasma HIV-1 RNA levels, in a

cohort of HIV-1 infected adult Kenyans not meeting criteria for antiretrovirals.

Timeline:

FY 2008 = Year 2nd year of activity

Year started: 2007

Expected year of completion:2009

Funding:

Funds received to date: $154,500.00

Funds expended to date: NONE

Funds requested to complete the study:

FY 08: $160,000.00

Beyond FY08: $160,000.00

Describe funds leveraged/contributed from other sources:

The University of Washington supports several of the personnel involved in this evaluation from other Grant

sources.

Status of Study:

KEMRI SSC approval obtained 4/07

KEMRI ERC approval obtained 07/07

University of Washington IRB approval pending

Kilifi SSC approval 5/07

Kisumu District Hospital Site approval 04/07

Evaluation now in final planning stages. Data collection tools have been finalized and database

development is underway. Staff hiring and training will commence once funds are released to permit.

Anticipated start of recruitment is late August, 2007.

Lessons Learned:

Pending.

Information Dissemination Plan:

We are now organizing Community Advisory Board's (CAB's) in Nairobi, Kisumu and Kilifi. Information

about the evaluation will be disseminated to the community before, during and after the evaluation through

the CAB's. In addition, the results of this evaluation will be submitted for publication in the peer reviewed

literature.

Planned FY08 Activities:

We plan to initiate enrollment of subjects in August, 2007. We plan to continue enrollment until the target of

850 individuals is met and to continue three monthly follow up visits for all enrolled participants in FY 2008.

Database development will continue and capacity building to improve service delivery at each of the

evaluation sites will continue in FY 2008.

Budget Justification for FY2008 Budget (USD):

Salaries/ fringe benefits: $98,000

Equipment: $7,500

Supplies: $9,000

Travel: $10,000

Participant Incentives: $7,500

Laboratory Testing: $21,000

Other: $7,000

Total: $160,000

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 TB/HIV (#8830), and ARV Services (#7100).

2. ACTIVITY DESCRIPTION

University of Washington (UW) will expand a long-standing research collaboration with the University of

Nairobi to provide HIV care to 12,000 people with advanced HIV, including 120 children at 3 care sites, and

support the training of 30 individuals in the provision of HIV-related palliative care services. UW will support

treatment services at Coptic Hospital, a faith-based facility in Nairobi that provides services to both the

general population and to individuals identified through research programs at the University of Nairobi. In

addition, UW will support treatment services to two "daughter" clinics (clinics supported by the Coptic

Church at facilities in Nyanza Province and in the industrial area of Nairobi. Other important aspects of the

UW/Coptic Hospital program support behavior change and risk reduction for people with HIV/AIDS, with

specific emphasis on patients with less advanced HIV, in whom rates of discordant partnerships have been

found to be high. Funds will be used to support salaries of health care providers in accordance with

Emergency Plan guidance, logistics (primarily pharmacy management), dissemination of informational

materials (about ARVs and adherence) to patients, and procurement of commodities such as laboratory

reagents. This partner will maintain data concerning the numbers of clients served and will report this

information both nationally and through the Emergency Plan.

UW has a long presence in Kenya and extensive experience in HIV prevention and treatment both in the

United States and internationally. The University has a long-standing research collaboration with the

University of Nairobi, and has provided extensive capacity building in immunology and epidemiology,

including supporting long-term training for University of Nairobi staff in the United States. University of

Nairobi staff has also donated their time to support the establishment of HIV care services at Coptic

Hospital. By June 2006, the HIV Clinic (Hope Clinic) was providing care for more than 4000 patients.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

These activities will contribute to expansion of access to palliative care services for people with HIV,

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

provision of these services.

4. LINKS TO OTHER ACTIVITIES

These services will link closely to ARV treatment services provided at Coptic Hospital (#7100), Palliate

Care: TB/HIV services (#8830) and also link directly to the Nairobi network center at Kenyatta National

Hospital and to other services provided through the expanding partnerships between other US-based

Universities and the University of Nairobi.

5. POPULATIONS BEING TARGETED

These programs target people living with HIV/AIDS including infants (0 - 5 years) and children (6 - 14 years)

and private and public health care workers.

6. KEY LEGISLATIVE ISSUES ADDRESSED

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

7. EMPHASIS AREAS

This activity includes minor emphases in commodity procurement, development of network/linkages/referral,

human resources, information, education, and communication, local organization capacity building, logistics,

strategic information, training, and quality assurance and supportive supervision.

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 (#7099) and ARV Services (#7100, #7004).

2. ACTIVITY DESCRIPTION

The University of Washington (UW) will expand a long-standing research collaboration with the University of

Nairobi in the support of TB/HIV services at 3 delivery sites within Kenya. UW will offer TB screening to

6,000 HIV-infected patients and HIV testing for 500 TB patients; approximately 250 will be diagnosed with

TB/HIV. UW will support treatment services at Coptic Hospital, a faith-based facility in Nairobi that provides

services to both the general population and to individuals identified through research programs at the

University of Nairobi. In addition, UW will support treatment services to two "daughter" clinics (clinics

supported by the Coptic Church at facilities in Nyanza Province and in the industrial area of Nairobi). Funds

will be used to support improved screening and diagnosis. Refresher training of laboratory staff will be

initiated and basic laboratory microbiology capacity improved in order to meet the increased needs of TB

testing. 10 health care workers will be trained to provide clinical prophylaxis and/or treatment for TB to HIV-

infected individuals.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

These activities will contribute towards the provision of integrated TB/HIV care by reducing TB morbidity

and mortality in HIV-infected individuals and also reducing HIV related morbidity and mortality in TB patients

co-infected with HIV. 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 and ARV services currently supported by UW,

and ART services coordinated by and supported through the National AIDS and STD Control Program

(NASCOP).

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 emphases in commodity procurement, human resources, development of

networks/linkages/referral systems, local organization capacity development, quality assurance, quality

improvement and supportive supervision, and training.

THIS IS AN ONGOING ACTIVITY. THE NARRATIVE HAS BEEN UPDATED TO REFLECT CHANGES.

This activity was begun with 2007 plus-up funds and is part of a five-site effort to strengthen the link

between clinical and household settings for HIV+ children. All sites meet regularly with a sixth entity,

AED/Capable Partners, for real-time sharing of lessons learned and review the effectiveness of different

approaches in preparation for scale-up.

The Mwangalizi model is being tested in response to concern expressed by clinicians that assuring optimal

care for HIV+ OVC was difficult in many instance because they were accompanied to different clinic visits

by different relatives or community members, necessitating constant re-education of adults managing care

of children.

Central to the approach is recruitment of adult patients who are successfully managing their own care to

accompany pediatric patients to all clinic visits when a consistent caregiver from the household is not

available. These "accompagnateurs" will be trained to be on watch for development of side effects or

complications, remunerated for their time, and expected to perform home visits to monitor medication

consumption. They will also be expected to develop an ongoing and supportive relationship with the OVC

household, assess the social environment and refer for needed services, and seek wherever possible to

identify a household or community contact who can be prepared to assume the long-term responsibility of

being a treatment advocate for the child.

Sites were carefully selected to represent a cross section of Nairobi and coastal urban slum (Eastern

Deanery, Coptic, and Bomu), peri-urban (AMPATH/Eldoret, Bomu) and rural (Kericho District Hospital)

communities. Standard measures of household and clinician satisfaction with the value-added by the

accompagnateur, accompagnatuer satisfaction with the experience, and clinical progress of OVC

participating in the program will be tracked. Numbers of OVC served are captured under care and

treatment activities.

N/A (exempt)