Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 3476
Country/Region: Kenya
Year: 2009
Main Partner: Henry M. Jackson Foundation for the Advancement of Military Medicine
Main Partner Program: NA
Organizational Type: Private Contractor
Funding Agency: USDOD
Total Funding: $18,593,780

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $1,837,590

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ Prime partner HJF MRI has been competitively selected to implement the activity.

+DNA Polymerase Chain Reaction for HIV testing for Early Infant Diagnosis (EID) will be supported for all

facilities implementing PMTCT services in the Rift Valley Province through the new partner and the Kenya

Medical Research Institute/Walter Reed Project Clinical Research Center Kericho laboratory.

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

In COP 2009, a total of 300 health workers will be trained to address the shortage of skilled human

resources. In addition, training of mentor mothers, peer educators and community health workers will be

emphasized to enhance effective task shifting.

COP 2008

Geographic coverage has been expanded to include Kisumu West district in Nyanza province. DNA

Polymerase Chain Reaction for HIV testing for early infant diagnosis will be supported for all facilities

implementing PMTCT services in the Rift Valley through the Walter Reed Project research laboratory.

1. LIST OF RELATED ACTIVITIES

This activity relates to activities in Counseling and Testing, HIV/AIDS Treatment: ARV services, Palliative

Care: TB/HIV, Palliative Care: Basic Health Care and Support OVC and APHIA II Rift Valley.

2. ACTIVITY DESCRIPTION

Since August 2001, the Kenya Medical Research Institute /Department of Defense (KEMRI/DOD) had been

implementing a Prevention of Mother-to-Child Transmission of HIV infection (PMTCT) program in the

Kericho District of the south Rift Valley Province. With Emergency Plan (EP) support, KEMRI/DOD has

scaled-up PMTCT services in 10 other districts of south Rift Valley Province (SRV) and will continue to

scale up in Kisumu West District (KWD) of Nyanza province. The number of PMTCT sites has increased

from three to over 205 and as a result 157,571 pregnant women had received PMTCT Counseling and

Testing (CT) by end of March 2008. In the period between October 2007 and March 2008, 29,197 pregnant

women presented for their first antenatal visit, of which 28,952 received their HIV test results. Among them,

970 women were identified as HIV-infected and 847 women and 739 of their HIV exposed infants received

ARV prophylaxis. Male involvement has been encouraged through the development of Saturday male

clinics in some health facilities in the region. Even though the PMTCT program has been successful;

inadequate numbers of trained Health Workers (HW), limited working space, poor infrastructure, weak

logistics and supply chain management, inadequate management, as well as stigma and discrimination in

the communities continues to limit the full utilization of PMTCT services and further access to care and

treatment by the HIV-infected women and family members. Low levels of male involvement, lack of

appropriate infant feeding options, and limited access to Family Planning (FP) information and services are

further barriers. The SRV Province and KWD has 274 health facilities and 216 are currently providing

PMTCT services. In 2009 COP, HJF MRI-SRV will continue to work with Provincial and District Ministries of

Health (MOH) Health Management Teams (HMT) to address these barriers in an effort to scale up PMTCT

services to a total of 250 health facilities. The coordination with Government of Kenya in the implementation

of this activity will ensure sustainability and quality of the services. Of the 112,722 expected pregnancies in

SRV and KWD; HIV CT services will be provided to 97,435 (86%) pregnant women during the antenatal,

intra-partum, and immediate postpartum period. Additionally of the 5,102 total expected HIV infected

pregnant women, 4,377 (86%) HIV-infected pregnant women and 4,074 (80%) of their babies will receive

ARV prophylaxis. All HIV +ve pregnant women will be staged clinically and immunologically by WHO criteria

and CD4 cell count testing respectively. Women in WHO stage 3 & 4 and all those with CD4 cell count less

than 350 will be initiated on ART. Those in WHO stage 1 & 2 with CD4 cell count greater than 350 will be

initiated on AZT from 28 weeks gestation. Of the targeted 4,377 HIV-positive pregnant women 1,313 (30%)

will get a minimum of Single dose nevirapine (SdNVP), 2,189 (50%) will receive short course AZT from 28

weeks of pregnancy and SdNVP, and 875 (20%) will get ART. All the HIV +ve pregnant women who

receive SdNVP will be given AZT and 3TC combination for one week post natally to cover the Nevirapine

"tail" to reduce the development of NVP resistance. All exposed babies will receive SdNVP, 3TC for one

week and AZT for six weeks. Nevirapine tablets will be dispensed to all HIV+ pregnant women at first

contact to minimize missed opportunities. All HIV +ve pregnant women and their infected or exposed

babies will be started on cotrimoxazole (CTX) prophylaxis till they are confirmed HIV negative. All pregnant

women will be given Malaria Intermittent Presumptive Treatment (IPT) and Insecticide Treated Nets (ITN). A

total of 300 health workers will be trained to address the shortage of skilled human resources. In addition,

technical assistance will be provided by 2 additional locally employed staff. Priority areas in 09 COP include

provision of a package of services consisting of expanding CT to achieve universal coverage, complete

ANC profile and birth planning, improved obstetric care, HIV staging in both ANC and delivery units, ARV

and OI prophylaxis, scaling up of more efficacious ARV prophylactic regimens, ART for eligible women,

facilitating HIV EID; counseling and support on maternal, infant and young child nutrition; TB screening for

HIV-positive pregnant women. CT within the PMTCT program will be extended to 19,827 (20%) male sexual

partners of the pregnant women through the Men as Partners (MAP) initiative, Provider Initiated Testing and

Counseling (PITC) in FP and Child Welfare Clinics (CWC); and improving access to FP services. Emphasis

will be placed on primary prevention for the majority of women identified as HIV -ve through PMTCT

programs. We plan to enhance greater involvement of people living with HIV and AIDS (GIPA) through the

facility and community based psychosocial support groups, Mentor Mothers, PwP and MAP. This will link

mothers and their families to palliative care including TB services and home-based care, ART PMI malaria

prevention activities, FP services and income generating activities. Dry Blood Spots (DBS) will be used for

Polymerase Chain Reaction (PCR) testing for the HIV exposed or infected children. Follow-up and referral

as appropriate of the HIV-infected women, their HIV exposed children, and their sexual partners will be

supported. Counseling and support for infant and young child nutrition will be provided. FP services will be

supported through wrap around programs. The KEMRI/WRP CRC laboratory in Kericho will provide HIV

PCR diagnostic testing services to the whole of Rift Valley province. All HIV-positive children below 18

months will be started on ART as soon as they are diagnosed irrespective of CD4 cell counts and WHO

clinical staging within the MCH settings.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

Activity Narrative: This KEMRI/WRP activity will contribute to approximately 7.6% of the total, direct PMTCT Emergency Plan

targets of 1,300,000 pregnant women offered CT in FY 2009. This will also support government efforts of

ensuring that at least 80% of pregnant women have access to PMTCT services by the end of 2008 with a

50% reduction in pediatric HIV infections. Planned activities will improve equity in access to HIV prevention

and care and treatment services since the currently underserved rural communities will have better access.

KEMRI will work to ensure the availability of networks and linkages among medical sites where AIDS care

and treatment are provided for both adults and children.

4. LINKS TO OTHER ACTIVITIES

The PMTCT activities will relate to the following KEMRI-SRV comprehensive approach to HIV/AIDS care

and treatment: Palliative Care: Basic Health Care and Support, CT Treatment: ARV services, OVC, and

TB/HIV. The women will also be screened for TB as a direct link with TB/HIV services. Linkages between

PMTCT service and care outlets will be strengthened to improve utilization of care opportunities created

through PEPFAR funding.

5. POPULATIONS BEING TARGETED.

This activity targets adults of reproductive age, pregnant women, family planning clients, infants, and

People Living With HIV/AIDS (PLWHA) including HIV-positive pregnant women. Strategies to improve

quality of services will target MoH staff, doctors, nurses, midwives, and other health care workers such as

clinical officers and public health officers in both public and faith based facilities as well as the local

communities through training, Support Supervision, and Health Education.

6. KEY LEGISLATIVE ISSUES ADDRESSED.

This activity will increase gender equity in programming through PMTCT services targeted towards

pregnant women and their spouses. Women bear a high HIV burden through not only primary infection but

also as caregivers and impact of stigma and discrimination. Identifying these women through PMTCT will

provide an opportunity to access care for themselves, their spouses, and their infants - all targeting

improved pregnancy outcomes. Increased availability of PMTCT and PMTCT+ services will increase access

and help reduce stigma at community and facility levels. Men will be encouraged to come for CT services

and male PMTCT clinics will be expanded. Psychosocial Support Groups, mentor mothers and Peer

Counseling and Prevention with Positives (PwP) will be encouraged to improve on PMTCT uptake and to

also reduce fear of stigma and discrimination.

7. EMPHASIS AREAS

The major emphasis area in this activity is training health care workers and facilitating EID. Minor emphasis

will be placed on infrastructure, development of networks/linkages and referral systems, quality assurance,

quality improvement and supportive supervision.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14902

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14902 4804.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $2,021,145

Defense Research Institute

6967 4804.07 Department of Kenya Medical 4249 3476.07 South Rift Valley $1,141,540

Defense Research Institute

4804 4804.06 Department of Kenya Medical 3476 3476.06 South Rift Valley $550,000

Defense Research Institute

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $350,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $620,000

This PHE activity, "How to Optimize PMTCT Effectiveness (HOPE) Project" was approved for inclusion in

the COP. The PHE tracking ID associated with this activity is KE.08.0203. This PHE is an FY08

Collaborative.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Estimated amount of funding that is planned for Public Health Evaluation $620,000

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $35,906,467

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Key Result 1: Strengthen programs with combination prevention interventions.

Key Result 2: Expand scope and coverage of targeted interventions for most-at-risk populations (MARPs).

Key Result 3: Support development and scale up of targeted comprehensive prevention approaches.

Key Result 4: Strengthen national HIV prevention planning and coordination through support to the National HIV Prevention Task

Force.

CURRENT PROGRAM CONTEXT

The Kenya Emergency Plan (EP) Sexual Transmission Prevention (STP) program continues to intensify prevention interventions

by increasing coverage, improving quality, and enhancing program efficacy to reduce the risk of HIV transmission. The STP

program consistently integrates prevention across all program areas through a combination of prevention interventions. Kenya's

approach targets both the general population as well as MARPs. In the country, personal risk perception has not increased

although HIV knowledge levels have. Data from the 2007 Kenya AIDS Indicator Survey (KAIS) indicate that four out of five adult

Kenyans do not accurately know their HIV status. Prevention education that emphasizes correct knowledge of status is therefore

an increasingly important building block to a comprehensive prevention strategy, and a standardized ABC+T (Testing) approach

will be pursued.

The HVAB program will continue to strengthen interventions contributing to abstinence, delayed sexual debut, and adoption of

secondary abstinence among young people. Addressing cross-generational sex and providing education regarding the associated

risk of early marriage will be a key focus, linked with income-generating activities (IGAs) to reduce risk determinants that increase

this vulnerability. The HVAB program employs a balanced approach that focuses on youth and adults with fidelity and testing

messages, as well as working in concert with the HVOP program to provide the right mix of age-appropriate interventions. The

HVOP program has sharpened its focus on promoting correct and consistent condom use among sexually active persons of

unknown HIV status or with known discordant HIV status, both to the general public and MARPs.

The 2008 UNAIDS Modes of Transmission (MOT) Study indicates that MARPs contribute more than one-third of new infections in

Kenya. Targeted interventions with a comprehensive package of services will be scaled-up for sub-populations at higher risk of

HIV infection, including commercial sex workers (CSW) and their clients; men who have sex with men (MSM) and their partners;

fishermen; casual heterosexual concurrent relationships; discordant couples; and prisoners.

The Prevention with Positives (PwP) strategy is incorporated across all HIV prevention, care and treatment interventions with a

particular emphasis on reaching discordant couples with education on safer sex and greater awareness that long-term

discordancy carries an increased risk due to frequency of exposure. An important milestone achieved this year was the launch

and rollout of the PwP clinical package. A standardized package of interventions is being developed for a PwP community

strategy. A National PwP Task Force has been established and work is underway on a toolkit to guide evidence-based, high-

quality interventions for people living with HIV (PLHIV). A minimum prevention package for CSW is being finalized and will be

rolled out by NGO and health ministry implementers. Standard guidelines will also be developed for youth programs and other

interventions.

Ongoing EP-supported youth programs will be invigorated through additional, collaborative activities with the Partnership for an

HIV-Free Generation. This initiative will enable the EP to leverage new public-private partnerships toward enhancing youth HIV

prevention and linking young people to economic opportunities to the greatest extent possible.

The majority of the HIV-positive population resides in rural areas of Kenya. Although there has not been a systematic mapping of

the coverage of prevention interventions, it is clear that additional efforts must target rural populations. Emerging data on

geographic prevalence has guided programming priorities, particularly for MARPs in Nyanza, Nairobi, Coast, and Rift Valley

provinces.

Gender considerations have been incorporated across the entire program portfolio. Specific interventions addressing male norms,

increased vulnerability of young women and girls, gender and sexual-based violence, and cross-generational sex are an important

focus for all programs.

A national communication campaign will help to scale up universal access to HIV prevention. National-level prevention leadership

is also being strengthened. Through the Capacity Project, the EP supports a Senior HIV Prevention Expert and a Youth Affairs

Officer at NACC. Similarly, the EP will support a National Officer at WHO to provide technical guidance in prevention. In 2008, the

EP STP program helped bring about formation of a high-level National HIV Prevention Task Force (NHPTF) led by the National

AIDS Control Council (NACC) to re-invigorate and steer national prevention efforts. An important expected output of the NHPTF is

to aid development of a new Kenya National AIDS Strategic Plan (KNASP) with a more robust prevention agenda that is well-

informed by KAIS, the Kenya Demographic and Health Survey 2008 (KDHS), the MOT study, and evidence-based practice.

Moreover, the new KNASP should incorporate consensus emerging from the 2008 National HIV Prevention Summit, which

emphasized that effective prevention strategies must embrace a combination approach and recognized the need to expand the

scale and quality of prevention interventions across the country.

STATISTICS

The 2007 KAIS documented national HIV prevalence of 7.8% among adults 15-49. There are significant gender disparities with

women having a higher prevalence (8.7%) than men (5.6%). Among youth, women aged 15-24 are four times more likely to be

HIV-positive than their male peers (6.1% versus 1.5%). KAIS also showed a marked variation between rural and urban residents,

with 70% of HIV-positive adults living in rural areas. Nationally, the highest prevalence was found within the 30-34 age bracket.

Geographically, prevalence remains highest in Nyanza Province at 15.3%. This is followed by Nairobi at 9%, Coast at 7.9%, and

Rift Valley at 7%, all significantly contrasting with the North Eastern Province at 1%. The number of HIV-positive adults in Rift

Valley (estimated 322,000) is greater than in Coast (estimated 135,000) and Nairobi (estimated 176,000) combined.

About two-thirds of HIV-positive Kenyan adults report currently being in a union, yet there is only 50% condom use among HIV-

positive sexually-active individuals. 10% of monogamous married couples and 14% of polygamous couples have one or more

partner infected with HIV. Ongoing HIV testing and counseling initiatives, including couple CT and home-based CT, have helped

to identify couple discordance.

An important sub-group that has previously not been targeted as "high-risk" is married individuals. Among HIV-positive people,

45% have a partner who is not currently infected. Discordance, particularly in marriage, presents a great risk.

SERVICES

The USG team of prevention technical experts from USAID, CDC, DoD, and Peace Corps jointly plans, reviews program

progress, and provides technical guidance to the entire Kenya prevention portfolio. This synergy will be enhanced in 2009 through

joint technical meetings for all implementing partners to exchange best practices, ensuring consistent prevention messaging and

reducing duplication of effort.

The Partnership for an HIV-Free Generation will work with the STP ITT to infuse corporate strategies to optimize access for youth

prevention services, such as an intensified campaign for CT for youth in Kenya. Through a PPP that includes Warner Bros. and

Intel, a computer game will be launched and piloted at youth centers to test the effectiveness of popular entertainment as a

medium to impact key behavioral outcomes. Services that closely link prevention and CT services will be strengthened. The

Ministries of Public Health & Sanitation and Medical Services will remain key partners in prevention activities, providing a nucleus

around which all other prevention services will be provided. The GoK's Community Strategy will be strengthened to provide

comprehensive prevention education and referral for services.

A comprehensive prevention package for CSW, developed with NASCOP leadership, will be rolled out as a standardized

approach to service provision. This will include peer education and risk reduction education, CT, STI screening and treatment,

condom promotion and distribution, and HIV care and treatment. Clients of CSWs will also be targeted. MARP prevention

interventions will be scaled up, guided by mapping services within prevention program areas, including sexual risk reduction

messages, condom promotion and provision, communication campaigns, couples counseling and testing, discordant couple

interventions, and support group activities.

Prevention education, including a national mass media campaign, will be intensified through the APHIA II Health Communication

and Marketing (HCM) program. Internews will train TV, radio, and print journalists to more actively and accurately report on HIV

prevention through media sources around Kenya. Increased male involvement in prevention efforts will include scaling up the Men

as Partners program to address gender stereotypes that predispose men to sexual risk behaviors, as well as sexual and gender-

based violence. An expanded program with uniformed services at the workplace, their families, and host communities, as well as

with prisoners, will reinforce safer sexual behavior and emphasize the benefits of reduction of multiple concurrent partners.

PEPFAR partners will also target fishing communities in Nyanza with combination interventions.

AB programs will expand coverage for youth and general population prevention activities to optimize coverage in locations not

previously reached. This will be achieved through a mix of life skills education, community education, peer education, and

interventions targeting couples and older adults to promote fidelity with knowledge of status and partner reduction. Specific gender

programs include an ongoing house girls' initiative and programs by the Kenya Girl Guides Association, linkages with IGAs

through the K-Rep microfinance program and with the Women's Justice and Empowerment Initiative for legal rights awareness

and improved post-rape medical services.

Alcohol and substance abuse prevention, including prevention education, counseling and referral, will continue to be integrated

within targeted primary prevention services.

Consultations will be held with the GoK, World Bank, DFID, and other development partners to assure commodity security

especially for male condoms in the country. Given limited supplies of lubricant gel in the country, a more effective means to

procuring these will be explored. New approaches to increasing access to and use of female condoms will also be pursued.

Overall, the STP team continues to examine geographic coverage to reduce duplication of efforts and ensure optimal coverage.

REFERRALS AND LINKAGES

Prevention has been integrated into other program areas, and key prevention messages are integrated with service provision.

Prevention programs will work to identify appropriate referral mechanisms so that prevention efforts translate to increased access

to CT, PMTCT, care and treatment, and vice versa. Where a comprehensive package of services is offered, an M&E system will

be incorporated into the package. EP-supported prevention programs will seek to leverage wrap-around services in family

planning in health care settings, including PMTCT, which are supported through the GoK, USAID Population funds, and other

partners.

POLICY

In 2008, the Ministry of Education will rollout a standardized, in-school curriculum on life-skills training and the EP will support its

implementation. The EP STP program is supporting the development and dissemination of prevention guidelines for MARPs,

including a comprehensive prevention package of services for sex workers and a PwP package. Data from KAIS, KDHS, and

MOT study will continue to inform prevention priorities as well as development of the next KNASP in 2009. Promotion of

Meaningful Involvement of People Living with HIV will be achieved through supporting prevention advocacy by PLHIV at various

levels. This will include interfacing with GoK through peer education and support group involvement.

CHALLENGES

A clearer operational definition of what an STP target "reached" entails is needed. Ambiguity arises from the broad range of

prevention interventions that are attributed to a "reach," which may range from a single intervention (e.g., a peer education

session) to a combined approach that may include life-skills curriculum training, theatre, counseling and testing targeting a single

individual or defined group.

As prevention programming expands its targeted interventions for MARPs, the per capita prevention cost will likely rise owing to

the intensity required to access hard-to-reach populations, as well as the mix of interventions in a comprehensive package;

however, over time, this such targeted interventions should help substantially diminish care and support costs, as fewer people

become infected.

SUSTAINABILITY

Training and the involvement of community members as the primary implementers sets a platform for sustaining programs beyond

EP funding. The EP will work to further empower and build the capacity of CBOs, PLHIV groups, and other indigenous groups to

achieve the organizational and technical capacity to carry out HIV prevention work in a sustainable fashion.

MONITORING AND EVALUATION

There is a close collaboration with GoK on a harmonized M&E system in the country. Also, through APHIA II Evaluation, a District

Education Monitoring and Management Information System will be implemented to assess the impact of HIV on the education

sector. Specific indicators will be developed with the SI program to monitor the integration of prevention across other program

areas.

WORK OF HOST GOVERNMENT AND OTHER DEVELOPMENT PARTNERS

The prevention program will work with the Kenya Institute of Education in streamlining the life-skills curriculum. It will also work

with NASCOP to roll out the comprehensive prevention packages, both through the provincial and district health management

teams, as well as through the work of USG-funded implementing partners. The National HIV Prevention Summit has been

established as an annual technical consultation for prevention stakeholders, led by the NACC and co-sponsored by the USG,

UNAIDS, and other key partners.

Table 3.3.02:

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $515,715

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ Prime Partner Henry Jackson Foundation Medical Research International (HJFMRI) has been

competitively selected to implement this activity in the place of KEMRI.

+ The geographical coverage has been expanded to include Nandi districts and Transmara District within

the South Rift Valley province.

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross -cutting attributions in education through supporting life skills training and

HIV prevention education within the context of education settings. This will be done in conjunction with the

Ministry of Education. It will involve training of peer educators among school going children, teachers and

parents who will be equipped with communication and leadership skills to enhance their ability to reach their

peers with HIV prevention messages. The cost implication will be at $15,000

COP 2008

1. LIST OF RELATED ACTIVITIES

N/A

2. ACTIVITY DESCRIPTION

The South Rift Valley (SRV) through KEMRI/WRP has provided HIV comprehensive care and support to six

districts in the South Rift Valley since 2005. Although HIV testing, care and support have been very

successful programs prevention efforts focusing on Abstinence/Being Faithful in the larger area have been

minimal. HIV prevention interventions for very vulnerable populations in this region has been traditionally

neglected therefore having minimal affects on the learning and subsequently adapting new behaviors that

will systematically and successfully limit the number of new infections that occur in this region on an annual

basis. In FY09, Henry Jackson Foundation Medical Research International, (HJFMRI/SRV) will scale up the

comprehensive HIV prevention program focusing on minimizing the risks for young people as well as

support the development of healthy relationships that will significantly reduce the risks related to the

acquisition of HIV. The HJFMRI/SRV AB program will focus its efforts in the activity in the expansion and

implementation of Families Matters! Program, WHY WAIT? A Family Enrichment Curriculum and Men as

Partners in HIV Prevention (MAPP). The interventions are evidence based curriculums that will be scaled-

up through out the seven districts in the south Rift Valley through local faith based organizations and

churches as well as in conjunction with the Ministry of Education. Families Matters! Program focuses on

augmenting the family unit as the major support in reducing the risks of HIV that young people face as well

as provides families with the skills and knowledge to discuss issues of HIV and human sexuality in a

positive and productive manner with their children. HJFMRI/SRV will also continue working with the

university student population at East Africa Baraton University through the on-going support of the I Choose

Life program by training 50 people in the program and reaching over 50,000 individuals. The HJFMRI/SRV

AB program will initiate a working relationship with the Kenya Girl Guides Associations Movement in the

Schools to promote HIV/AIDS prevention, through abstinence and/or being faithful by focusing in training

peer educators in life skills as well as identified teachers and community leaders in comprehensive

HIV/AIDS prevention curricula. Together these three programs will reach over 117,560 individuals with

HIV/AIDS prevention. The HJFMRI/SRV AB program will also be active participants in the development and

the implementation of the Healthy Youth Initiative (HYPE) as it is expanded nationally past the urban areas

of Kenya. HJFMRI/SRV will actively identify community based and faith based organizations that work with

the youth of south Rift Valley and engage them in the development of interventions that HYPE could

support and be effective with rural youth. The HJFMRI/SRV AB program will also partner with other

organizations in the implementation of the comprehensive HIV prevention interventions such as Kericho

Youth Center, AIC Litein and Tenwek Hospital.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

This activity will contribute to the national Emergency Plan AB program by ensuring that all interventions

follow evidence-based approach to prevention that is informed by rigorous analysis of Kenya's epidemic.

The major focus of this activity will focus on the youth especially those at heightened risk of HIV by

strengthening the larger systems that these youth operate in through focusing on family and community

structures that will be supportive in evading HIV infection. A major focus will be on young girls that are at a

heightened risk of HIV by also focusing on the protection of the girl child from gender based violence or

coercion. The HJFMRI /SRV AB program will target a total of 117,560 individuals reached through

community outreach that promotes HIV/AIDS prevention through abstinence and/or being faithful and train

an additional 1,417 individuals in the promotion of HIV/AIDS prevention.

4. LINKS TO OTHER ACTIVITIES

This activity is linked to other prevention activities in the DOD Emergency Plan prevention portfolio such as

the HJF MRI/SRV OP activity and the Live with Hope Center's AB and OP activity. They are also linked to

counseling and testing activities in the south Rift Valley with partners such as Tenwek Mission Hospital, Live

with Hope Center and HJFMRI/SRV. The links to these activities provide a comprehensive approach to

prevention from abstinence to the correct and consistent use of condoms as outlined in the PEPFAR

Guidance for ABC programs. The HJFMRI/SRV AB activity will also be linked with local Orphans and

Vulnerable Children (OVC) partners to ensure that all OVC receive age-appropriate HIV prevention

interventions, addressing the heightened risk this population is in to be abused or taken advantage of.

5. POPULATIONS TARGETED

This activity targets the general population from children to adults recognizing that prevention activities are

comprehensive and the development process of human sexual development is also an on-going transitional

process. Other populations that are targeted for this activity will be teachers and religious leaders through

the work that HJFMRI/SRV AB will do with faith based organizations as well as the local Ministry of

Education schools. This activity will also focus on street youth and orphans and vulnerable children,

recognizing the heightened risk that this population is exposed to due to their vulnerable situation.

6 & 7. EMPHASIS AREAS/KEY LEGISLATIVE ISSUES ADDRESSED

The HJFMRI/SRV AB activity will address issues in gender especially in the areas of addressing male

Activity Narrative: norms and behaviors through the MAPP program as well as increasing gender equity in HIV/AIDS programs

by focusing interventions at the family level through Families Matter!. Efforts will also be made in protecting

OVC and the girl child against violence and coercion. In-service trainings will also be an emphasis area to

ensure that the services and interventions are de-centralized and reach the most people.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16997

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16997 16997.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $360,000

Defense Research Institute

Emphasis Areas

Gender

* Addressing male norms and behaviors

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Estimated amount of funding that is planned for Education $15,000

Water

Table 3.3.02:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $280,475

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ Prime Partner Henry Jackson Foundation Medical Research International (HJFMRI) has been

competitively selected to implement this activity in the place of KEMRI.

+ The geographical coverage has been expanded to include Nandi North and Nandi South districts and

Transmara District within the South Rift Valley province.

+ The target population has been scaled up to include touts, food vendors, and bicycle and motor cycle

riders. Based on the lessons learned during the FY07 activity, these groups form a large percentage of sex

work clientele otherwise known as the networks of sex workers.

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross-cutting attributions in Economic Strengthening. The activity will facilitate

education and awareness on income generation through linkage with experts in the field of micro credit and

micro enterprise and entrepreneurship. It will also facilitate registration of the groups with the social welfare

in order to access the services. The activity will cost $3,000.

COP 2008

The only changes to the program since approval in the 2007 COP are:

•Geographic coverage has been expanded to include Bomet District, Bureti District, Nandi North and Nandi

South;

•The target population has been expanded include discordant couples, personnel of public service vehicles,

university students at East Africa Baraton University and people living with HIV;

•$7,000 of this activity is programmed with funds from the $7 million FY 2008 plus up for the Healthy Youth

Programs Initiative;

•$137,500 of this activity is programmed with funds for the promotion, education and awareness of male

circumcision as a prevention intervention;

•Other changes include the following new interventions in the OP activity:

-Men as Partners in HIV Prevention

-Positive Prevention in Community Settings

-I Choose Life program for University Students

1. LIST OF RELATED ACTIVITIES

This activity relates to activities in Abstinence and Being Faithful (#6891) and Counseling and Testing

(#6968).

2. ACTIVITY DESCRIPTION

KEMRI/Walter Reed/SRV embarked on a new piloted initiative in South Rift Valley in the area of Condoms

and Other Prevention in 2007 in order to bring prevention to high-risk populations in two stop-over locations

along the Nariobi-Kisumu transport highway corridor within Kericho District. Both sites have been extremely

underserved in the area of prevention which has fueled the prevalence rate to increase among core

transmitters as well as the surrounding general communities. KEMRI South Rift Valley program has had a

comprehensive HIV care program for the residents of south Rift Valley since the 2005 Emergency Plan

which includes counseling and testing as well as HIV/AIDS treatment. These activities will be implemented

by Henry Jackson Foundation Medical Research International (HJFMRI) South Rift Valley. A significant

aspect of the existing HJFMRI/South Rift Valley HIV comprehensive care program which has been missing

is in the area of prevention, especially among high-risk populations. The reliance on conventional voluntary

counseling and testing (VCT) sites to address this need has not been a sufficient prevention intervention. In

FY 2009, Henry Jackson Foundation Medical Research International (HJFMRI) South Rift Valley (SRV) will

address this existing gap in HIV-AIDS prevention by targeting 134,883 individuals in South Rift Valley in

creating a sustainable prevention program which addresses the specific risk factors of commercial sex

workers (CSW), touts, food vendors, as well as other high-risk adults in South Rift Valley. The estimated

HIV prevalence rate is 7-8% among the general population, but the targeted group for this activity is

estimated to be higher than that. Even after personal knowledge of HIV status, there is a significant gap in

prevention activities due to the lack of personal knowledge and skills that assist an individual to change

behavior. HJFMRI/SRV will address this issue in South Rift Valley with condom promotion and STI

identification and management. HJFMRI/SRV OP Program will also target 343 people to be trained in

promoting HIV/AIDS prevention among high-risk adults. In FY09 HFFMRI/SRV OP program will expand the

above activities to the rest of the predominantly rural region specifically in the area of condom promotion.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

HJFMRI/SRV's new activity in Condoms and Other Prevention will contribute to the overall objective of

reducing high-risk behaviors among high-risk adults. This activity will also empower and train 257

individuals in South Rift Valley in the promotion of routine testing of STIs as well as the promotion of

consistent and correct condom use. This activity will target 86,479 individuals with HIV prevention

messages as well as behavior change skills that significantly minimize their risk behaviors. 89 condom

dispensers will also be set up throughout the South Rift Valley.

4. LINKS TO OTHER ACTIVIITES

This activity is linked to Live with Hope's Abstinence and / or Being Faithful program (#6891) and

HJFMRI/SRV AB Program as other prevention activities occurring in South Rift Valley. Through

coordination the two programs will work closely together in identifying populations to reach with prevention.

Counseling and testing services through HJFMRI/SRV (#6968) will also be linked to this activity in the

promotion of gaining personal knowledge of HIV status as a key to prevention and access to care.

5. POPULATIONS BEING TARGETED

This activity will target adults in the general population with prevention messages as well as the most at-risk

populations of commercial sex workers and mobile populations; specifically truck drivers. Brothel owners

and bar maids will also be a targeted population for this activity. In FY 09, this activity will include touts, food

vendors, bicycle and motor cycle riders as well as prison officers and inmates.

6. KEY LEGISLATIVE ISSUES ADDRESSED

Activity Narrative: This activity will address adult men in educating them about the identification of male norms and behaviors

which may be risk factors in HIV-AIDS transmission. The project activities with CSWs will increase gender

equity in HIV-AIDS programs as well as increasing women's access to income and productive resources.

Stigma reduction will also be addressed through information, education and community mobilization.

7. EMPHASIS AREAS

The primary focus of HJFMRI/SRV in this activity will be to mobilize the community in the participation of

these prevention activities as well as reduce stigma in specific high-risk populations. This activity will also

dedicate part of its time to information, education and communication in the development of material that

serves as mass media prevention campaigns as well as in training of individuals to sustain the prevention

activities.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14903

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14903 8808.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $240,000

Defense Research Institute

8808 8808.07 Department of Kenya Medical 4249 3476.07 South Rift Valley $375,000

Defense Research Institute

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Estimated amount of funding that is planned for Economic Strengthening $3,000

Education

Water

Table 3.3.03:

Funding for Biomedical Prevention: Voluntary Medical Male Circumcision (CIRC): $400,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross-cutting attributions in human capacity development through training of lay

and community health workers for task shifting. It will also develop local management and leadership skills

for community based groups. Of the allocated budget, at most 20% will be spent on this.

COP 2008

1. ACTIVITY DESCRIPTION

HJFMRI-South Rift Valley (SRV) has provided HIV comprehensive care and support to six districts in the

south Rift Valley since 2005. KEMRI- south Rift Valley has been working in targeted divisions among 6

districts in the rural settings within the Southern Rift Valley Province where approximately 80% of men are

circumcised, nearly ¾ by ‘traditional circumcisers'. In FY08 the HJFMRI- South Rift Valley ‘male

circumcision program was able to follow up on over 2000 boys aged between 10-17 years who underwent

male circumcision through prevention and STI counseling, and ABC Messaging. In FY09, HJFMRI-SRV

male circumcision will develop a comprehensive HIV prevention program that will focus on minimizing the

risks for young people as well as support the development of healthy relationships that will significantly

reduce the risks related to the acquisition of HIV. The HJFMRI-SRV male Circumcision program will focus

its efforts in the activity in the development and implementation of WHY WAIT? A Family Enrichment

Curriculum, Families Matter! Program (FMP); and Men as Partners in HIV Prevention (MAPP). These are

proven interventions designed on evidence based curriculums that will be scaled-up through out the seven

districts in the south Rift Valley through partnerships with the local communities, faith based organizations

and churches as well as in conjunction with the Ministry of Education. In FY09 the program will target to

reach and follow -up 5000 boys between the ages of 11-14 years, an important age group that can easily

be influenced by peer pressure; there exists an important window of opportunity before the boys become

sexually active and delay sexual debut. The HJFMRI-SRV circumcision program will develop and

disseminate Ministry of Health approved trainings and IEC Materials (brochures and Posters) to ensure that

Comprehensive HIV prevention messaging and interventions are included in the Circumcision ceremonies

while young men are in seclusion following circumcision. The HJFMRI-SRV CIRC program will train a total

of 400 people: 20 people in Families Matter! Program, 300 people in MAPP and 100 people in Why Wait?

curricula. Together these three programs will reach over 30,000 individuals with HIV/AIDS prevention who

are predominantly in the rural populations. In addition, the targeted surveillance will permit the ability to

gather information and better understand complications and adverse events associated with the current

provision of male circumcision in South Rift Valley and inform the policy making process. The FMP and

‘Why Wait' a Family Enrichment Curricula focus on augmenting the family unit and by extension the

individual social networks as the major support in reducing the risks of HIV that young people face as well

as provides families with the skills and knowledge to discuss issues of HIV and human sexuality in a

positive and productive manner with their children with an aim of delaying sexual debut and adoption of

healthy sexual behaviors..

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA

This activity will contribute to the national Emergency Plan Male Circumcision program by ensuring that all

interventions follow evidence-based approach to prevention that is informed by rigorous analysis of Kenya's

epidemic. The major focus of this activity will focus on the youth especially those at heightened risk of HIV

by strengthening the larger systems that these youth operate in through focusing on family and community

structures that will be supportive in evading HIV infection. A major focus will be on young girls that are at a

heightened risk of HIV by also focusing on the protection of the girl child from gender based violence or

coercion. The HJFMRI-SRV CIRC program will target a total of 30,000 individuals reached through a

comprehensive male circumcision HIV prevention package and train an additional 400 individuals in the

various HIV/AIDS prevention curricula.

3. LINKS TO OTHER ACTIVITIES

This activity is linked to other prevention activities in the DOD Emergency Plan prevention portfolio such as

the HJFMRI-SRV AB, and OP activity and the Live with Hope Center's AB activity. They are also linked to

counseling and testing activities in the south Rift Valley. The links to these activities provide a

comprehensive approach to prevention from a male circumcision perspective as outlined in the PEPFAR

Guidance for ABC programs. The HJFMRI-SRV CIRC activity will also be linked with local Orphans and

Vulnerable Children (OVC) partners to ensure that all OVC receive age-appropriate HIV prevention

interventions, addressing the heightened risk this population is in to be abused or taken advantage of.

4. POPULATIONS TARGETED

This activity targets the general population from children to adults recognizing that prevention activities are

comprehensive and the development process of human sexual development is also an on-going transitional

process. Other populations that are targeted for this activity will be teachers, community and religious

leaders through the work that HJFMRI-SRV CIRC will do with community-based and faith based

organizations as well as the local Ministry of Education schools. This activity will also focus on street youth

and orphans and vulnerable children, recognizing the heightened risk that this population is exposed to due

to their vulnerable situation.

5. EMPHASIS AREAS/KEY LEGISLATIVE ISSUES ADDRESSED

HJFMRI-SRV CIRC activity will address issues in gender especially in the areas of addressing male norms

and behaviors through the MAPP program as well as increasing gender equity in HIV/AIDS programs by

focusing interventions at the family level through FMP and Why Wait?- A family enrichment curriculum.

Efforts will also be made in protecting OVC and the girl child against violence and coercion. In-service

trainings will also be an emphasis area to ensure that the services and interventions are de-centralized and

reach the most people.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16827

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16827 16827.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $307,000

Defense Research Institute

Emphasis Areas

Gender

* Addressing male norms and behaviors

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $80,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $41,349,738

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Key Result 1: Provide HIV care and support services for 600,000 adults.

Key Result 2: Provide a Basic Care Kit (BCK) to 400,000 HIV-positive persons including a safe water system, cotrimoxazole

(CTX) for opportunistic infection (OI) prophylaxis, an insecticide-treated bed net, condoms, educational materials, and

multivitamins.

Key Result 3: Provide direct antiretroviral treatment (ART) support for 270,000 HIV-positive adults and indirect support for an

additional 10,000.

Key Result 4: Expand integration of prevention education and services in care and treatment programs.

Key Results 5: Expand provider-initiated, family, and couple HIV testing and counseling services in care and treatment settings.

CURRENT PROGRAM CONTEXT

Kenya's HIV care and ART services have significantly expanded in the last four years. The five-year Kenya Emergency Plan (EP)

goals were to support 300,000 in care and 250,000 on ART by September 2010. However, by July 2008, >500,000 adult Kenyans

had received facility and community HIV care services. The number of ART patients has increased from <5,000 in 2003 to over

200,000 (90% adults) by July 2008, and the number of ART sites has increased from 5 pilot sites to over 500 established sites.

Scale-up continues at a rapid pace, with >10,000 initiating care and 5,000 initiating ART monthly. This tremendous expansion is

attributed to increased funding and scale-up primarily through the EP with some Global Fund (GF) support. Other five-year plan

goals achieved include establishment of a national care and ART task force, revision of policy and guidelines for OI care and ART,

and the training of >15,000 health care workers (HCW) on care and ART.

STATISTICS

According to the recently completed Kenya AIDS Indicator Survey (KAIS), there are ~1.4 million HIV-positive adults aged 15-64 in

the country, 390,000 of whom require ART. HIV testing and counseling (HTC) have not reached many of these persons, with 83%

of adult HIV-positive Kenyans not knowing their status. However, among those who knew their status, KAIS revealed high ART

(90%) and CTX (74%) coverage.

Two national surveys conducted in 2007 provided information about care and treatment services. An EP-supported longitudinal

national ART survey conducted at 30 ART sites in 2007 indicated that 78% of patients remained alive and on ART one year after

initiation; 12% were lost to follow-up, 5% died, 4% transferred care, and 1% discontinued ART. Further, 93% of those in follow-up

remained on their first-line regimen at their most recent visit. An HIV basic care service survey at 60 sites revealed that nutritional

advice was the most common type of care provided (98%), followed by secondary prevention (97%), HTC (90%), support groups

(75%), and adult ART (58%). Over 80% of facilities provided condoms and CTX; over 30% offered safe water and bed nets. Non-

opioid pain control was available at 83% of sites, although 5% of sites reported having opioids.

SERVICES

In 2009, the approximate number of HIV-positive Kenyans in EP-supported care and ART will reach 775,000 and 300,000

respectively (55% and 77% of total demand). Decentralization to lower-level health facilities, including health centers and

dispensaries, is anticipated to increase the number of care and treatment sites from 500 to 800, of which 700 provide ART. The

EP will directly support 90% of patients (including 270,000 on ART) and indirectly support nearly all patients. EP funds will train

over 2,000 HCW through classroom training and mentorship, and have already supported Kenyan adaptation of WHO mentorship

guidelines for nurses and clinical officers.

A key 2009 program emphasis is HTC expansion in HIV care settings, including provider-initiated testing and counseling (PITC) in

clinical facilities, and couple and family testing in facility and community settings. Implementing partners will leverage care and

ART program funds to provide HTC within their facilities and expand outreach activities to offer family members home- or facility-

based HTC. PITC will also be provided in hospices through support to the Kenya Hospice and Palliative Care Association

(KHEPCA).

All HIV-positive persons identified through VCT, PITC, couple, and family testing in facility and community settings will be referred

to a nearby health care facility for care and ART evaluation. Patients will have quarterly clinic visits, including CD4 testing twice

yearly, to determine ART eligibility or for treatment monitoring as per Kenyan guidelines.

By September 2010, ~600,000 (43%) of HIV-positive adults will receive EP-supported facility, community, and/or home-based

basic care services (family and couple HTC, TB screening, and CTX) from over 800 service delivery points; 300,000 will receive

both community and facility services. A subset, 400,000 (75%) who are in care but not yet on ART, will be prioritized to receive a

BCK; 200,000 (32%) will receive treatment of other OIs and 270,000 (42%) will receive ART. EP support will scale-up the

provision of the cryptococcal antigen test. Pain management will include non-opioids, acetaminophen and non-steroidal anti-

inflammatory drugs; opioids will be limited to registered palliative care centers. The USG will continue collaboration with KHEPCA

to advocate for policy changes to expand access to pain medication. The EP will continue to provide care and ART services to

hard-to-reach populations, and involve organizations of persons living with HIV (PLHIV) through psychosocial support groups,

PLHIV employment as peer educators, HIV treatment awareness activities, wrap-around food programs, and income-generating

activities.

Prevention with Positives (PwP) activities will be expanded in health care facilities and at the community level. A technical working

group, chaired by the National AIDS and STI Control Programme (NASCOP), has been established. In 2008, the first national

HCW PwP trainings-of-trainers occurred. Core clinical PwP activities include: partner/family member HTC, encouraged/assisted

disclosure, condom education and provision, STI screening/treatment, and referral to family planning services. Community PwP

materials will be developed and launched in 2009.

Currently, two pilot programs provide cervical cancer screening to a limited number of women through non-EP funding. The USG

team is assessing their protocols, financial investment, and site capacity to provide screening and treatment services and that of

their tertiary referral sites to provide radiation and/or chemotherapy. Based on the findings, a determination will be made as to

how best 2009 EP funds might support limited cervical cancer screening activities in HIV settings.

Over 60 health care facilities receive Food by Prescription (FBP) to distribute to eligible patients, and >50,000 adult patients have

benefited. Other nutritional support is provided through leveraging of private funds and food production programs. In 2009, the

FBP project will expand to support an additional 40,000 adults, bringing the total ever supported to 100,000. EP funds have

supported nutrition guidelines and protocol development, including entry and exit criteria using BMI and other parameters.

The EP will continue supporting 850 contract clinical staff at government and mission facilities, including clinical officers, nurses,

lab technologists, and pharmacists. Other implementing partners also employ additional staff. Yet, despite EP efforts and that of

other development partners, Kenyan health care facilities remain staffed at ~50% of optimal levels. Various approaches have

been suggested to task-shift HCW roles and responsibilities to other cadres and/or community members, and the MOH has

embarked upon a Community Strategy to ensure Kenyan communities have the capacity and motivation to take up an essential

role in health care delivery. EP funds will promote community ownership of and participation in health care delivery, including HIV

care and ART programs, which should help improve the quality of both general health services and HIV programs. Communities

will be empowered to contribute to policy setting, resource mobilization and allocation, and program development, implementation,

and evaluation.

REFERRALS AND LINKAGES

HIV-positive patients identified through HTC services - including PMTCT, TB/HIV, VCT, PITC, and home-based counseling and

testing - will be linked to care and treatment services. HIV-positive pregnant women will be enrolled in care at Maternal and Child

Health (MCH) or HIV care clinics where they will start CTX and be evaluated for ART. Currently, ART is only available through

HIV care and ART sites; however, a small program will pilot ART in MCH sites. All patients enrolled in clinical HIV care programs

will receive TB screening during routine visits. A standardized TB screening tool for use in HIV settings has been developed and

will be implemented in collaboration with NASCOP and the TB program. HIV-positive men identified through HTC during voluntary

medical male circumcision (VMMC) activities will be linked to care; HIV-negative men in discordant relationships will be referred

for VMMC.

POLICY

Kenya has developed and implemented national ART and OI prevention and treatment policies and guidelines. During 2009, ART

guidelines will undergo reassessment/revision, including a likely shift to a tenofovir-based first-line regimen. CTX and

multivitamins are recommended for all PLHIV. Policy on other HIV care components remains poorly defined, and, in 2009, EP

funds will support care policy development.

EP funds have supported development of a decentralization policy and mentorship guidelines to guide multi-tasking and task-

shifting to lower level health facilities, and implementation of these policies and guidelines will continue in 2009.

SUSTAINABILITY

Over 80% of Kenya ART and care programs are within MOH facilities. In 2009, the EP will continue to support HCW didactic

trainings and mentorship. Implementing partners will be encouraged to integrate care and ART plans into the district annual

operations plans. In addition, partners will be encouraged to establish, support, and build the capacity of local, indigenous

organizations. Currently, two umbrella agreements support over 70 local indigenous organizations.

The concept paper for Kenya's PEPFAR Partnership Compact commits the Government of Kenya (GoK) to a minimum of 10%

annual increases in direct budget support for ARV procurement, which will enhance program sustainability.

MONITORING AND EVALUATION

Data collection and reporting will be strengthened at all levels to increase and improve reporting to NASCOP and PEPFAR. The

NASCOP Systems Subcommittee has adapted quality of care indicators to be incorporated into routine M&E reporting. TB

indicators will be incorporated into HIV care and ART reporting to capture active TB cases and ART uptake among HIV/TB co-

infected patients. The USG team will incorporate customized indicators, including those current, ever, and newly initiated in care,

and differentiate between adults and pediatric patients. Indicators to capture those receiving community and/or facility care will be

developed to avoid double-counting. In 2009, persons reported as receiving basic care and support will receive at least one

clinical service, as well as at least one service in another domain of palliative care.

Currently, implementing partners struggle with the existence of several electronic database systems to capture facility patient-level

care and ART data. A data assessment of the most commonly used systems occurred in November 2007, and a WHO-consultant

is assisting in data variable harmonization. EP funds will assist further development of patient-level computerized database

systems capable of reporting to both NASCOP and PEPFAR, moving toward consensus on a single or limited menu of electronic

systems.

A national survey to monitor emergence of HIV drug resistance (HIVDR) among ART patients has been planned using 2008

funds. These data and that of the early warning indicators will assist NASCOP and other national and international partners to

design strategies to improve ART outcomes, strengthen recommendations for optimal first- and second-line regimens, and

provide indications for time of regimen switch to optimize ART clinical management and minimize the emergence of HIVDR.

WORK OF HOST GOVERNMENT AND OTHER IMPLEMENTING PARTNERS

NASCOP coordinates all care and ART activities and oversees development and implementation of care and ART policy,

guidelines, and training curriculums in Kenya. A national care and ART taskforce, chaired by NASCOP and including

representation from the USG, WHO, UNAIDS, Medecins Sans Frontieres (MSF) and other development partners, meets quarterly

to deliberate on care and ART issues. In 2008, GF resources procured ARVs for ~75,000 and a limited number of OI drugs, and

GoK-procured first-line ARVs for ~25,000. MSF directly supports care and ART for over 15,000. The Clinton Foundation (CF)

procures second-line ARVs for adults and, in 2006, employed 1,120 nurses for a three-year placement in districts with severe

staffing shortages; the GoK is to absorb these nurses after expiry of the contract in 2009. WHO and UNAIDS provide technical

support to NASCOP and have assisted with the WHO guideline adaptation on IMAI and mentorship.

OUTSTANDING CHALLENGES/GAPS

Key remaining barriers include insufficient human resources, inadequate space, and inconsistent access to care and ART

commodities for further scale up. It is hoped that adoption of the Partnership Compact will help increase HCW staffing, and that

implementation of the GoK's Community Strategy, decentralization policy, and mentorship activities will promote multi-tasking and

task-shifting to expand ART availability to lower level facilities. Funds allocated to RPSO will permit the construction and

renovation of health care physical infrastructure, including laboratories, pharmacies, and care and treatment clinics.

Despite ART scale-up in Kenya, the GoK funding allocations to expand their ARV procurement and other commodities remains

low, and the distribution system is weak. In 2008, the GoK has allocated ~$7 million for ARV procurement to cover 25,000

patients on generic first-line regimens. However, this is insufficient to cover the current rate of scale-up and GoK plans to adopt

safer, more efficacious, and more expensive ARV regimens. GF Round 2 Phase 2 only procured ARVs to cover 42,500 patients

for a period of three years. Yet, as this target was quickly exceeded (~75,000), it is unclear how these extra patients will continue

to be covered. The USG team will continue to encourage the GoK to commit more funds for procurement of ARVs, as well as to

assure the security of other commodities.

Table 3.3.08:

Funding for Care: Adult Care and Support (HBHC): $1,050,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ the prime partner changes from KEMRI to HJF-MRI

+ all sections referring to pediatric care and support have been moved from this narrative to a new program

(PDCS Care)

+ emphasis areas will be expanded to include prevention with positives, nutrition management (Food By

Prescription) for moderate to severely malnourished clients on care and support, and task shifting and

involvement of PLWHA in defaulter tracing and other non-technical aspects of comprehensive ART.

+ number of service outlets providing HIV related palliative care (excluding TB) changes to 100

+ number of individuals provided with HIV related palliative care (excluding TB) changes to 4,800

+ number of individuals trained to provide HIV related palliative care (excluding TB) changes to 150

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross-cutting attributions in HCD through its on-site CME training for doctors,

nurses, clinical officers, pharmacists, nutritionists, and HIV program managers. 2.5% of the budgetary

allocation will be attributed to this activity.

It also supports Food & Nutrition tools and service delivery through meeting critical staff gaps and equipping

health facilities to be able to offer quality nutrition services. 2.5% of the budgetary allocation will be

attributed to this activity. The activity additionally supports nutrition commodities by leveraging on the INSTA

Food By Prescription Support program, currently being implemented in four partner hospitals (Longisa

District Hospital, AIC Litein Mission Hospital, Kericho District Hospital, & Kapsabet District Hospital). In FY

09, mechanisms will be put in place to expand this support to all the 100 palliative care service outlets in all

the 8 districts under the SRV program coverage. 2.5% of the budgetary allocation will be attributed to this

activity.

COP 2008

The only change to the program since approval in the 2007 COP is:

+geographic coverage has been expanded to include Kisumu West District in Nyanza Province and

Kipkelion District in Rift Valley, therefore increasing the geographic coverage from 6 to 8 districts.

1. LIST OF RELATED ACTIVITIES

This activity relates to HIV/AIDS Treatment/ARV services, Palliative Care: TB/HIV, Counseling and Testing,

Prevention, OVC and PMTCT.

2. ACTIVITY DESCRIPTION

The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed/KEMRI-HIV project in

collaboration with the Ministry of Health and Faith-based (including a local community based organization)

health care programs within 8 districts (2 new districts added to the previous 6 districts) in the South Rift

Valley and Nyanza Provinces of Kenya.

The South Rift Valley Program serves a population of approximately 2.7 million people, with a HIV

prevalence ranging from 5% to as high as 19% in some congregate settings. In 2006, about 100,000 adults

were estimated to be living with HIV. As of March 31, 2007, the South Rift Valley program was providing

basic health care and support services to 16,065 HIV infected patients, of whom 6021 were on ARVs. In

FY09 the program will reach 4,800 clients with facility based basic care services.

To ensure sustainability the program will work hand in hand with the Ministry of Health and NASCOP in

offering basic health care and support services. In FY08, concerted efforts were made to support quality

clinical care for HIV infected patients including routine patient follow up, laboratory monitoring, prevention

(including Co-trimoxazole Preventive Therapy) and treatment of opportunistic infections (OIs), and

treatment literacy and drug adherence. Nutritional (including multi-vitamin supplementation) support;

psychosocial care, including support groups to encourage positive living, disclosure counseling, and mental

health services; prevention with positives; family planning and STI services were supported. Regular

support supervision and technical assistance; and timely, efficient and accurate data collection, analysis

and dissemination were further consolidated.

In order to decongest the overcrowded district level facilities and enhance accessibility of basic care

services by the rural underserved population, decentralization of basic health care services and follow up of

stable patients at lower level facilities (health centers and dispensaries) will continue to be supported in

accordance with the network model. In FY09, this model will be expanded to support additional lower level

facilities throughout the 8 districts, bringing the number of facilities offering basic health care in the region to

100. By doing so, over 40% of the current patients seeking basic care services will be able to access the

services in nearby rural facilities. To support the scale up, 150 additional health workers will be trained on

basic health care and support.

In FY 2008, the South Rift Valley basic health care and support program supported Live with Hope Center

(LWHC) in their community home based care program which has been receiving Emergency Plan funds

since FY 2004. In FY 2009, the program will continue to serve and care for over 1,000 individuals in their

homes in the provision of home based basic health care as well as psychological support and counseling

through community clinical health workers as well as PLWHA community volunteers.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

This activity will contribute substantively to Kenya's FY08 goal of providing facility based basic care and

support to 460,200 clients, by providing services to 33,000 individuals (7% of the overall FY 2008

Emergency Plan national target). The collaboration with MOH, other GOK offices and major stakeholders

will ensure these services are sustainable.

4. LINKS TO OTHER ACTIVITIES

This activity is linked directly to the other KEMRI-SRV HIV/AIDS program initiatives in 8 districts in the SRV

and Nyanza provinces of Kenya. It is directly related to KEMRI-South Rift ARV services in the identification

and provision of palliative care to all HIV+ patients (including those not on ARVs). It is also linked to the

Activity Narrative: orphans and vulnerable children (OVC) program to ensure those HIV+ children in palliative care that require

additional services are adequately linked to receive the support.

5. POPULATION BEING TARGETED

The KEMRI-SRV basic health care and support program serves the civilian population in the SRV region.

The program will target primarily those people affected by HIV/AIDS including discordant couples,

caregivers as well as children since the main objective is to provide supplemental care to existing ART

services. Health care providers (both in public and private institutions) will also be targeted by increased

palliative care training to enhance their capacity to provide basic health care services. The work

accomplished by LWHC will be a demonstration of palliative care work with a community/faith based group

in Kericho district.

6. KEY LEGISLATIVE ISSUES ADDRESSED

This activity will address increasing gender equity in HIV/AIDS programs by ensuring that both men and

women access basic health care and support services. Traditionally, women are more receptive to the

service but efforts will be made through a strong peer support network and counseling services to

encourage men to access services as well. Counselors will continue to be used to address psychosocial

issues that may contribute to the spread of HIV, including issues of disclosure and discordance among

partners. The effort of decentralization of services to lower level facilities through the network model will

continue to be strengthened and will help in reducing stigma and discrimination by the delivery of services

at the community level.

7. EMPHASIS AREAS

This activity includes emphasis on minor construction/renovation of health facilities to ensure adequate

space to offer basic care services; human capacity development including training and empowering the

health workers to provide basic health care and support services by supporting necessary commodities;

data collection, analysis and dissemination, which will further support program monitoring and evaluation;

collaboration with the MOH and NLTP to support family planning, malaria prophylaxis and treatment and

commodities for TB diagnosis and treatment; and increasing gender equity in HIV/AIDS programs, by

ensuring that equitable number of women, and targeting increased access of services by men.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14904

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14904 6922.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,050,000

Defense Research Institute

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $18,750

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $18,750

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $18,750

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $6,450,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ The prime partner changes from KEMRI to HJF-MRI

+ All sections referring to pediatric ART have been moved from this narrative to a new program area (PDTX

Treatment)

+ emphasis areas will be expanded to include prevention with positives, nutrition management (Food By

Prescription) for moderate to severely malnourished clients on ART, and task shifting and involvement of

PLWHA in defaulter tracing and other non-technical aspects of comprehensive ART

+ Number of service outlets providing antiretroviral therapy changes to 68

+ Number of individuals newly initiating antiretroviral therapy during the reporting period changes to 6,000

+ Number of individuals who ever received antiretroviral therapy by the end of the reporting period changes

to 21,600

+ Number of individuals receiving antiretroviral therapy at the end of the reporting period changes to 18,000

+ Number of health workers trained to deliver antiretroviral therapy services according to national &/or

international standards changes to 150

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross-cutting attributions in HCD through its on-site CME training for doctors,

nurses, clinical officers, pharmacists, nutritionists, and HIV program managers. 2.5% of the budgetary

allocation will be attributed to this activity.

It also supports Food & Nutrition tools and service delivery through meeting critical staff gaps and equipping

health facilities to be able to offer quality nutrition services. 2.5% of the budgetary allocation will be

attributed to this activity. The activity additionally supports nutrition commodities by leveraging on the INSTA

Food By Prescription Support program, currently being implemented in four partner hospitals (Longisa

District Hospital, AIC Litein Mission Hospital, Kericho District Hospital, & Kapsabet District Hospital). In FY

09, mechanisms will be put in place to expand this support to all the 68 ART service outlets in all the 8

districts under the SRV program coverage. 2.5% of the budgetary allocation will be attributed to this activity.

COP 2008

1. LIST OF RELATED ACTIVITIES

This activity relates to activities in HBHC, TB/HIV, and HVCT.

2. ACTIVITY DESCRIPTION

The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed/KEMRI-HIV project in

collaboration with the Ministry of Health and Faith-based (including a local community based organization)

health care programs within 8 districts (2 new districts added to the previous 6 districts) in the South Rift

Valley and Nyanza Provinces of Kenya.

The South Rift Valley Program serves a population of approximately 2.7 million people, with a HIV

prevalence ranging from 5% to as high as 19% in some congregate settings. In 2006, about 100,000 adults

were estimated to be living with HIV. As of March 31, 2007, the South Rift Valley program was providing

basic health care and support services to 16,065 HIV infected patients, of whom 6021 were on ARVs. One

year later, the numbers had risen to 20,706 and 8339 on care and treatment respectively. In FY09 the

program targets to enroll 6,000 new clients into ART.

To ensure sustainability, the program built the technical and management capacity of all the hospitals

providing treatment by targeting 115 health care workers to be trained in ART (including pediatric AIDS

treatment) in FY 2007 & FY 08. In FY 09, 150 health workers will be trained to deliver adult antiretroviral

services according to national &/or international standards.

FY07 & FY 08 funds were used to encourage positive living, prevent HIV infection transmission or re-

infection, enhance community mobilization, reduce stigma and discrimination, and increase treatment

literacy and adherence. Funds were also used to continue and/or initiate technical assistance from 5 locally

employed staff.

Kericho District and Tenwek Mission hospitals will continue to be supported as referral units for the SRV for

patients requiring more specialized medical care, with Kericho District Hospital continuing to provide Quality

Assurance and Control oversight for diagnostics (HIV and Opportunistic Infection (OI)), monitoring, and

quality of treatment in the regional network for the rural health center facilities as well as the larger SRV.

To enable the facilities cope with the increasing number of patients and to improve accessibility of HIV

treatment services in the rural underserved populations, based on the network model initiated in FY 2006,

the program will continue to support the decentralization of treatment of stable patients to rural health

facilities by building the capacities for these facilities to offer HIV treatment services. In FY 2009, this model

will support a total of 68 health facilities in the delivery of ART services throughout the SRV.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

This activity will continue contributing to the Emergency Plan result for increased number of individuals on

ARV treatment, and contribute to Kenya's 5 year strategy target by providing ARV services to over 21,600

individuals throughout the eight districts. It will strengthen the capacity of the health systems to offer ART

and strengthen the referral network for ARV treatment provision in collaboration with host government

workers, specifically with the National AIDS/STI Control Program (NASCOP) at the district level.

4. LINKS TO OTHER ACTIVITIES

KEMRI-SRV ART activity is closely linked with KEMRI-SRV palliative care program for those individuals

who qualify for basic health care and support as well as with KEMRI-SRV PMTCT program in the provision

of comprehensive care for pregnant women who are HIV infected and qualify for treatment. This activity is

also linked with KEMRI-SRV counseling and testing (CT) programs as an entrance point for care. It is also

similarly linked to Tenwek and Live with Hope CT programs. It is also linked to KEMRI-SRV TB/HIV

program, and Samoei Community Response and Live with Hope's Orphans and Vulnerable Children (OVC)

programs in Kericho District.

Activity Narrative: 5. POPULATION BEING TARGETED

The KEMRI-South Rift Valley adult treatment program will target the general population including adults,

and family planning clients as well as people affected by HIV/AIDS through HIV/AIDS-affected families,

OVC, and people living with HIV/AIDS. New rural health care facilities will increase coverage and access to

all these targeted populations. Health care providers, both in the private and public sector, will also be

targeted by increased ART training thus increasing the number of clients able to be served more efficiently.

6. KEY LEGISLATIVE ISSUES ADDRESSED

The KEMRI-South Rift Valley HIV program will increase gender equity in HIV programming by ensuring that

equitable numbers of women including children are receiving treatment. The activities will address stigma

associated with HIV status through information, education, and communication materials targeted to health

care providers, caregivers, and communities.

7. EMPHASIS AREAS

This activity includes emphasis in training, strategic information, human resources, targeted evaluations,

and commodity procurement. SRV will procure supplies for HIV diagnoses and staging (e.g. CD4 counts) as

well as safety monitoring for HIV treatment (e.g. hemoglobin, liver transaminases). It will also obtain medical

supplies for providing HIV treatment services and procure and train additional staff as needed to ensure

quality care is delivered in light of their increasing workload as more patients are recruited.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14908

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14908 6973.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $7,170,714

Defense Research Institute

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $161,250

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $161,250

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $161,250

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Treatment: Adult Treatment (HTXS): $150,000

This PHE activity, "Utility of Viral Load Monitoring In Addition to Routine CD4 + WHO Clinical Staging In

Patients Receiving Antiretroviral Therapy in the South Rift Valley of Kenya" was approved for inclusion in

the COP. The PHE tracking ID associated with this activity is KE.07.0044. A copy of the progress report is

included in the Supporting Documents section.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17878

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17878 17878.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $400,000

Defense Research Institute

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Estimated amount of funding that is planned for Public Health Evaluation $150,000

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 10 - PDCS Care: Pediatric Care and Support

Total Planned Funding for Program Budget Code: $2,750,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Key Result 1: Provide direct HIV care and support services for 75,000 children, and indirect support for an additional 6,000

children.

Key Result 2: Provide Basic Care Kits (BCK) to 40,000 HIV-positive children including a safe water system, cotrimoxazole (CTX)

for opportunistic infection (OI) prophylaxis, an insecticide-treated bed net, and multivitamins.

Key Result 3: Provide direct antiretroviral treatment (ART) support for 30,000 HIV-positive children, and indirect support for an

additional 12,000.

Key Result 4: Expand the integration of pediatric HIV services with maternal and child health (MCH) services, strengthen linkages

and referrals across PMTCT, TB programs, wrap-around services, community, and OVC services.

Key Result 5: Expand HIV testing and counseling (HTC) for infants, children, adolescents, and their families.

CURRENT PROGRAM CONTEXT

Through the Emergency Plan (EP), USG agencies support a clinical care model focusing on pediatric support centers that offer a

broad range of services, including HTC, clinical monitoring, diagnosis and treatment of OIs, nutritional supplements, referrals to

pediatric support groups, and linkages to OVC support. Community-based support will complement these efforts through

psychosocial activities and paralegal services.

The Kenya Five-Year EP strategy proposed expansion of the depth and breadth of pediatric ART capacity, as well as the

development of community and facility-based pediatric ART programs with an emphasis on OVC. This strategy fosters an

environment where older youth are treatment advocates for younger ones, and targets infected young adults as prime ART

candidates. Although the strategy does not include pediatric targets, the five-year EP goals are to support the care of 300,000

patients and 250,000 on ART by September 2010 of which 10% were to be children. More than 56,000 Kenyan children have

received facility and community HIV care services as of July 2008.

Kenya has rapidly expanded pediatric HIV care and ART services since 2004, increasing the number of Kenyan children receiving

ART from < 2,000 in September 2004 to 16,000 in March 2008. This significant increase is attributed to increased funding and

scale-up primarily through the EP, Clinton Foundation, Global Fund support, and the tireless efforts of many committed

individuals.

STATISTICS

According to the National AIDS and STI Control Programme, there are 100,000 HIV-positive children in Kenya, 50,000 of who

currently require ART. Since 2006, Kenya has scaled-up early infant diagnosis (EID) using dry-blood spot/DNA PCR testing with

34,000 children tested through three reference laboratories that had networked 1,214 sites as of June 2008.

As of June 2008, over 56,000 children had accessed USG-supported pediatric HIV care services at 554 sites, including national

referral, provincial, district, faith-based, and private hospitals, as well as health centers. These sites are distributed across Kenya

with 23% located in Nyanza Province, where an estimated 30% of HIV-positive children reside.

As of March 2008, 350 of 500 ART sites provided pediatric ART to 16,000 children; 60% are Government of Kenya (GoK)

facilities. At minimum, every district hospital is equipped to provide pediatric ART. Based on data from one district facility, Kericho

District Hospital, 75% of children receiving HIV care and treatment are ?5 years of age, whereas children <1 year of age

constitute 8%, and children ranging from 2-4 years of age account for 17%. A national pediatric ART survey will provide further

information on pediatric ART outcomes.

SERVICES

In 2009, the total number of Kenyan children in care and on ART will reach 75,000 and 30,000 respectively. EP support will

strengthen service delivery systems including referrals. The number of sites providing pediatric care will increase to 1,200;

approximately 700 of these sites will offer ART. The EP will provide direct support to >80% of these pediatric ART sites and

indirect support to nearly all care sites.

In 2009, the EP will prioritize identification of exposed/infected children <5 years of age. Improved diagnosis and treatment will be

achieved through EID for those <18 months of age, PITC in clinical settings, family-testing through clinical and community HTC

strategies, and the launch and use of the combined mother-child card.

EP funds will expand networked EID sites to more than 2,000 that have the collective capacity to test at least 60,000 children

(60% of all exposed children will be identified in PMTCT settings). PITC will be offered to all HIV-exposed children by increasing

HTC for children of enrolled adult patients as well as through the use of the new mother-child health card. The card will assist in

identifying exposed infants in MCH clinics. HIV-positive infants identified through DNA PCR testing will be started on ART

irrespective of CD4 count or WHO staging. Exposed children will be followed until their status is confirmed and they are linked to

pediatric care services as well as ART for those that are HIV-positive. Per MOH guidelines, EP will support CTX for confirmed HIV

-positive children and for all exposed children until their HIV status can be conclusively determined.

By September 2010, EP funds will provide a package of basic care services to 75,000 HIV exposed/infected/affected children

through facility, community, and/or home-based care services; 30% will receive both community and facility-based services.

Services include nutrition assessment, growth monitoring, safe water interventions, malaria prevention, OI management, psycho-

social support, TB screening, and CTX at service delivery points. A subset of 40,000 will receive a BCK together with their parents

and/or guardians. The EP will strengthen pediatric TB case finding, diagnosis and treatment, and will increase availability of the

cryptococcal antigen test.

In 2009, EP funding will strengthen community care services. EP facility-based partners will strengthen relationships with

community-based organizations to facilitate community linkages. EP partners will provide or establish linkages with HIV

community care services through Community Health Extension Workers (CHEW) or Community Health Workers (CHW). CHEW

or CHW activities will include pediatric and family HTC, patient referrals, tracking, and enrollment into clinical care for all identified

HIV-positive children. In addition, CHEW and CHW will be involved in monitoring usage of BCK and assisting with refills, pediatric

and family medication adherence counseling and monitoring, and patient education regarding general health issues.

In 2009, consistent with the evidence suggesting the need for early diagnosis and treatment, the MOH will offer ART for all HIV-

positive children <18 months of age regardless of CD4 to improve treatment outcomes among infants. It is estimated that 40% of

the 75,000 children provided with HIV basic care services will receive ART. Several MCH programs are currently piloting ART

provision for HIV-positive mothers and infants; this approach will be assessed and expanded if proven successful.

Over 60 health facilities and organizations provide nutritional support to children; more than 5,000 children >6 months of age have

received nutritional supplements. Other nutritional support is provided through leveraging of private funds and innovative food

production programs. In 2009, 10,000 children will receive therapeutic nutrition or supplementary feeding support. All enrolled

children will receive anthropometric status assessment, nutritional education, and counseling. All EP-funded programs will

continue to advocate for and support exclusive breastfeeding for infants for the first six months of life with appropriate weaning

and nutrition education to all affected families, which will build upon the EP-supported development of national infant and young

child nutrition guidelines.

In 2009, the Kenya Pediatric Association will provide additional pediatric training and mentorship for health care workers. EP

funds will train over 3,000 HCW through classroom training and mentorship.

REFERRALS AND LINKAGES

HIV-positive children identified through HTC services will be linked to care and treatment services. Exposed children identified

through PMTCT will be enrolled into care at MCH or HIV clinics. The mother-child card will be used at all PMTCT sites to ensure

the child is enrolled into care and receives all routine health services. Growth and child health will be monitored together with

provision of CTX and ART for infected children. Exposed children will be provided with CTX prophylaxis until HIV-positive status is

excluded.

Care and ART clinics will expand pediatric TB screening. TB clinics will offer HTC among children with TB and improve referral

mechanisms. HIV-positive children identified in OVC programs will be referred to pediatric ART sites for staging and treatment

and those enrolled in facility programs will be referred to OVC programs for additional services.

POLICY

In 2009, the MOH will initiate a national pediatric care and treatment strategy to define stakeholder roles in the care and treatment

of HIV-positive children. It will identify pediatric care locations and the roles and responsibilities among the various members (e.g.,

caregivers, psychosocial care providers, community, and health facilities) involved in care delivery. Every pediatric patient will

have a multi-disciplinary care plan involving all care providers.

In line with the MOH Second National Health Sector Strategic Plan (2006-2010), a key emphasis will be the decentralization of

pediatric care and ART services to lower level facilities for ART initiation and follow-up. Such facilities will be strengthened to offer

comprehensive pediatric HIV care and ART services. EP funds will be used to develop regional activities such as quality

assurance, clinical mentoring, and supervision based upon the network model.

The lack of a clear policy on HTC in children and pediatric HTC guidelines remains a barrier to early identification of HIV-positive

children. In 2009, the EP will support the development of updated HTC guidelines for HIV-exposed children, for sick children in

whom HIV is suspected, and their families. EP funds will also support the development of pediatric specific ART guidelines by

adopting and adapting the updated WHO pediatric recommendations.

SUSTAINABILITY

USG will continue advocating for other development partners and the MOH to play a greater role in pediatric HIV care and

treatment. EP funds will build MOH capacity to provide pediatric HIV care and treatment. In 2009, EP funds will continue to

support KPA, an indigenous organization, to conduct HCW pediatric trainings and mentorship. Currently, two EP umbrella

cooperative agreements support over 70 local indigenous organizations. Implementing partners will be encouraged to integrate

pediatric care and ART plans into the annual district operations plans and health facility work-plans. In addition, they will be

encouraged to establish, support, and to build the capacity of indigenous organizations. EP will work closely with the Kenya

Medical Training Colleges and the Universities to introduce pre-service training of health care providers in pediatric care and

treatment to reduce the need for in-service training which is not sustainable in the long term.

MONITORING AND EVALUATION

M&E systems will be strengthened at facility and regional levels to improve NASCOP and EP reporting. Quality indicators (e.g.

percentage of HIV-exposed children enrolled into care) will be incorporated into routine M&E activities. In 2009, pediatric specific

indicators disaggregated by age will be developed to measure the quality of pediatric programs. Indicators to capture the number

of children receiving community, OVC services, and/or facility-based care will be developed to avoid double-counting. In 2009,

children reported as receiving basic care and support will receive at least one clinical service, plus at least one service in another

domain of care and support (psycho-social, spiritual, social, or preventive).

WORK OF HOST GOVERNMENT AND OTHER IMPLEMENTING PARTNERS

All EP pediatric care and treatment activities are closely coordinated with NASCOP. The national pediatric care and ART

taskforce chaired by NASCOP, whose membership includes USG, CF, WHO, UNAIDS, Medecins Sans Frontieres, and other

development partners, meets quarterly to deliberate on pediatric care and treatment issues. CF procures all pediatric ARVs and

OI drugs, supports the EID testing networks, and pediatric ART provider trainings. WHO and UNAIDS provide technical support to

NASCOP. GF resources will support limited pediatric OI drug procurement.

OUTSTANDING CHALLENGES/GAPS

Key remaining barriers specific to the provision of pediatric care and treatment activities include disclosure, stigma, lack of HCW

confidence in pediatric ART initiation, suboptimal adherence to medication, and difficulties providing continuity of care due to

multiple and changing caregivers. The Mwangalizi (accompagnateurs) pilot project, which trains and employs HIV-positive women

and other experienced adults to improve continuity of caregivers presenting with children at clinic visits, is being simultaneously

implemented and assessed; if effective, it will be expanded. The new mentorship and decentralization guidelines will promote

HCW capacity for initiation of pediatric ART and will increase access to ART. The development of pediatric specific HTC

guidelines is expected to improve care, reduce stigma and increase disclosure. Adolescent care, treatment, adherence and

disclosure remain a challenge, as does sexual and reproductive health needs for HIV-infected adolescents. Child psychosocial

support groups and involvement of a multi-disciplinary team of experts may help to address this challenge

Other barriers include insufficient human resources, inadequate space, and inconsistent access to care and ART commodities for

further scale-up. It is hoped that adoption of the Partnership Compact will assist in increasing HCW staffing and that

implementation of the GoK Community Strategy and mentorship activities will promote multi-tasking and task-shifting to expand

ART availability to lower-level facilities. Funds allocated to RPSO will permit renovation of pediatric-friendly care and treatment

clinics that will enhance play therapy. The USG team will continue to encourage the GoK to commit more funds for procurement of

ARVs, as well as to assure the security of other commodities.

Table 3.3.10:

Funding for Care: Pediatric Care and Support (PDCS): $150,000

ACTIVITY UNCHANGED FROM COP 2008:

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross-cutting attributions in human capacity development through in service

training of health care workers including clinical officers, nurses and doctors in the provision of pediatric

basic health care and support services as well as early infant diagnosis. 2.5% of the budgetary allocation

will be attributed to this activity. This activity will also support pediatric nutritional assessment and

counseling before and during ART. 5% of the budgetary allocation will be attributed to this activity.

Procurement of pediatric weighing scales, stadiometers, MUAC tapes and other equipment required to carry

out effective nutritional assessment will be supported. Micronutrient supplementation according to WHO

guidance will be provided. 5% of the budgetary allocation will be attributed to this activity.

COP 2008

The only change to the program since approval in the 2007 COP is:

+geographic coverage has been expanded to include Kisumu West District in Nyanza Province and

Kipkelion District in Rift Valley, therefore increasing the geographic coverage from 6 to 8 districts.

1. ACTIVITY DESCRIPTION

The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed Project in collaboration with

the Ministry of Health and Faith-based (including a local community based organization) health care

programs within 7 districts in South Rift Valley Province (Transmara, Bomet, Bureti, Kericho, Kipkelion,

Nandi South, & Nandi North) and one district (Kisumu West) in Nyanza Province. The South Rift Valley

Program serves a population of approximately 2.7 million people, with a HIV prevalence ranging from 5% to

as high as 19% in some congregate settings. In 2006, about 100,000 adults were estimated to be living with

HIV, and about 15,000 being children under 15 years. Only about 2,300 (15.1%) of the HIV positive children

had access to HIV services. The SRV program will seek to address this gap in HIV services in this

vulnerable population. The scope of care services to be provided will range from early infant diagnosis, to

linkage to care & treatment for the HIV positive for clinical monitoring, prevention and treatment of OIs &

other HIV related ailments, malaria, pneumonia, diarrhea, and pain symptom management. The program

will also provide other components of the minimum package of pediatric basic health care and support

including provision of cotrimoxazole prophylaxis, nutritional assessment and support including

supplementation & treatment for nutrient deficiencies, deworming, and psychosocial counseling & support.

In order to increase the number of HIV positive children accessing care, the program will strengthen the

linkages between PMTCT Programs and pediatric care & treatment, pediatric training and sensitization for

early infant diagnosis, routine testing of children, laboratory capacity building and system strengthening for

Early Infant Diagnosis (EID). HIV diagnosis in babies will be done at six weeks after birth by collecting Dry

Blood Samples (DBS). A new focus will be on routine testing of sick children in pediatric medical settings

which is expected to rapidly identify large numbers of HIV positive children and provide possibility of direct

links to treatment and care. Adherence to care will be supported through extensive training of health care

providers on pediatric psychosocial counseling and support. As of March 31st, 2008, the South Rift Valley

program had enrolled a total of 2,327 children into its HIV care & treatment program, out of whom 1,552

were on basic health care and support, and 775 were on ARVs. In FY 09 the program targets to reach

5,400 children with the basic care and support services. To be able to do this and to and ensure

sustainability the program will work hand in hand with the Ministry of Health and NASCOP. A total of 68

health facilities will be supported to offer quality pediatric care services. Of these facilities, 12 are partner

main hospitals (8 district hospitals, 2 plantation, & 2 mission hospitals). In order to avoid congesting the

already overcrowded district level facilities and enhance accessibility of basic care services by the rural

underserved population, decentralization of basic health care services and follow up of stable patients at

lower level facilities (health centers and dispensaries) will be supported in accordance with the network

model, that has been successfully used in adult care and support. The health facility support will include

minor renovations to create children friendly care and support centers, procurement of necessary

equipment, and supplies. The human resource requirements will be reviewed as necessary. To support the

scale up, 150 health workers will be trained on basic health care and support, including EID, nutrition, and

psychosocial counseling and support. Regular support supervision and technical assistance; and timely,

efficient and accurate data collection, analysis and dissemination will also be consolidated.

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA

This activity will contribute substantively to Kenya's FY 09 goal of providing basic care and support to

76,900 children, by providing services to 5,400 individuals (7% of the overall FY 2008 Emergency Plan

national target). The collaboration with MOH, other GOK offices and major stakeholders will ensure these

services are sustainable.

3. LINKS TO OTHER ACTIVITIES

This activity is linked directly to the other SRV HIV/AIDS program initiatives in 8 districts in the SRV and

Nyanza provinces of Kenya. It is directly related to South Rift ARV services in the identification and

provision of palliative care to all HIV+ patients (including those not on ARVs). It is also linked to the SRV

PMTCT program, where children will be identified, and those diagnosed as HIV infected linked to care &

treatment. In addition, it is linked to the orphans and vulnerable children (OVC) program to ensure those

HIV+ children in palliative care that require additional services are adequately linked to receive the support.

4. POPULATION BEING TARGETED

The SRV pediatric basic health care and support program serves the predominantly rural population in the 8

districts. The program will target primarily those children affected by HIV/AIDS since the main objective is to

provide supplemental care to existing ART services. Health care providers (both in public and private

institutions) will also be targeted by increased basic health care training to enhance their capacity to provide

quality care services.

5. EMPHASIS AREAS

Major emphasis is on commodity procurement (drugs for opportunistic infections, nutritional supplements

and pain relief) with minor emphasis in the areas of human resources, training and infrastructure.

Activity Narrative:

New/Continuing Activity: Continuing Activity

Continuing Activity: 14904

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14904 6922.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,050,000

Defense Research Institute

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Malaria (PMI)

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $3,750

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $7,500

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $7,500

Economic Strengthening

Education

Water

Table 3.3.10:

Funding for Treatment: Pediatric Treatment (PDTX): $700,000

ACTIVITY UNCHANGED FROM COP 2008:

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross-cutting attributions in human capacity development through in service

training of health care workers including clinical officers, nurses and doctors in the provision of pediatric

ART services as well as early infant diagnosis, and basic health care. 2.5% of the budgetary allocation will

be attributed to this activity. This activity will also support pediatric nutritional assessment and counseling

before and during ART. 5% of the budgetary allocation will be attributed to this activity. Procurement of

pediatric weighing scales, stadiometers, MUAC tapes and other equipment required to carry out effective

nutritional assessment will be supported. Micronutrient supplementation according to WHO guidance will be

provided. 5% of the budgetary allocation will be attributed to this activity.

1. ACTIVITY DESCRIPTION

The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed Project in collaboration with

the Ministry of Health and Faith-based (including a local community based organization) health care

programs within 7 districts in South Rift Valley Province (Transmara, Bomet, Bureti, Kericho, Kipkelion,

Nandi South, & Nandi North) and one district (Kisumu West) in Nyanza Province. The South Rift Valley

Program serves a population of approximately 2.7 million people, with a HIV prevalence ranging from 5% to

as high as 19% in some congregate settings. In 2006, about 100,000 adults were estimated to be living with

HIV, and about 15,000 being children under 15 years. Only about 2,300 (15.1%) of the HIV positive children

had access to HIV services. The SRV program will seek to address this gap in HIV services in this

vulnerable population, by facilitating their access to the life saving antiretroviral treatment (ART). This will be

a continuum of the pediatric basic care and support package, whereby in addition to clinical monitoring,

prevention and treatment of OIs & other HIV related ailments, malaria, pneumonia, diarrhea, and pain

symptom management, the children will be put on ART. The program will also continue providing other

components of the minimum package of pediatric basic health care and support including provision of

cotrimoxazole prophylaxis, nutritional assessment and support including supplementation & treatment for

nutrient deficiencies, deworming, and psychosocial counseling & support. Adherence counseling and

support will be offered, which in Kericho District Hospital will leverage on the activities of the ‘Muangalizi'

project. The ‘Muangalizi' project seeks to improve adherence to clinic appointments and ART for those HIV

infected children enrolled for ART, through support to the caretaker. In order to increase the number of

HIV positive children accessing treatment, the program will strengthen the linkages between PMTCT

Programs and pediatric care & treatment, pediatric ART training and sensitization for early infant diagnosis,

routine testing of children, and laboratory capacity building and system strengthening for Early Infant

Diagnosis (EID). HIV diagnosis in babies will be done at six weeks after birth by collecting Dry Blood

Samples (DBS). A new focus will be on routine testing of sick children in pediatric medical settings which is

expected to rapidly identify large numbers of HIV positive children and provide possibility of direct links to

treatment. As of March 31st, 2008, the South Rift Valley program had enrolled a total of 2,327 children into

its HIV care & treatment program, out of whom 1,552 were on basic health care and support, and 775 were

on ARVs. In FY 09 the program targets to provide ART services to 600 children newly initiating ART, to

make a total of 2,160 children ever started and 1,800 receiving ART at the end of the reporting period. To

be able to do this and to and ensure sustainability the program will work hand in hand with the Ministry of

Health and NASCOP. A total of 68 health facilities will be supported to offer quality pediatric ART services.

Of these facilities, 12 are partner main hospitals (8 district hospitals, 2 plantation, & 2 mission hospitals). In

order to avoid congesting the already overcrowded district level facilities and enhance accessibility of ART

services by the rural underserved population, decentralization of ART services and follow up of stable

patients at lower level facilities (health centers) will be supported in accordance with the network model,

which has been successfully used in adult ART. The health facility support will include minor renovations to

create children friendly ART centers, procurement of necessary equipment, and supplies. The human

resource requirements will be reviewed as necessary. To support the scale up, 150 health workers will be

trained on pediatric ART, including EID, nutrition, and psychosocial & adherence counseling and support.

Regular support supervision and technical assistance, and timely, efficient and accurate data collection,

analysis and dissemination will also be consolidated.

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA

This activity will contribute substantively to Kenya's FY 09 goal of providing ART to 43,092 children, by

providing services to 2,160 individuals (5% of the overall FY 2009 Emergency Plan national target). The

collaboration with MOH, other GOK offices and major stakeholders will ensure these services are

sustainable.

3. LINKS TO OTHER ACTIVITIES

This activity is linked directly to the other SRV HIV/AIDS program initiatives in 8 districts in the SRV and

Nyanza provinces of Kenya. It is directly related to South Rift pediatric basic care and support services in

the provision of ART to all HIV infected children who qualify for ART. It is also linked to the SRV PMTCT

program, where HIV infected children will be identified, and those diagnosed as HIV infected linked to care

& treatment. In addition, it is linked to the orphans and vulnerable children (OVC) program to ensure those

HIV infected children in basic care that require ART services are adequately linked. The ART program also

links with the ‘Mwangalizi' pediatric ART adherence support project in Kericho District Hospital.

4. POPULATION BEING TARGETED

The SRV pediatric ART program serves the predominantly rural population in the 8 districts. The program

will target primarily those children affected by HIV/AIDS since the main objective is to provide ART services.

Health care providers (both in public and private institutions) will also be targeted by increased pediatric

ART training to enhance their capacity to provide quality ART services.

5. EMPHASIS AREAS

Major emphasis is on commodity procurement (ART, drugs for opportunistic infections, nutritional

supplements and pain relief) with minor emphasis in the areas of human resources, training and

infrastructure.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14908

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14908 6973.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $7,170,714

Defense Research Institute

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Malaria (PMI)

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $17,500

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $35,000

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $35,000

Economic Strengthening

Education

Water

Program Budget Code: 12 - HVTB Care: TB/HIV

Total Planned Funding for Program Budget Code: $19,230,846

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Key Result 1: Reduce the tuberculosis (TB) burden by providing TB screening for 50% of HIV-positive persons at enrollment into

care.

Key Result 2: Reduce the HIV burden by providing HIV testing to over 90% of TB patients, their partners and families.

Key Result 3: Improve referral and tracking mechanisms between HIV and TB service delivery points.

Key Result 4: Strengthen Multiple Drug Resistant TB (MDR-TB) surveillance through expanded program and laboratory capacity

for TB case-finding, diagnostics, and drug susceptibility testing (DST).

Key Result 5: Optimize coordination of USG and other sources of TB and HIV funding.

CURRENT PROGRAM CONTEXT

In Kenya, TB is the leading cause of death of people living with HIV (PLHIV), and HIV is the greatest driver behind the nearly

three-fold rise in Kenya's TB burden over the last ten years. TB/HIV is a priority program area for the Division of Leprosy,

Tuberculosis and Lung Disease (DLTLD), the National AIDS and STI Control Program (NASCOP), the Emergency Plan (EP),

WHO, and other partners. In the Five-Year Strategy, the EP emphasized identifying persons in need of ART through wide-scale

diagnostic HIV testing and counseling of TB patients. The EP has supported development of new HIV testing guidelines and a

training curriculum to equip providers with essential skills, as well as supporting Kenya's overall TB/HIV national strategy. As part

of their national mandates, DLTLD and NASCOP guide TB and HIV policies and coordinate implementation of collaborative

activities through national, regional, and district coordinating bodies.

Free TB and HIV services are delivered to patients in Kenyan public and mission hospitals. Since 2004, TB/HIV activities have

advanced on the national agenda and are well articulated in the National TB Strategic Plan. National, provincial and district

TB/HIV coordinating bodies have been formed and guidelines on HIV testing for TB patients have been widely distributed and

implemented. USG technical support contributed to the distribution and widespread use of the TB/HIV training curriculum and an

integrated TB/HIV monitoring tool. From 2005-2008, facilities offering TB treatment increased from 1,600 to 1,909, and those

offeringTB diagnosis from 619 to 930. More than 80% of TB patients receive HIV testing, and 80-90% of co-infected patients

receive cotrimoxazole (CTX) therapy. Approximately 80% of co-infected TB patients are eligible for ART; at least 30% receive

ART before completion of TB treatment.

The EP has recently supported TB/HIV media campaigns to empower health workers to deliver quality TB and HIV services,

encouraged increased and intensified case-finding in HIV care settings, and have expanded secondary prevention activities

(Prevention with Positives [PwP]) to reduce the national TB and HIV burdens. EP funds have further supported the development

of TB infection control (IC) policy guidelines and training of MOH personnel.

STATISTICS

Kenya's national TB burden remains high. TB case notification rose six-fold from 53/100,000 persons in 1990 to 338/100,000 in

2007. The number of TB patients is projected to increase to 120,000 in 2009 and to 130,000 in 2010. Kenya has 1,909 TB

treatment sites; 930 (49%) provide TB diagnostic services. Directly observed therapy (DOTS) coverage is universal, with

treatment observed by either a provider or a treatment partner. In 2007, Kenya achieved a TB case detection rate of 70% and

treatment success rate of 85%. The national HIV prevalence among TB patients in 2007 was 48%, but exceeded 80% in some

settings. The percentage of MDR-TB patients is estimated at <1%, however drug susceptibility testing was only performed in 40%

of the 9% re-treatment cases in 2007.

SERVICES

USG has a TB/HIV coordinator at each implementing agency and supports TB/HIV activities through funding and technical

support. USG technical staff participate in policy work groups and provide technical assistance to the host government and

implementing partners. In 2009, EP funds will support the placement of a TB/HIV staff member at NASCOP to improve TB/HIV

coordination. HIV testing for TB patients is the standard of care and efforts will be made to ensure that consistent and quality

counseling and testing messages continue to be improved. Approximately 80% of co-infected TB patients are eligible for ART by

WHO staging criteria, and 30-50% receive ART before completion of TB treatment depending on the facility. In the next phase,

Kenya plans to achieve the following goals: over 90% of TB patients will be tested for HIV and 100% and 50% of all eligible TB

patients will be placed on CTX and ART, respectively.

In 2008-09, provision of ART in TB clinics will be piloted in collaboration with NASCOP and DLTLD. DLTLD, in collaboration with

NASCOP, will incorporate and expand PwP activities as part of strengthening contact tracing practices in TB control, and

contributing to the overall national strategy to achieve HIV control. Initiating at pilot sites and expanding toward national coverage,

PwP will be implemented in TB clinics targeting the large number of HIV-POSITIVE TB patients served. EP funds will support

expanded use of Community Health Workers (CHW) to identify and refer suspected TB patients, assist with family TB/HIV

screening, and provide adherence support and patient education.

Kenya will continue to prioritize intensified TB case-finding and TB infection control at all HIV entry points. TB screening in HIV

care and treatment settings is occurring in most settings. In 2009, concerted efforts will be made to standardize such screening

through the distribution and implementation of national guidelines for TB screening and referrals in HIV care settings. The TB and

HIV programs will also develop IC implementation procedures for health care facilities, targeting two provinces for a phased

rollout. Besides assisting to formulate IC policy, the EP will support assessment of TB IC prevention and control procedures in

selected facilities to establish gaps and needs and develop IC work and evaluation plans to protect patients and health workers at

specific sites, including prisons. Currently, four organizations (EDARP, AMPATH, AMREF, and MSF) implement isoniazid

preventive therapy (IPT) under close monitoring by DLTLD. Further expansion is anticipated in 2009 on a case-by-case basis,

depending on facility capacity to diagnose TB, sustain patient adherence, and document treatment outcomes.

In addition, the EP will continue to assist Kenya's response to the threat of MDR-TB by improving national laboratory surveillance

capacity, promoting best TB care practices, and treating drug-resistant patients. Presently, the EP is strengthening the national

Central Reference TB Laboratory (CRL) culture and drug sensitivity testing (DST) capacity through improvements in physical

infrastructure, culture diagnostics, and development of a laboratory information system. Through EP support, Kenya plans to

optimize DST for TB re-treatment cases according to national guidelines and expand national coverage of external quality

assessments (EQA) for sputum microscopy services from the present 20% to 50% by 2010. The EP will support ongoing

decentralization and strengthening of DST capacity in regional laboratories, including those supported by KEMRI, DOD, and

AMPATH. These efforts, complemented by those of other partners, will provide better insight into the MDR-TB burden and

contribute to planning for sustained control. In 2009, DLTLD plans to pilot MDR-TB treatment on an ambulatory basis as part of

implementing the national strategy.

The EP continues its contribution to expanding fluorescence microscopy (FM), which did not exist in Kenya in 2003. EP funds

have since procured and placed seven microscopes in five regions, and, in 2009, they will procure an additional five microscopes

for other high-volume regional sites.

The USG and DLTLD consider TB/HIV work in the prisons as an essential component of the national agenda. Through a yet to be

determined new partner, the EP will support improvement and expansion of quality TB/HIV care and treatment services from 12

high-volume prisons and expansion of such services to an additional 5 in collaboration with Kenya Prisons Services, DLTLD, and

NASCOP.

Kenya recently launched international standards for TB care, which seeks to facilitate engagement of all providers in accepted

levels of care in public and private practice. In 2007, the private sector registered 1,804 TB cases, and the EP is building on this

reporting to promote best practices pivotal to prevention of HIV and MDR-TB.

Approximately 10% of registered TB patients in Kenya are children. In 2008, NASCOP, DLTLD, WHO, USG, and other

stakeholders consulted on how to improve pediatric TB/HIV management. Pediatric TB screening and surveillance evaluation is

planned soon. Information from these activities will strengthen both pre-service and in-service trainings to improve pediatric case

identification. In 2009, through intensified case finding of adults, more children will be screened and tested for both TB and HIV.

Co-infected children will receive both TB and HIV treatment; HIV-positive children without active TB will receive CTX, IPT, and

ART if eligible.

In 2009, the EP will support procurement of TB and HIV laboratory commodities, including rapid test kits, through SCMS and

drugs (ART and CTX) through in-country mechanisms.

REFERRALS, LINKAGES, MONITORING AND EVALUATION

Kenya TB registers include TB/HIV variables. Moreover, a program evaluation is underway to monitor referrals to HIV services

and establish proportions of co-infected patients enrolled in HIV care and receiving CTX and ART, with the overall goal of

establishing a joint TB/HIV co-management review to reconcile referrals through standardized reporting systems, including

adequate feedback mechanisms.

Currently, only 26% of TB treatment points offer ART. HIV care and ART registers need to develop TB variables to capture TB

screening, diagnosis, referral, and treatment among their patients. Decentralizing ART services will improve access for eligible TB

patients served in lower levels of care. Facilities and community groups will be encouraged to collaborate and provide a two-way

referral or communication system to coordinate outreach activities to identify and support TB/HIV patients.

In 2008, EP support piloted electronic data collection tools to improve accuracy and efficiency in recording and reporting of

TB/HIV patients, as well as to allow for facility-based program evaluation. In 2009, the EP will support expanding this pilot to assist

Kenya in establishing a national electronic TB/HIV reporting system. In addition to required EP indicators, TB/HIV implementers

will be encouraged to document some or all of the following custom indicators as part of strengthening TB and HIV programs: (1)

number and percent of HIV-positive patients in HIV care screened for TB; (2) number and percent of TB suspects/patients tested

for HIV; (3) number and percent of HIV-positive registered TB patients/suspects; (4) number and percent of HIV-positive TB

patients receiving CTX; and (5) number and percent of HIV-positive TB patients receiving ART.

POLICY

Kenya's National HIV/AIDS Strategic Plan (KNASP) includes expanded programming for TB/HIV activities coordinated by a

national committee established by the Ministry of Health (MOH), in which USG technical staff participates. In response to the 2005

Maputo Declaration calling for extraordinary measures by African governments to contain HIV and TB, the MOH has submitted a

Cabinet Paper seeking legislation to declare TB a national emergency. If enacted, this legislation will promote increased

mobilization of TB control resources. Policy considerations include how HIV and TB programs can best support cross-cutting

laboratory services at regional and district levels, and how EP funds can best support human resource needs. Kenya plans to

establish policies for TB-screening and diagnosis for all patients receiving HIV services in ART, PMTCT, and VCT clinics, as well

as in hospital wards. USG agencies also participate in working policy committees for PwP, TB infection control in HIV care

settings, IPT, laboratory services, MDR-TB control, TB/HIV monitoring systems, human resource plans, and TB care standards in

all settings, including pediatric services.

SUSTAINABILITY

Greater sustainability will, in part, be achieved through encouraging implementing partners to be part of the national, regional, and

district TB/HIV work plans that support local government infrastructure, human capacity development, commodity distribution, and

national health management information systems.

WORK OF HOST GOVERNMENT AND OTHER IMPLEMENTING PARTNERS

USG agencies work in a complementary manner with the DLTLD, NASCOP, WHO, the National Public Health Laboratory

Services (NPHLS), and all implementing partners through the National TB Interagency Coordinating Committee and the National

TB/HIV Coordinating Committee. Kenya has recently received Round 6 TB Global Fund support, which will be used to upgrade 50

TB diagnostic facilities annually, conduct training for TB/HIV trainers, and train 80 health workers in 5 districts each year. Kenya

applied for Round 8 Global Fund TB funding (2009 to 2013) to support collaborative TB/HIV activities and a national TB

prevalence survey; however, the Global Fund Board recently announced that Kenya's Round 8 applications for HIV, TB, and

Malaria all had not been approved. In 2006-07, through a centrally-funded OGAC/WHO collaboration, Kenya received additional

funding for expanded TB/HIV activities in 30 districts; support for these activities will be mainstreamed into 2009 EP and other non

-EP funding. To maximize USG resources, both PEPFAR and USAID TB support are factored in an updated 2009 Joint Country

TB/HIV program work plan. In 2009, the TB Control Assistance Program will provide support for TB/HIV collaborative activities,

and DOTS expansion.

OUTSTANDING CHALLENGES/GAPS

A principal challenge facing Kenya is to maintain the high coverage (>80%) of HIV testing among TB patients. This will be

managed in part through sustained advocacy; enhanced coordination of partnerships and funding; sustained staff hiring, training

and retention; improved field supervisions; and enhanced commodity security. Another challenge is the provision of optimal

TB/HIV services for the pediatric population. One strategy to address this issue has been described above. Recurrent challenges

include insufficient human resources, weak laboratory infrastructure, and slow disbursement of Global Fund support.

Table 3.3.12:

Funding for Care: TB/HIV (HVTB): $1,300,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ prime partner was changed from Kenya Medical Research Institute to Henry Jackson Foundation (HJF)

which was competitively selected to implement the activity .

+ TB Community services and outreach will be enhanced to complement the facility based TB prevention,

diagnostic, and treatment activities.

+ number of service outlets providing clinical prophylaxis &/or treatment for TB to HIV infected individuals

changes to 40

+ number of HIV infected individuals attending HIV care or treatment services that are receiving treatment

for TB disease changes to 1,500

+ number of individuals trained to provide clinical treatment for TB to HIV infected individuals changes to 50

+ number of registered TB patients who received counseling and testing for HIV and received their results at

a USG-supported TB service outlets

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross-cutting attributions in human capacity development through its on-site CME

training for health care workers to provide TB/HIV services. This will also include enhancing the capacity of

the government's DTLCs to improve supervision, coordination and general management of TB/HIV services

in the districts. 2.5% of the budgetary allocation will be attributed to this activity.

It also supports Food & Nutrition tools and service delivery through meeting critical staff gaps and equipping

health facilities to be able to offer quality nutrition services to TB patients. 2.5% of the budgetary allocation

will be attributed to this activity. The activity additionally supports nutrition commodities by leveraging on the

INSTA Food by Prescription Support program, for TB/HIV co-infected patients with moderate to severe

malnutrition. 2.5% of the budgetary allocation will be attributed to this activity.

1. LIST OF RELATED ACTIVITIES

This activity relates to HIV/AIDS Treatment/ARV services, Basic Health Care and Support, Community Care

Services, Counseling and Testing, Prevention, OVC and PMTCT .

2. ACTIVITY DESCRIPTION

The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed HIV project in collaboration

with the Ministry of Health and Faith-based health care programs within 8 districts in the South Rift Valley

(SRV) and Nyanza Provinces of Kenya. The program serves a population of approximately 2.7 million

people, with a HIV prevalence ranging from 5% to as high as 19%, and a TB prevalence of about 300 per

100,000 population. On average about 30-50% of TB patients are co-infected with HIV.

In FY09 the SRV Program will continue to strengthen and scale up the ongoing FY08 TB/HIV activities in

the 8 districts, in the following key areas: 1) Reduce burden of HIV among TB patients/suspects and their

partners and families through expanded HIV testing, delivery of Cotrimoxazole (CTX), ARVs and positive

HIV prevention in TB settings; 2) Reduce burden of TB among PLWHA through intensified TB screening

and TB infection control in HIV Care settings; 3) Strengthen collaboration of TB and HIV services including

joint planning, coordination and support supervision, monitoring and evaluation, and patient referral and

tracking systems; 4) Contribute to the overall national program agenda to strengthen local and international

partnerships in delivery of TB/HIV services, and strengthen capacity for quality diagnostic and treatment TB

services for PLWHA and containment of emerging threat of MDR-TB. Through this concerted effort, in

FY09, the SRV program will strive to achieve 95% HIV testing for TB patients, 100% provision of CTX to co-

infected patients, and 50% provision of ART to those eligible. To achieve this, in FY09, the program will

train an additional 50 health workers to provide TB/HIV services in 40 health facilities in the region; provide

HIV testing to 3,000 TB patients; and offer TB and HIV services to 1,500 TB/HIV co-infected patients.

Additionally, 16,500 patients accessing HIV services in the region will be screened for TB, and those found

positive provided with TB treatment.

In FY09, Integrated TB/HIV Clinic will be strengthened in all the 8 district hospitals in the region. The model

is unique in that TB/HIV co-infected patients are managed by one care provider. In this model, all TB

patients are offered HIV testing, recognition and management of STIs and HIV prevention messages. Those

with TB/HIV co-infection receive CTX and comprehensive HIV care, support and treatment.

The program will continue to support lower level facilities to provide or link patients to TB/HIV services. The

district hospital will continue to be strengthened as the referral unit for TB/HIV patients requiring specialized

diagnostic, treatment or in-patient services from the lower level facilities.

Working in collaboration with the Division of Leprosy Tuberculosis and Lung Diseases (DLTLD) to ensure

sustainability, the program will continue to support improvement of the capacities of the laboratories in

smear microscopy, and Kericho district hospital lab will continue to offer quality assurance in smear

microscopy (augmented by fluorescent microscopy) in the region. Additionally the program will continue to

strengthen optimized referral of specimen for TB culture and sensitivity to the upcoming TB culture lab;

efficient and timely supply of TB drugs to all the TB treatment sites; regular support supervision and

technical assistance to all the health facilities offering TB and HIV services; use of standardized national

registers and reporting tools; and timely, efficient and accurate data collection, analysis and dissemination.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

SRV will contribute towards the provision of integrated TB/HIV care by reducing TB morbidity and mortality

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

activities will further contribute to the overall national program agenda to strengthen local and international

partnerships in delivery of TB/HIV services and containment of emerging threat of MDR-TB.

4. LINKS TO OTHER ACTIVITIES

This activity is linked to SRV ARV services throughout the 8 districts; SRV Counseling and Testing, with a

primary focus on provider initiated testing and counseling; Tenwek Mission Hospital's CT activity and the

Activity Narrative: SRV PMTCT program, as part of comprehensive care services offered to HIV infected pregnant women. It

also links to the new program areas of Community Care services by providing a continuum of TB services

from the health facility to the community; as well as the Pediatric Care and Treatment programs by

providing TB prevention, diagnostic & treatment services to children in care or ART.

5. POPULATION BEING TARGETED

The SRV program supports the predominantly rural population in 8 districts in Rift Valley and Nyanza

provinces. This activity will target the general population of both adults and children, but primarily those

infected with TB or HIV, including discordant couples. Trainings under this activity will focus on health care

workers both in the public and private sectors. All TB/HIV activities will be implemented in accordance and

in collaboration with host government programs, namely the National AIDS/STI Control Program (NASCOP)

and the Division of Leprosy Tuberculosis and Lung Diseases DLTLD)

6. KEY LEGISLATIVE ISSUES ADDRESSED

The SRV TB/HIV activity will address increasing gender equity in HIV/AIDS programs, by ensuring that

equitable number of women and children are receiving treatment. The activities will address stigma

associated with TB/HIV status through information, education and communication materials targeted at

health care providers, caregivers, patients and communities.

7. EMPHASIS AREAS

This activity includes emphasis on minor construction/renovation of health facilities to ensure adequate

space to offer TB/HIV services; human capacity development including TB/HIV training and empowering the

health workers to provide TB/HIV services by supporting necessary commodities; data collection, analysis

and dissemination, which will further support program monitoring and evaluation; collaboration with the

NLTP program who support commodities for TB diagnosis and treatment; and increasing gender equity in

HIV/AIDS programs, by ensuring that equitable number of women and children are receiving treatment, and

targeting increased access of services by men.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14905

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14905 6975.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,200,000

Defense Research Institute

Table 3.3.12:

Funding for Care: Orphans and Vulnerable Children (HKID): $300,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ Prime Partner Henry Jackson Foundation International (HJFMRI) South Rift Valley has been competitively

selected to implement this activity in the place of KEMRI.

+The Muangalizi component of the program will be enhanced to include post disclosure support to

normalize the experience of HIV in the family, with a focus on households looking after HIV positive children

under the Muangalizi model.

+ The activity will also support the evaluation of the Muangalizi pilot in collaboration with the other 4 USG

supported and participating sites to facilitate lessons learnt and identification and documentation of the

effectiveness of different approaches to facilitate scale up.

COP 2008

1. LIST OF RELATED ACTIVITIES

This activity relates to activities in Counseling and Testing (#6968), Antiretroviral Therapy program (#6973),

Abstinence and/or being faithful (#6981), Counseling and Testing (#6979) and Orphans and Vulnerable

Children (#7035).

2. ACTIVITY DESCRIPTION

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. The HJFMRI-

South Rift Valley program will also leverage additional funding available through the Muangalizi project to

reach an additional 500 OVC with comprehensive care packages through existing faith based organizations

such as Tenwek Mission Community Health and AIC Litein's community health program. Kericho District

Hospital has been providing HIV treatment and care since 2004. The number of pediatrics receiving the

services as at the end of March 2008 was 723. A total of 285 are on ARVs whereas 438 are on care. The

Mwangalizi concept was founded on the premise that HIV positive children experience better health

outcomes when there is a continuum of care between the health facility and the home in the form of

consistent follow up and clinic accompaniment by a caregiver or Mwangalizi. The psycho-social needs of

the older OVC will also be an area of expansion in FY 2009 by establishing support groups and Kids clubs

that are developed by OVC/youth that will be trained in peer counseling and support as well as HIV

prevention and issues of sexual reproductive health.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

HJFMRI-SRV OVC Program will ensure that OVC continue to receive care and support from their original

community. This approach is supported by the Kenya Emergency Plan in which the needs of the OVC in

terms of consistent care are identified at the community level and subsequently cared for. Mwangalizi will

continue working with the children by strengthening the linkage between clinical and household settings for

better quality and continuum of care. This intervention is not an expansion of the OVC programming and will

serve all HIV positive children who are currently or will one day be on ART.

4. LINKS TO OTHER ACTIVITIES

This activity is linked with HJFMRI South Rift Valley Antiretroviral Therapy (ARV) program (#6973), as the

Mwangalizi are encouraged to be members of the clinics' ART program or are other HIV positive individuals

who are living positively. It is also linked with HJFMRI-South Rift Valley Counseling and Testing (CT)

program (#6968). In addition, HJFMRI's program South Rift Valley will provide counseling and testing to

willing caregivers and households of the OVC and all HIV positive children in hopes of having more people

knowing their status. HJFMRI-South Rift Valley will also work with South Rift Valley Abstinence and Being

Faithful and Live with Hope Center (LWHC) Abstinence and Be Faithful Programs (#6981) to ensure that

the OVC receive correct HIV prevention information that will reduce their vulnerability for HIV infection.

5. POPULATIONS BEING TARGETED

HJFMRI South Rift Valley will target people affected by HIV/AIDS by focusing their training activities on

caregivers to support the OVC and providing psychosocial support to HIV positive children and HIV/AIDS-

affected families which includes widows/widowers and other caregivers. Community leaders and teachers

will also be targeted as HJFMRI South Rift Valley will work closely with them in an effort to fight stigma and

discrimination towards children infected with HIV, which often leads to neglect and or lack of appropriate

care which leads to non adherence to ART and clinic appointments among the children.

6. KEY LEGISLATIVE ISSUES ADDRESSED

In accordance with the Emergency Plan FY 2009 approach to OVC care and support, HJFMRI-South Rift

Valley OVC Mwangalizi model will be an integral part of a community wrap around service that will address

the needs of the whole child. Every child enrolled at the Kericho District Hospital ART clinic under the

auspices of HJFMRI-South Rift Valley will be ensured a consistent follow up as well as psychosocial

support.

Activity Narrative: 7. EMPHASIS AREAS

HJFMRI-South Rift Valley OVC Program will focus their attention on increasing the involvement of

community members in addressing factors that hinder the HIV positive children from receiving optimal

clinical care. Another emphasis of HJFMRI-South Rift Valley's efforts will be establishing and strengthening

the capacity of caregivers to facilitate disclosure in a sensitive and culturally appropriate manner.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14906

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14906 12478.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $300,000

Defense Research Institute

12478 12478.07 Department of Kenya Medical 4249 3476.07 South Rift Valley $150,000

Defense Research Institute

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $32,980,007

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Key Result 1: Through Emergency Plan (EP) support, at least 5 million Kenyans will be counseled and tested for HIV in 2009,

using the different approaches.

Key Result 2: Scale up provider initiated HIV testing and counseling in health facilities (PITC), testing 1.5 million patients and

family members to make HIV testing part of routine care in health facilities.

Key Result 3: Implement HIV testing campaigns at national and sub-national levels, with USG supporting 1 million of 3 million to

be tested, in order to expand knowledge of HIV status and promote stigma reduction, including 500,000 in PITC.

Key Result 4: Increase emphasis on couple and family testing in all HIV testing and counseling services, including PMTCT and

ART clinics so that at least 500,000 couples are tested together in either community or health facility settings.

Key Result 5: Use recent national survey findings to guide expansion of Home-based HIV Testing and Counseling (HBTC) to high

HIV burden regions, testing at least 1 million people to increase access to HIV prevention, care and treatment.

CURRENT PROGRAM CONTEXT

The Government of Kenya (GoK) is committed to the achievement of Universal Access to HIV Testing and Counselling (HTC) and

has set a target that 80% of adult Kenyans and all exposed children will have been tested for HIV by 2010. Kenya's national

testing target will enhance access to prevention as well as care and treatment services. HTC services will therefore be expanded

vertically and horizontally, through multiple delivery modes, and in all strata of society, across age and gender.

In order to increase the pace of expansion of HTC services in the country, all EP-funded programs will be encouraged to

incorporate HTC into their activities. Other prevention, care, and treatment programs have the potential to leverage resources to

integrate HTC services by strengthening referral systems and enhancing collaboration across programs.

STATISTICS

Data from the 2007 Kenya AIDS Indicator Survey (KAIS) show that there has been a significant increase in knowledge of HIV

status in Kenya. At least 36% of Kenyans have ever been tested, up from 14% in 2003 (KDHS, 2003). The proportion of those

who have ever been tested has more than doubled in the four years since the onset of PEPFAR. The same data show that this

increase is greater among women than men, largely due to expansion of PMTCT services. Predictably, the increase is also

greater in urban versus rural areas. Despite the impressive increase in coverage, the majority of adult Kenyans have never been

tested for HIV. Among HIV-positive persons in Kenya, nearly 80% are unaware of their correct status and have thus not benefited

from the rapidly expanding EP-supported prevention, care and treatment services. Moreover, there is a high rate of couple

discordance in Kenya, with 45% of married HIV-positive persons having an HIV-negative spouse or co-habitating partner.

Nyanza Province still has the highest HIV prevalence (15.3%) in Kenya, followed by Nairobi (9%). North Eastern Province has the

lowest prevalence (1%). In 2009, EP HTC resources will be more deliberately focused on regions with the highest prevalence. In

these regions, population-level activities, such as HBCT, will be expanded to improve access to HTC services and also as a key

strategy to encourage couple HTC. Particular emphasis will also be placed on the early identification of HIV-positive individuals

through expansion of PITC in health facilities. In the other regions, more targeted approaches, such as mobile and workplace

HTC, will be employed.

In 2009, it is anticipated that EP funds will be used to provide HTC services for five million people. We anticipate that EP funding

will directly support well over half of Kenya's national HTC services in 2009 in both health facility and community settings. Health

facility settings include PMTCT and tuberculosis (TB) settings, whereas community settings include mobile and outreach HCT as

well as home based HTC. In 2009, EP will also support indirect activities, such as procurement of test kits and media campaigns.

Overall, EP support will facilitate the achievement of 80% of Kenya's national target, either directly or indirectly, by 2010.

SERVICES

In health facilities, HTC services are primarily provided through in-patient services and selected out-patient sites. KAIS showed

that the majority (72%) of those who had ever been tested received HTC services in a government or private health facility. The

goal of HTC in health facilities is the integration of HTC into the general health system, so that HTC becomes part of the basic

health care package. HTC services in health facilities are chiefly provided by health care workers. In order to improve the attitude

of health care workers toward HIV, greater sensitization and training activities will be implemented. This includes expanding

access to HTC and Post-Exposure Prophylaxis (PEP) for health workers. Health worker professional associations, welfare groups,

and training institutions will also be engaged. Rapidly expanding Voluntary Medical Male Circumcision (VMMC) interventions will

consistently include PITC as part of their comprehensive prevention activities.

In the community, HTC is provided either at home, in a mobile HTC site, at the workplace, or at free-standing HTC sites. HTC can

be provided in any community facility that adheres to national standards. Experience from pilots in Kenya and elsewhere have

shown that HBCT is less expensive than stand-alone fixed services and effectively reaches couples and those in lower economic

strata. For these reasons, HBTC will be expanded in areas of high prevalence and low knowledge of HIV status in 2009.

According to KAIS, 85% of Kenyans nationally are willing to be counseled and tested for HIV in their homes and, HBTC programs

in Kenya have shown very high rates of acceptance. This unique community approach has ensured that couples and families are

tested together which enhances family and community support for HIV prevention, care, and treatment.

Couple HTC will remain an important area of focus in 2009. Training and mentorship for couple HTC will be expanded in all health

facility or community service points. Specific partners will be funded to facilitate training and mentorship for couple HTC and

development of information booklets and other IEC materials to support couples. In addition, a national media campaign targeting

couples will be launched and executed in 2009. A national indicator for couple HTC will be adopted and monitored by all HTC and

PMTCT partners, to further emphasize - and measure - its status as a national priority.

KAIS data also demonstrates that among youth aged 15 to 24, HIV prevalence is four times higher among women than same-

aged men. To help address this, EP support for youth-friendly HTC centers and services will be strengthened and expanded in

2009. Prevention partners will also leverage public-private partnership resources, in collaboration with the Partnership for an HIV-

Free Generation, to promote youth HTC. Ongoing linkages and expanded leveraging of HTC services within Orphan and

Vulnerable Children (OVC) activities will also ensure children access HIV testing and are linked appropriately into care and

treatment.

In 2008, the national HTC training curriculum was standardized and harmonized into a single modular training package. In 2009,

this will be rolled out nationally, necessitating updating of national trainers and printing of the new training materials.

In 2009, APHIA II Health Communication and Marketing (HCM) will continue to promote HTC interventions through their national

media campaigns. Community-based mobilization and local promotion through radio will remain important interventions to ensure

community awareness of HTC activities.

REFERRALS AND LINKAGES

Kenya's new National HTC Guidelines are aimed at improving referral and linkage from HTC services to comprehensive HIV

prevention, care, and treatment, as well as other health services. The Guidelines promote a shift from anonymous to confidential

HTC and prioritize integration of HTC into other health services, as well as incorporation of other services into HTC. To make

operational these broad national strategies, the EP will support HTC in all health facilities, including TB, STI, and in-patient

services. All EP-funded care and treatment partners will be encouraged to implement HTC within their geographical areas, both

within health facilities and at the community level. All prevention partners will similarly be encouraged to include HTC in their

activities.

Working closely with the Ministries of Public Health & Sanitation (MPHS) and Medical Services (MMS), and other stakeholders,

the EP will further strengthen key referral systems through review of referral tools, printing and distribution of such tools, and

conducting regular assessments of the system.

POLICY

New national HTC guidelines were released in 2008 and further dissemination will occur in 2009. The National AIDS and STI

Control Program (NASCOP), in conjunction with international organizations and the USG, developed the guidelines to harmonize

approaches in line with international policy recommendations. In 2009, new training curricula and other operational tools will be

produced to improve quality of services.

EP funds will contribute to the procurement of test kits to complement planned procurements through Global Fund (GFATM) and

the Japanese International Cooperation Agency (JICA). As a substantial contribution to national scale-up, the EP will secure

sufficient test kits for at least five million individuals to be tested and counselled in 2009.

SUSTAINABILITY

Capacity building and systems strengthening of local indigenous partners in HTC remains an important part of EP-supported

activities. HTC activities in Kenya are developed in partnership with the GoK to ensure full integration into the larger health plan.

PITC activities and services are implemented through staff from local MPHS/MMS facilities to promote sustainability. In 2009,

PITC training will be incorporated in all medical training colleges so that all new health care professionals are trained in HTC.

MONITORING AND EVALUATION

The EP program in Kenya supports and works closely with MPHS/MMS at national and regional levels to strengthen data

management and reporting through provision of technical guidance and review and printing of data collections tools. EP will also

provide critical staff support to MPHS/MMS with short- and longer-term deployment of epidemiologists and behavioral scientists to

assist and strengthen program evaluation. The EP will also continue to support system development such as the electronic

medical records and e-health.

WORK OF HOST GOVERNMENT AND OTHER IMPLEMENTING PARTNERS

In 2009, the EP will continue to work closely with MPHS and MMS, as well as other key stakeholders. The EP will support national

capacity for coordination and supervision to strengthen field capacity in implementing programs. This support will focus on (1)

policy development and review, (2) monitoring and evaluation, and (3) commodity security. At the national level, the USG will work

with NASCOP and the Kenya Medical Supply Agency (KEMSA). In the field, the USG will work closely with Provincial and District

Health Management Teams to ensure HTC services are implemented according to national guidelines and standards.

ACHIEVEMENTS AND OUTSTANDING CHALLENGES/GAPS

To date, the greatest achievement of the Kenyan HTC program is the broad scope of HTC approaches, which expands the

opportunities and options through which people may learn their HIV status. Areas requiring more efforts include (1) expanding

couple HTC to deal with high rates of discordance; (2) reaching more children and youth with HTC; (3) urgently addressing the

discrepancy between men and women being tested and counseled, especially in rural areas; and (4) improving the quality of HTC

services provided.

Table 3.3.14:

Funding for Prevention: HIV Testing and Counseling (HVCT): $2,100,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ The HJFMRI-South Rift Valley CT Program will now include the targets and budgetary allocation for Live

With Hope Center and Tenwek Mission Hospital.

+ The number of individuals counseled and tested according to national and international guidelines is

210,000 individuals.

COP 2008

The only changes to the program since approval in the 2007 COP are:

+ geographic coverage has been expanded to include Kisumu West district in Nyanza Province and

Kipkelion district in Rift Valley Province

+ the target population has been expanded to include the general population in home based counseling and

testing

1. LIST OF RELATED ACTIVITIES

The Henry Jackson Foundation Medical Research International- South Rift Valley Counseling and testing

activities will relate to HIV/AIDS treatment/ARV services, TB/HIV, Abstinence/Being Faithful, Orphans and

Vulnerable children and Condoms and Other Prevention.

2. ACTIVITY DESCRIPTION

In FY 2009, Henry Jackson Foundation Medical Research International (HJFMRI) South Rift Valley will

continue to provide HIV counseling and testing (CT) services in partnership with the Ministry of Health

(MOH) in seven districts in the south Rift Valley Province and one district in Nyanza province. Together the

eight districts represent a collection of 70 MOH district hospitals, sub-district hospitals, and health facilities

as well Live With Hope Center, Tenwek Mission Hospital, AIC Litein Mission Hospital and Kericho Youth

Center that will be equipped and supported to serve as nationally registered CT sites in reaching

communities with Counseling and Testing services. In FY 2009, the eight districts will provide CT services

to over 210,000 people in the traditional voluntary counseling and testing (VCT) sites as well as through the

provider initiated testing and counseling (PITC), Mobile/Moon Light VCT and Household/Family Testing

strategies. Twenty (20) individuals will be trained in voluntary counseling and testing, while (fifty) 50

clinicians will be trained in Provider Initiated Tested Counseling; to enable them provide PITC in health

facilities. An additional twenty (20) will be trained in couple counseling & Testing and an additional 10 will be

trained in home based counseling and testing. In implementing this, HJFMRI-South Rift Valley will work

closely with the district AIDS/STI coordinators (DASCO) in order to strengthen coordination and referral,

especially between CT and care services. Technical assistance will be provided by 3 locally employed staff.

The combination of client-initiated (VCT) and provider-initiated CT services will significantly contribute to an

increased proportion of Kenyans learning their HIV status in the south Rift Valley Province, which has a

population of greater than 2.5 million and a HIV prevalence rate of approximately 7%. HJFMRI-South Rift

Valley CT Program will also continue to maintain the 1 youth friendly stand alone site in Kericho which

combines recreational services as well as CT services in this very dynamic approach to behavior change

and HIV prevention among the youth. The center was established in partnership with Kericho District

Hospital with support from PEPFAR in FY 2004, and has successfully assisted over 1000 youth between

the ages of 15-24 per month to learn their HIV status. The center also offers youth-friendly mobile VCT

services in collaboration with mobile reproductive health clinics in the larger district. HJFMRI will also

continue to work in developing mobile VCT activities in conjunction with MOH to reach populations of the

districts who have poor or no access CT services. This will be the primary method used in Transmara

District, because part of the population in the district has a nomadic lifestyle and also there are parts of the

district that are hard-to-reach. The prevalence rate in this district which borders Tanzania is estimated to be

around 8-9% but accessibility of HIV services is extremely limited. HJFMRI south Rift Valley Mobile VCT

activities will reach at least 90,000 individuals in FY 2009 in the eight districts served by HJFMRI. This

number will part of the annual CT target for HJFMRI south Rift, referred to above.

3. CONTRIBUTION TO OVERALL PROGRAM AREA

The South Rift Valley Province is one of the areas in Kenya that have large rural populations which account

for 70% of all HIV infections (KAIS 2007). These rural areas will be the main target of the CT initiative in FY

2009. Together with the MOH, HJFMRI-South Rift Valley will provide high quality CT services both to the

Tea farming community and to the general community through mobile/Moonlight CT services. Currently,

mobile CT services are conducted weekly and reach between 100 and 250 clients per week. In order to

meet the needs of rural Kenya, KEMRI-South Rift Valley CT Program will assist the MOH to scale up mobile

CT services in these areas. These coordinated CT activities will successfully provide VCT as well as PITC

to over 200,000 Kenyans in the south Rift Valley Province. This combined effort to extend quality CT

services to this geographical area will successfully contribute to 7% of 2009 Emergency Plan CT targets for

Kenya.

KEMRI-South Rift Valley will be instrumental in contributing to the national objectives of extending CT to

hospital patients and TB patients in both the inpatient and outpatient clinical settings. The youth recreational

center and VCT site in Kericho will continue to consistently target out of school and in-school youth, a

special population that has become a national focus in the provision of VCT services through scaling up

their services to reach rural youth in Kericho and Kipkelion districts.

4. LINKS TO OTHER ACTIVITIES

This activity is linked to HJFMRI-south Rift Valley ARV services by ensuring that every individual who has

tested positive for HIV in the CT service is linked to care and treatment. This activity is also linked to

HJFMRI-south Rift Valley TB/HIV to ensure that every person who tests positive for TB is given the

opportunity to test for HIV in the PITC setting. This activity is also linked to prevention activities by Live with

Hope AB, and KEMRI-South Rift Valley AB and KEMRI-south Rift Condoms and Other Prevention program.

5. POPULATIONS BEING TARGETED

KEMRI SRV CT activity will target the general population, including children and youth. Mobile VCT

services will target migratory populations in Transmara and other hard-to reach populations. HJFMRI is

working in partnership with the MOH offices in eight districts and therefore will be in a position to train public

health care workers in PITC in the clinical settings as well as private health care workers in AIC Litein

Activity Narrative: Mission, Tenwek Mission Hospital, Kericho Youth Center and Live With Hope Center. HJFMRI, in FY 2009,

will train and equip 50 public health care workers in PITC in order to support the national scale-up of CT in

clinical settings within Kenya. The youth center in Kericho will also target its CT services to out-of school

youth as well as other most at risk youth like street youth. AIC Litein shall also put efforts into reaching

people with disabilities particularly the deaf. In general, VCT activities provide CT services to the most at-

risk populations. CT activities are done collaboratively with National AIDS control Program staff at the local

level.

6. KEY LEGISLATIVE ISSUES ADDRESSED

HJFMRI-South Rift Valley, in partnership with the MOH and other partners, will improve gender equity in

accessibility of CT services within the eight districts in South Rift Valley. CT will be an important intervention

strategy in challenging current sexual norms that have contributed to the risks of contracting HIV in many of

the rural communities. Through information and education material stigma surrounding issues of knowing

HIV one's status will also be addressed.

7. EMPHASIS AREAS

HJFMRI South Rift Valley efforts in CT will be divided between community mobilization/participation, human

resources, information and communication, infrastructure, and training. HJFMRI-SRV will improve the

awareness of its CT services by focusing a part of its efforts in community mobilization and participation.

Other efforts will also go towards the training of 50 health care workers in the provision of CT services in the

clinical setting. Many of the health care settings do not have the existing space to provide CT services and

therefore some of the efforts in FY 2009 will be to make minor renovations in the already existing

infrastructure of the medical health facilities.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14907

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14907 4828.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,280,000

Defense Research Institute

6968 4828.07 Department of Kenya Medical 4249 3476.07 South Rift Valley $750,000

Defense Research Institute

4828 4828.06 Department of Kenya Medical 3476 3476.06 South Rift Valley $560,000

Defense Research Institute

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Funding for Laboratory Infrastructure (HLAB): $1,980,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ KMOD becomes a sub partner to HJFMRI/South Rift Valley.

+ The new coverage areas include Kisumu West, Nakuru Provincial General Hospital to provide Quality

Assurance/Quality Control activities.

+ Scaling up EID to cover the whole of Rift Valley region.

+ Expanding testing services to include microbiology, mycology and drug resistance.

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports the key cross cutting attribution of human capacity development through training 160

laboratory technicians/technologists in hematology, chemistry, CD4 and QA/QC with emphasis on

interpretation of results generated in the laboratories. This will be achieved through pre-service/ in-service

training, workshops and seminars facilitated by internal and external experts. Further training of a laboratory

auditor will improve the overall quality of services and general evaluation of the program. This activity will

also support one lab technologist for higher national diploma training in molecular diagnosis and one in

microbiology at Kenya Medical Training College or equivalent. Laboratories in all the sites will be

strengthened on requisite Quality Assurance procedures, laboratory procedures and management, use of

SOPs and implementation of QA/QC systems for the follow up of about 40,000 HIV patients thus

contributing to the overall national target of treating 550,000 people by the year 2010.

COP 2008

1. ACTIVITY DESCRIPTION

Under the US DOD, the Kenya Medical Research Institute (KEMRI)/ South Rift valley (SRV)/Kisumu West

and Kenya Ministry of Defense (KMOD) PEPFAR Program have been providing laboratory support for HIV

care to approximately 32,000 patients, of which 15000 have started ART. This laboratory support has been

provided in two forms: through the Regional laboratory and direct district level/ facility support.

Statistics: There are a total of 17 functional/running labs under the DOD PEPFAR Program. 8 labs have the

capacity to do CD 4 tests while 17 have the capacity to either perform hematologies or chemistries or both.

We plan to empower 18 laboratories to be able to perform QA for rapid tests being performed in all the

testing facilities. Kenya Medical Research Institute/ Walter Reed Project Clinical Research Center

(KEMRI/WRP CRC), Kericho laboratory is currently the only facility performing EID for the whole Rift Valley

region.

Services: From the inception of the EP Program, the KEMRI/WRP CRC, has been used as a nodal point for

training and empowerment of all the laboratories in the 18 treatment facilities in the Program. Initially, only

KEMRI/WRP CRC lab had the potential of doing all the HIV/ART monitoring tests, but this has been

transferred to most of the treatment facilities except for the CD4 tests that are done in only 7 sites. This was

easily achieved through procurement of necessary equipments for hematology, chemistries and CD4 for all

the treatment facilities within the EP program.

Due to this rapid growth and expansion of the lab services, it became necessary to hire four lab officers who

could coordinate the laboratory activities within the Program through training, development of SOPs and

adherence to good clinical laboratory practices. This has improved services in most of the laboratories while

improving standards within these laboratories.

Though some laboratories have been supported for the last four years using the laboratory annual

allocations, this has so far been supplemented by procurements done centrally through SCMS.

TB diagnostic services (ZN microscopy) are being expanded from the current 47 to 100 besides putting up a

TB culture lab at KEMRI/WRPCRC, Kericho. Support to this activity will provide accurate and timely

diagnosis of TB in about 32,000 HIV positive patients in the SRV and Kisumu west. It will also serve as a

reference lab for the whole Rift Valley region.

Among other tests to be expanded include diagnostic tests for other opportunistic infections including

mycology and parasitology besides strengthening simple ZN and fluorescent microscopies. Strengthening

of capabilities within KEMRI/WRPCRC laboratory for mycology and parasitology will ease a rollover to other

treatment facilities through trainings, SOP development and QA/QC coordination.

Other concurrent services provided to all the laboratories include biannual validation and verification studies

for all equipments, quarterly submissions of split samples for QA/QC and finally biannual participation in

external quality assurance in hematology, flowcytometry and chemistry.

To be able to maintain good service provision, service contracts have been/will be provided for all

equipments in all the USG supported sites. This ensures continuity of services while prolonging the life

spans of equipments in use within the Program.

With the accreditation of the KEMRI/WRP CRC laboratory in Kericho by the College of American

Pathologists (CAP), it has become necessary to utilize the expertise within this facility to develop the

Nakuru Provincial General Hospital (PGH) laboratory to attain its rightful identity besides attaining good

standards. This will be attained through provision of trainings, SOP development, QA/QC coordination and

overall technical assistance. This will in the long run enable the PGH laboratory to oversee some of the

QA/QC aspects currently performed by the KEMRI/WRPCRC laboratory for the region.

Kombewa-District Hospital in Kisumu West District is another new site requiring further support for

laboratory renovation, human resource, equipments, and reagents. The patient uptake in this area is high

and will need adequate support for quality provision of services.

In preparation for emerging drug resistant strains, the KEMRI/WRP CRC lab is building capacity using its

current expertise in viral load and DNA molecular tests to perform drug resistance tests for all clients

suspected to be failing on their drug regimens in the whole Rift Valley region. Further funding will be

needed to support this Program for reagents, consumables and equipment servicing. A specialist in

molecular diagnosis will be needed to facilitate and run these services.

Referrals and Linkages: The CRC lab is the reference lab for all the HIV/ART monitoring services within the

Program. Kericho District Hospital (KDH) laboratory has also been developed to handle all referred

specimens from the other sites except services within the military premises. Health Centers, dispensaries

Activity Narrative: and some private institutions send samples to any of the treatment facilities of their convenience for

analysis for hematology and chemistries. All sites that have no capacity to perform CD4s refer them to

either KEMRI/WRPCRC or any of the 7 facilities with flow cytometry equipments. The current approach is to

empower KDH to perform all HIV/ART monitoring tests while KEMRI/WRP CRC acts as a back up site and

main facilitator of QA/QC and validations. Armed Forces Memorial Hospital (AFMH) will also be empowered

to have referral capabilities for the military clients. All samples are logged in a laboratory book and once

analyzed; results are dispatched to the sending institution through any of the following methods:

•Securicor courier services

•Direct deliveries to near by sites

•Telephone calls for all critical or positive CRAG results

For EID, samples are directly relayed to KEMRI/WRP CRC laboratory from the collecting sites while others

would deliver to a treatment facility (whichever is convenient) for subsequent dispatch to KEMRI/WRP CRC.

Most sites use Securicor courier service recommended by the Clinton Foundation to deliver samples to the

KEMRI/WRP CRC lab. Once samples have been analyzed, results are dispatched using either the

Securicor courier service or directly delivered to the nearby sites. On the second day of delivery of results, a

follow up call is made to a point of contact at the sample collection site to confirm if the results have been

fully received. Further follow up to the client is not made. This does not apply to other samples unless a

complaint arises. A questionnaire has been developed to capture such deficits if any arises which is usually

distributed to sites on a quarterly basis. Analysis of the questionnaire is done by an independent department

(IT) before results are submitted to the lab for use. An SOP has been developed for reporting and

interpretation of the questionnaire results.

Finally, the development of protocols for quality assurance schemes and off-loading such activities as

individual sites develop capacity will continue. Given the close collaboration and working relationship with

KDH, Nakuru PGH, AFMH, these sites will continue to be developed to offer backups for safety labs, flow

cytometries, QA/QC support to other treatment facilities.

2. CONTRIBUTIONS TO OVERALL PROGRAMME AREA

In FY09, this activity will contribute to training 160 laboratory technicians/technologists in hematology,

chemistry, CD4 and QA/QC with emphasis on interpretation of results generated in the laboratories. This

will be achieved through pre-service/ in-service training, workshops and seminars facilitated by internal and

external experts. Further training of a laboratory auditor will improve the overall quality of services and

general evaluation of the Program. This activity will also support one lab technologist for higher national

diploma training in molecular diagnosis and one in microbiology at Kenya Medical Training College or

equivalent. Laboratories in all the sites will be strengthened on requisite Quality Assurance procedures,

laboratory procedures and management, use of SOPs and implementation of QA/QC systems for the follow

up of about 40,000 HIV patients thus contributing to the overall national target of treating 550000 people by

the year 2010.

3. LINKS TO OTHER ACTIVITIES

This activity relates to KEMRI-SRV/Kisumu West/ KMOD activities in HIV/AIDS treatment: ARV services,

palliative care: TB/HIV, palliative care: basic health care and support, counseling and testing, and

prevention of mother-to-child transmission.

4. POPULATIONS BEING TARGETED

The target population for this activity is primarily people living with HIV/AIDS that are identified through the

care and treatment centre's in the KEMRI- SRV/Kisumu West/ KMOD portfolio.

5. EMPHASIS AREAS/ KEY LEGISLATIVE ISSUES ADDRESSED

The activity includes emphasis on renovations, maintenance of laboratory equipments in the ministry of

health lab facilities as well as minimal work at CRC laboratory. Other emphasis areas will also include

human capacity development both in pre-service training and in-service training. This activity will also be

part of wrap around programs in health in the area of safe motherhood and TB.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16508

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16508 16508.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,575,000

Defense Research Institute

Emphasis Areas

Construction/Renovation

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $60,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.16:

Funding for Strategic Information (HVSI): $760,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ In FY 2009 the fund will be used to strengthen the reporting systems from the health centers to the district

level, this will be done by enhancing email systems and purchase of motor bikes.

+ Facilitation of data clerks salary who are currently working at the sites.

+ The funds will be used for health care worker trainings on, Data Quality, Data use and importance of data.

SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity supports key cross-cutting attributions in human capacity development through training of data

handling personnel in data management, health management information system, data collection, reporting

tools, analysis, monitoring and evaluation in support of HMIS for program data, and building the capacity of

South Rift to analyze and utilize surveillance, survey and other strategic information. The data handling

personnel will work closely with program managers and health care workers to help in monitoring of

activities, prepare work plans, make field visits to assess implementation progress and evaluate the rate of

activity scale up and prepare and submit timely reports

COP 2008

1.ACTIVITY DESCRIPTION

This activity will strengthen the provincial and district level Health Management

Information Systems (HMIS) currently in use by MOH at health facilities and Community Based Program

Activity Reporting (COBPAR) currently being rolled by NACC through Constituency AIDS Control

Committees (CACC), through three key components.

Component 1:

Support South Rift Valley 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 South Rift Valley and MOH's

district level 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 South Rift Valley 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 the 6 districts

and their heath facilities to collect, report, analyze, 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 the

Emergency Plan, MOH, NACC and other stakeholders, in line with the "three ones" principle. South Rift

Valley 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 200 facility based data point staff on the new data collection/reporting tools and data use for

improving program performance, and hold quarterly and annual stakeholders' information dissemination

meetings.

South Rift Valley 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 South rift Valley. These efforts should result into demonstrated evidence in

increased national level reporting by up to 60% from health facilities to NASCOP national database.

2.CONTRIBUTIONS TO OVERALL PROGRAM AREA

The activity builds on 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 the six districts

and their health facilities in strategic information in addition to supporting the training of 200 facility based

data point staff, SI, program managers in M&E/HMIS, reporting and data use for program management.

3.LINKS TO OTHER ACTIVITIES

This activity links to South Rift Valley activities in the areas of MTCT, HVCT, HVTB, HKID, HBHC and HTXS

by providing linkages between the patient data monitoring system and PEPFAR and national reporting

systems through better data generated at each of the treatment sites. In addition, this activity will link to the

HVSI activities to be carried out by NASCOP.

4.POPULATIONS BEING TARGETED

This activity targets host government workers and other health care workers like M&E and HMIS officers 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 of M&E program management.

5.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), Information Technology (IT) and

Communications Infrastructure and Other SI Activities.

Activity Narrative:

New/Continuing Activity: Continuing Activity

Continuing Activity: 16827

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16827 16827.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $307,000

Defense Research Institute

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $300,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.17:

Subpartners Total: $11,903,760
Tenwek Hospital: $897,776
Longisa District Hospital: $489,473
Africa Inland Church Litein Hospital: $1,394,757
Kapkatet District Hospital: $886,048
Kericho District Hospital: $2,084,489
James Finlay Limited: $606,029
Unilever Tea Kenya: $459,846
Londiani Sub-District Hospital: $1,032,781
Kapsabet District Hospital: $1,109,969
Nandi Hills District Hospital: $838,214
Live With Hope Centre: $620,000
Kilgoris District Hospital: $684,345
I Choose Life: $210,033
Kericho Youth Centre: $340,000
Samoei Community Development Programme: $250,000
Cross Cutting Budget Categories and Known Amounts Total: $2,224,250
Human Resources for Health $350,000
Public Health Evaluation $620,000
Education $15,000
Economic Strengthening $3,000
Human Resources for Health $80,000
Human Resources for Health $18,750
Food and Nutrition: Policy, Tools, and Service Delivery $18,750
Food and Nutrition: Commodities $18,750
Human Resources for Health $161,250
Food and Nutrition: Policy, Tools, and Service Delivery $161,250
Food and Nutrition: Commodities $161,250
Public Health Evaluation $150,000
Human Resources for Health $3,750
Food and Nutrition: Policy, Tools, and Service Delivery $7,500
Food and Nutrition: Commodities $7,500
Human Resources for Health $17,500
Food and Nutrition: Policy, Tools, and Service Delivery $35,000
Food and Nutrition: Commodities $35,000
Human Resources for Health $60,000
Human Resources for Health $300,000