Africa Medical Research Foundations (AMREF) goal is to implement high quality prevention, care, & treatment of HIV, sexually transmitted infections, and related opportunistic infections in the Kibera slums where the HIV prevalence is almost twice the national. AMREF also has a Maternal, Newborn and Child Health and a School Health project in Kibera. The three projects work in an integrated manner with a strong focus on women and children, leveraging on each others resources while providing different entry points to proving better health care for the people in Kibera.Cost efficiency is being addressed through integration of services, use of existing evidence-based efficient strategies, task shifting, implementing more facility-based training and mentorship as opposed to offsite training, evaluating cost effective strategies for defaulter management, LAB networking, and mobilization. AMREF is closely working with the government, local community based organizations and community members in project implementation by building their capacity & ensuring that project activities are well coordinated and in line with the governments priorities. AMREF is also supporting the implementation of the community strategy which enables better planning, coordination and the efficient use of resources. AMREF is working closely with the government through the MOH & the District Health Management Team. The community health centre in Kibera is run jointly by AMREF & the government. The government posts staff to the facility and the plan is to eventually hand over the facility to the government to run it while AMREF continues to offer technical support.Since 2004 AMREF has procured 4 vehicles. No vehicle will be required in FY 12 and 13. This activity suppports GHI/LLC.

AMREF will continue to support comprehensive HIV care and support in 4 health facilities in Langata District, Nairobi, namely: Kibera AMREF, Ushirika, Uhuru Camp and Langata health center. By March 2011 AMREF had cumulatively enrolled 6,398 in HIV care; of these 3106 patients were active and on cotrimoxazole prophylaxis. The overall patient retention stood at 67%.

AMREF will work with the Ministry of Health (MoH) at the provincial, district and health facility level, to jointly plan, coordinate, implement and ensure provision of quality HIV care and support to 3,604 adult patients in FY12 and 4,139 adult patients in FY13.

AMREF will offer a package of services including: HIV testing to partners and family members of index patients and enrolling or referring/linking those that test HIV positive to care and support; provision of Basic Care Kit (safe water vessel, multivitamins, insecticide-treated mosquito nets, chlorine for water treatment and educational materials); supplemental and therapeutic nutrition (FBP) to all eligible HIV positive patients; prevention with positives(PwP); and family planning and reproductive health services including cervical cancer screening to all enrolled women.

AMREF in collaboration with MoH will support targeted capacity building (training and mentorship) for health care workers and offer continuous medical education on care and support, such as OI diagnosis and treatment. AMREF will identify areas with staff shortages, support recruitment of additional staff, and support good commodities management practices to ensure uninterrupted supply of commodities. AMREF will also support ongoing community interventions for HIV infected individuals, including peer education and support groups (for adherence messaging and psychosocial support), defaulter tracing and follow up to improve retention in all facilities; water, sanitation and hygiene programs; economic empowerment and income generating activities; home based care services; gender based violence support programs; vocational training; social and legal protection; and food and nutrition (food security) programs.AMREF will adopt strategies to ensure access and provision of friendly services to youth, elderly and disabled populations. Strategies to increase access of care services by men will be employed, including supporting male peer educators, mentors and support groups, and supporting women to disclose and bring their male partners for testing, care and treatment. AMREF will continue to strengthen data collection and reporting at all levels to improve reporting to National AIDS and STI Control Programme (NASCOP) and PEPFAR. AMREF will adopt the New Generation Indicators and support the development and use of electronic medical records system in accordance with NASCOPs guidelines. AMREF will continue using the quality of care indicators (CQI) for monitoring the quality of HIV care and support services and integrate them into routinely collected data. The CQI results will be used to evaluate and improve clinical outcomes. AMREF will do cohort analysis and report retention rates as required by NASCOP. AMREF will support joint Annual Operation Plan (AOP) planning, implementation, monitoring and evaluation and health system strengthening to facilitate sustainability.

African Medical Research Foundation (AMREF) will support TB/HIV activities in 4 health facilities in Nairobi: Kibera AMREF, Ushirika, Uhuru and Langata. Nairobi province has HIV prevalence of 8.8% and reported 2,974 HIV positive patients screened for TB between April and June 2011. The HIV prevalence in TB infected patients is 45.5%. AMREF has been supporting TB/HIV services in the 4 sites since 2003 in line with the Ministry of Health Division of Leprosy, Tuberculosis and Lung Disease (DLTLD) and the National AIDS and STI Control Program NASCOP. By the end of March 2011 (SAPR 11), 600 TB patients received HIV testing, 288 TB HIV confected patients were identified. A total of 5,480 HIV positive patients were screened for TB.

In the next two years covering FY 12 and FY 13, AMREF will intensify efforts to detect TB cases through clinical exams, laboratory investigations and ensure successful TB treatment through provision of appropriate treatment. AMREF will ensure that each facility providing TB/HIV services has adequate and well trained clinical staff supported by well equipped and staffed laboratory, including sputum specimen transport where laboratory services are unavailable.To reduce the burden of TB in HIV infected patients, AMREF will support intensified TB screening at each clinical encounter using the national screening tool for 3204 and 3679 HIV infected patients in FY12 and FY13 respectively. It is expected that 160 co-infected patients identified in FY12 and 184 co-infected patients in FY13 will be put on TB and HIV treatment. All patients without active TB will be provided with Isoniazid Preventive Therapy (IPT) as per national IPT protocol.

To reduce the burden of HIV in TB patients, AMREF will ensure that at least 95% of TB patients are screened for HIV and 80%TB-HIV co-infected patients are put on cotrimoxazole and ARVs as early as possible regardless of the CD4 count as per the national guidelines. AMREF will support the one stop model that provides integrated TB and HIV services in all TB clinics. All TB clinics will be stocked with cotrimoxazole and ARVs, and 60 HCW trained as needed.

To strengthen TB infection control in HIV settings, AMREF will ensure that the national IC guidelines are available at all sites and training of staff on IC is done. AMREF will support scaling up of at least 2 components of the national TB infection control strategy in HIV care settings, one of which should be fast tracking of patients with cough for expedited diagnostic work up and treatment

To improve surveillance and management of drug-resistant TB, AMREF will support timely transport of sputum specimens of TB retreatment cases from health facilities to the central reference laboratory for drug susceptibility testing and ensure return of the results to those facilities AMREF will also support scaling up of drug-resistant treatment sites thus expanding access to MDRTB treatment.

AMREF will also support expansion of prevention with positive (PwP) services in TB clinics, TB/HIV control activities in the prisons, strengthening linkages between facility and community-based services, and improving patient referrals and tracking systems. To strengthen HVTB program monitoring, AMREF will support reporting of selected custom indicators to assist with program management and evaluation and monitoring of new activities.

AMREF is in year 2 of PEPFAR II, since October 2010. AMREF will support pediatric services in 4 health facilities in Nairobis Langata District: Kibera AMREF, Ushirika, Uhuru Camp and Langata. By March 2011 AMREF had 296 children in care.

In FY 12 AMREF will provide care and support services to 376 children currently on care. The number of children currently on care will increase to 440 during the FY 13.

AMREF will provide comprehensive, integrated quality services, and scale up to ensure 352 HIV infected infants are put on ARV prophylaxis and all HIV exposed children access pediatric care services. AMREF will improve access to cryptococcal antigen testing, TB screening and management; pain and symptom relief and management; and psychosocial support (including disclosure counseling and support) provided through education, counseling and linkages to facility or community based support groups. AMREF will strengthen the provision of therapeutic or supplementary feeding support to children with growth faltering, provision of vitamin A, zinc, and de-worming); provision of safe water, sanitation and hygiene interventions (WASH) in the community and health facilities to prevent diarrhea and other illnesses among the HIV infected, exposed and other children in the community; and malaria screening, treatment and provision of long lasting insecticide treated nets in malaria endemic areas. Emphasis will be on enhanced follow up and retention of all identified HIV infected and exposed children.

AMREF will support the integration HIV services into routine child health care and survival services in the maternal child health department, including growth and development monitoring, immunization as per the Kenya Expanded Program on Immunization guidelines, case management of diarrhea, pneumonia, and other childhood illnesses, and community outreach efforts. They will also support the care of the newborn by supporting hospital delivery and ensuring that there is provision for newborn resuscitation and care (thermal care, hygiene cord care), and prophylactic eye care.

AMREF will support hospital and community activities to provide the needs of the HIV infected adolescents such as support groups to enhance disclosure and adherence messaging, PwP, substance abuse counseling, support for transitioning into adult services and teaching life skills.AMREF will ensure optimized linkages of children to various programs, including TB/HIV, PMTCT and OVC services, and other community based programs, including education, protection and legal and social services.

AMREF will also support relevant class-based and on-job trainings, including continuous medical education. AMREF will strengthen pediatric data collection and reporting at all levels to increase and improve reporting to NASCOP and PEPFAR. With guidance from the national PEPFAR office, the new generation indicators will be adopted. To improve the quality of care and strengthen pediatric services AMREF will support supervision and mentorship activities and use the quality of care indicators (CQI and HIVQuaL) for monitoring the quality of pediatric HIV services that have been adopted by NASCOP and integrate them into routinely collected data.

Target population: AMREF will continue to provide high quality HTC services to all patients and accompanying relatives and friends attending 4 health care facilities within Kibera and surrounding communities in Nairobi. They include couples, pregnant women, post natal clients, family planning clients, TB patients, outpatient clients, maternity patients, child welfare clinics and in the in-patient wards. Current HIV prevalence in Kibera is estimated to be 15%. HTC Approaches: AMREF utilizes both client and provider initiated HIV testing and counseling (PITC) strategies. Family testing (facility based or targeted home testing) has been introduced in an effort to reach out to sexual partners and children of HIV infected index clients. HTC is provided everywhere in the facility where the patients come in contact with the health workers-ANC, TB clinic, outpatient clinic, pediatric clinic, MCH clinic, Social work, Nutrition etc. Achievements and targets: In the past one year, AMREF had a target to counsel and test 15,000 persons in health facilities (excluding PMTC settings) and they managed to reach a total of 16,903 (112%) with 1229 testing positive (7,3%). Out of this number, 351 were tested as couples. A total of 35 health care workers have been trained in PITC. For COP 2012, AMREF will targets to test 24,000 persons of which 20% of them will be tested as couples, 10% will be children below the age of 15. Testing algorithm: National HIV testing algorithm is used. Referrals and linkages: Clients who test HIV positive are escorted to CCC where their demographic details are taken including the patients contact information. Client referral forms have been introduced and staffs have been trained on how to use them. In addition, introduction and use of Electronics Medical Records system has made it easier to follow up on individual patients. AMREF also uses a family form to ensure that it is able to track all the members of a family if one of them tests positive in the four supported facilities. Promotional activities for HTC: AMREF employs several strategies to promote HTC. These include the use of community radio to promote the importance of HTC including couple testing; production and distribution of IEC materials to promote HTC; Combination of HTC with outreaches to provide medical care; and Identification of strategies to promote male involvement in ANC. In addition to this, all patients are given health talks including the need for HIV counseling and testing and the importance of couple testing. Quality management: All AMREF supported health facilities are participating in Proficiency testing program as required. AMREF has also instituted the use of observed practice and counselor support supervision to ensure quality of counseling and testing. There is also the use of EQA at the National Referral Laboratory on every 20th client. Monitoring and evaluation: AMREF uses all ministry of health tools to capture HTC data, both for couples and individual patients. These include HTC lab Register and Facility summary tool (MOH 711). MOH approved HTC lab registers have been introduced at all HIV testing points except PMTCT. The team is working in close collaboration with the facility management team to ensure timely and accurate reporting to Ministry of Health and to the Donor.

AMREF implements comprehensive prevention, care and treatment programs in Nairobi province. In FY 2012/13, AMREF will expand HIV prevention services to include evidence based behavioral interventions (EBIs) for specific target populations in clinical settings at comprehensive care center (CCC), TB and Maternal Child Health (MCH) clinics as part of HIV combination prevention programs. The EBIs will include Positive Health and Dignity Prevention (PHDP) targeting adult male and female and adolescents living with HIV (PLHIV); and Sister to Sister EBI (S2S) targeting sexually active HIV negative women attending the MCH clinics. PHDP is an ongoing 5-10min group and individual level intervention that targets PLHIV in clinical and community settings. This mechanism will support this intervention which constitutes of ART adherence counseling and support; partner and family testing; provision of PEP to the discordant spouse; treatment for prevention once approved; safer pregnancy counseling and provision of modern contraception; sexual risk reduction counseling including reduction of sexual partners, alcohol counseling, promoting of consistent and correct condom use; Sexually Transmitted Infections (STI) screening and treatment and using meaningful involvement of people living with HIV/AIDS ( MIPA ). The efficacy of PHDP has been shown to be 68% in preventing transmission of HIV, and 96% in treatment for prevention.

S2S is a 20 minute individual level intervention that targets women of reproductive age that focuses on self efficacy, safer sex negotiation skills and condom use. Condoms are 80% effective in heterosexual relationships when used correctly and consistently.

AMREF will use HVOP funding to recruit and support appropriate peer educators/counselors to reinforce prevention messages delivered by health providers as a feasible model for task-shifting in the provision of PHDP in clinical settings, and specifically promote MIPA. It will support placement of 5 Peer Educators at the MCH, TB and CCC Clinics in hospitals, and 2 Peer educators at health centers and provide appropriate counseling space. One of the peer educators will do regular client home follow up to strengthen ART adherence.

Approximately 1.6 million Kenyans are PLHIV. The Kenya AIDS Indicator Survey 2007 showed 6% of couples to be in discordant relationships. Nairobi province HIV Prevalence is high (8.8%). AMREF will reach 2030 (60%) PLHIV in FY2012 and 2725 (70%) in FY 2013 with a minimum package of PHDP. It will implement S2S EBI on a pilot basis.

Quality assurance for EBIs will be promoted through appropriate training and certification of peer educators using approved national curricula, standard job-aids and guidelines and regular supervision.

AMREF will work with appropriate national Technical Working Groups (TWG) to support integration of HIV prevention into care and treatment programs in clinical settings. These programs will also be linked to other HIV community programs. PLHIV will be specifically linked to STI and FP services, as necessary, through patient escorts.

Monitoring of PHDP and S2S will be done through the review/input of AMREF implementation plan, analysis of KePMS data, quarterly reviews, semiannual and annual reports. Evaluation will be conducted through operation research of combination HIV prevention and periodic surveys (Kenya Demographic and health survey, Kenya Indicator AIDS Survey, Kenya Service Provision Assessment).

AMREF will support 4 PMTCT sites in Langata District with about 4000 expected pregnancies annually and HIV prevalence of 11%. By end of March 2011 SAPR, AMREF had counseled and tested 1763 pregnant women, given ARV prophylaxis to 163 HIV positive pregnant women and 91 infants, and trained 33 Health Care Workers in PMTCT.

In FY12, AMREF will offer HIV counseling and testing to 3,810 pregnant women attending ANC and give ARV prophylaxis to 336 HIV infected pregnant women. The HIV infected women will receive a CD4 test after undergoing WHO clinical staging. AMREF will give HAART to all eligible HIV positive pregnant women, in line with the revised PMTCT national guidelines. In FY13, AMREF will increase the number of pregnant women counseled to 4,000, offer ARV prophylaxis to 409 pregnant women and 352 infants, and offer EID to 352 infants.

AMREF will focus on 4 prongs of PMTCT: primary prevention; family planning; ARV prophylaxis to all HIV positive pregnant mothers and exposed infants; and care and treatment to eligible HIV positive mothers, partners and children. The minimum care package will include health and HIV education, individual/family HIVCT, clinical/laboratory monitoring and assessment, OI screening and treatment, ARV prophylaxis and treatment for both mother and baby, nutritional support, psychosocial support, PWP, follow up and retention, referral and linkages. AMREF will also incorporate TB screening into routine antenatal care.

AMREF will support ART integration into MCH clinics, access to FP/RH services, and establish or strengthen infection control and waste management activities. Hospital delivery will be supported through provision of delivery beds and sterile delivery packs, training, working with CHWs and TBAs to promote community-facility referral and health education.

AMREF will support enrollment and follow up of 352 HIV exposed infants to access CTX, ARV prophylaxis, safe infant feeding practices as per national guidelines and other EID services using the HIV exposed infant register until 18 months. AMREF will facilitate ART initiation for those who test positive before 2 years.

AMREF will adopt retention strategies for mothers and babies by supporting use of diaries and registers for tracking defaulters, having a structured mentorship and supervision plan, enhancing data quality and streamlining M&E gaps including orientation of new MOH ANC/maternity registers and utility of data at facility level for program improvement and quarterly progress reports to CDC.

AMREF spends $18 per woman for PMTCT, which will now stretch to cover all PMTCT prongs and wrap around like malaria prevention in line with GHI principles. Program quality and proficiency testing will be emphasized to validate PMTCT results.

AMREF will train 30 HCWs in both FY12 and FY13 on the revised PMTCT and infant feeding guidelines. AMREF will conduct community engagement activities to strengthen referral linkages and also increase demand for ANC and other health services such as couple CT services.

African Medical Research Foundation (AMREF) will support treatment services in 4 sites within Langata district in Nairobi Province. Nairobi province has an estimated population of 3.1 million people with an estimated adult HIV prevalence of 8.8% compared to the national 7.1%. By the end of March 2011 SAPR results, AMREF had initiated 3,016 adults and children of ART of whom 2000 were active.

In FY12, AMREF will jointly work with the Ministry of Health (MoH) to continue supporting expansion and provision of quality adult HIV treatment services in line with MoH guidelines to 2,092 patients currently receiving ART and 313 new adults resulting to cumulative 2,511 adults who have ever been initiated on ART. In FY13, this number will increase to 2,327 currently receiving ART and 317 new adults resulting to 2,828 adults who have ever been initiated on ART.

AMREF will support in-service training of 50 and 40 HCWs in FY 12 and 13 respectively, continuous mentorship and capacity building of trained health care workers; identify human resources and infrastructure gaps and support in line with MoH guidelines; support good commodities management practices to ensure uninterrupted availability of commodities.

AMREF will support provision of comprehensive package of services to all PLHIV including ART initiation for those eligible; laboratory monitoring including biannual CD4 testing, viral load testing for suspected treatment failure (through strengthened laboratory networks); cotrimoxazole prophylaxis; psychosocial counseling; referral to support groups; adherence counseling; nutritional assessment and supplementation; prevention with positives (PwP); FP/RH; improved OI diagnosis and treatment including TB screening, diagnosis and treatment.

AMREF will continue to support ongoing community activities and support for HIV infected individuals including education by peer educators and use of support groups to strengthen adherence, effective and efficient retention strategies; referral and linkages to psychosocial support groups, economic empowerment projects, and Home Based Care, food and nutrition programs. AMREF will support provision of friendly services to youth and special populations. Additionally, AMREF will do cohort analysis and report retention rates as required by the national program and discuss the analysis results with facility staff in order to improve program performanceAMREF will adapt the quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV treatment services integrate them into routinely collected data; use the results to evaluate and improve clinical outcomes and additionally support short term activities with great impact and better patient outcomes.

AMREF will adopt strategies to ensure access and provision of friendly HIV treatment services to all including supporting peer educators, support groups, disclosure, partner testing and family focused care and treatment. AMREF will continue to strengthen data collection and reporting at all levels to increase and improve reporting to NASCOP and PEPFAR. Use of an electronic medical records system will be supported and strengthened.

African Medical Research Foundation (AMREF) will support implementation of pediatrics services in Langata Districts in Nairobi Province. Nairobi province has an estimated population of 3.1 million people with an estimated adult HIV prevalence of 8.8% compared to the national 7.1%. AMREF has been supporting pediatric ART services in 4 sites (Kibera AMREF, Ushirika, Uhuru camp and Langata Health Center) in Nairobis Langata district and by the end of March 2011 SAPR results 148 children had been initiated on ART of whom 84 were active. In FY12, AMREF will jointly work with the Ministry of Health (MoH) at all levels to continue supporting, expanding and ensuring provision of quality pediatric HIV treatment services as per MoH guidelines to 132 children currently receiving ART and 26 new children resulting to cumulative 159 children ever initiated on ART. In FY 13, this number will increase to 161 children currently receiving ART and 24 new resulting to cumulative 183 children ever initiated on ART. AMREF will support comprehensive pediatric ART services including growth and development monitoring; immunization as per the Kenya Expanded Program on Immunization; management of childhood illnesses; OI screening and diagnosis; WHO staging; ART eligibility assessment; laboratory monitoring including 6 monthly CD4, hematology and chemistry (through strengthening of lab networks); Pre-ART adherence and psychosocial counseling; initiation of ART as per MoH guidelines; Toxicity monitoring and treatment failure assessment through targeted viral load testing; Adherence strengthening; enhanced follow up and retention; support EID as per MoH guidelines and PITC to all children and their care givers attending Child Welfare clinics; support family focused approach; community outreach efforts and integration of HIV services in other MNCH services.

AMREF will support hospital and community activities to support the needs of HIV infected adolescents through support groups to enhance disclosure and adherence messaging, PwP, substance abuse counseling, teaching life skills, providing sexual and reproductive health services and support their transition into adult services.

AMREF will support in-service training of 50 and 40 HCWs in FY 12 and 13 respectively, continuous mentorship and capacity building of trained health care workers on specialized pediatric treatment including management of ARV treatment failure and complicated drug adverse reactions; identify human resources and infrastructure gaps and support in line with MoH guidelines; support good commodities management practices to ensure uninterrupted availability of commodities. Linkage of ART services to pediatric care services, PMTCT, TB/HIV, community programs, and other related pediatric services will additionally be optimized.

AMREF will continue to strengthen data collection and reporting at all levels to increase and improve reporting to NASCOP and PEPFAR. Additionally, AMREF will review data and evaluate programs to inform programming and decision making. Use of an electronic medical records system will be supported and strengthened. AMREF will strengthen local capacity as part of the transition plan to MOH for sustainable long-term HIV patient management in Kenya.