APHIAplus Rift Valleys overarching goal during FY12 is to improve the quality of service delivery in the region. The objectives are to: (1) strengthen the Clinical Services program by improved mentorship and supervisory support to specific facilities to achieve better care and treatment outcomes; (2) re-align service demand creation activities to facility service delivery; (3) strengthen and expand support for the implementation of the community health strategy and linked interventions addressing social determinants of health (SDH). The implementation framework will be consistent with a country-driven process facilitated by partners as outlined in the USAID/Kenya PFIP.

To improve quality of service delivery, additional technical personnel will be recruited and deployed to provide mentorship and supervisory support to local partners, communities, and facilities, and augment the current project staff. Need-based short-term engagement with required technical experts will also be considered to offer necessary skill building support.Local facilities and implementing partners have been engaged formally through agreements and work plans to build and enhance systems to develop and sustain capacity required for effective service delivery. Inputs to support the implementing mechanisms at both the community and facility levels will be handed over when capacity for their use and distribution is established. Under this award, FHI has purchased 2 vehicles to support the outreach mentorship and supervisory teams based regionally. FHI also uses vehicles from previous awards. An additional 40 motorbikes will be needed in FY12 for social workers to reach the various target groups. This activity supports GHI/LLC and is funded primarly with pipeline funds in this budget cycle.

The target audience for HBC will include HIV-positive children, adolescents, and adults, both at the community and health facility. The aim is to reach 80,000 individuals through facility-based and community home based care in 10 counties in Rift Valley. Service providers will be familiarized with the recently launched PWP guidelines. Lifelong Cotrimoxazole (CTX) will be offered to all HIV-positive patients to prevent opportunistic infections. Partner and family testing will be promoted through active invitation to the health facility using the index client approach. Promotion of condom use, especially among couples, will reduce re-infection and enhance prevention. Screening and treatment for TB and STIs will be offered routinely. Anthropometric measurement and nutritional assessment will be performed on the HIV-positive patients and individuals who are malnourished will be rehabilitated with supplemental or therapeutic feeding. FP counseling will be strengthened and dual methods of protection will be offered. Peer counselors (community health volunteers living positively) at the health facilities will facilitate bi-directional linkages and referrals between the facilities and community programs.Using a family centered approach, APHIAplus will ensure OVCs in HCBC households receive support to address the social determinants of health, such as livelihood and economic strengthening, skill building, commodities to address hygiene and sanitation, social protection particularly for women and children, and food security and nutrition. The OVC program will have linkages with PMTCT, TB/HIV, health communication, and counseling and testing programs. APHIAplus will provide services based on the PEPFAR care service menu and focus on treatment literacy, relief of symptoms, FP interventions, safe water, HIV testing for family members, condom distribution, alcohol abuse counseling, disclosure support, gender violence support services, food security activities, health education, and household economic empowerment.District institutions will be supported to integrate, plan, lead, monitor, and evaluate home and community care support programs. Quality assurance and quality improvement for community interventions will be key in ensuring that standards of care are met. APHIAplus will support the District HBC coordinators and CHEWs to monitor and evaluate HCBC and community PWP activities. The project will also roll out a longitudinal database to monitor service provision to all OVCs and improve reporting.

APHIAplus Nuru ya Bondes prime partner Family Health international (FHI) was competitively selected to implement this activity. The implementing partners will provide comprehensive support to 95,000 OVC and their families, based on PEPFAR OVC guidance, both directly and through leveraged resources from other partners in selected sites in ten counties within Rift Valley province. The activities target OVCs, caregivers of OVCs, and CHWs in selected counties and will be delivered through local implementing partners. The local capacity of each organization will be strengthened through support supervision and mentorship to ensure quality service provision to OVCs. The implementing partners will work with community leaders, religious leaders, and volunteers as well as partner with other existing community-based and faith-based organizations.In 2012, APHIAPlus will support integration of the OVC project within the governments KEPH strategy thereby ensuring that OVC volunteers are part of the CUs; particularly vulnerable OVC are referred to nutrition programs; OVCs requiring food and nutritional services receive food supplements through the NHP program; government OVC standards for quality improvement are rolled out; and OVC coordination and child protection structures are strengthened at the community level. The capacity of local implementing partners will be strengthened through trainings and mentoring and support supervision to ensure the activities are implemented in line with the required standardsAPHIAPlus will also work with the government to improve coordination, supervision, and monitoring of OVC activities. Key to this objective is the need to strengthen the reporting system and support supervision at the local level. Monthly reporting tools for CHWs will be used to collect information at the community and will be analyzed at the implementing partners level. The project will utilize a longitudinal database to monitor service provision to all OVCs and improve data quality.The capacity of implementing partners will be strengthened through the training of trainers on high quality comprehensive OVC care. Key community stakeholders will be engaged through structures such as the AACs and child protection committees and will be given the authority to identify vulnerable children and their needs, assess existing community resources and gaps, establish a coordination and referral mechanism, and plan and monitor a joint response to the OVC.

The target population for TB/HIV activities is PLWHA, their partners and household contacts, health care workers in all the TB control zones in Nakuru County including health care workers (HCW) in the private sector managing HIV supported by GoldStar Network (GSN). TB/HIV collaborative activities will complement those that are delivered through the National TB Control program and supported by TBCARE Project. Supported facilities will integrate the five I strategies into the management of TB and HIV co-infected individuals. HCWs in HIV integrated facility service areas (CCCs, MCH, pediatric, STI/RH/FP, medical and OPD) will receive an orientation and mentoring on integration of the five I strategies, interventions, and TB ICF /IPT/IPC protocols as well as quality assurance tools. Following National Guidelines recommendations for HIV infected patients without active TB, Isoniazid preventive therapy (IPT) will be offered initially at 25 supported level 4 facilities. IPT will be progressively scaled-up based on site preparedness and capacity. HIV infected individuals with active TB disease, identified through the integrated HIV service areas, will be initiated on TB treatment and linked to commodities and monitoring systems within the TB program. IPC administrative, environmental, and personal protection measures will be instituted at the 25 supported HIV service areas. The IPC intervention will be linked to facility-based IPC integration support through the National TB program. As a result, more HIV infected individuals will be screened for TB and initiate IPT in supported facilities. In addition, there will be increased detection of MDR-TB through active surveillance of dually infected individuals.Integration of the five priority I strategies and interventions into private sector providers under the GSN will also increase reach and contribute to increased TB case detection, improved treatment outcomes, and enhanced surveillance for early detection and referrals of MDR-TB cases. APHIA plus and the National TB programs will mentor healthcare providers to build capacity around TP/HIV through CMEs, support supervision, and EQA activities. All TB/HIV supported activities are recorded and reported using the existing National M&E framework and tools.APHIAplus will now support the TB IPC initiative, started by the TBCARE project in Nakura County, which integrates TB/HIV activities into community health services through the community units. Through this initiative, 25 CHEWs and 180 CHWs were trained under the TBCARE Project from 9 selected CHUs and TB/HIV coordination forums established at County and district levels. The project will continues to support facilities and the CUs with trained CHWs to implement household activities and provide TB/HIV preventive, case finding, and case-holding services. Jointly with the National TB program and TBCARE Project support, APHIAplus will assess and document the resultant impact on trends in case finding, case holding, default tracing, and return to treatment for both TB and HIV in the supported communities.

APHIAplus NyaB will institutionalize the care of pediatric HIV infected infants, children, and adolescents into the MNCH ambulatory care clinics through dedicated clinics managed by staff whose competencies to address the evolving needs of infected children has been adequately built and supported. The program will target children aged 0-15 and identified through the 114 supported HIV CT sites. Children will be followed until they are transition into the adult CT clinics.Following HIV diagnosis, appropriate CT will be provided based on the national pediatric and adolescent care and treatment guidelines. Follow-up visits for monitoring and assessments will be scheduled to ensure access to drugs, commodities, and primary and basic care packages. All immunization and supplementary feeding will be provided as well as clinical review of response to treatment. Parents/guardians counseling will be undertaken to promote treatment adherence. Older childrens groups and adolescent support groups will be established to promote adherence and disclosure. Dedicated pediatric mentors will be identified who will support the establishment and strengthening of the pediatric care and support services embedded into the regional multidisciplinary mentorship teams.Cohort analysis of CT outcomes for pediatric and adolescent HIV patients will be undertaken separately from adult analysis to better identify and address issues that affect quality of care and support received by this cohort. Existing tools for recording and reporting will be used by all providers and facility-based mentors. Children and adolescents surviving to adulthood will be transitioned, through appropriate sexual and reproductive health counseling, to the adult CT programs. These resources will also provide integrated outreach and clinical diagnostic assistance using IMCI, for improved referral and health services for the children in those communities who are infected or affected by HIV/AIDS.

APHIAplus Nuru Ya Bonde will strengthen laboratory networking in Rift Valley and initiate laboratory upgrading towards WHO-AFRO laboratory accreditation. Nakuru level 5 laboratory and six regional level 4 laboratories will be upgraded. As a basis for quality improvement, the 12 pillars of Laboratory Quality Improvement will form the backbone of this step-wise laboratory accreditation program. The selected laboratories will be staffed by APHIAplus and Capacity Project Laboratory Technologists as embedded technical support staff to assist the quality assurance officer at the Level 5 laboratory and the laboratory in-charges in the other six laboratories with baseline quality systems audits, preparation and implementation of improvement plans, monitoring of quality and performance standards, infrastructure and equipment improvements; as well as assist with instituting internal quality controls and building capacity of laboratory staff and linkages to external quality assurance and control mechanisms. Identified infrastructure and equipment upgrades and renovations will be undertaken through project support. Generic standards and customized quality assurance tools will be provided or developed. Provider knowledge and skills updates will be regularly undertaken through in-facility mentorship, CMEs and facilitated supervision. Quality assurance of laboratory testing will be instituted internally and EQA through linkage to Laboratory Centers of Excellence at AMPATH in Eldoret and Kericho Hospitals. This will be undertaken for selected HIV testing, TB diagnostics and other parameters. The selected seven laboratories earmarked for the upgrading program will support the lower-level and catchment area laboratories at participating facilities through established networks of referrals for specimen examination, commodity and supplies access, provider competency building, monitoring, and promotion of quality standards.Monitoring of laboratory quality improvement will be undertaken primarily for the selected seven laboratories using the one-to-five-star tiered rubric accreditation approach following annual audits of the 12 pillars. Onsite inspection of laboratory operating procedures and practices will be undertaken by APHIAplus Project Laboratory scientists using standardized checklists. The objective is for laboratories to attain progressive increases annually in the accreditation scores from the baseline Zero Star.Training and support, based on SLMTA principles, will be provided through in-facility laboratory training facilitated by the APHIAplus Project Laboratory Scientists on Good Laboratory Practices (GLP), while off-site training of providers will be undertaken at the AMPATH training institute at the Eldoret Level 6 Referral Laboratory. Practical attachments will also be facilitated at the Walter Reed Reference Laboratory. By the end of one year, at least 15 laboratory personnel drawn from the seven laboratories will have undertaken laboratory in-service update training at the AMPATH Level 6 Facility and all 114 HIV Care and Treatment supported sites will have been networked to the seven upgraded laboratories.

APHIAplus Nuru Ya Bonde will support HIS and M&E aimed at strengthening the recording, reporting, and use of data for decision making at the district, facility, and community level within 32 districts of operation. APHIAplus will work within the national M&E plans and requirements and ensure that all data sources, data collection activities, and timeframes for data reporting are consistent. APHIAplus will provide on-job training and mentorship to service providers, community volunteers, and health information staff using a standard M&E mentorship checklist. The HMIS mentors will visit district hospitals and selected high volume ART facilities monthly, while other facilities will be visited quarterly for targeted support. At selected high volume ART sites, APHIAplus will train health care providers and health information staff on the COMPACT EMR system to improve recording, reporting, and use of ART data for decision making and patient care. The mechanism will provide essential computers, related commodities, and staff to support the use of the COMPACT EMR system. APHIAplus will work together with the MOH to determine the tools needed by facilities and improve distribution of HMIS/CBHIS tools to health facilities and CUs to ensure timely recording and quality reporting. In addition, APHIAplus will print CHIS tools and build the skills of health service providers and community health volunteers to record, report, and use data through onsite training and mentorship.Through the District DQA teams, APHIAplus will support quarterly routine data quality assessments using the national DQA protocols for health facilities and support implementation of data quality improvement plans. At the community level, APHIAplus will ensure quarterly data quality assessments. APHIAplus will also conduct bi-annual data quality assessments for selected sites to ensure data reliability as well as consistent improvement in data quality. APHIAplus will support capacity building for MOH HMIS staff on the use of the DHIS by providing onsite technical assistance and mentorship for the health information staff and DHMT. In selected district hospitals, APHIAplus will provide computers and related commodities to support the use of the DHIS. At the community level, APHIAplus will strengthen the linkage between the community and facility reporting by supporting the DHRO to monitor reporting rates from CUs and monthly CHW data review meetings, where feedback on reporting will also be shared. APHIAplus will also ensure community data management systems support generation of reports to monitor key performance indicators.To monitor project performance, aggregate monitoring data will be shared with different technical teams to monitor performance in and increase use of quality services, create demand for health services, address social determinants of health, and contribute to MOH, GoK and PEPFAR objectives. Internal monthly data review meetings will involve all key technical team leaders to validate results and identify and plan to address gaps in implementation. At the district level, APHIAplus will support monthly data review meeting for district and facility health managers and service providers. LQAS methodology will be used to monitor performance annually on selected indicators. A sex worker baseline survey will also be conducted to inform design of targeted intervention for this group.

APHIAplus Nuru ya Bonde together with the Capacity Project has hired and trained 4 multi-disciplinary VMMC teams using the national VMMC curriculum. The teams are based at Naivasha District Hospital and Nakuru Provincial General Hospital. The project will support the MOH to expand the VMMC activities in Nakuru County to reach the uncircumcised males, the majority of whom are migrant workers. APHIAplus aims to reach 3,500 males in the next year. VMMC promotional activities will be carried out at community level and in work places around Naivasha and Nakuru. In addition, the project will work with the MOH to build the capacity of P/DHMTs and health care workers to plan and provide VMMC services as part of an integrated HIV prevention package that includes community education and mobilization activities. APHIAplus will support the MOH to disseminate the national VMMC M&E tools to ensure appropriate documentation, follow-up, and recording of adverse events. For quality assurance, a VMMC expert will be engaged on a quarterly basis and will provide targeted mentorship to individual team members and train them on how to manage adverse events.

The target populations include in-school male and female youth in mid-primary school (aged 10-15) and in secondary school (aged 16-19); couples and unmarried youth reached through FBO targeting youth aged 10-24; women in long term relationships (aged 18-65) and couples. Some of the factors that lead youth to engage in risky behavior include peer pressure to experiment with sex, drugs, and alcohol. Youth are also at risk because of poor negotiation skills for abstinence and condom use when they initiate sexual activity. Other factors include cultural practices such as FGM, early marriage, socially sanctioned early engagement in sex, and being exposed to sexual and gender based violence. OVC, aged 10-17, are another target group because they are at risk of sexual exploitation by guardians and neighbors when they are in child-headed households and often at risk for low self-esteem. Risky behaviors predisposing adult men and women aged 18-55 are: concurrent sexual partnerships, abuse of drugs and alcohol, low usage of condoms, and poor health seeking behavior when infected with STIs. The interventions targeting youth and couples in the community will focus on increasing awareness and perception of risk, promoting uptake of clinical services, encouraging those abusing drug and alcohol abuse to seek help and join support groups, promoting knowledge of HIV status and couples testing, and building skills in partner disclosure. The peer-led discussion sessions will be guided by the Time to Live Christian and Muslim guide and will be implemented in Nakuru, Trans Nzoia, Elgeyo-Marakwet, Pokot, Kajiado and Narok counties.The youth will be reached through one-on-one, peer-led group sessions and school-based life skills training using the KIE approved Life Skills Curriculum. The youth will also be organized into Health Clubs that will engage in SRH structured discussions, debates, and brain-teaser competitions. APHIAplus Nuru ya Bonde will utilize the mass media campaign being rolled out by HFG and/or radio programs and the Teens Talk magazine. For youth aged 16-19, a combination of the Peer to Peer curriculum, the Y-Peer and Tuko Pamoja curriculum will be used as appropriate. The interventions will provide supportive peer networks to encourage low risk behavior. The project will engage parents, PTAs, and BOG to ensure that the immediate environment supports low risk behaviors. The in-school interventions will cover four counties: Nakuru, Nandi, Pokot, Tranzoia and Narok. Quality of the program will be assured through a dual level supervision and monitoring; the school inspectors will monitor the program as part of their regular monitoring and will be supported by project technical officers, while implementing partner staff will monitor the activities and report accordingly. Regular DQA will be conducted to ensure data quality. Prevention activities targeting youth aged 16-19 will be linked to youth friendly service promotion for STI screening, HTC, and other RH services. Among the younger cohort, the linkage to services will be restricted to de-worming, vitamin supplementation, and treatment adherence for those living positively. The data collection tools include a session diary/log maintained by the session facilitator and teachers. The Project staff and District Quality Assurance Officer (DQASO) will ensure reporting quality.

APHIAplus Nuru Ya Bonde will expand HCT by supporting all districts to undertake targeted HIV Counseling and Testing services to reach youth out of school. In addition, outreach activities will be integrated into community promotion activities through mass media, community dialogue, action days, and social and sporting events. CT activities will also target market days that congregate traders and business persons. VMMC outreaches will integrate CT services into workplaces targeting men especially from non-circumcising communities. Integrated MARPs outreaches will target CSWs along business routes and centers. All community outreach CT services, including house-to-house CT activities, will refer individuals who test positive to facilities.Facility-based HIV CT services in APHIAplus zone 3 will target pregnant women, couples and partners of PLWHA, MARPs, youth seeking YFS, and clients accessing services at the supported health facilities. At all 642 APHIAplus supported health facilities, provider initiated HIV testing & counseling (PITC) will be the predominant approach. HIV testing is routinely offered to patients, their family members, and visitors seeking ANC, maternity, postnatal, MNCH, TB, in-patient and other outpatient services with the option to opt-out. Other approaches include outreach/mobile voluntary counseling and testing (VCT) targeting hard to reach populations and campaigns like the couple testing community RRIs. Youth friendly counseling centers will be strengthened to increase access to HIV CT for youth. Service providers will be oriented on adolescent and youth-friendly sexual and reproductive health services. Health facilities will also identify index HIV clients and CHWs and community counselors will provide family-based HIV testing to promote early identification of HIV infected family members and access to HIV CT.The nationally recommended HIV testing algorithm will be in used in all APHIAplus supported sites and all service providers will receive information on the revised HTC guidelines through facility-based CMEs and technical updates. An additional number of providers will receive information on the national HTC quality assurance strategy and an initial 150 health facilities enrolled into the national proficiency HTC testing program. Further provider training on the re-testing recommendations contained in the HTC guidelines will be given to facilitate a structured approach in implementation. Partner testing will be promoted in care settings through active invitation for partners of identified cases seeking HIV CT services. Support groups linked to supported health facilities will be strengthened and community peer volunteers identified to facilitate intra-facility referrals into community programs and facilitate tracing of defaulters to follow-up CT. Service providers and peer volunteers will use mobile phone messaging to communicate with individuals after HIV CT to enhance linkages for enrollment, follow-up, and retention in CT. Existing HTC tools will be used at all entry points and summary reports prepared by HTC mentors based in the health facilities and the anchor CU facilities.

The target populations to be covered as OP will include: students of tertiary learning institutions ages 19-24 both male and female (approx. 16,000) as well as out-of-school youth 16-25; male and female sex workers (size estimation to be conducted) and MSM 18-45 years (approx. 600); pastoralists and livestock traders and women who serve them aged 18-54 years; men and women in workplaces 18-55 years; passenger transport sector (matatu crew and their families) 18-45 years; small scale traders, artisans, boda-boda drivers 18-45 years.The OP targeted populations are predisposed by concurrent sexual partnerships and sexual liaisons with partners of unknown HIV status, poor health seeking behavior, low condom usage for dual protection, abuse of alcohol and drugs, low knowledge of HIV status, non-disclosure of status to partners, and prevalence of SGBV.Youth interventions in tertiary learning institutions will include peer-led awareness raising sessions, group sessions, peer-counseling, professional counseling, tele-counseling, on-site referrals and linkage to CCC to raise perception of risk, build self-efficacy in adhering to prevention strategy, reduce stigma, and promote uptake of services. Youth living with HIV/AIDS (YLWHA) will participate in activities though a support group, incorporating PWP strategy and specific interventions for drug and alcohol abuse.The OSY intervention will include peer-led sessions and referrals to health services. The main aim is to increase awareness and perception of personal risk that will lead to seeking knowledge of status and health care services, including ANC and FP services. The sex worker, MSM, and passenger transport sector interventions will include peer-led awareness raising sessions supported by health services offered at DICs to increase access and uptake. The sessions for each of these high risk target groups will be determined by regular risk assessments and risk reduction planning. The services targeting high risk groups combine prevention, care, and treatment, both on-site at the DIC and through comprehensive outreach activities. This includes STI screening and treatment, ANC services, FP services, and referrals. The implementing partner serving sex workers and passenger transport sector offers ART to PLWHA. Additionally, they offer economic strengthening, financial and computer literacy, and linkages to micro-finance partners.

APHIAplus Nuru Ya Bonde is supporting 642 PMTCT sites of which 114 sites are offering comprehensive PMTCT interventions with intensified mentorship support to achieve the EMTCT goal, which ensures all these facilities have achieved a reduction in HIV transmission to <5% for all exposed neonates. In the next two years, 230 sites will receive comprehensive PMTCT support towards achieving the EMTCT goal. Concurrently, a minimum PMTCT package of targeted intervention support will be provided at the remaining PMTCT sites through outreach mentorship and linkages to national training, commodities management, and district supportive supervision, with the aim of progressively transitioning to comprehensive EMTCT packages.Through engagement with the existing 114 sites, costing of the interventions will be undertaken to obtain the unit cost per PMTCT client reached. In the next two years, innovative measures will be instituted to address high burden areas to reduce the unit cost and facilitate expanded coverage and program effectiveness. Strategies to achieve decentralized PMTCT services will include: expanded integration of HIV prevention into facility-based and outreach RH/FP services, and ARV prophylaxis and maternal/infant therapy into MNCH services; focus on the unmet needs for FP services among all HIV-positive women and their partners through PwP implementation; linkages with male neonatal, sibling, and partner circumcision services; and improvements in PNC service delivery and follow-up of infected mother-exposed baby pairs. In addition, activities to achieve decentralized PMTCT services include: integration into the Community Strategy; early identification of pregnancy by CHWs; access to counseling and testing for couples and families; improved follow-up care and treatment for pregnant HIV-positive women; and facility deliveries through referrals vis-à-vis integration of mobile phone technology for information alerts and reminders.APHIAplus has developed PMTCT intervention package standards compliant with current National PMTCT Guidelines. They will be used as a basis for monitoring implementation and compliance of quality standards. District supervision and program mentorship teams at the district and project-supported site levels will use the standards to monitor facility quality, determine needs for improvement, and set targets. Existing national PMTCT quality assurance tools will be made available at all facility sites and providers will be supported, through the mentorship teams, to use the tools. National data collection and reporting tools will be distributed to the sites. Through facility Quality Improvement Teams, all data collected will be analyzed and then utilized for decision making and planning for service delivery improvement. This will be undertaken through data review exercises at six month intervals to capture the progress in the implementation of the PMTCT care services and the outcomes for mother and infants at both the facility and community levels. Clinic data on immunizations, growth monitoring, including nutrition support, rehabilitation and treatment services for exposed and infected babies will inform the collection of outcome data. Service outcome indicators from the community strategy indicator data, such as community mobilization for PMTCT, stigma reduction interventions, male involvement, and couple counseling and testing, will be analyzed and monitored from the catchment CUs.

APHIAplus Nuru Ya Bonde is currently supporting 114 HIV care and treatment sites with comprehensive interventions packages. Due to the variable performance in the different treatment sites, APHIAplus will focus on strengthening the quality of services offered at these supported facilities and progressively decentralize treatment services to other sites using an outreach mentorship approach. To strengthen the quality of care and treatment services, APHIAplus will review the comprehensive package of interventions, deploy six regional multidisciplinary mentorship teams, provide intensive support to 16 poorly performing care and treatment sites, provide on-going enhanced support to 25 other sites, and maintain regular support to the remaining 71 sites to ensure adoption and maintenance of quality care and treatment standards for adults and adolescents. In addition, APHIAplus will upgrade six regional hub laboratories to support the delivery of quality laboratory networking services for the participating care and treatment sites. Integrated post-training clinical mentorship will be conducted for the individual providers and sites through the mentorship teams in order to refine and improve their skills. Mentor and mentee logbooks will be used to objectively monitor and assess the impact of the mentorship activities. Additional validation of mentorship effectiveness will be undertaken through the adoption of the on-line Therasim evaluation approach for individual providers. In-facility Quality Improvement Teams will be established and operationalized to undertake oversight of improvement initiatives, which address poor performance.APHIAplus will increase access to CD4 tests and viral load testing by supporting the transportation system of samples and results between health facilities and the laboratory hubs in network and National HIV reference laboratory. To improve retention in care and treatment, mobile phone messaging for patients on treatment, patient support groups, and linkages to CHW home-based follow-up will be established in functional CUs. Adolescent-friendly clinic days will be established to cater for this unique cohort.Monthly ART cohort reports will be compiled and used to review clinical outcomes. Active default tracing mechanisms will be instituted through the community structures, the patients support group, peer counselors, and through SMS messaging. To adequately address co-morbid conditions, the proportion of patients screened and diagnosed with TB, of TB-HIV co-infected patients on HAART, and of patients diagnosed with NCDs will be monitored. Intensified ART adherence counseling will be conducted for all new patients initiating treatment and medication use counseling will be provided during follow-up to increase ART adherence.ADR and adverse event monitoring will be instituted. Thus, patients who develop treatment failure will have access to non-standard regimens, facilitated through the Level 5 Hospital Treatment Review Team. Targeted focus on ART adherence counseling for frontline service providers will build their capacity to offer the service. Peer counselors will be deployed from the support groups to further support retention to treatment.

APHIAplus NYaB will scale-up pediatric care and treatment in the region. At present about 10% of current, newly and ever enrolled on CT are aged 0-15 years. This proportion will be increased to approximately 15% in the next two years. In the next two years, all adult/adolescent CT sites will strengthen the delivery of pediatric CT services to ensure optimization of entry points into CT and improved follow-up through integration of pediatric HTC into MNCH services and in-patient pediatric care services. Identification of HIV exposed and infected children will be intensified through longitudinal follow-up of HEI and PITC for the infants with unknown status in the health facilities. Early infant diagnosis facilities will be scaled-up to ensure provider competence to collect quality DBS samples and transport samples to regional laboratories for HIV DNA PCR diagnosis. Mentorship teams will ensure providers minimize missed opportunities for HIV diagnosis among exposed children. OJT for service providers on collection of DBS samples will be conducted in the facilities to improve diagnosis of HIV among the HEI. Turnaround times for receipt of results will be analyzed for each facility and optimized through measures to reduce time waiting for and relaying results to mothers. Service providers will be mentored on the prompt initiation of ART for children less than two years old with confirmed HIV status, while access to CD4 and viral load testing will be facilitated through laboratory networks linking regional labs with the National HIV Reference Laboratory to enhance evaluation and monitoring of patients. APHIAplus will build the capacity of health service providers in pediatric HIV management through targeted trainings and clinical mentorship to ensure that regimen dosing is age appropriate. Nutritional assessments of pediatric patients and therapeutic and supplemental feeding will be an integral part of their evaluation and monitoring. Access to all other immunization care, supplementation, and growth monitoring services will be undertaken in compliance with National Guidelines.Adolescent-friendly clinic days will be established and adolescent support groups formed. These will be managed separately from the adult and pediatric clinic days and facilitated by providers who have been trained in adolescent care. Adolescent clubs promoting healthy and positive living will be linked to adult role model mentors who are living positively.

The use of the HEI register and mother-baby booklets will be promoted and data complied to assess HIV transmission rates every month. Other outcomes will be analyzed to enable the development of facility-based responses to address poor outcomes. This effort will be undertaken by the pediatric HIV care and treatment mentor based in the supported health facility in conjunction with the Quality Improvement Team.