1. Goals and objectives: The goal of this mechanism is to increase access to quality comprehensive HIV prevention services for Most-At Risk Populations (MARPS) in Nairobi Province. The objectives are to provide continued support to the implementation and scale-up of a combination of evidence-based package of services to SWs, MSM and PWID. The project also serves as a learning hub for other MARPS projects in the country.2. Cost-efficiency strategy: Implementation of this project has a strong community engagement and uses a peer-led approach in outreach services and delivering behavioral interventions. The mechanism leverages from the Health ministries and has a broad stakeholder involvement. The central drop in center will serve as a center of excellence through Gates foundation partnership and provide a learning hub to support other MARPS programs in the region.3. Transition to country partners: This project forms an integral part of the national Technical working group hosted by NASCOP. It works in a collaborative partnership with University of Nairobi and is establishing a Kenyan entity to carry on this program. It also partners with the NOSET, a local CSO that implements services for PWID.4. Vehicle information: Four project vehicles have been bought so far, all under a previous mechanism in FY06, 07, 08. These vehicles support field outreach activities and transport staff and peers to the various hotspots in the entire Nairobi province. They also support supervision and logistical activities across the ten drop in centers/clinics for sex workers that are located in fairly distant parts of the city. Additionally, they support distribution of supplies. This partner is not requesting vehicle purchase in FY12.This activity supports GHI/LLC.

University of Manitoba (UOM) will support HIV care for the general population as well as Most at Risk Populations (MARPS) with a focus on Men who have sex with Men (MSM) and Sex Workers (SW). By March 2011, UOM had cumulatively enrolled 8,226 patients in HIV care of whom 7,950 individuals were active and 7,567 patients were on Cotrimoxazole prophylaxis.

UOM 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 5,370 current adult patients in FY12 and 6,613 current patients in FY13.

UOM will offer comprehensive care and support 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, condoms, chlorine for water treatment and educational materials); therapeutic nutrition (FBP) to all enrolled HIV positive patients; prevention with positives(PwP); and cervical cancer screening to all enrolled women.

UOM in collaboration with MoH will support targeted capacity building (training and mentorship) for health care workers and additionally offer continuous medical education on care and support, e.g. OI diagnosis and treatment. UOM will identify areas with staff shortages, support recruitment of additional staff, and support good commodities management practices to ensure uninterrupted supply of commodities.

UOM will also support ongoing community interventions for HIV infected individuals including peer education and use of support groups to provide adherence messaging; effective and efficient defaulter tracing and follow up to improve retention in all facilities; referral and linkages to community based psychosocial support groups; water, sanitation and hygiene programs; economic empowerment - income generating activities (IGAs); home based care services; gender based violence support programs; vocational training; social and legal protection; food and nutrition programs. UOM 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 such as supporting male peer educators, mentors and support groups, and supporting women to disclose and bring their male partners for testing and care and treatment.

UOM will continue to strengthen data collection and reporting at all levels to improve reporting to the National AIDS & STI Control Programme (NASCOP) and PEPFAR. UOM will do cohort analysis and report retention rates as required by NASCOP. UOM will adopt the new generation indicators and support the development and use of electronic medical records system in accordance with NASCOP guidelines. UOM will adapt the quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV care and support services, integrate them into routinely collected data, and use the results to evaluate and improve clinical outcomes. UOM will to support joint Annual Operation Plan (AOP) development, implementation, monitoring and evaluation, and health system strengthening to facilitate sustainability.

University of Manitoba (UOM) will support TB/HIV activities in the Nairobi region which has an HIV prevalence of 7% and reported 17,444 cases of TB. UOM targets both general population as well as Most at Risk Populations (MARPS) with a focus on Men who have sex with Men (MSM) and Sex Workers (SW). The HIV prevalence in TB infected patients is 45.5%. UOM has been supporting TB/HIV services in 5 sites in line with the Ministry of Health Division of Leprosy, Tuberculosis and Lung Disease (DLTLD) and the National AIDS and STI Control Program (NASCOP). Between October 2010 and March 2011, 121 TB patients received HIV counseling and testing and all the 82 (100%) TB HIV co-infected patients identified received cotrimoxazole prophylaxis.In FY12 and 13, UOM will intensify efforts to detect TB cases through clinical exams and laboratory investigations and ensure successful TB treatment through provision of appropriate treatment. UOM 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. UOM will ensure that adequate supplies of anti-TB drugs are available and that the national TB treatment guidelines are followed. All TB patients on treatment will be monitored both clinically and through periodic sputum examination.To reduce the burden of HIV in TB patients, UOM will ensure that at least 95% of TB patients are screened for HIV and all 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. UOM 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 30 HCW will be trained in FY12 and 20 in FY13.To reduce the burden of TB in HIV infected patients, UOM will support intensified TB screening for 4,774 in FY12 and 5,878 in FY13 at each clinical encounter using the national screening tool. 239 co-infected patients identified in FY12 and 294 in FY13 will be put on TB treatment and those without active TB will be provided with Isoniazid Preventive Therapy as per national IPT protocol.To strengthen TB infection control in HIV settings, UOM will ensure that the national IC guidelines are available at all sites and training of staff on IC is done. UOM 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, UOM 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. UOM will also support scaling up of drug-resistant treatment sites thus expanding access to MDR-TB treatment.UOM will also support expansion of prevention with positive 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, UOM will support reporting of selected custom indicators to assist with program management and evaluation and monitoring of new activities.

University of Manitoba (UOM) will continue to support 5 facilities in Nairobi Province. UOM targets both general population and children born to Most at Risk Populations (MARPS). By March 2011, UOM had ever enrolled 276 children with 146 active and receiving Cotrimoxazole.

In FY12, UOM will provide care and support services to 561 children currently on care. The number of children currently on care will increase to 704 in FY13. UOM will provide comprehensive, integrated quality services and scale up to ensure all HIV exposed children access pediatric care services.

The focus of pediatric care services will continue to be provision of comprehensive, integrated quality services including strengthening the use of the Mother-baby booklet, early infant diagnosis, universal provider initiated testing and counseling, and ensure those identified as HIV-infected are linked to care and ART services.

UOM will ensure children enrolled in care receive quality clinical care services including clinical history and physical examination; WHO staging, CD4 tests, and other basic tests; opportunistic infection diagnosis, prophylaxis and management; TB screening; pain and symptom relief and management; and psychosocial support. Additional key care services will include nutritional assessment, counseling and support based on the WHO and IYCF guidelines (including 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 in health facilities; and malaria screening, treatment and provision of long lasting insecticide treated nets in malaria endemic areas.

UOM will support integration of 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. Exposed children management and follow up will continue to be supported and will include enrollment, HIV testing (PCR-DNA and antibody testing) as per the national guidelines, provision of Nevirapine throughout the breastfeeding period, follow up and retention, and linkages of those positive to care and ART services.

UOM will support hospital and community activities to meet the needs of the HIV infected adolescents: support groups to enhance disclosure and adherence messaging, PwP, substance abuse counseling, support for transitioning into adult services and teaching life skills.

Commodity access, infrastructure development, and relevant trainings will continue to be supported.

UOM will strengthen pediatric data collection and reporting at all levels to increase and improve reporting to NASCOP and PEPFAR.

The University of Manitoba is a MARPs project targeting Female sex workers and Male sex workers including MSMs and IDUs. The mechanism operates 7 clinics for the sex workers within Nairobi city. The exact population of these groups is not known but size estimation exercise is underway. The prevalence from program data across those seven sites range from 16% to 31% for the female sex workers and 37% for the male sex workers. Couples are also served in the wider combination prevention (sex workers with regular partners). IDUs are a much harder population to access.The HVCT approach used is Provider initiated testing and counseling (PITC) and all clients are appropriately given HIV education, offered testing and given risk reduction counseling. Those who test HIV positive are enrolled into care and treatment offered within the clinics. The same clients are screened for STIs and offered appropriate treatment. The clients are tested every three months, and as risky behavior are reported as per the national guidelines. HTC is provided as part of combination prevention.Over the last 9 months have tested and counseled 8,167 clients (8059 female sex workers and 108 male sex workers). In 2012 the program will reach 41,000 clients with testing and counseling services. This number includes the re-testing that happens every three months and when a risky act has occurred. Out of these 20% will target couples while 60% will target new testers. Work with IDU will be rolled out in 2012 once the guidelines are finalized.The program uses the national testing algorithm.The clients receive comprehensive package of services including care and treatment in the clinics but follow up by phone is done for clinic defaulters.The program follows the national quality management guidelines and participates in the proficiency testing quarterly and collection of DBS for the 20th client tested and counseled per counselor. Support supervision is carried out for the service providers on continuous basis.The program develops work plans and conducts biannual data quality audits and monthly data supervision is carried out and this informs the program implementation improvement.New indicators like couples tested, discordant couples have been incorporated in the data collection tools.The national M&E framework is used including use of national registers and data collection tools and reporting will be through the DHIS in future. Quality services is ensured by adherence to national guidelines, use of national certified kits and participation in the External quality assurance through proficiency testing run by the government.

Promotional activities are conducted by peer mobilization and mass media from the national perspective on the need to know status.

The University of Manitoba will continue to expand access to a high quality comprehensive package of services for MARPS including SWs and MSM. Majority of the individuals targeted will be women aged 18-55 years. An estimated 10% of the target will be male sex workers, some of whom are MSM. High risk sexual behavior prevalent among sex workers including incorrect and inconsistent condom use particularly with regular sex partners will be a key focus. Other risk factors that will be addressed include douching practices, excessive alcohol and drug use, and low adherence to treatment.This mechanism will support implementation of the Combination Prevention Interventions for SWs as defined in the National Guidelines for the package of services for SWs. Behavioral interventions include peer education and outreach, condom and lubricant demonstration and distribution and risk assessment, risk reduction counseling and skills building. Specific evidence-based behavioral interventions for this group will be Sister to Sister, a 20 minute individual level intervention that targets women of reproductive age that focuses on self efficacy, safer sex negotiation skills and condom use. Safe in the City, a video-based intervention for use in waiting rooms for condom skills-building. Biomedical interventions include HTC, STI screening and treatment, TB screening and referral to treatment, HIV care and treatment, RH services, Emergency contraception and Pre-exposure prophylaxis. There is also a strong consideration for initiating Treatment as Prevention for these MARPS groups and initiating Pre-exposure prophylaxis where feasible. There will be screening for drug and alcohol abuse, referral for treatment, provision of psychosocial support and linkages to family and social services, especially to address the vulnerability of children of SWs. Structural interventions will focus on enhancing a 100% condom use Program (CUP) nationally, mitigation of sexual violence and support to expand choices beyond sex work as a risk-reduction strategy.The geographic focus of these activities will be Nairobi Province. Up to fifteen sites/drop-in-centers will be supported to intensify coverage and increase access to services. A close collaboration with the City council health facilities, particularly the Casino STI clinic downtown to improve their capacity in serving high-risk populations will be established. This project will reach an estimated 36,000 SWs in Nairobi, including 30,000 FSWs with a HIV prevalence of 29.3% and 2500 MSW/MSM, 500 PLWHIV with community PWP intervention and 3025 PLWHIV with clinical PWP. Further size estimation and mapping exercises will be conducted in Nairobi to provide an objective re-assessment of population sizes and provide a validated estimate to guide programming and planning.A center of excellence in the SWOP City branch will be established through partnership with the Gates foundation to serve as a learning hub for programs providing services to SWs. Services are closely linked to other public and non-government services e.g. the clinics/drop in centers are registered to receive some drug, condoms and other supplies from central drug procurement mechanisms and report to their local District and provincial health authorities. Quality assurance will be enhanced through a close project monitoring, use of standardized national tools across sites, regular staff and peer review forums.

The drug use epidemic in Kenya has a HIV prevalence over two times more than that of the general population. HIV prevalence amongst PWID is 18.3%. Amongst needle-sharing sharing IDUs, prevalence is 30% while for non-needle sharing PWID, it is 5%. This mechanism will therefore target the PWID population in general, and provide appropriate targeted responses to each of the sub-groups within this population to address their varied risk profiles. Among social networks drug-users, high risk sexual and injecting practices include multiple sexual partners, unprotected sex among injecting peers, needle-sharing and flash-blood sharing. Women who use or inject drugs face additional risks due to their engagement in sex work and in transacting sex for drugs. They also face additional stigma, which becomes exacerbated in the event of a pregnancy. These behaviors are reinforced by multiple determinants such as criminalization of injecting drug use, and poverty among majority of the self-identified IDUs.This mechanism will support the set up and scale up of a comprehensive package of services targeting 8,300 PWID/PWUD who will receive a 8-intervention package of services per the PEPFAR and UNAIDS/UNODC guidelines. These services include Medication-Assisted Treatment (MAT) for drug-dependence treatment, ART, HTC, STI prevention and treatment, Condom demonstration and distribution for PWID and their partners, targeted behavioral interventions and IEC materials, TB p, diagnosis and treatment and vaccination, diagnosis and treatment of viral hepatitis. Some program interventions will be implemented for the first time in Kenya, and will involve careful planning with a broad range of stakeholders, including involvement of local administration with a view to enlisting the crucial buy-in and support for an enabling environment. This activity will be carefully rolled out to assure efficiency in rolling out drug dependency treatment. Service providers in this program will receive training in addiction counseling and managing drug dependence treatment, in collaboration with the national Treatnet II program and will be closely linked with the National drug-dependence treatment centers ie Mathare Hospital and Coast General Hospital for on-going mentorship. Out-patient treatment will be the desirable model of offering MAT, backed by a close follow-on addiction counseling therapy.Situational assessments in Nairobi and Mombasa in June 2010 revealed large underserved needs in Nairobi and Ukunda, an emerging drug-shooting hub in the South Coast which require an intense coverage. This mechanism will facilitate this rapid roll-out of services through a subaward with UNODC to support the Nairobi Outreach services Trust (NOSET), an IDU-serving CSO in Nairobi and another CSO in the Ukunda region as appropriate.The IDU Technical working group led by NASCOP, with participation from the Health Ministrys Mental Health Services will adapt and disseminate national PWID program guidelines, MAT treatment protocols and reporting tools to guide implementation. Training, supportive supervision and mentorship will be provided to these program. Other key players with who this program will work with include the UNODC, NACADAA and the HIV treatment and care programs. PWID/PWUD will be served in the SWOP MARPS clinics to ensure a close follow-on to their treatment and adherence.

University of Manitoba (UOM) has been implementing PMTCT services in Nairobi targeting both the general and Most at Risk Population (MARPS) In Nairobi Provinces. 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%.In FY12, UOM will offer HIV counseling and testing to 952 pregnant women at the ANC and give ARV prophylaxis to 82 HIV infected pregnant women. The HIV infected women will receive a CD4 test after undergoing a WHO clinical staging. UOM will give HAART to all eligible HIV positive pregnant women in line with the revised PMTCT national guidelines. In FY13, UOM will increase the number of pregnant women counseled to 1000 offer ARV prophylaxis to 102 pregnant women and 88 infants and do EID for 88 infants.

UOM will focus on 4 prongs of PMTCT: primary prevention; prevention of unwanted pregnancies, 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 /or treatment, ARV prophylaxis and treatment for both mother and baby, nutritional support, psychosocial support, PWP, follow up, retention , referral and linkages. UOM will incorporate TB screening into routine antenatal care.UOM will reach 300 of 1st ANC attendees with couple CT to identify discordant and concordant couples to improve primary prevention and facilitate linkage to HIV care and treatment for the eligible.

UOM will support integration of ART in MCH clinics, access to FP/RH services, establish or strengthen infection control and waste management activities.

UOM will support hospital delivery through provision of delivery beds and sterile delivery packs, training, working with CHWs and TBAs to promote community- facility referral mechanism, health education and community services providing skilled birth attendance. UOM will train 30 health care workers in FY12 and equal number in FY13.

UOM will support safe infant feeding practices as per national guidelines; enrollment and follow up of 88 of babies born to HIV infected mothers to access CTX, ARV prophylaxis and EID services using the HIV exposed infant register till 18 months. UOM will facilitate ART initiation for those who test positive before 2 years.

UOM will adopt efficient 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.

Program quality and proficiency testing will be emphasized to validate PMTCT results.UOM will train HCWs on PMTCT and provide orientation to the revised PMTCT and infant feeding guidelines and engage in community activities for demand creation for health services such as male involvement with couple CT services, referral and linkages.

University of Manitoba (UOM) will support treatment targeting both the general and Most at Risk Population (MARPS) 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 March 2011 SAPR, UOM had supported 3,626 adults ever initiated on ART and 3,094 were active as per SAPR 2011.

In FY12, UOM 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 3,991 patients currently receiving ART and 1,210 new adults resulting to cumulative 4,789 adults who have ever been initiated on ART. In FY13, this number will increase to 4,899 currently receiving ART and 1,224 new adults resulting to 6,013 adults who have ever been initiated on ART.

UOM in collaboration with MoH will support in-service training of 30 and 20 health care workers in FY12 and FY13 respectively, identify human resources and infrastructure gaps and support in line with MoH guidelines, and support good commodities management practices to ensure uninterrupted availability of commodities.

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

UOM will continue to support ongoing community activities and support for HIV infected individuals including peer education and support groups to strengthen adherence, effective and efficient retention strategies, referral and linkages to psychosocial support groups, economic empowerment projects, Home Based Care, and food and nutrition programs. UOM will support provision of friendly services to youth and special populations. UOM 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.

UOM 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 support short term activities with greater impact and better patient outcomes. Additionally, UOM 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 performance. UOM 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.

University of Manitoba (UOM) will support implementation of pediatric HIV services in Nairobi. Nairobi Province has an estimated population of 3.1 million people respectively with an estimated adult HIV prevalence of 8.8% compared to the national 7.1%. UOM targets both general population and children born to Most at Risk Populations (MARPS). UOM will support integrated, comprehensive pediatric HIV treatment services in Nairobi Province. As of March 2011 SAPR, UOM had enrolled 144 children on ART with 120 active on treatment.

In FY12, UOM 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 228 pediatrics currently receiving ART and 46 new pediatrics resulting to cumulative 274 pediatrics ever initiated on ART. In FY13, this number will increase to 269 pediatrics currently receiving ART and new 41 resulting to cumulative 315 pediatrics ever initiated on ART.

UOM 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; treatment failure assessment through targeted viral load testing; Adherence strengthening; and enhanced follow up and retention. UOM will also support EID as per MoH guidelines, PITC to all children and their care givers attending Child welfare clinics, family focused approach, community outreach efforts, and integration of HIV services in other MNCH services.

UOM will support hospital and community activities to meet the needs of the HIV infected adolescents such as 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.UOM will support in-service training of 50 and 30 HCW in FY12 and FY13 respectively, continuous mentorship and capacity building of trained HCW on specialized pediatric treatment including management of ARV treatment failure and complicated drug adverse reactions. UOM will also identify human resources and infrastructure gaps and support in line with MoH guidelines as well as 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.

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