The USAID-AMPATH Partnership HIV Program is a comprehensive clinical care program. All HIV and tuberculosis (TB)-related care and treatment are provided free at the point of care for patients through the Kenya National Leprosy, Tuberculosis, and Lung Disease (NLTLD) Program. The HIV clinical care protocols used by AMPATH are consistent with those recommended by the Government of Kenya (GOK) and the World Health Organization (WHO). In addition to providing antiretrovirals to both HIV infected adults and children, AMPATH also has an extensive prevention of Mother-To-Child Transmission (pMTCT) program, conducts facility and community-based HIV counseling and testing, provides nutritional support for its most food insecure and malnourished patients, and builds patient self-sufficiency through offering income security programs including skills training, micro-financing, a fair-trade-certified crafts workshop and an agricultural co-operative. AMPATHs activities take place within GOK and non-governmental facilities, and at the grassroots level in multiple communities. AMPATH cooperates and collaborates with all levels of health providersfrom specialists at tertiary care facilities to community health workersto provide effective and culturally appropriate care. This partner plans to procure 5 vehicles in FY12. This activity supports GHI/LLC and is funded primarily with pipeline funds in this budget cycle.

AMPATH provides HIV care services to PLHIV which are mainly preventive and include: HIV diagnosis; antiretroviral treatment; CTX prophylaxis; treatment of OIs; palliative care; prevention, early detection and treatment of TB; and nutritional therapy.Other preventive services include: PMTCT, PEP, couples C&T and PwP. is the adult population aged 18years and above.Support services provided:? Six month nutritional support for very ill patients, those with very low socioeconomic power and those with low BMI.? Social support for patients unable to pay for housing or school fees for their children, transportation support for those who come from far, to pregnant women and those on high risk express care.? Psychosocial support addresses psychosocial; It aids adherence issues, stigma and co-morbidities e.g. TB infection and substance abuse.? Outreach services Outreach workers follow patients missing clinic visits by use of a locator form that is filled on a patients initial visit and when the patient relocates.? HAART and Harvest initiative (HHI) - provides demonstration farms for patients on best farming practices to ensure food security and financial stability. In conjunction with WFP, these farms also produce some of the food distributed to our patients in the clinics.? Family Preservative Initiative provides microfinance for starting up small businesses and boosts the capital base for business expansion. It helps constitute self help groups, provides training on fiscal management, business plans, skills and vocational training e.g. for bead work by women. It also provides employment opportunities at a fair-trade-certified crafts workshop where women patients do bead work for sale.? Legal Aid Centre for Eldoret (LACE) provides legal representation for patients who have no means of getting legal redress.? OVC support through provision of basic needs and ensuring protection of their interests as well supporting child-headed households.? The model of care is facility-based government owned hospitals, HBC for counselling and testing and onward referral and linkage to care is provided. There are currently 25 sites and 40 satellites being run and various other facilities which are being supported within the catchment areas.Services have been scaled up to improve reach to patients with advanced HIV disease, pregnant women and HIV/TB co-infected patients. Integration of HIV prevention, care and treatment with RH/FP services ensures improved access to care and protection from HIV.There is a move towards country self sustenance through training and retention of health care workers, managers, administrators, health economists, and other civil service employees critical to functions of a health system and supporting efforts to identify and implement harmonized health systems measurement tools. Enrolled patients undergo nutritional, social, psychosocial assessment and they also give detailed information on their residence. This helps enhance retention in care.Referrals to care within and out of AMPATH for continuity of care; Patients undergoing inpatient or outpatient treatment are usually referred back to their care centres after they receive the services they had sought to continue with care.Linkages are available with other program sites like APHIA PLUS in the north rift, CDC in Nyanza, and Walter Reed in Nandi that offer HIV care. Cross referrals are also done for continued care of patients from these program sites to AMPATH.

The OVC Program empowers OVC, their families, and their communities to build a foundation of action and hope for a healthy and sustainable future. The program uses a holistic and multi-disciplinarian approach to strengthen the capacity of families and communities to care and protect their OVC by prolonging the lives of the HIV-infected children and supporting the OVC. The programassists OVC within their families/community, allowing them to socialize, learn and address challenges within their own environment. Our target population is orphans and/or HIV-positive children aged seventeen years and below.Upper age exceptions are made when assisting child-headed households. The program currently functions in seven AMPATH sites. We have registered over 20,000 children.We offer access to education, protection, basic needs/shelter, food security, psychosocial support, medical care and economic empowerment. OVC social workers and community health workers (CHW) work with families on the ground to determine their needs using comprehensive household and individual assessments, and ranking them according to the Child Status Index . This data is entered and monitored in the OVC database. Frequent follow-up visits by the CHW and/or social worker allow proper monitoring and evaluation of the intervention(s) and their impact. Interventions are reported using an intervention coding system. This system allows the OVC program to confirm when needs have been successfully addressed and whether the interventions are effective. OVC families that are struggling economically are linked to Family Preservation Initiative where they gain access to training on agriculture, IGAs, and Group Integrated Savings for Empowerment. A combination of training, saving, and borrowing capital allow long-term economic growth and security for the family. In the districts, we have strong ties to existing childrens networks, and Quality Improvement teams; sit on Area Advisory Councils and within the Regional Childrens Forum. We also link with Community Development and Bursary Fund managers to bridge gaps in OVC educational funding. AMPATH OVC program has achieved 85% of objectives and targets set in our COP. Our explicit OVC protocols make the program scalable and replicable to any site.Our educational interventions have increased the overall mean grade of our OVC from C plain to C plus. We have enabled OVC households to realize their potential in terms of assets and resources by use of SWOT analysis and setting of smart goals, thus improving the standard of life for most of our OVC. The OVC program has been instrumental in forming over 80 GISE groups in less than a year. These groups are actively saving, loaning and paying dividends to OVC Guardians. This is our exit strategy ensuring that families work towards self-reliance to support their OVC. The OVC program functions on a limited budget despite the fact that the number of OVC increases continually. This severely limits our expansion to new sites and the ability to offer services to the growing number of OVC in existing sites. Financial limitations have also made it difficult to hire enough data staff to enter data and create reports in a timely manner for purposes of monitoring and evaluationTransport remains a challenge. OVC has a simple, flexible data collection tool. We continue to adapt our system to meet new and changing reporting needs.

AMPATH continues to offer Quality TB services in 25 sites targeting all children and adults in parts of North Rift, Nyanza and Western Kenya. The entire population is screened in our catchment area as an entry point for care services for TB or TB/HIV patients. The program serves an estimated population of 15 Million. Testing for TB and HIV both within the communities and health Facilities through the cough monitor program and the home based counseling and testing is provided. Once a client is found positive for any of the 2 diseases they are then referred for continuation of care at the nearest heath facility. Currently 4,000 clients are receiving TB/HIV treatment. Our current TB/HIV activities include;ICF Cough Monitor Program based in 49 health facilities within and surrounding the AMPATH catchment areas.Screening for TB in the Home-Based Counseling Testing program using counselorsCommunity Based MDR-TB program using health care workers who are in-charge of administering the medications throughout the duration of therapy.TB/ HIV integration among all AMPATH sites is done in coordination with the ministry of health.Provision of IPT to all HIV infected patients without signs of active TB disease and all TB exposed children less than 5 years.Opt-out? HIV testing in accordance with Kenya national TB screening guidelines for all patients presenting at AMPATH sites. HIV-TB co-infected patients are managed by AMPATH personnel using standard treatment algorithms for both TB and HIV that have been developed and approved collaboratively by the national Division of Leprosy, TB and Lung Disease and AMPATH.Immediate initiation of ART among HIV patients diagnosed with TB in line with the WHO and national guidelines.ICF of TB among HIV patients in all the clinics. AMPATH clinics are offered TB culture, when reagents are available.Provision of sputum culture for DST for all TB retreatment patients cared for at AMPATH affiliated clinics.Nutritional Support is provided for the TB/HIV co-infected patients, and MDR-TB patients. Plans are under way to also include the TB/HIV negative.Prevention with Positives program - where we trace, test and screen the partners of our clients whether HIV positive or not.The TB/HIV program is involved in continuous on-site and off-site trainings and mentoring of personnel to be able to carry out their activities.AMPATH provides a wide range of comprehensive care to all of its patients including nutritional support, legal services, and microfinance.A central M&E office based at AMPATH verifies our reports ensuring quality data and advising appropriately. This office also ensures continuous update of our reporting tools in line with the program and stakeholders requirements. For standardization and improvement of data quality we have developed TB encounter forms that are used to gather data from patients while receiving care. Data collected is entered into the AMRS, the PDAs and MS-Access databases for research projects. Our Accomplishments are:Treated 7 out of 25 enrolled MDR TB patients with the community based DOTS plus program. Our experiences have informed the country program that has now adopted the community based approach to treating MDR TB patients.Received the Job Bwayo recognition award for excellence in care and research in Kenya.We plan to scale up our cough monitor program to 60 sites and to increase surveillance for MDR TB.

Targets for next 2 yrs: 2000-3000 newly enrolled; 1000-2000 new on ARTTarget populations: North Rift, Western and NyanzaBuilding capacity of health care providers:Training on comprehensive HIV care 3 monthly and on adherence and disclosure counseling quarterly; train on procedures including DBS for Early Infant Diagnosis aiming at 100% nurse coverage in next 2 years ; Mentor providers monthly; build laboratory infrastructure to do more tests including biochemistry, CD4 and hematology. Decentralize data entry.Building capacity to supervise:Contribute to development of national targets & tools, pediatric curricula, training guidelines and manuals, reportable indicators for individual patients and individual sites; use the Kenya Pediatric Association mentorship template to evaluate sites; use our electronic medical records to distil reports to the national level through the districts and provinces; use M&E strategic plan to evaluate the pediatric program in the sites,Adherence & retention on treatment:Continued training on adherence counseling to 80% of staff in all sites; introducing adherence screening tools before initiating patients on ART in all sites; training one nurse adherence counselor per site; initiating home visits in all sites for patients who have adherence concerns; daily educational sessions in clinics on importance of continued care and involve the community, , and local media in disseminating information; Introducing community based care in 50% of the sites to decongest clinics.Integration & linkage of treatment:Train MCH personnel to do routine HIV screening during immunization at 6 weeks and 9 months; provide pediatric HIV care in MCH and OPD in 50% of the sites in 3 years; continue aggressive nutritional assessments and management and provide nutritional support to malnourished children and lactating mothersEarly infant diagnostic services (EID) & PITC HIV testing:Train Nurses on DBS in all sites; Strengthening linkages between delivery points & testing points for EID; Increasing number of pMTCT sites; Increasing HIV antibody screening in 100% of admitted children; Advocating for Point of care diagnosis & Initiating Home based testing using CHW; for children and adolescents and initiate school based testingCD4 % availability & viral load monitoring:Decentralizing CD4 testing to more health centers and ensuring 6 monthly CD4% testing in all HIV infected children Increasing capacity to do viral testing (by availing transportation of specimen to MTRH) for children before initiating ART and for follow-up in those with suspected treatment failureAdolescents treatment & transitioning to adult services.Training COs, nurses on adolescent focused care and introduce encounter forms in all sites with adolescent care; Renovating spaces, Introducing support groups and group counseling for adolescents from age 14-15 as they transition to adult careUse of pediatric HIV data with the USG and national program:Continued use of Electronic Medical Record System to collect data, decentralizing data entry and continue monthly sharing of data with GOK and USG. Analyze data to inform national policy and continue doing operational research. 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.

The clinical laboratories at AMPATH provide specialist reference laboratory services forAMPATH patients and other patients as per the established laboratory protocols / SOPs.The laboratories have also capacity to provide technical services for clinical studies as per the study protocols.The AMPATH Labs have responsibilities for:Expanding laboratory capacity to perform routine HIV diagnostic and monitoring tests by ensuring that approximately thirty (30) AMPATH facilities are strengthened to provide enhanced laboratory services annually.HIV testing laboratories within the AMPATH catchment areas are accredited according to national or international standards.Ensuring that annually six (6) laboratories have capacity to perform HIV ELISA tests, eighteen (18) laboratories have capacity to perform CD4 tests and thirty (30) laboratories have capacity to perform TB Diagnostics.Ensuring that annually forty (40) individuals are trained in the provision of laboratory-related activities.The AMPATH Laboratories now receives reagents and associated supplies for six thousand (6000) CD4 Tests, six hundred (600) EID and six hundred (600) vViral load tests per month from USAID through CHAI and SCMS. The laboratory has now started receiving requisitions for laboratory tests from non-AMPATH sites (APHIA Plus) for these tests in the North Rift and Western Kenya regions.The AMPATH Laboratories performs routine laboratory monitoring and diagnostic tests for AMPATH patients including approximately six thousand long ELISAs, two thousand TB microscopy, four hundred TB cultures, eight thousand syphilis diagnostics, one hundred thousand CD4 tests. Eight thousand EID and viral load tests, sixty thousand chemistries and hematologies annually.To achieve the goal of improving the standards of health facility laboratories in western Kenya and the North Rift region, the AMPATH Laboratories have a mentorship program in GCLP that covers all staff at health facility laboratories. This program has so far covered eighteen health facility labs in western Kenya and six in north rift. By the end of 2012 all laboratory staff at the health facilities in these two regions will have undergone this training. Following this training the facilities will be monitored on quarterly basis to assess progress being made towards improvement in the quality of laboratory services being provided and institute proper corrective and preventive actions. At the end of the year the laboratories will be assessed using the WHO-AFRO Checklist that is used to establish the level of the laboratory services provided at the facility. Already the AMPATH Laboratories have mentored the western provincial general hospital laboratory to a three star laboratory following assessment by KENAS.

HIV prevention interventions focusing on AB will target youth from 15 29 years, men and women aged 15 49 years at the workplace as well as the general population where feasible.School-based HIV prevention programsFor the majority of young people, the first sexual relations are not within marriage. On the contrary, first sexual relations are mostly casual. The proportion of young people who engage in abstinence until marriage has been declining over time.Strategies:Campaigns to delay sexual debut among youth between 15 & 19 years in secondary schools within AMPATH coverage areas will be conducted. Parents will be encouraged to start Abstinence messaging at an early age through counseling. HIV awareness and prevention will be addressed by in-school youth peer prevention programs. These approaches will be implemented in selected schools as a prototype and replication in other schools encouraged. Campaigns will be done at least thrice a year in the prototype schools.HIV prevention in tertiary learning institutionsStrategies:For youths between 19 & 24 years, strategies will be adopted to help them develop life skills for personal risk assessment in order to safely transition from abstinence to sexual activity. These will be youth out of school or those in tertiary learning institutions since studies have revealed that youth in institutions of higher learning engage in behavior that could expose them to the risk of HIV infection through engagement in sexual activities, often with multiple partners.Workplace HIV Prevention ProgramsThe workplace involves the environment as well as the culture or practices practiced at the workplace. It is seen to be a convenient and conducive setting for HIV and AIDS control activities and workplace based interventions since it is where a considerable number of men and women meet, interact and educate one another on many issues of importance to human life.StrategiesPrograms with AB and appropriate C messaging and services will be developed to reach men and women between 15 & 49 years in the workplace. Issues relating to adult male behaviour, risk perception and intergenerational and transactional sex will be addressed through interpersonal communication . These prevention messages will be delivered during risk-reduction counseling. Partner reduction messages will be given, emphasizing faithfulness to one partner, mutual fidelity while discouraging intergenerational and multiple sex partnerships.Prevention with Positives (PwP)Scaling up of PwP in AMPATH will be integrated in all settings including testing points and where HIV infected persons are being provided with care both at the facility and in the community.StrategiesMessages on abstinence and being faithful will be continually provided to Adults and adolescent and youth clients who are already HIV infected; through support group sessions and during interaction with the health care providers.The HIV prevention interventions will be implemented in selected populations in all twenty-five (25) AMPATH sites that are spread throughout the western Kenya region. The population served by AMPATH is approximately 2.8 million peopleAB prevention activities provided to the different cohorts is closely linked to the HIV C & T.

AMPATHs HIV counseling and testing activities target the general population including couples, pregnant women, MARPs. Activity coverage areas include Western Kenya region with estimated population of 2.8 million in eight districts. The HIV prevalence in this region is estimated at 7.7%. Over the last 12 months AMPATH has tested and provided results to 132,384 1individuals in the door to door testing in Teso, Port Victoria, Chulaimbo, and Kapsaret sites. This involves the use of client-initiated HIV counseling and testing which mainly focuses on VCT. In addition, AMPATH conducts provider-initiated testing and counseling in outpatient and Inpatient departments and TB Clinics including perpetual home based counseling and testing in all communities.AMPATH uses the Ministry of Health approved serial testing algorithm in all the sites.The table below summarizes the targets and achievement for number of individuals who received testing and counseling and were provided with results using the approaches employed during the past one year.Approach Target and Annual ResultPerpetual Home Based C&T: Target 132,442: Actual 132,384PITC : Target 140,000 : Actual 130,044PMTCT: Target 40,000: Actual 79,562VCT: Target 12,000 : Actual 6,722To enhance the ability of staff to effectively conduct HIV testing and counseling, AMPATH provided Counselor Refresher trainings, 65 individuals were trained. The trainings will continue during COP 2012.AMPATH continues to ensure substantial allocation of its budget to support testing and counseling activities. During the last year Kshs 89,566,003 supported the provision of HCT/PHCT activities in the geographical area of coverage. To ensure provision of quality and comprehensive services, AMPATH has an effective referral linkage mechanism that supports identification and linkage of clients to other components of AMPATH program including Care and support, and treatment. All patients details are recorded in referral forms to facilitate easy tracking of patients who are referred to facilities but do not eventually access care and treatment services.Emphasis is placed on the safety and storage of test kits. Test kits are stored and handled as per the recommended protocols.Quality assurance and quality control of results is carried for every 20th client specimen taken by nurse counselors. In cases of discordant couples, samples for Long ELISA are taken for comparison; correct samples are maintained as per laid guidelines. AMPATH reference LAB supervisors also conduct quality checks by internal audit QA and external audit QAJoint supervisory visits are carried out by AMPATH and MOH staff on a monthly basis.AMPATH makes use of CHWs, CHEWs to mobilize communities for increased uptake of testing and counseling activities.Data collected from the Door to door testing is captured electronically using the G1 Android phones, and then synchronized to the AMRS.Data from the facility based C&T is captured through the MOH data collection Tools.

Other HIV prevention interventions will target youth from 15 29 years, most-at-risk-populations (MARPs) such as long distance truck drivers, sex workers, fisherpersons, prisoners, men who have sex with men as well as the general population.

HIV prevention in tertiary learning institutionsFormation or strengthening of post-test clubs for continued HIV education and awareness will be supported. Condom education and supply will be enhanced in addition to messaging on AB.

HIV Prevention at the WorkplaceWorkplace support networks for PLHIV will be established at their places of work where possible. There will be education on the use of condoms and supply will be done in collaboration with the ministry of health.

Prevention with Positives (PwP)There will be education on condom use and supply to individual clients through the existing distribution outlets. Self risk assessment and risk reduction counselling for clients will be conducted.

Most-at-risk-populationsSpecific interventions targeting each of the MARPs will be developed. These will include economic empowerment for alternative income for sex workers as well as risk reduction among long distant truck drivers, fisherpersons, prisoners and MSM.

Media advocacyThis will be used as a medium to provide cross-cutting HIV prevention information and educate the audience.

STI educationThis will be provided to all audiences considered to be sexually active due to the established association between HIV risk and presence of STIs

Alcohol and substance abuseEducation will be provided to the general population and efforts made to design specific programs targeting the alcohol brewers where feasible.Mechanisms to Promote Quality AssuranceSupport supervision will be done on a continuous basis and performance Gaps identified will be addressed through appropriate strategies.

Integration and /or linkage with other services/platformsImplementation of the HIV prevention services will be in an integrated manner to ensure effective linkage with, care and support, treatment and PMTCT.

Monitoring & Evaluation PlansData will be collected using tools that will be specifically developed for the various interventions and shared with all the stakeholders.

Transmission rate by 18 month ELISA is currently 3.6%The target for the next 2 years:To reduce transmission to less than 5% for all districts within AMPATH coverage and within the next 5 years to reduce transmission to less than 1%.Building capacity:PMTCT clinical care is provided by clinical officers and nurses. They identify pregnant and breastfeeding women who need ARVs for prophylaxis and treatment and the protocol for managing them. Training is also provided for routine antenatal and postnatal care and family planning counseling. Consultants, Medical Officers and selected clinical officers provide clinical mentorship, offer support supervision and are consulted on complicated obstetric or medical cases.Staffs are trained and involved in identifying HIV infected women at the MCH and Labor Ward, initiate management and refer them to the HIV clinic.PMTCT services are offered in 57 comprehensive facilities and 106 satellite sites. There is an initiative to provide PMTCT services to all level III facilities in the AMPATH catchment areas. AMPATH PMTCT managers participate in review of National PMTCT guidelines as well as NASCOP PMTCT Technical Working Groups.At regional, district and site level, clinical supervisors monitor the observation of protocols for PMTCT in the various levels and availability of commodities required for PMTCT.

Scale up of PMTCT activities:Prevention of infection is done is collaboration with home based counseling and testing in the community. At the facilities there is support of VCT, and strengthening of PITC and testing of all ANC mothers, mothers in MAT and PNC mothers.Counseling and provision of FP services to HIV infected women is carried out in the HIV clinic with the aim of having integrated services in all HIV care facilities.All pregnant and breastfeeding HIV infected women are evaluated for eligibility for ARVS; HAART is prescribed accordingly. All HIV exposed infants are given prophylactic ARVs.PMTCT patients who default are visited at home within 2 weeks of the missed visit. Couple counseling is promoted in all the facilities. In the community, testing of the entire family is done through the HCT team.Increase of PMTCT uptake:All pregnant or lactating women are tested at the MCH clinic. Those found positive are linked to routine ANC, PNC and PMTCT services.In the community, community-owned resource persons (CORPS) and community health workers (CHWs) are trained in PMTCT and encourage pregnant women to get tested for HIV and promote PMTCT services. They do undertake community mobilization and talk about various health issues in community gatherings including HIV testing , care, and PMTCT.Integration of PMTCT with routine MCH/RH services:HIV infected patients are comprehensively managed by the AMPATH team. CD4 count and WHO clinical staging are done for eligibility for treatment or prophylaxis in all HIV-infected mothers. ANC and PNC care is routinely carried out.Establishment of cervical cancer screening in 4 facilities and the initiative is being rolled out.12 facilities have fully integrated FP in the HIV clinic; this is being rolled out to cover all facilities that offer PMTCT services.Pregnant and lactating mothers with inadequate food supply are provided with food support.

AMPATH training on HIV/AIDS focus on ART both in adult and pediatric patients. Other trainings include palliative care, PMTCT, PITC, Pediatric Disclosure, Cervical Cancer Screening and HCT. Family planning training is conducted under reproductive health.The program provides mentorship to clinicians, nurses and laboratory staff over a three month period.Preceptor programs are available using experienced clinicians and nurses who serve as role models and facilitators. They coach, inspire and support the development of new qualified professionals through transition from new learner to practicing professional.

Support supervision helps in addressing quality/performance gaps and allows the program to asses and monitor the quality of services provided to patients. Supervision is based on the National guidelines and protocols.Indicators used to track and evaluate clinical outcomes include:Percent of new patients with CD4=200 receiving cART within 3 months; Percent of HIV-positive persons receiving Cotrimoxizole (CTX) Prophylaxis; Number of patients Ever enrolled; Number of patients Ever started of ARVs; Number of patients Active on ARVs; Cumulative Number of patients deceased; Number of patients lost to follow up; Couples tested for HIV (in the last month/ ever tested); No. of women tested for HIV in ANC; and No. of HIV-positive pregnant women on treatment.

The number of clients tested and enrolled into the program indicates the performance of the professionals. The enrolled clients are then retained in the program.The data obtained will help identify good performance and areas which require improvement and will guide identification of areas requiring improvement.The following activities support retention of patients initiated on ART:Outreach program for patients who miss appointments; reduces the cumulative numbers of patients lost to follow up and increase the number of No-show patients who are followed up.To increase staff competence; monthly, quarterly and annual review meetings will be conducted. The meetings will help asses training needs among staff. Trainings will subsequently be conducted to increase knowledge and skills that will be used to improve staff performance. CHWs located around the sites will be engaged to reach clients timely and improve adherence.The adherence activities supported include:Psychosocial Counselling - addresses the emotional and social needs of HIV patientsAdherence counseling Focuses on both adherence to care and treatment and behavior change.Patient education for treatment buddies who will supervise or support the patients.Use of adherence enhancers - using counseling, medication diaries, pill boxes, buddy/partner system, modified DOT and telephone remindersSix month nutritional support will be provided tor index patients and their dependentsSocio-economic support is given to retain patients on care.Outreach services -for follow up of clients who miss clinic appointments with no prior communication.Peer counseling provides psychosocial support to all clients from enrolment through the continuum of care.The target population is all HIV infected adults in the catchment area. Patients enrolled into care receive ARV treatment when they are eligible; treatment for opportunistic infections, cotrimoxazole prophylaxis and TB screening on enrolment and subsequently depending on signs and symptoms and history of exposure, use on isoniazid for prophylaxis.

Target populations: North Rift, Western and NyanzaProvision of drugs, food and other commodities for pediatric clients:Continue providing co-trimoxazole for all breastfeeding HIV exposed children, all non-breastfeeding children before confirmation of negative status and all HIV infected children irrespective of age or disease stage; continue providing treatment for opportunistic infections in all sites using revolving pharmacy fund; provide vitamin supplementation to all HIV infected children; strengthen and facilitate referral to level 3,4 or 5 facilities for complicated disease; provide ITN for children in Malaria endemic areas; continue aggressive nutritional assessments in at all visits by nutritionists, nurses and clinicians; enhance the use of automatically calculated reminders for malnourished children; Continue to provide nutritional supplementation for malnourished children and adolescents and evaluation of socio-economic status.Adolescents with HIV:Continue disclosure, support groups counseling targeting all adolescents; expand adolescent focused care services to 50% of sites in 5 years; initiate group counseling sessions and support groups for adolescents transitioning into adult services; continue adherence screening before initiating ART, initiate home visits and enhanced counseling in adolescents with adherence problems, employ nurse counselors specific to adherence and disclosure counseling support; strengthen counseling on sexuality and risk reduction; initiate support groups for disclosed adolescents for positive living; avail family planning servicesSupervision, improved quality of care and strengthening of health services.Continue regional consultant visits and mentorship to clinics; continuous quality improvement related to pediatric HIV care primary objectives and continuous medical education during site visits; continue leadership in protocol revisions/updates/dissemination and National representation in development of guidelines and curricula

Activities promoting integration with routine pediatric care, nutrition services and maternal health services.Train MCH personnel to do routine HIV screening during immunization at 6 and 9 months; Introduce pediatric HIV care in MCH in 50% of sites .; train outpatient & inpatients nurses and clinicians on HIV care protocols in all level 3 and above facilitiesActivities to strengthen laboratory support and diagnostics for pediatric clients.Continue to build laboratory infrastructure to do more tests including biochemistry, CD4 and hematology; train and impart skills to nurses in all sites on DBS for early infant diagnosis and rapid HIV testing; continue network to support DNA PCR, CD4, biochemistry and viral loads in facilities unable to do the tests; utilize the existing referral system to level 3,4 5 or 6 facilities.Plans for monitoring and evaluation.Work with M&E team on the strategy for the coming 2-5 years; continue monthly evaluations of the key indicators and dissemination of the report to GOK through the facilities program leaders