International Medical Corps (IMC) provides funding and technical support to build capacity for quality, integrated TB/HIV services in Kenyan Prisons Services (KPS). The goal is to reduce the new HIV infections, improve the quality of life of those infected and affected and mitigate the socio-economic impact of the epidemic in KPS countrywide. IMC goal and objectives are linked to Kenyas PF and GHI strategies and are directly aligned to PF pillars 1-3, prevention, care and mitigation, treatment, and systems strengthening. Strategies to reduce maternal and child mortality and eliminate MTCT include supporting family planning integration into HIV clinics. M&E plans will align with PEPFAR and country PF. Training on and use of MOH HMIS systems will be supported to eliminate parallel M&E

Cost efficiency is being addressed through integration of services, use of existing evidence-based efficient strategies, task shifting, implementing more facility-based training and mentorship as opposed to offsite training. Efforts are being made to avoid duplication by holding stakeholders forums to streamline partner activities and collaborate with USG partners to leverage their activities in other areas.

IMC has put in place a system for program management that involves KPS officers at the national, provincial and station level. On a monthly basis, a joint team of program managers from Kenya prisons, MOH and IMC provides support supervision to supported sites. Plans are transition activities to KPS by the end of the of 2013

IMC has procured 4 vehicles between 2009 and 2011. Two vehicles are being requested with FY2012 funds since coverage will be expanded to more regions. These will be used by program staff for support supervision. This activity supports GHI/LLC.

International Medical Corps (IMC) supports HIV care and prevention activities in Kenya prisons as a national program targeting some 50,000 inmates, over 15,000 prison staff and their families and thousands of host communities. Kenya has about 100 prisons and IMC is currently supporting 40 of these.

USG technical, capacity building and financial support to prisons HIV services are factored into District and Provincial Annual Operation Plans (AOP) jointly prepared and coordinated by the MOHand Kenya Prison Services (KPS). Building on achievements of the last 3 years, IMC will strengthen the scope and quality of program activities in 12 prisons covered to date and expand to additional prisons over the next 2 years. Cumulatively, some 7,000 patients, 1,190 of these in the first half of FY 2011, were placed on different spectra of the basic care package to extend and improve quality of life throughout the HIV illness.

This basic care included prevention and treatment of opportunistic infections (OIs), nutritional supplementation through food by prescription (FBP), adherence counseling, treatment of diarrhea and other HIV/AIDS-related complications, STI diagnosis, treatment and condom provision(non inmates) and a wide range of psychological, spiritual, social, and HIV prevention services. In the next phase, the spectrum and quality of these services will be expanded and strengthened through coordinated efforts of the MOH, IMC, KPS, USG agencies and other stakeholders. Expanded activities in old and new prisons will support 3,913 current adult patients in FY12 and 4,737 current patients in FY13.

IMC will continue to support clinical services (pain relief, safe water, multivitamins, nutritional support, prevention and treatment of OIs and other complications such as diarrhea, cervical cancer screening and Kaposis sarcoma); psychological and spiritual services (group and individual counseling, end-of-life care, bereavement services); social services (vocational training, income-generating activities (IGA), legal services, training caregivers) and HIV prevention services (partner/couples testing, risk reduction counseling, adherence counseling, STI diagnosis and treatment, family planning and condom provision). Efforts will be made to ensure clients, especially inmates, are retained in care in case they are either transferred from one prison to another or discharged to civilian life at the end their sentences. Patients in care will be linked, in an integrated manner, to other HIV treatment, care and prevention services including TB screening, treatment and prevention.

IMC, in collaboration with MOH and KPS will support capacity building (staff training, mentorship, CMEs) for 50 health care workers in 2012 and 40 in 2013 to ensure high quality clinical and other services. The partner will also support good supply chain practices to ensure uninterrupted supply of commodities. IMC will continue to strengthen data collection and reporting at all levels and conduct cohort analysis and report retention rates as required by the HIV program (NASCOP) and PEPFAR.

IMC will adopt the new generation care indicators and support on-going development and use of NASCOPs electronic medical records system. The partner will adopt the quality of care indicators (CQI, HIVQUAL) to monitor prisons HIV care and support services and integrate these into routinely collected data and use the results to evaluate and improve clinical outcomes.

International Medical Corps (IMC) supports HIV care and prevention activities in Kenya prisons as a national program targeting some 50,000 inmates, over 15,000 prison staff and their families and thousands of host communities. Kenya has about 100 prisons and IMC is currently supporting 40 of these.

IMC supports TB/HIV activities in Kenya prisons as a national program targeting inmates, prison staff and host communities. The prisons are located in settings with diverse HIV rates ranging from 1% in North Eastern Province to 15% in Nyanza Province against a national average of 7.1%. HIV and crowded conditions fuel high TB rates especially in the prisons located in high burden regions where co-infection rates are as high as 80%.

In the first half of FY 10, a total of 373 newly diagnosed TB patients received their HIV results in USG-supported prisons. Over the same period, 12,531 clients (new inmates and patients in HIV care) were screened for TB leading to a yield of 78 active cases overall, 228 HIV-infected clients in HIV care received treatment for TB disease. A total of 75 TB re-treatment cases were registered out of whom 70 (93%) had drug susceptibility testing with no drug resistant TB was detected over this period. In the next 2 years, IMC will continue to intensify efforts to detect and treat TB cases in the prisons through timely clinical and laboratory evaluations. Each prison will receive adequately trained and supported clinical and laboratory staff. IMC will ensure adequate supply of TB drugs administered according to national guidelines. TB patients on treatment will be monitored clinically and through periodic sputum examination.

To reduce HIV burden for TB patients, the partner will ensure that all TB patients are screened for HIV and estimated 95% co-infected patients promptly placed on CPT and ARVs in line with MOH guidelines. IMC will support the one stop shop model to provide integrated services in all prisons. TB and HIV clinical staff will undergo both in-services and refresher trainings to gain proficiency in management of both diseases.50 health care workers will be trained in FY 12 while 40 in FY13.

To reduce the burden of TB in HIV infected patients, 3,478 in FY12 and 4,210 in FY13 HIV infected patients will be screened for TB in HIV care settings. 174 co-infected patients identified in FY12 and 211 co-infected patients identified in FY13 will be put on TB treatment and those without active TB will be provided with Isoniazid Preventive Therapy (IPT) as per national IPT protocol.

To strengthen TB infection control (IC), IMC will support distribution and use of national IC guidelines in all prisons and on-going reforms to decongest these facilities. Coughers will be triaged and fast tracked and inmates on TB treatment isolated. To improve surveillance and management of drug-resistant TB, IMC will support timely DSTs for TB re-treatments and ensure all MDR-TB cases are treated to cure.

IMC will continue to strengthen electronic connectivity between data management unit at the KPS HQs and the prisons as part of efforts to establish national electronic TB and HIV medical records systems. IMC will adopt the new generation TB/HIV indicators and support timely processing and uploading. Data will be used to evaluate progress and improve clinical outcomes.

Target population: The primary target population for the IMC Prison project is the inmates and prison staff and their families. The project also serves the prison host community. There are 103 prisons in Kenya with a total inmate population of 51,642 at any given time point and annual turnover of 260,000. There are 19,828 prison staff with 79,312 family members. The HIV prevalence in the prison population is estimated at 15.2%. Currently HTC services are offered in 46 prisons within the Prison Medical Services. In FY2012, the project will specifically target the prison inmates, prison staff and their families that include couples and youth.HTC Approaches: HTC services are provided through both client initiated and provider initiated approaches. PITC is offered in the health units where prisoners and staff seek medical services, while CITC is used in the stand alone VCT and outreach/mobile sessions.

Targets and achievements: In 2010 COP, IMC Prisons has provided HTC services to a total of 48,618 individuals out of a target of 20,000. Among this, there were 684 couples 37 of whom had HIV discordant results. The program supported the re-training of 24 service providers on HTC guidelines. In FY2012, the program will provide HTC services to 40,100 prison inmates and staff as part of the comprehensive HIV prevention package.

Testing algorithm: The national HTC algorithm is used

Referrals and linkages: All individuals diagnosed with HIV infection are immediately linked to HIV care and treatment services within the prison medical services. At the point of transfer between prisons the medical transfer forms provide information on the prisoner knowledge of status and if infected the care and or treatment regimen. Peer led networks facilitate follow up of inmates to ensure access to and also adherence to care and treatment regimens. Monitoring of effectiveness of the referral mechanism is conducted through review of records. Referral forms are issued to HIV infected individuals who have been discharged from prison so they can continue accessing services in other care settings in the community. The mechanism for follow up at community level is through the prison-community reintegration structure.

Quality management: HTC services provided in the prison settings are provided in line with the national HTC guidelines. Service providers are trained and certified as mandated by NASCOP. In line with the national Quality Assurance strategy, providers participate in proficiency testing and a counselor supervision framework is in place. The use of job aids also ensures adherence to standards.

Monitoring and evaluation: The program uses national tools for data collection and reporting. These tools capture the range of national and PEPFAR indicators including information on testing provided to key populations, couple HTC and individual level data.

Promotional activities for HTC: To create demand for HTC services all inmates are given information and education on the importance of knowledge of HIV status. The information is provided as part of the combination HIV prevention package. Prison staff are also given information during parades and other capacity building forums. Information on the importance of HIV testing is also provided as part of the patient Education at the outpatient waiting bays.

IMC implements comprehensive prevention, care and treatment programs for uniformed services (prisons) nationally. In FY 2012/13, IMC will expand HIV prevention services to include evidence based behavioral interventions (EBIs) for specific target populations in clinical and community settings as part of HIV combination prevention programs. It will target adults and adolescents living with HIV (PLHIV); sexually active HIV negative incarcerated female, prison staff, incarcerated male and youth with the following EBIs;

Healthy Choices 2 (HC2) targets youth 13-17 years, in out-of- school settings and focuses on safer sex, condom use, and negotiation and communication skills. It consists of 8 one hour modules. START is an individual level intervention targeting incarcerated males delivered at 6 pre and post release sessions and can also be adapted for individuals leaving correctional facilities. It focuses on HIV/STI/ Hepatitis health education, safe sex/condom provision at post release, assessment of personal risk and linkage to other services.

S2S is a 20 minute individual level intervention that targets women of reproductive age that focuses on self efficacy, safer sex negotiation skills and condom use. Condoms are 80% effective in heterosexual relationships when used correctly and consistently. Respect has 2 brief individual sessions targeting general population and youth, originally for heterosexual negative persons focusing on reduction of STDs/HIV, risk reduction, condom use and clients understanding of personal risk.

PHDP is an ongoing 5-10min group and individual level intervention that targets HIV infected persons in clinical and community settings, focusing on partner testing, risk reduction, condom use, disclosure, adherence, STI reduction and family planning. The efficacy of PHDP has been shown to be 68% in preventing transmission of HIV, and 96% in treatment for prevention. IMC will support roll out of video-led EBIs such as Safe in the City to 25,000 inmates.

IMC will recruit Peer Educators (PEs) to reinforce prevention messages delivered by health providers as a feasible model for task-shifting in provision of PHDP in clinical settings, and promotion of MIPA. It will support placement of 5 PEs at MCH, TB and CCC clinics in hospitals, 2 PEs at H/C and provide counseling space. One of the PEs will do client follow up to strengthen ART adherence. IMC will procure 15 containers for counseling space.

The national HIV prevalence is (7.1%).The prevalence is higher among female youth15-24 years. Prisons contribute to 15% of new infections in Kenya. IMC will reach 2204 (60%) PLHIV in FY2012 and 3118 (70%) in FY 2013 with a minimum package of PHDP, 5000 and 10,000 of incarcerated persons in 2012 with S2S and START. 2,200 youth will be reached with HC1/2 10,000 uniformed persons and 19,999 inmates reached with Respect.Quality assurance for EBIs will be promoted through training, certification of service providers using approved national curricula, standard job-aids, guidelines and regular supervision.

IMC will support integration of HIV prevention into care and link programs to community programs. PLHIV will be linked to STI/FP services through patient escorts.

Monitoring of EBIs will be done through review of IMC implementation plan, analysis of KePMS data, quarterly reviews and reports. Evaluation will be conducted through operation research of combination HIV prevention and periodic surveys.

IMC supports HIV care and support activities in Kenya prisons as a national program targeting some 50,000 inmates, over 15,000 prison staff and their families and thousands of host communities. Kenya has about 100 prisons and IMC is currently supporting 40 of these.

IMC supports PMTCT activities in Kenya prisons. In the first half of FY 11, 1660 pregnant women received HIV counseling and testing and received their test results in the prison settings. 124 (7.5%) of these women tested HIV+ out of whom 81 (65 %) received ART prophylaxis to protect their unborn babies. All HIV+ mothers were enrolled in the prisons comprehensive HIV care and treatment clinics while 40 of these women delivered in the prison health facilities. PCR HIV test results for HIV exposed infants are being compiled.

In FY12, IMC will offer HIV counseling and testing to 1,429 pregnant women at the ANC and give ARV prophylaxis to 119 HIV infected pregnant women. The HIV infected women will receive a CD4 test after undergoing a WHO clinical staging. IMC will give HAART to all eligible HIV positive pregnant women in line with the revised PMTCT national guidelines. In FY13, IMC will increase the number of pregnant women counseled to 1,500 offer ARV prophylaxis to 144 HIV infected pregnant women and 124 HIV exposed infants and do early infant diagnosis (by PCR-DNA testing) for 124 infants.

HIV positive pregnant women will be assessed clinically and staged using WHO criteria and baseline CD4 levels. Additional services will focus on the 4 PMTCT prongs: primary HIV prevention, FP to stem unwanted pregnancies, ARV prophylaxis for all HIV+ pregnant mothers and their exposed infants, care and treatment for eligible mothers, partners and children. The minimum care package will include health education, individual and family HIV counseling and testing, clinical and laboratory monitoring, OI screening, prevention and/or treatment, ART prophylaxis and treatment for both mother and baby, nutritional and psychosocial support. Additional interventions will include TB screening, TB treatment for mothers with active TB and TB prevention (IPT) for mothers without active disease. Among prison staff and host communities, IMC will expand couple counseling and testing targeting at least 450 of 1st ANC attendees. HIV prevention interventions will be provided to discordant couples to prevent new HIV transmissions and facilitate linkage to prison HIV care and treatment services. The partner will promote skilled deliveries and support improvement of infrastructure and adequate supply of commodities such as sterile delivery packs.

IMC will support promotion of safe infant feeding and postnatal ART prophylaxis practices in line with MOH guidelines. HEI will be monitored for HIV infection by PCR-based early infant diagnostic (EID) tool and children who test PCR positive before 2 years will be initiated on ART. Mothers and their babies will be retained in care through strategic use of community health workers and appointment diaries and registers to track defaulters.

IMC will support staff training 60 in FY 12 and 60 in FY13. This to include structured mentorship and support supervision program to ensure that prison PMTCT services produce high quality data essential for program planning and evaluation. IMC will spend less than $18 per woman and use the same amount to cover the four PMTCT prongs and the wraparounds such as safe water and malaria prevention.

IMC supports HIV care and prevention activities in Kenya prisons and services targeting ~50,000 inmates, ~15,000 prison staff and their families and host communities. The prisons are located in settings with diverse HIV prevalence ranging from 1% in North Eastern Province to 14.9% in Nyanza Province against a national of 7.1%. As per 2011 SAPR results, a cumulative 1,751 adults on ART and 1,292 were active in the IMC supported sites.

In FY12, IMC will jointly work with the MoH and KPS to continue supporting provision of quality adult HIV treatment services in the prisons to 1,334 patients currently receiving ART and 182 new adults resulting to cumulative 1,601 adults who have ever been initiated on ART. In FY13, this number will increase to 1,471 currently receiving ART and 184 new adults resulting to 1,785 adults who have ever been initiated on ART.

IMC in collaboration with MoH will support in-service training of 50 and 40 health care workers in FY 12 and FY 13 respectively; identify human resources and infrastructure gaps and support in line with MoH guidelines; support good commodities management practices to ensure uninterrupted availability of commodities.

IMC will support provision of comprehensive package of services to all PLHIV including ART initiation for those eligible; laboratory monitoring including biannual CD4 testing, viral load testing for suspected treatment failure (through strengthened laboratory network); cotrimoxazole prophylaxis; psychosocial counseling; referral to support groups; adherence counseling; nutritional assessment and supplementation; prevention with positives (PwP); FP/RH (non prisoners); improved OI diagnosis and treatment including TB screening, diagnosis and treatment. Ongoing community interventions for PLHIV including education by peer educators and use of support groups to provide adherence messaging, defaulter tracing and follow up will continue to be supported to improve retention in all sites.

IMC will continue to support inter prison referral mechanisms and linkages to other health facilities to prisoners released or pardoned for continuity of HIV services. In the prisons, IMC will support ongoing community activities including education by peer educators and use of support groups to strengthen adherence, effective and efficient retention strategies; food and nutrition programs. Additionally, IMC 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.IMC will adapt the quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV treatment services integrate them into routinely collected data; use the results to evaluate and improve clinical outcomes and additionally support short term activities with great impact and better patient outcomes.IMC 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. IMC will continue to strengthen data collection and reporting at all levels to increase and improve reporting to KPS HQs, NASCOP and PEPFAR. Use of an electronic medical records system will be supported and strengthened.