UON Partnership for Advanced Care and Treatment Centers of Excellence (COE) project goal is to enhance the technical capacity of staff and faculty to provide high quality, evidence-based, comprehensive and integrated HIV prevention, care and treatment services at Kenyatta National Hospital (KNH) and Pumwani Maternity Hospital (PMH). They will support Kenyas HIV programs by establishing networks and capacity building HCW to ensure provision of quality HIV care and treatment services as well as by supporting policy, guidelines and curriculum development. COE will strengthen the capacity of KNH and PMH to ensure data quality, analysis, reporting, and use for evidence-based programming. Electronic medical records systems will be supported to ensure quality and sustainable M&E systems to inform program implementation and improvement. Periodic patient level outcome studies will be carried out to assess quality of interventions.

Cost efficiency is being addressed through integration of services, staff, use of existing evidence-based efficient strategies, task shifting, implementing more facility-based training and mentorship as opposed to offsite training, evaluating cost effective strategies for defaulter management, laboratory networking, and mobilization.

UON is a locally based university. To ensure transition and sustainability, COE will transfer administrative and program responsibility to PMH and KNH. Financial reporting systems will be established and integrated quality management teams in the facilities will be supported so that skills are transferred to staff in the two institutions.

COE acquired 1 van in 2011 to strengthen community based treatment prevention and defaulter tracing. No vehicle will be required in FY 12.

This activity supports GHI/LLC.

The University of Nairobi, Partnership for Advanced Care and Treatment, Centers of Excellence (COE) will continue to support pediatric ART services as part of integrated, comprehensive HIV clinical services in Kenyatta National Hospital (KNH) in Nairobi province. By March 2011, COE had cumulatively enrolled 14,946 patients in HIV care including 4,219 active patients on cotrimoxazole prophylaxis.

COE will work with the Ministry of Health (MoH) at the provincial, district and health facility levels, to jointly plan, coordinate, implement and ensure provision of quality HIV care and support to 4,773 current adult patients in FY12 and 9,251 current patients in FY13. A package of care services will be offered including HIV testing to partner and family members of index patient and enrolling or referring/linking those that test HIV positive to care and support; provision of Basic Care Kit (safe water vessel, multivitamins, insecticide-treated mosquito nets, chlorine for water treatment and educational materials); supplemental and therapeutic nutrition (FBP) to all eligible HIV positive patients; prevention with positives(PwP); and cervical cancer screening to all enrolled women.

In collaboration with MoH, COE 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. Areas with staff shortages will be identified and additional staff recruited. COE will also support good commodities management practices to ensure uninterrupted supply of commodities will be supported.

Ongoing community interventions for HIV infected individuals will be supported including peer education and 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; Home Based Care services; Gender based violence support programs; vocational training; social and legal protection; and food and nutrition programs.

COE 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 adopted including supporting male peer educators, mentors and support groups, and supporting women to disclose and bring their male partners for testing and care and treatment.

COE will continue to strengthen data collection and reporting at all levels to improve reporting to NASCOP and PEPFAR. COE will adopt the new generation indicators support the development and use of electronic medical records system in accordance with NASCOP guidelines. COE will continue using the quality of care indicators (CQI) 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. COE will do cohort analysis and report retention rates as required by the NASCOP. COE will support joint Annual Operation Plan (AOP) development, implementation, monitoring and evaluation, and health system strengthening to facilitate sustainability.

The University of Nairobi, Partnership for Advanced Care and Treatment, Centers of Excellence (COE) has been supporting pediatric ART services as part of integrated comprehensive HIV clinical services in Kenyatta National Hospital (KNH) in Nairobi province since October 2010. Nairobi province reported 17,444 TB patients in 2010. By the end of June 2011, 1,337 TB patients received HIV testing and 703 TB/HIV co-infected patients were identified and 33% of these were put on ART.

In FY12 and FY13, COE will work with the Ministry of Health (MoH) to intensify efforts to detect TB cases through clinical exams and laboratory investigations and ensure successful TB treatment through provision of appropriate treatment. They will ensure that KNH has adequate and well trained clinical staff supported by well equipped and staffed laboratory to carry out tests. Adequate supplies of anti-TB drugs will be available and strategies to ensure that the national TB treatment guidelines are followed will be employed. All TB patients on treatment will be monitored both clinically and through periodic sputum examination.

To reduce the burden of HIV in TB patients, COE will ensure that all TB patients are screened for HIV and 95% 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. A one stop model which provides integrated TB and HIV services in all TB clinics will be supported. All TB clinics will be stocked with cotrimoxazole and ARVs. COE will train 300 HCWs in FY12 and 200 in FY13 on TB/HIV, 5Is and data management.

To reduce the burden of TB in HIV infected patients, COE will support intensified TB screening for 4,243 in FY12 and 8,222 in FY13 for HIV infected patients in HIV care settings using the national screening tool. 212 active TB patients in FY12 and 411 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 in HIV settings, COE will ensure that the national IC guidelines are available at all sites and training of staff on IC is done. 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 will be supported.

To improve surveillance and management of drug-resistant TB, the KNH lab will be equipped to support drug susceptibility testing for the retreatment cases both from KNH and other facilities and ensure return of the results to those facilities. They will also support scaling up of drug-resistant treatment thus expanding access to MDRTB treatment.

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

The University of Nairobi, Partnership for Advanced Care and Treatment, Centers of Excellence (COE) has been supporting pediatric care and support as part of integrated, comprehensive HIV clinical services in Kenyatta National Hospital (KNH) and Nairobi Province. By March 2011, COE had 1,547 children enrolled in care with 1,273 receiving HIV care, 914 on ARV prophylaxis, and 582 on cotrimoxazole prophylaxis.

In FY12 and FY13, COE will provide care and support services to 498 and 984 children currently on care respectively. COE will provide comprehensive, integrated quality services and scale up to ensure 1,053 HIV infected infants are put on ARV prophylaxis and all HIV exposed children access pediatric care services.

COE will continue to work with the Ministry of Health (MoH) at all levels to coordinate scale up and strengthening of pediatric care and support services. To improve the quality of care, they will support supervision and mentorship activities, adapt quality of care indicators, integrate the indicators into routinely collected data, and use the data to assess quality of pediatric HIV services.

Child survival interventions including growth and development monitoring; immunization; nutritional assessment, counseling, and support (including provision of therapeutic or supplementary feeding for the malnourished and vulnerable children, vitamin A supplementation, zinc, and de-worming); safe water, sanitation and hygiene interventions; and malaria screening, treatment, and provision of insecticide treated nets in malaria endemic areas will be provided. HIV palliative care services including specialist pediatric clinics, TB/HIV care, psychosocial care, and Prevention with Positive (PwP) activities will be provided.

COE will prioritize the identification of HIV exposed children < 24 months of age by provision of EID (PCR-DNA) for < 18 months of age and antibody testing for those > 18 months at the MCH, PITC, family-testing through clinical and community HTC strategies, and by use of the mother-baby booklet at MCH. Cotrimoxazole prophylaxis will be provided to all HIV exposed infants and ART provided for all the HIV infected. Follow up and retention of all identified HIV exposed children, HIV testing per the national guidelines, and provision of Nevirapine throughout the breastfeeding period will be strengthened.

Priority will be to ensure children enrolled in care are promptly evaluated for ART using CD4 and WHO staging; have access to diagnostic tests for opportunistic infection including cryptococcal antigen testing; are managed for opportunistic infections; and are provided with basic HIV care package including cotrimoxazole prophylaxis, multivitamins, safe water systems, TB screening, and pain and symptom relief and management. COE will support strengthening of the regional system of samples/results transfer and quality control to optimize the utilization diagnostic tests including CD4 counts, DNA PCR for Early Infant Diagnosis, viral load, and resistance testing.

Community activities will be strengthened to meet the needs of adolescents including support groups to enhance disclosure, adherence messaging, defaulter training, PwP, provision of reproductive health services, substance abuse counseling, support for transitioning into adult service, and teaching life skills. Linkages of children to various community programs including OVCs, education, and legal and social services will be provided.

The University of Nairobi (UON) in collaboration with their co-partner, University of Maryland through the Department of Medical Microbiology, Kenya AIDS Vaccine initiative (KAVI) Laboratory will support the national laboratory accreditation initiative through WHOStepwise process by giving on-site mentorship and training in Good Clinical Laboratory Practice (GCLP) and Laboratory Quality Management Systems (LQMS) in accordance with SLMTA task-based training principles to three Ministry of Health laboratories National HIV Reference laboratory (NHRL), Mbagathi DH. Such training will be designed to impact all the staff at the two labs without taking them away from their routine work. Both MOH and CDC have resolved to steer away from hotel trainings for technical personnel. Specifically, KAVI staff experienced in laboratory quality systems will work shoulder-shoulder with MOH laboratory quality officers and managers to implement ISO 15189 standards at each laboratory. Regular internal audits based on the WHO step-wise accreditation checklist will be conducted and corrective measures supported. UON-KAVI will also support preparations for external audits towards accreditation. To support facility based improvement projects AGHPF will procure stationery items and minor essential laboratory supplies such as thermometers, timers, safety boxes, diamond pencils, signage and safety devices.

Through this cooperative agreement UON- KAVI lab will give expert technical assistance to MOH, National AIDS and STD Control Program (NASCOP) and NHRL in matters related to testing for HIV diagnosis and management. This will include evidence based selection of test kits, kit evaluation, post-market surveillance, determination of testing algorithms, equipment/method validation and use of program data for decision making. This efforts will enable Kenya to successfully implement the ten steps for quality of rapid HIV/Tb/malaria testing as prescribed by CDC; Internal DGHA laboratory.

In line with GHI principles improved laboratory systems will benefit all testing areas including TB, malaria, HIV related opportunistic infections and neglected tropical diseases. These activities are in line with the Kenya/USG partnership framework which seeks to enhance laboratory quality systems. Additionally this activity strengthens local organizations and fosters sustainability and country ownership.

This cooperative agreement will be monitored by CDC Kenya through regular quarterly meeting to review progress on the work plan, compliance to the Notice of Award and USG regulations. MOH- National Laboratory Accreditation Committee guidelines will be followed to ensure country ownership and sustainability.

This activity, implemented by a local partner, will contribute directly to three accredited laboratories in Kenya and training of at least 60 health care workers. The exact cost of improving laboratory quality through the WHO Step- wise accreditation process and of running a quality HIV management laboratory support service are not yet known. This activity will provide critical information for more accurate forecasting, planning and budgeting for laboratory support for program activities. MOH laboratory managers will acquire skills in developing facility budgets and advocating for a fair share of resources both centrally and at facility level.

Target population: UON -COE will support all HIV testing and counseling services at Kenyatta National Hospital located in Nairobi City. Target population will include all patients, their family members and caretakers who access out and in patient services in all the supported facilities.

HTC Approaches: The program will utilize provider initiated opt out approach and the services are offered within all out patient departments, TB clinics, FP, ANCs, special clinics, HIV clinics (targeting family members) and in patient departments. The counseling and testing is either done within the consultation rooms by trained clinicians or in counseling rooms by lay counselors within the outpatient departments if space is available or at the laboratories.

Targets and achievements: In COP 2012, UON-COE will target to provide HTC services to a total of 79,000 persons of which 20% will be tested as couples and 10% will be children below the age of 15.

Testing algorithm: National algorithm is being used.

Referrals and linkages: In order to strengthen referrals, UON-COE will put in place several important strategies. They include: use of peer educators as patient escorts from one hospital department to the CC; same day enrollment of clients to CCC; use of an integrated defaulter tracing system for tracing patients who default on care or ART upon enrollment; introduction of documented referral system by use of the NASCOP referral booklet; use of mobile phones to follow up whether the client was actually enrolled.

Quality management: In order to improve and monitor quality of HTC services, UON-COE will put in place the following strategies: Training and continuing education of HTC providers; strict adherence to the standard operating procedures outlined in the national HTC guidelines; management of HIV rapid kits as per the guidelines; putting in place a functional QA systems as provided for in the national HTC guidelines; participation in EQA- proficiency testing and finally by conducting support supervisory visits.

Monitoring and evaluation: UON-COE will use all ministry of health tools to capture HTC data, both for couples and individual patients. These include HTC lab Register and Monthly summary tool (MOH 711). MOH approved HTC lab registers will be introduced at all HIV testing points except PMTCT.

Promotional activities for HTC: All patients attending the supported facilities will be given health talks including the need for HIV counseling and testing and the importance of couple testing. Couples are given priority services. Sexual partners of HIV positive clients will be given individualized invitations though the index clients and available avenues for testing including individualized home testing.

UON COE implements comprehensive prevention, care and treatment programs in Nairobi province. In FY 2012/13, UON COE will expand HIV prevention services to include evidence based behavioral interventions (EBI) for specific target populations in clinical settings at comprehensive care center (CCC), TB and Maternal Child Health (MCH) clinics as part of HIV combination prevention programs. The EBI will include Positive Health and Dignity Prevention (PHDP) targeting adult male and female and adolescents living with HIV (PLHIV); and Sister to Sister EBI (S2S) targeting sexually active HIV negative women attending the MCH clinics.

PHDP is an ongoing 5-10min group and individual level intervention that targets PLHIV in clinical and community settings. This mechanism will support this intervention which constitutes of ART adherence counseling and support; partner and family testing; provision of PEP to the discordant spouse; treatment for prevention once approved; safer pregnancy counseling and provision of modern contraception; sexual risk reduction counseling including reduction of sexual partners, alcohol counseling, promoting of consistent and correct condom use; STI screening and treatment and using meaningful involvement of people living with HIV/AIDS (MIPA). The efficacy of PHDP has been shown to be 68% in preventing transmission of HIV, and 96% in treatment for prevention.

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

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

Approximately 1.6 million Kenyans are PLHIV. The Kenya AIDS Indicator Survey 2007 showed 6% of couples to be in discordant relationships. Nairobi province HIV Prevalence is high (8.8%). UON COE will reach 2689 (60%) PLHIV in FY2012 and 6090 (70%) in FY 2013 with a minimum package of PHDP. It will implement S2S EBI on a pilot basis.

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

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

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

The University of Nairobi, Partnership for Advanced Care and Treatment, Centers of Excellence (COE) has been supporting PMTCT services as part of integrated, comprehensive HIV clinical services in Kenyatta National Hospital (KNH) and Pumwani Maternity Hospital in Nairobi Province since October 2010. Nairobi has an estimated 114,920 pregnancies per year and a HIV prevalence of 7%.

By June 2011, 6,866 (55% of annual target) pregnant women were tested and counseled for HIV of whom 461 were HIV positive, ARV prophylaxis given to 739 women in the ANCs and delivery units, and DNA-PCR tests were carried out for 673 infants of which 9 (1.6%) were positive among the 542 received. 63 HCW have been trained on PMTCT.

In FY12, COE will offer HIV counseling and testing to 11,415 pregnant women at ANC and give ARV prophylaxis to 1,008 HIV infected pregnant women. The HIV infected women will receive a CD4 test after undergoing WHO clinical staging. COE will give HAART to all eligible HIV positive pregnant women in line with the revised PMTCT national guidelines. In FY13, COE will increase the number of pregnant women counseled to 11,986, offer ARV prophylaxis to 1,225 pregnant women and 1,053 infants, and do EID for 1,053 infants.

COE 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 treatment, ARV prophylaxis and treatment for both mother and baby, nutritional support, psychosocial support, PWP, follow up, retention, and referral and linkages. COE will incorporate TB screening into routine antenatal care.

COE will reach 3,596 of 1st visit 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. COE will support integration of ART in MCH clinics, access to FP/RH services, and establish or strengthen infection control and waste management activities. COE 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.

COE will adapt 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 utilization 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.

COE will train 100 HCWs in FY 12 and an equal number in FY13 on PMTCT and provide orientation to the revised PMTCT and infant feeding guidelines. COE will engage in community activities for demand creation for health services such as male involvement with couple CT services and referral and linkages.

The University of Nairobi Partnership for Advanced Care and Treatment and Centers of Excellence (COE) will support treatment services at Kenyatta National Hospital (KNH). KNH is the national referral hospital in Kenya. COE has been supporting the development of sustainable technical leadership in HIV prevention, care and treatment in Nairobi province since October 2010 to ensure provision of evidence-based, high quality, comprehensive and integrated HIV services that meet national quality standards including adult care and treatment. As of March 2011 SAPR, 8,788 patients had been initiated on ART and 4,634 were active.

In FY12, COE will jointly work with the Ministry of Health (MoH) to continue supporting expansion and provision of quality adult HIV treatment services as per MoH guidelines to 6,300 patients currently receiving ART and 918 new adults resulting to cumulative 7,560 adults who have ever been initiated on ART. In FY13, this number will increase to 6,990 currently receiving ART and 929 new adults resulting to 8,489 adults who have ever been initiated on ART.

COE will support in-service training of 300 and 200 HCWs; continuous mentorship of trained health care workers on specialized treatment, including management of patients with ARV treatment failure and complicated drug adverse reactions; 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.

COE will support provision of a 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; and improved OI diagnosis and treatment including TB screening, diagnosis, and treatment.

Ongoing community interventions for PLHIV including peer education and use of support groups to provide adherence messaging and defaulter tracing and follow up will continue to be supported to improve retention in all sites. COE will do cohort analysis and report retention as required by MoH.

COE will adapt the quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV treatment services, integrate them into routinely collected data, and use the results to evaluate and improve clinical outcomes. COE will also support strategies to ensure access and provision of friendly HIV treatment services to all including supporting peer educators, mentors, support groups, and supporting patients to disclose and bring their partners for testing and care and treatment.

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

The University of Nairobi, Partnership for Advanced Care and Treatment, Centers of Excellence (COE) has been supporting pediatric treatment in Kenyatta National Hospital (KNH) since October 2010. 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%. As of June 2011, 1,292 children (83% of annual targets) had been initiated on ART and 651 were active.

In FY12, COE will 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 1,109 pediatrics currently receiving ART and 222 new pediatrics resulting to cumulative 1,331 pediatrics ever initiated on ART. In FY 13, this number will increase to 1,256 pediatrics currently receiving ART and new 200 resulting to cumulative 1,531 pediatrics ever initiated on ART.

COE 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; and adherence strengthening. COE will support enhanced follow up and retention, EID as per MoH guidelines and 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.

COE 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.

COE will support in-service training of 300 and 200 HCWs in FY12 and 13 respectively as well as continuous mentorship and capacity building of trained health care workers on specialized pediatric treatment including management of ARV treatment failure and complicated drug adverse reactions; identify human resources and infrastructure gaps and support in line with MoH guidelines; and 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.

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