CARE International (CI) supports the Ministry of Health (MOH) in implementing HIV activities in 6 districts of Nyanza province namely: Kisii Central & South, Marani, Gucha South, and Nyamira North & South. They will support provision of high quality, comprehensive HIV prevention, care and treatment services including PMTCT, adult and pediatric HIV care and treatment, and TB/HIV. They will also strengthen the capacity of the MOH and indigenous institutions in line with the GHI principles. CI will support decentralization as well as integration of HIV services into existing clinics including MCH and TB clinics.

To increase cost efficiency, CI will continue to work with the MOH through a sub-grant and jointly prepare work plans with the DHMT and PHMT to avoid duplication of services. Integration of services into MOH service delivery systems will be strengthened.

CI has adopted strategies to transition programs to government and strengthens systems through integration of HIV services and referrals. Additionally, they will support staff training, improvement of data management and setting up Electronic Medical Records. CI will support development of harmonized program structures for community-facility linkages and reporting.

The program coverage will be decentralized to more facilities, to improve access to HIV services. Two vehicles will be required to support the additional transport logistics. The program is in the process of procuring 5 vehicles using FY10 funding and had 1 vehicle carried forward from their previous cooperative agreement with CDC. This activity supports GHI/LLC.

CARE International (CI) has been supporting comprehensive adult care and support services in 37 public health facilities in Nyanza province since April 2011.

In FY12/13 they will continue to support comprehensive clinical services in the current 37 sites and scale up services to new sites.

CI will work with the Ministry of Health (MoH) at Provincial and District levels to jointly plan, coordinate, implement and ensure provision of quality HIV care and support services to 10,321 and 11,911 patients in FY 12 and FY13, respectively.

They will offer comprehensive care and support package of services including HIV testing to the partner and family members of index patient and enrolling or referring those that test HIV positive to care and support; provision of Basic Care Kit with safe water vessel, multivitamins, insecticide-treated mosquito nets, condoms, chlorine for water treatment and educational materials; Food By Prescription (FBP) to all enrolled HIV positive patients; prevention with positives (PwP); and cervical cancer screening to all enrolled women.

CI will collaborate with the MoH to support targeted capacity building (training and mentorship) for health care workers and offer continuous medical education on care and support, such as OI diagnosis and treatment. CI will identify areas with staff shortages, support recruitment of additional staff, and support good commodities management practices to ensure uninterrupted supply of commodities.

CI will continue to support ongoing psychosocial and community activities including peer education; referral and linkages to community based psychosocial support groups to strengthen adherence; effective and efficient retention strategies of patients on follow up; water, sanitation and hygiene programs; income generating activities; Home Based Care; vocational training; social and legal protection; and food and nutrition programs. CI will adopt strategies to ensure access to friendly services for youth, elderly and physically or mentally challenged 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.

CI will strengthen data collection and reporting at all levels to improve reporting to NASCOP and PEPFAR. The New Generation Indicators will be adopted and the development and use of electronic medical records system in accordance with NASCOPs guidelines will be supported. CIwill adapt the quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV care and support services and integrate them into routinely collected data. The results will be used to evaluate and improve clinical outcomes.

CI will support formulation and implementation of MOH-coordinated District Annual Operation Plans (AOP) within which health systems will be strengthened to facilitate sustainability. The partner will also support establishment of a strong M&E system.

CARE International has been supporting integration of TB/HIV services, hiring of additional staff and commodity support in 37 sites in Kisii Central, Marani, Gucha South and Kisii South Districts since April 2011. CARE International is implementing the first of a 5 year co-operative agreement with CDC and will continue to support TB/HIV services in the current 37 sites and scale up services to additional 12 sites.

In FY12 and 13, CARE International will support the Ministry of Health (MoH) Provincial and District Health Management Teams to plan, coordinate, and implement quality comprehensive collaborative TB/HIV services prioritized in Kenyas 5-Year National AIDS and TB Strategic Plans. Efforts to detect TB cases and ensure delivery of appropriate treatment will be intensified.

To reduce the HIV burden for TB patients, routine HIV screening for all TB patients will be supported, and efforts to ensure at least 95% TB-HIV co-infected patients are provided with comprehensive HIV care and treatment services in line with MoH guidelines will be optimized.

To reduce the burden of TB in HIV infected patients, support of intensified TB screening will continue, for 9,174 in FY12 and 10,588 in FY13, patients in HIV care settings and put 459 and 529 patients on TB treatment respectively. Patients without active TB will be put on isoniazid preventive therapy (IPT) according to the national protocol. To strengthen TB infection control (IC) in HIV settings, national IC guidelines will be made available and implemented including expedited diagnosis of patients with a cough and staff training on infection control.

To improve diagnosis, surveillance and management of both new and drug-resistant TB, CARE International will support a sputum network to facilitate timely shipment of specimens from health facilities to testing centres within the districts and to the central reference laboratory for drug susceptibility testing for TB retreatment cases and ensure return of results. Additional support will be provided for the ambulatory model of DR-TB treatment in Nyanza South by providing additional support to Kisii Level 5 hospital.

CARE International will continue to strengthen overall TB/HIV data management to ensure data of high quality are summarized and reported quarterly using custom MOH and new generation PEPFAR indicators. The partner will also support the development and use of electronic medical records system in accordance with MoH guidelines, and adapt cohort analysis and quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV care and support services. Indicators will be integrated into routinely collected data and use the results to evaluate and improve program activities. Finally, CARE International will support appropriate operations research designed to strengthen program performance.

CARE International has been supporting comprehensive pediatric care and support services in 37 public health facilities in Kisii Central, Marani, Gucha South and Kisii South Districts in Nyanza Province. The partner is implementing the first year activities of a 5 year co-operative agreement with CDC and will continue to support comprehensive clinical services in the current 37 sites and scale up services to 12 new sites.

In FY 12, CARE International will continue to provide care and support services to 1,079 children currently on care and increase to a cumulative total of 1,267 children in FY 13. 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 linking those testing HIV positive to care and treatment services.

The program will be strengthened to ensure children enrolled in care receive quality clinical care services, including clinical evaluation; WHO staging; CD4 and other basic tests; opportunistic infection diagnosis, prophylaxis, and management; TB screening; pain and symptom relief and management; and psychosocial support. Additional 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.

CARE International will support integration of HIV services into routine child health 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. CARE International will also support the care of the newborn by supporting hospital delivery and provision of newborn resuscitation and care (thermal care, hygiene cord care, and prophylactic eye care). HIV exposed children management and follow up will continue to be supported, including enrollment, HIV testing (PCR-DNA and antibody testing) per the national guidelines, provision of Nevirapine throughout the breastfeeding period, follow up and retention, and linkages of positive children to care and ART service. Hospital and community activities will be strengthened to support 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 and infrastructure development will continue to be supported. Relevant trainings will continue to be supported. CARE International will strengthen pediatric data collection and reporting at all levels to increase and improve reporting to NASCOP/PEPFAR and conduct cohort analysis to inform programming.

The goal of the country as reflected in Kenya National Aids strategic plan (KNASP III) is to reach 80% knowledge of HIV status in the country by 2013. Nyanza Province, which has a population of about 5.1 million people, carries the highest HIV burden in Kenya. With an estimated adult HIV prevalence of 14.9% compared to the national 7.1%, ~500,000 people are living with HIV.

CARE Clinical services supports direct implementation of comprehensive prevention, care and treatment activities in four districts in Nyanza Province that include: Kisii Central, Kisii South, Gucha South and Nyamira Districts. It covers several program areas and activities that include HIV Testing and Counseling in health care settings. The overall goal of this mechanism is to increase use of high quality, comprehensive HIV services in four districts of Nyanza Province, Kenya.

In FY 10, CARE supported Provider Initiated Testing and Counseling services in the four districts with emphasis in the Outpatient department, Inpatient and Child welfare Clinics. Between October 2010 and June 2011, a total of 57,732 people were offered comprehensive HTC services. A total of 2,578 (4.5%) individuals were identified as HIV infected and were linked to care and treatment services.

Guided by gaps identified in KAIS, KDHS 2009 and program data, CARE will continue to support HTC service implementation in the four districts with specific area of focus being facility-based Provider Initiated Testing and Counseling (PITC) approach. CARE will work with the Ministry of Health (MOH) at the county, District and health facility levels to jointly plan, coordinate and implement HTC services for both adults and children in support of the KNASP III and the District and Provincial level MOH annual operation plans.

CARE will target clients at the out-patient, in-patient and child welfare clinics with emphasis on enhancing diagnosis of HIV status among individuals with unknown HIV infection status, enhanced knowledge of HIV status with emphasis of identifying HIV infected individuals and HIV sero-discordant couples and strengthened linkage to appropriate HIV prevention, care and treatment services. CARE will target a total of 110,000 individuals with HTC of whom 10% will be pediatrics. These will contribute 1.7% of the national targets which aims at increasing knowledge of HIV status to at least 80% of the Kenyan adult population. These targets have been sub-divided to county and district level targets to guide implementation and program monitoring.

CARE will work to identify areas with training and mentorship needs, staff shortages and support appropriately through a MOH driven mechanism which ensures ownership and program sustainability.

All HIV-infected persons will be linked to care, treatment and other HIV prevention services at the facility and community level. Referrals will be strengthened by working together with SI team in implementing an effective referral strategy. HIV-negative individuals will be referred to PEPFAR supported prevention services. CARE will strengthen the WHO recommended multistep approach to Quality Assurance in counseling and testing. QA audit teams will be strengthened at the counties. CARE will continue to strengthen data collection, analysis, utilization and reporting at all levels to increase and improve reporting to NASCOP and PEPFAR.

CARE implements comprehensive prevention, care and treatment programs in Nyanza province. In FY 2012/13, CARE will expand HIV prevention services to include evidence based behavioral interventions (EBIs) 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 EBIs 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; Sexually Transmitted Infections (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.

CARE 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 centers 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. Nyanza province has the highest HIV Prevalence (14.9%). CARE will reach 5814 (60%) PLHIV in FY2012 and 7841 (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.

CARE 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 CARE 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).

CARE International (CI) has been supporting PMTCT services in 80 facilities in Kisii, Central, Kisii South, Marani, Gucha South, Nyamira North and Nyamira South Districts in Nyanza Province since 2010. As of March 2011 (SAPR), these districts had counseled and tested 13,807 pregnant women, provided ARV prophylaxis to 641 HIV positive pregnant women, provided ARVs prophylaxis to 300 infants, supported early infant diagnosis and follow up of HIV exposed infants, provided nutritional supplements to eligible pregnant women, and trained 416 HCWs on PMTCT revised guidelines.

In FY12, CI will support provision of HIV counseling and testing to 45,706 pregnant women at the ANCs and ARV prophylaxis to 2,306 HIV infected pregnant women. The HIV infected women will receive a CD4 test after undergoing WHO clinical staging and provision of HAART to all eligible HIV positive pregnant women according to revised PMTCT national guidelines will be supported. In FY13 CI will supported an increase in the number of pregnant women counseled and tested for HIV to 47,991, offer ARV prophylaxis to 2,801 pregnant women and 2,409 infants, and provide EID for 2,409 infants.

CI will focus on the 4 prongs of PMTCT: primary prevention; family planning, 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, TB screening, ARV prophylaxis and treatment for both mother and baby, nutritional support, psychosocial support, PWP, follow up, retention, referral, and linkages.

A total of 14,397 of 1st visit ANC attendees will be reached with couple CT to identify discordant and concordant couples to improve primary prevention and facilitate linkage to HIV care and treatment for the eligible. CI will support integration of ART in MCH clinics, access to FP/RH services, and establish or strengthen infection control and waste management activities.

Hospital delivery will be supported through provision of delivery beds and sterile delivery packs, training, working with CHWs and TBAs to promote community-facility referral mechanisms, health education, and community services providing skilled birth attendance.

CI will support safe infant feeding practices as per national guidelines; enrollment and follow up of 2,409 of babies born to HIV infected mothers to access CTX, ARV prophylaxis, and EID services using the HIV exposed infant register to 18 months. ART initiation for those who test positive before 2 years will be facilitated.

CI will adopt efficient retention strategies for mothers and babies by supporting use of diaries and registers for tracking defaulters and having a structured mentorship and supervision plan. Training of 100 HCWs in FY12 and equal number FY13 will be supported. Enhancing data quality and streamlining M&E gaps will continue, 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.

CI will support orientation of health care workers on the revised PMTCT and infant feeding guidelines and engage the community in activities for demand creation for health services such as male involvement with

Care International (CI) has been supporting comprehensive adult HIV treatment services since 2011 in government health facilities in Kisii Central, Marani, Gucha South and Kisii South Districts.

In FY12, CI will jointly work with the Ministries of Health (MoH) at all levels to continue supporting, expanding and ensuring provision of quality adult HIV treatment services as per MoH guidelines to 9,249 adults receiving ART and 2,257 new adults resulting to cumulative 11,099 adults ever initiated on ART.

In FY 13, this number will increase to 10,944 adults receiving ART and 2,283 new adults for a cumulative 13,382 adults ever initiated on ART.

CI will support in-service training of 50 and 40 HCWs in FY 12 and FY 13 respectively, support continuous mentorship and capacity building of trained HCWs, 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.

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

Support for ongoing community activities and for PLHIV will continue, including strengthened peer education and support groups to improve adherence, effective and efficient retention strategies, referral and linkages to psychosocial support groups, economic empowerment projects, Home Based care, and food and nutrition programs. Provision of friendly services to youth and special populations will be supported. Additionally, CI 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

CI will adopt quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV treatment services and integrate them into routinely collected data. The results will be used to evaluate and support short term activities to increase impact and improve clinical outcomes.

CI will adopt strategies to ensure access and provision of friendly HIV treatment services to all including peer educators, support groups, partner testing and family focused care and treatment. CI 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 record system will be supported and strengthened.

CARE International (CI) has been supporting comprehensive pediatric treatment services in public health facilities in Kisii Central, Marani, Gucha South and Kisii South districts since 2011.

In FY12, CI 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 949 patients currently receiving ART and 190 new ones resulting to a cumulative 1,139 patients ever initiated on ART.

In FY 13, this number will increase to 1,063 pediatric patients currently receiving ART and 171 new ones for a cumulative 1,310 pediatrics ever initiated on ART.

Provision of comprehensive pediatric ART services will be supported, 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; enhanced follow up and retention; support EID as per MoH guidelines and PITC to all children and their care givers attending Child welfare clinics; support family focused approach; and community outreach efforts and integration of HIV services in other MNCH services.

CI will support hospital and community activities to support the needs of HIV infected adolescents: 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.

Support will be provided for in-service training of 100 and 80 HCWs in FY 12 and 13 respectively, 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, identification of human resources and infrastructure gaps and support in line with MoH guidelines, and support of 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 be optimized. Linkage of ART services to pediatric care services, PMTCT, TB/HIV, community programs, and other related pediatric services will be optimized.

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