APHIAplus Rift Valleys overarching goal during FY12 is to improve the quality of service delivery in the region. The objectives are to: (1) strengthen the Clinical Services program by improved mentorship and supervisory support to specific facilities to achieve better care and treatment outcomes; (2) re-align service demand creation activities to facility service delivery; (3) strengthen and expand support for the implementation of the community health strategy and linked interventions addressing social determinants of health (SDH). The implementation framework will be consistent with a country-driven process facilitated by partners as outlined in the USAID/Kenya PFIP.

To improve quality of service delivery, additional technical personnel will be recruited and deployed to provide mentorship and supervisory support to local partners, communities, and facilities, and augment the current project staff. Need-based short-term engagement with required technical experts will also be considered to offer necessary skill building support.

Local facilities and implementing partners have been engaged formally through agreements and work plans to build and enhance systems to develop and sustain capacity required for effective service delivery. Inputs to support the implementing mechanisms at both the community and facility levels will be handed over when capacity for their use and distribution is established. Under this award, FHI has purchased 2 vehicles to support the outreach mentorship and supervisory teams based regionally. FHI also uses vehicles from previous awards. An additional 40 motorbikes will be needed in FY12 for social workers to reach the various target groups. This activity supports GHI/LLC and is funded primarly with pipeline funds in this budget cycle.

The target audience for HBC will include HIV-positive children, adolescents, and adults, both at the community and health facility. The aim is to reach 80,000 individuals through facility-based and community home based care in 10 counties in Rift Valley. Service providers will be familiarized with the recently launched PWP guidelines. Lifelong Cotrimoxazole (CTX) will be offered to all HIV-positive patients to prevent opportunistic infections. Partner and family testing will be promoted through active invitation to the health facility using the index client approach. Promotion of condom use, especially among couples, will reduce re-infection and enhance prevention. Screening and treatment for TB and STIs will be offered routinely. Anthropometric measurement and nutritional assessment will be performed on the HIV-positive patients and individuals who are malnourished will be rehabilitated with supplemental or therapeutic feeding. FP counseling will be strengthened and dual methods of protection will be offered. Peer counselors (community health volunteers living positively) at the health facilities will facilitate bi-directional linkages and referrals between the facilities and community programs.

Using a family centered approach, APHIAplus will ensure OVCs in HCBC households receive support to address the social determinants of health, such as livelihood and economic strengthening, skill building, commodities to address hygiene and sanitation, social protection particularly for women and children, and food security and nutrition. The OVC program will have linkages with PMTCT, TB/HIV, health communication, and counseling and testing programs. APHIAplus will provide services based on the PEPFAR care service menu and focus on treatment literacy, relief of symptoms, FP interventions, safe water, HIV testing for family members, condom distribution, alcohol abuse counseling, disclosure support, gender violence support services, food security activities, health education, and household economic empowerment.

District institutions will be supported to integrate, plan, lead, monitor, and evaluate home and community care support programs. Quality assurance and quality improvement for community interventions will be key in ensuring that standards of care are met. APHIAplus will support the District HBC coordinators and CHEWs to monitor and evaluate HCBC and community PWP activities. The project will also roll out a longitudinal database to monitor service provision to all OVCs and improve reporting.

APHIAplus Nuru ya Bondes prime partner Family Health international (FHI) was competitively selected to implement this activity. The implementing partners will provide comprehensive support to 95,000 OVC and their families, based on PEPFAR OVC guidance, both directly and through leveraged resources from other partners in selected sites in ten counties within Rift Valley province. The activities target OVCs, caregivers of OVCs, and CHWs in selected counties and will be delivered through local implementing partners. The local capacity of each organization will be strengthened through support supervision and mentorship to ensure quality service provision to OVCs. The implementing partners will work with community leaders, religious leaders, and volunteers as well as partner with other existing community-based and faith-based organizations.

In 2012, APHIAPlus will support integration of the OVC project within the governments KEPH strategy thereby ensuring that OVC volunteers are part of the CUs; particularly vulnerable OVC are referred to nutrition programs; OVCs requiring food and nutritional services receive food supplements through the NHP program; government OVC standards for quality improvement are rolled out; and OVC coordination and child protection structures are strengthened at the community level. The capacity of local implementing partners will be strengthened through trainings and mentoring and support supervision to ensure the activities are implemented in line with the required standards

APHIAPlus will also work with the government to improve coordination, supervision, and monitoring of OVC activities. Key to this objective is the need to strengthen the reporting system and support supervision at the local level. Monthly reporting tools for CHWs will be used to collect information at the community and will be analyzed at the implementing partners level. The project will utilize a longitudinal database to monitor service provision to all OVCs and improve data quality.

The capacity of implementing partners will be strengthened through the training of trainers on high quality comprehensive OVC care. Key community stakeholders will be engaged through structures such as the AACs and child protection committees and will be given the authority to identify vulnerable children and their needs, assess existing community resources and gaps, establish a coordination and referral mechanism, and plan and monitor a joint response to the OVC.

APHIAplus Nuru ya Bonde together with the Capacity Project has hired and trained 4 multi-disciplinary VMMC teams using the national VMMC curriculum. The teams are based at Naivasha District Hospital and Nakuru Provincial General Hospital. The project will support the MOH to expand the VMMC activities in Nakuru County to reach the uncircumcised males, the majority of whom are migrant workers. APHIAplus aims to reach 3,500 males in the next year. VMMC promotional activities will be carried out at community level and in work places around Naivasha and Nakuru. In addition, the project will work with the MOH to build the capacity of P/DHMTs and health care workers to plan and provide VMMC services as part of an integrated HIV prevention package that includes community education and mobilization activities. APHIAplus will support the MOH to disseminate the national VMMC M&E tools to ensure appropriate documentation, follow-up, and recording of adverse events. For quality assurance, a VMMC expert will be engaged on a quarterly basis and will provide targeted mentorship to individual team members and train them on how to manage adverse events.

APHIAplus Nuru Ya Bonde will expand HCT by supporting all districts to undertake targeted HIV Counseling and Testing services to reach youth out of school. In addition, outreach activities will be integrated into community promotion activities through mass media, community dialogue, action days, and social and sporting events. CT activities will also target market days that congregate traders and business persons. VMMC outreaches will integrate CT services into workplaces targeting men especially from non-circumcising communities. Integrated MARPs outreaches will target CSWs along business routes and centers. All community outreach CT services, including house-to-house CT activities, will refer individuals who test positive to facilities.

Facility-based HIV CT services in APHIAplus zone 3 will target pregnant women, couples and partners of PLWHA, MARPs, youth seeking YFS, and clients accessing services at the supported health facilities. At all 642 APHIAplus supported health facilities, provider initiated HIV testing & counseling (PITC) will be the predominant approach. HIV testing is routinely offered to patients, their family members, and visitors seeking ANC, maternity, postnatal, MNCH, TB, in-patient and other outpatient services with the option to opt-out. Other approaches include outreach/mobile voluntary counseling and testing (VCT) targeting hard to reach populations and campaigns like the couple testing community RRIs. Youth friendly counseling centers will be strengthened to increase access to HIV CT for youth. Service providers will be oriented on adolescent and youth-friendly sexual and reproductive health services. Health facilities will also identify index HIV clients and CHWs and community counselors will provide family-based HIV testing to promote early identification of HIV infected family members and access to HIV CT.

The nationally recommended HIV testing algorithm will be in used in all APHIAplus supported sites and all service providers will receive information on the revised HTC guidelines through facility-based CMEs and technical updates. An additional number of providers will receive information on the national HTC quality assurance strategy and an initial 150 health facilities enrolled into the national proficiency HTC testing program. Further provider training on the re-testing recommendations contained in the HTC guidelines will be given to facilitate a structured approach in implementation. Partner testing will be promoted in care settings through active invitation for partners of identified cases seeking HIV CT services. Support groups linked to supported health facilities will be strengthened and community peer volunteers identified to facilitate intra-facility referrals into community programs and facilitate tracing of defaulters to follow-up CT. Service providers and peer volunteers will use mobile phone messaging to communicate with individuals after HIV CT to enhance linkages for enrollment, follow-up, and retention in CT. Existing HTC tools will be used at all entry points and summary reports prepared by HTC mentors based in the health facilities and the anchor CU facilities.

APHIAplus Nuru Ya Bonde is supporting 642 PMTCT sites of which 114 sites are offering comprehensive PMTCT interventions with intensified mentorship support to achieve the EMTCT goal, which ensures all these facilities have achieved a reduction in HIV transmission to <5% for all exposed neonates. In the next two years, 230 sites will receive comprehensive PMTCT support towards achieving the EMTCT goal. Concurrently, a minimum PMTCT package of targeted intervention support will be provided at the remaining PMTCT sites through outreach mentorship and linkages to national training, commodities management, and district supportive supervision, with the aim of progressively transitioning to comprehensive EMTCT packages.

Through engagement with the existing 114 sites, costing of the interventions will be undertaken to obtain the unit cost per PMTCT client reached. In the next two years, innovative measures will be instituted to address high burden areas to reduce the unit cost and facilitate expanded coverage and program effectiveness. Strategies to achieve decentralized PMTCT services will include: expanded integration of HIV prevention into facility-based and outreach RH/FP services, and ARV prophylaxis and maternal/infant therapy into MNCH services; focus on the unmet needs for FP services among all HIV-positive women and their partners through PwP implementation; linkages with male neonatal, sibling, and partner circumcision services; and improvements in PNC service delivery and follow-up of infected mother-exposed baby pairs. In addition, activities to achieve decentralized PMTCT services include: integration into the Community Strategy; early identification of pregnancy by CHWs; access to counseling and testing for couples and families; improved follow-up care and treatment for pregnant HIV-positive women; and facility deliveries through referrals vis-à-vis integration of mobile phone technology for information alerts and reminders.

APHIAplus has developed PMTCT intervention package standards compliant with current National PMTCT Guidelines. They will be used as a basis for monitoring implementation and compliance of quality standards. District supervision and program mentorship teams at the district and project-supported site levels will use the standards to monitor facility quality, determine needs for improvement, and set targets. Existing national PMTCT quality assurance tools will be made available at all facility sites and providers will be supported, through the mentorship teams, to use the tools. National data collection and reporting tools will be distributed to the sites. Through facility Quality Improvement Teams, all data collected will be analyzed and then utilized for decision making and planning for service delivery improvement. This will be undertaken through data review exercises at six month intervals to capture the progress in the implementation of the PMTCT care services and the outcomes for mother and infants at both the facility and community levels. Clinic data on immunizations, growth monitoring, including nutrition support, rehabilitation and treatment services for exposed and infected babies will inform the collection of outcome data. Service outcome indicators from the community strategy indicator data, such as community mobilization for PMTCT, stigma reduction interventions, male involvement, and couple counseling and testing, will be analyzed and monitored from the catchment CUs.

APHIAplus Nuru Ya Bonde is currently supporting 114 HIV care and treatment sites with comprehensive interventions packages. Due to the variable performance in the different treatment sites, APHIAplus will focus on strengthening the quality of services offered at these supported facilities and progressively decentralize treatment services to other sites using an outreach mentorship approach. To strengthen the quality of care and treatment services, APHIAplus will review the comprehensive package of interventions, deploy six regional multidisciplinary mentorship teams, provide intensive support to 16 poorly performing care and treatment sites, provide on-going enhanced support to 25 other sites, and maintain regular support to the remaining 71 sites to ensure adoption and maintenance of quality care and treatment standards for adults and adolescents. In addition, APHIAplus will upgrade six regional hub laboratories to support the delivery of quality laboratory networking services for the participating care and treatment sites. Integrated post-training clinical mentorship will be conducted for the individual providers and sites through the mentorship teams in order to refine and improve their skills. Mentor and mentee logbooks will be used to objectively monitor and assess the impact of the mentorship activities. Additional validation of mentorship effectiveness will be undertaken through the adoption of the on-line Therasim evaluation approach for individual providers. In-facility Quality Improvement Teams will be established and operationalized to undertake oversight of improvement initiatives, which address poor performance.

APHIAplus will increase access to CD4 tests and viral load testing by supporting the transportation system of samples and results between health facilities and the laboratory hubs in network and National HIV reference laboratory. To improve retention in care and treatment, mobile phone messaging for patients on treatment, patient support groups, and linkages to CHW home-based follow-up will be established in functional CUs. Adolescent-friendly clinic days will be established to cater for this unique cohort.

Monthly ART cohort reports will be compiled and used to review clinical outcomes. Active default tracing mechanisms will be instituted through the community structures, the patients support group, peer counselors, and through SMS messaging. To adequately address co-morbid conditions, the proportion of patients screened and diagnosed with TB, of TB-HIV co-infected patients on HAART, and of patients diagnosed with NCDs will be monitored. Intensified ART adherence counseling will be conducted for all new patients initiating treatment and medication use counseling will be provided during follow-up to increase ART adherence.

ADR and adverse event monitoring will be instituted. Thus, patients who develop treatment failure will have access to non-standard regimens, facilitated through the Level 5 Hospital Treatment Review Team. Targeted focus on ART adherence counseling for frontline service providers will build their capacity to offer the service. Peer counselors will be deployed from the support groups to further support retention to treatment.

APHIAplus NYaB will scale-up pediatric care and treatment in the region. At present about 10% of current, newly and ever enrolled on CT are aged 0-15 years. This proportion will be increased to approximately 15% in the next two years. In the next two years, all adult/adolescent CT sites will strengthen the delivery of pediatric CT services to ensure optimization of entry points into CT and improved follow-up through integration of pediatric HTC into MNCH services and in-patient pediatric care services. Identification of HIV exposed and infected children will be intensified through longitudinal follow-up of HEI and PITC for the infants with unknown status in the health facilities. Early infant diagnosis facilities will be scaled-up to ensure provider competence to collect quality DBS samples and transport samples to regional laboratories for HIV DNA PCR diagnosis. Mentorship teams will ensure providers minimize missed opportunities for HIV diagnosis among exposed children. OJT for service providers on collection of DBS samples will be conducted in the facilities to improve diagnosis of HIV among the HEI. Turnaround times for receipt of results will be analyzed for each facility and optimized through measures to reduce time waiting for and relaying results to mothers. Service providers will be mentored on the prompt initiation of ART for children less than two years old with confirmed HIV status, while access to CD4 and viral load testing will be facilitated through laboratory networks linking regional labs with the National HIV Reference Laboratory to enhance evaluation and monitoring of patients. APHIAplus will build the capacity of health service providers in pediatric HIV management through targeted trainings and clinical mentorship to ensure that regimen dosing is age appropriate. Nutritional assessments of pediatric patients and therapeutic and supplemental feeding will be an integral part of their evaluation and monitoring. Access to all other immunization care, supplementation, and growth monitoring services will be undertaken in compliance with National Guidelines.

Adolescent-friendly clinic days will be established and adolescent support groups formed. These will be managed separately from the adult and pediatric clinic days and facilitated by providers who have been trained in adolescent care. Adolescent clubs promoting healthy and positive living will be linked to adult role model mentors who are living positively.

The use of the HEI register and mother-baby booklets will be promoted and data complied to assess HIV transmission rates every month. Other outcomes will be analyzed to enable the development of facility-based responses to address poor outcomes. This effort will be undertaken by the pediatric HIV care and treatment mentor based in the supported health facility in conjunction with the Quality Improvement Team.