University of Maryland Partnership for Advanced Care and Treatment (PACT) in partnership with University of Nairobi supports the Ministry of Health (MoH) and Nairobi City Council in 9 districts in Nairobi to expand and maintain provision of comprehensive, high quality HIV prevention, care and treatment services.

PACT supports decentralization of HIV services by integrating these services into existing clinics including maternal and child health and TB clinics.Cost efficiency is being addressed through integration of services, reduction of the technical teams with increased capacity building of the MoH staff, use of existing evidence-based strategies, task shifting, implementing more facility-based training and mentorship rather than offsite training, evaluating cost effective strategies for defaulter management, laboratory networking, and mobilization.

The PACT program is strengthening capacity of the provincial and district health teams (PHMT/DHMT) and facility management to provide oversight for HIV services through several interventions that will support full integration of HIV prevention and care programs within these structures. The program has adopted a mentorship model that will build capacity in the DHMT. PACT supports employment of key staff, but will work with MoH to have these staffs absorbed into MoH payrolls before Year 5. PACT, in collaboration with the MoH, has developed a strategic information strategy for Comprehensive Care Clinic (CCC) and non CCC sites that will ensure timely and accurate reporting through district level mechanisms to the MoH and the donor. Data quality shall be monitored using biannual data quality assessment.

PACT procured 3 vehicles in 2010 and is not requesting for any vehicles in FY12.

This activity suports GHI/LLC principles

University of Maryland Partnership for Advanced Care and Treatment (PACT) project will support treatment activities in Nairobi City Council clinics, where it has been supporting HBHC since 2010. By March 2011 PACT had cumulatively enrolled 12,717 patients in HIV care and of these, 8,766 individuals were provided with HIV-related palliative care including 5,643 patients on cotrimoxazole prophylaxis. Patient booking diaries have been introduced and a total of 10 sites are now able to identify missed appointments. Community health volunteers have been engaged to assist in following up missed appointments. PACT will work with the Ministry of Health (MoH) at the provincial, district and health facility level to jointly plan, coordinate, implement and ensure provision of quality HIV care and support to 8,485 current adult patients in FY12 and 10,414 current patients in FY13.

PACT will offer comprehensive care and support package of services including: HIV testing to partners and family members of index patients 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, condoms, chlorine for water treatment and educational materials); therapeutic nutrition (FBP) to all enrolled HIV positive patients; prevention with positives (PwP); and cervical cancer screening to all enrolled women.

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

PACT will also support ongoing community interventions for HIV infected individuals 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 (IGAs); home based care services; gender based violence support programs; vocational training; social and legal protection; and food and nutrition programs.

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

University of Maryland-Partnership for Advanced Care and Treatment (PACT) program will support TB/HIV activities in Nairobi, where they have been working since 2010. In 2010, 190 TB patients were tested for HIV; 426 HIV patients were screened for TB and 25 trained in TB/HIV.

In FY12 and 13, PACT will intensify efforts to detect TB cases through clinical exams and laboratory investigations and ensure successful TB treatment through provision of appropriate treatment. PACT will ensure that each facility providing TB/HIV services has adequate and well trained clinical staff supported by well equipped and staffed laboratory, including sputum specimen transport where laboratory services are unavailable. PACT will ensure that adequate supplies of anti-TB drugs are available and that the national TB treatment guidelines are followed. All TB patients on treatment will be monitored both clinically and through periodic sputum examination.

To reduce the burden of HIV in TB patients, PACT will ensure that at least 95% of TB patients are screened for HIV and 100% and 80% TB-HIV co-infected patients are put on cotrimoxazole and ARVs respectively as early as possible regardless of the CD4 count as per the national guidelines. PACT will support the one stop model that provides integrated TB and HIV services in all TB clinics. All TB clinics will be stocked with cotrimoxazole and ARVs and be staffed with 80 trained HCW trained as needed.

To reduce the burden of TB in HIV infected patients, PACT will support intensified TB screening for 7,542 in FY12 and 9,257 in FY13 at each clinical encounter using the national screening tool. 377 co-infected patients identified in FY12 and 463 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, PACT will ensure that the national IC guidelines are available at all sites and training of staff on IC is done. PACT will support 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.

To improve surveillance and management of drug-resistant TB, PACT will support timely transport of sputum specimens of TB retreatment cases from health facilities to the central reference laboratory for drug susceptibility testing and ensure return of the results to those facilities. PACT will also support scaling up of drug-resistant treatment sites thus expanding access to MDRTB treatment.

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

University of Maryland-Partnership for Advanced Care and Treatment (PACT) program is a family-focused, comprehensive HIV prevention, care and treatment program working collaboratively with the Government of Kenya in Nairobi Province since 2010. PACT will support pediatric services in Nairobi.

By March 2011, PACT had enrolled 332 children in care with 149 receiving HIV care, 265 on cotrimoxazole prophylaxis, and 343 children on ARV prophylaxis. In FY12, PACT will provide care and support services to 887 children currently on care. The number of children currently on care will increase to 1,108 during FY13. PACT will provide comprehensive, integrated quality services, and scale up to ensure 3,028 HIV exposed infants are put on ARV prophylaxis and access pediatric care services.

PACT will improve access to cryptococcal antigen testing; TB screening and management; pain and symptom relief and management; and psychosocial support (including disclosure counseling and support) provided through education, counseling, and linkages to facility or community based support groups. PACT will strengthen the 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 in the community and health facilities to prevent diarrhea and other illnesses among the HIV infected, exposed, and other children in the community; and malaria screening, treatment, and provision of long lasting insecticide treated nets in malaria endemic areas. Emphasis will be on enhanced follow up and retention of all identified HIV infected and exposed children.

PACT will support the integration 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. They will also support the care of the newborn by supporting hospital delivery and ensuring that there is provision for newborn resuscitation and care (thermal care, hygiene cord care) and prophylactic eye care.

PACT will also 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, support for transitioning into adult services, and teaching life skills. PACT will ensure optimized linkages of children to various programs including TB/HIV, PMTCT and OVC services, and other community based programs such as education, protection, and legal and social services. PACT will also support relevant class-based and on-job trainings including continuous medical education.

PACT will strengthen pediatric data collection and reporting at all levels to increase and improve reporting to the National AIDS & STI Control Programme (NASCOP) and PEPFAR. With guidance from the national PEPFAR office, the new generation indicators will be adopted. To improve the quality of care and strengthen pediatric services, PACT will support supervision and mentorship activities and integrate the NASCOP adopted quality of care indicators (CQI and HIVQUAL) into routinely collected data for monitoring the quality of pediatric HIV services.

Target population: University of Marylands HIV testing and counseling activities targets all patients and accompanying relatives and friends attending health care facilities with unknown HIV status. Target population include: all out and in-patients together with their accompanying relatives and friends. They include couples, pregnant women, post natal clients, family planning clients, TB patients, outpatient clients, maternity patients, child welfare clinics and in the in-patient wards.

HTC Approaches: UOM utilizes both client and provider initiated HIV testing and counseling (PITC) strategies. Family testing has been introduced in an effort to reach out to sexual partners and children of HIV infected index clients.

Past targets and achievements: In the past one year, UOM had a target to counsel and test 33,000 persons in health facilities and they managed to reach a total of 22,414 (68%). Those who are HIV positive are enrolled into chronic care at the same facility or referred to facilities of their choice. A total of 30 health care workers have been trained in PITC while 50 health care workers will receive training on DBS collection. For COP 2012, UOM will provide HTC services to a total of 39,000 persons of which 20% will be tested as couples and 10% will be children below the age of 15.

Testing algorithm: National HIV testing algorithm is used.

Referrals and linkages: Clients who test HIV positive are escorted to CCC where their demographic details are taken including the patients contact information. Use of client referral forms has been introduced and mentorship is ongoing on use of the forms to refer clients to HIV care delivery points. Community health volunteers have been engaged to assist in tracing clients who miss clinic appointments. UOM is working with facility management to strengthen facility based multi-disciplinary committees part of whose mandate will be to monitor intra-facility referrals and linkages. Facilities supported by UOM will receive support to confirm inter facility referrals.

UOM technical assistance teams participates in District stakeholders forums that provide forums to evaluate district performance.

Promotional activities for HTC: All patients are 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 are given individualized invitations though the index clients and available avenues for testing include individualized home testing

Quality management: In collaboration with District Health Management Teams (DHMT), UOM also provide onsite mentorship on HIV testing and DBS collection. The team is in the process of scaling up number of sites participating in proficiency testing. UOM will support HIV counselors supervision starting year 2.

Monitoring and evaluation: UOM in collaboration with the DHMT is supporting the roll out and mentorship on of use of HTC registers. The registers are being introduced at all HIV testing points except PMTCT. The team is working in close collaboration with the facility management team to ensure timely and accurate reporting to Ministry of Health and to the Donor. Bi annual data quality assessment will facilitated as per recommendation from Ministry of Health.

UOM PACT implements comprehensive prevention, care and treatment programs in Nairobi province. In FY 2012/13, UOM PACT 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; 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.

UOM PACT 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%). UOM PACT will reach 4780 (60%) PLHIV in FY2012 and 6855 (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.

UOM PACT 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 UOM PACT 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 Kenya drug use epidemics prevalence is 18.3%, over two times more than that of the general population. HIV prevalence amongst PWID is 18.3% amongst needle-sharing sharing IDUs, prevalence is 30% while for non-needle sharing PWID, it is 5%. This mechanism will provide training and capacity strengthening services for service providers and programs serving PWID as well as target the PWUD/PWID population with appropriate targeted responses to each of the sub-groups within the PWUD/PWID population to address their varied risk profiles. These will include social networks of drug-users, addressing high risk sexual practices e.g. multiple sexual partners and unprotected sex as well and drug injecting practices such as needle-sharing and flash-blood practices among users and their peers. Women who use or inject drugs face additional risks due to their engagement in sex work and in transacting sex for drugs. They also face additional stigma, which becomes exacerbated in the event of a pregnancy. These behaviors are reinforced by multiple determinants such as criminalization of injecting drug use, and poverty among majority of the self-identified PWUD/PWID. Children of female PWID will also be linked to appropriate wrap around services that address gender and the needs of continually abused children. This mechanism will support the set up and scale up of a comprehensive package of services targeting 1400 PWID with MAT services and 5,000 with other wrap-around services in Nairobi. This will include capacity strengthening for Mathare National Mental hospital. A 9-intervention package of services per the PEPFAR and UNAIDS/UNODC guidelines will be offered i.e Medication-Assisted Treatment (MAT) for drug-dependence treatment, ART, HTC, STI prevention and treatment, Condom demonstration and distribution for PWID and their partners, targeted behavioral interventions and IEC materials, TB diagnosis and treatment and vaccination, diagnosis and treatment of viral hepatitis. Methadone and other MAT drugs and supplies will be centrally procured through a designated supply chain and therefore funds under this mechanism may not be used for drug procurement, unless under special circumstances. Per PEPFAR guidance, funds in this mechanism may not be used to procure Needle and Syringe Program (NSP) supplies but the program may work with other partners to support NSP. This program will play a key role in supporting training and mentorship for service providers and programs implementing services for PWID. They will work collaboratively with the public health sector/Nairobi Provincial Director of Medical Services; participate in national MARPS and PWUD/PWID forums careful planning with a broad range of community and local administration stakeholders with a view to enlisting the crucial buy-in and support for an enabling environment. Training will be conducted in collaboration with the national training program for use of national PWID guidelines and MAT treatment protocols. Out-patient treatment will be the desirable model of offering MAT, backed by a close follow-on addiction counseling therapy. PWID/PWUD and MAT treatment services will be integrated with the HIV comprehensive, care and treatment program that is currently implemented under this mechanism.

University of Maryland-Partnership for Advanced Care and Treatment (PACT) project will support PMTCT services in Nairobi Province, which has an HIV prevalence of 15.1%. PACT has been implementing PMTCT services in Nairobi since 2010. By March 2011 SAPR, PACT had counseled and tested 35,049 women in Maternal Child Health (MCH), 1950 received ARV prophylaxis, and 938 HIV exposed infants were offered PCR at 6 weeks.

In FY12, PACT will offer HIV counseling and testing to 32,810 pregnant women at ANC and give ARV prophylaxis to 2,898 HIV infected pregnant women. HIV infected women will receive a CD4 test after undergoing WHO clinical staging. PACT will give HAART to all eligible HIV positive pregnant women in line with the revised PMTCT national guidelines. In FY13, PACT will increase the number of pregnant women counseled to 34,450, offer ARV prophylaxis to 3,520 pregnant women and 3,028 infants, and do EID for 3,028 infants.

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

Efforts will be made to reach 10,335 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 and also support integration of ART in MCH clinics, access to FP/RH services, and establish or strengthen infection control and waste management activities.

PACT 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.

PACT will support safe infant feeding practices as per national guidelines and enrollment and follow up of 3,028 of babies born to HIV infected mothers to access CTX, ARV prophylaxis, and EID services using the HIV exposed infant register till 18 months. PACT will facilitate ART initiation for those who test positive before 2 years.

PACT will adopt efficient retention strategies for mothers and babies by supporting use of diaries and registers for tracking defaulters, having a structured mentorship and supervision plan, and 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. 90 Health Care Workers will be trained in FY12 and equal number in FY13 on PMTCT. PACT will also provide orientation to the revised PMTCT and infant feeding guidelines and engage in community activities for demand creation for health services such as male involvement with couple CT services.

University of Maryland Partnership for Advanced Care and Treatment (PACT) will support treatment in Nairobi Province. 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 March 2011 SAPR, 5,929 adults had been initiated on ART and 4,988 were active; defaulter tracing mechanisms strengthened in 10 sites.

In FY12, PACT 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 5,675 patients currently receiving ART and 223 new adults resulting to cumulative 6,810 adults who have ever been initiated on ART. In FY13, this number will increase to 5,842 currently receiving ART and 226 new adults resulting to 7,036 adults who have ever been initiated on ART.

PACT will support in-service training of 100 and 80 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.

PACT 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 support groups to provide adherence messaging, defaulter tracing, and follow up will continue to be supported to improve retention in all sites. PACT will also support strategies to ensure access and provision of friendly HIV treatment services to all including peer educators, mentors, support groups, and supporting patients to disclose and bring their partners for testing and care and treatment.

PACT will adopt 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. PACT will also do cohort analysis and report retention as required by MoH.

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

University of Maryland-Partnership for Advanced Care and Treatment (PACT) has been supporting and will continue to support pediatric treatment services in Nairobi Province. Nairobi Province has an estimated population of 3.1 million people with an estimated adult HIV prevalence of 8.8% compared to the national 7.1%. As of March 2011 SAPR, 149 children had been initiated on ART and 144 were active. PACT had also provided onsite, clinical mentorship to health care workers on pediatric treatment and established technical teams to plan, manage, mentor, and implement pediatric HIV services.

In FY12, PACT 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 183 pediatrics currently receiving ART and 100 new pediatrics resulting to cumulative 220 pediatrics ever initiated on ART. In FY 13, this number will increase to 667 pediatrics currently receiving ART and 90 new resulting to cumulative 757 pediatrics ever initiated on ART.

PACT 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; 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.

PACT 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.

PACT will support in-service training of 100 and 80 HCWs in FY 12 and 13 respectively, continuous mentorship and capacity building of trained HCWs 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.

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