APHIAplus Western Kenya is a five-year project funded by USAID to be implemented between January 2011 and December 2015 by a consortium led by PATH and comprising EGPAF, JHPIEGO, World Vision, and BroadReach. The project is designed to work with existing structures and build capacity at the provincial, district, facility, and community levels to achieve fully integrated service delivery in Nyanza and Western Provinces. The project team maximizes Kenyan ownership and aligns the aims of the project with the strategies of the USG and the GOK. The project will build the capacity of partners throughout the life of the project, and continuously transfer more responsibility to manage resources and project activities. APHIAplus builds on the lessons learned during APHIA II, expands successful approaches to high-need districts, and provides more support for interventions addressing the social and economic barriers to healthy lives.

The project is divided into two main result areas which contribute to USAID-Kenyas strategic objective of Improved health outcomes and impacts through sustainable country-led programs and partnerships. This project focuses on improving and expanding health services from Level 5 to Level 1 and increasing the demand for those services. The project also focuses on reducing the barriers that prevent communities from accessing health care and living healthy lives. APHIAplus Western Kenya has purchased seven vehicles in COP10 to support program activities Western and Nyanza Provinces. The vehicles include 3 Toyota Prados (KBQ 974C, KBQ 975C, KBQ 315J) and 4 Toyota Land Cruisers (KBQ 993C, KBQ 992C, KBQ 302J, KBQ 315J, KBQ 243P). This activity supports GHI/LLC and is funded with both FY12 and pipeline funds in this budget cycle.

The project supports peadiatric care and treatment in 48 sites in Nyanza and 66 in Western. This support will be scaled up to 62 and 75 sites in Nyanza and Western respectively in 2012.

The project will provide commodities at sites to support early infant diagnosis DBS PCR testing, HIV counseling and testing for older children and adolescents, and CD4 testing - including CD4% - in order to allow appropriate care and treatment services. In addition, the project will provide cotrimoxazole prophylaxis, nevirapine prophylaxis for infants and food by prescription for the malnourished children.

The project will continue to establish and facilitate existing peadiatric and adolescent support groups to promote adherence, peadiatric disclosure and psychosocial support for older children and adolescents. The peadiatric and adolescent services will be linked to and/or provided at the comprehensive care centre (CCC) for the continuum of chronic HIV care and treatment. Infant care will be integrated at MCH to offer seamless routinue MCH services like immunization and growth monitoring as well as HIV services.

HCWs will be supported with onsite and off-site mentorship as well as technical exchange visits for improved service provision. The project will facilitate quarterly PHMT and DHMT support supervision to sites for routinue monitoring of service delivery as well as program-specific supportive supervision. QA/QI initiatives using the HIVQUAL model will be introduced to monitor quality of care indicators at all project sites.

The project will carry out quarterly data performance review meetings and routinue continuous quality improvement initiatives at sites. These resources will also provide integrated outreach and clinical diagnostic assistance using IMCI, for improved referral and health services for the children in those communities who are infected or affected by HIV/AIDS.

The project plans to perform 25,000 male circumcisions in COP12. This target will be realized through static service delivery, outreaches and MOVE campaigns. The services will be provided at 21 health facilities in Nyanza and four in Western. These facilities are spread in 10 districts across the region.

The services will conform to WHO and national guidelines and include trainings, supplies, equipment and client follow up. Project staff will work with DHMTs/HMTs to provide supportive supervision to VMMC sites. Supervision will be guided by a checklist that ensures the services conform to WHO and national standards.

As part of the comprehensive MC package, testing and counseling will be provided on site to all clients on voluntary basis. Confidentiality will be observed during these sessions. This service will be extended to spouses or guardians/parents accompanying clients.

MC will be part of a comprehensive package for HIV prevention. Clients will have the benefit of receiving other HIV preventive information and services which include HTC, diagnosis and treatment of STIs, provision of condoms, and information on abstinence and faithfulness to uninfected partners. Clients will be linked to other HIV services including care and treatment services as necessary.

VMMC trainings will be provided using WHO and National VMMC guidelines. Training for MC under local anesthesia will be in two stages; theory sessions (knowledge), and practical (skills). This will be followed by continuous assessments and mentorship before confirmation on competency and certification by NASCOP.

The project will employ several approaches for demand creation. CHWs will be trained and equipped with relevant messages to promote MC in their communities. Peer groups will also be supported to reach youth, men and women with correct BCC messages. Community opinion leaders such as councils of elders and other leaders will continuously be used. Radio spots will be used to air interactive sessions to encourage dialogue on the services. The project shall also use magnet theatre groups to pass the messages during outreaches and during accelerated VMMC activities. Relevant IEC material shall be provided to health facilities and communities.

MC sites will be supplied with M&E tools. HRIOs will be supported to collect complete and timely MC data and transmit it to district levels.

The project supports HTC activities in 66 and 396 sites in Nyanza and Western provinces respectively. It will scale the support to 70 and 140 sites in Nyanza and Western respectively in the next one year. Target populations for APHIAplus Western Kenya include couples in the general population, particularly those who have never been tested before, most at-risk persons (MARPs), and pregnant women.

Strategies to reach these target populations with HIV counseling and testing include supporting the MOH to provide Client Initiated HIV Testing and Counseling (CITC), Provider Initiated HIV Testing and Counseling (PITC), Home-Based Testing and Counseling (HB-HTC), and to conduct targeted special outreaches to bring HTC services closer to priority populations (e.g. outreaches for hard-to-reach communities, fishing communities). The Project also supports HTC services in ANC and TB clinics and engages lay counselors in priority high-volume facilities.

The Project supported the testing of 148,906 Kenyans in its first year in Nyanza and 346,430 in Western, constituting coverage of 13.4%and 64.6% in Nyanza and Western provinces respectively. Of the total, 218,262 were done through PITC (124,081 in ANC clinic; 8481 in TB clinic), 102,432 through CITC, and 6580 through home-based HTC. Through the aforementioned approaches, the project expects to support the MOH to counsel and test over 629,564 Kenyans in 2012. Similar to achievements in year 1, the project expects approximately 390,000 to be achieved through PITC (162,200 in ANC clinic; 20,700 in TB clinic), 11,664 through CITC, 30,000 through home-based HTC and 15,000 through special outreaches.

The project supports the Ministry of Healths recommended algorithm for serial testing. Referrals and linkages to services for clients who test positive are facilitated through community health workers. Monitoring for linkages is facilitated through community-facility linkage meetings. To improve quality HTC services (both testing and counseling), the project facilitates provider and supervisor orientations on external quality assurance (EQA), on-job training for HTC, updates, regular coaching, and supportive supervision. Technical review meetings are held quarterly to discuss HTC performance, issues and promising practices. Dissemination of promising practices and lessons learned is an output of the performance review meetings.

To improve monitoring and evaluation of HTC, the project provides orientations to healthcare workers on M&E. In 2012, the project will support orientations to healthcare workers on the new HTC guidelines rolled out by NASCOP and the new HTC register MOH 362, which captures disaggregated indicators (eg couple, disability, MARPS).

Project support for demand generation and mobilization for HTC is done through two principle strategies: routine mobilization and community education done by community health workers, and project support for high-profile HTC campaigns and events (e.g. HTC Rapid Results Initiative, and World AIDS Day).

The project will use a combination approach to HIV prevention that incorporates behavioral, biomedical, and structural interventions targeting specific populations in defined geographic settings in Nyanza and Western. Tailored prevention messages targeting needs of individuals and communities will be used to generate demand for service while promoting healthy seeking behavior and risk reduction. Peer education, dialogue groups and use of multimedia channels like magnet theatre, focused outreaches, road shows, print materials and radio will be used.

Drivers of vulnerability, reduction of STIs, HIV acquisition and transmission, condom promotion among MARPS and vulnerable populations like fisher folks, low income women and migrant workers will be addressed.

MARPS

Female Sex Workers: 240 bar managers and stakeholders from 10 priority sites will be sensitized on the national MARP strategy prior to selection of 1000 FSWs for Peer Education training. Each trained peer educator will regularly reach 14 peers with repeat-prevention messages aimed at risk reduction, condom promotion and making referrals for service uptake.140,000 (1000 x 14 x 10) people will be reached in Nyanza and Western in FY12.

Men who have Sex with Men (MSM): An updated inventory of MSM hotspots in Kisumu will be developed. Implementation of MSM Intervention will continue using capture-recapture and snowball methods. Sensitizations, selection and training of peer educators based on National Guidelines for Sex workers shall be conducted. Structured repeat-peer education sessions, outreaches and referrals will follow. As per EBI programming, one peer educator will reach 14 peers with prevention messages. In year 2, 14,000 people (100 x 14 x 10 months) will be reached with repeat-prevention messages, condom promotion and referrals for STI management and biomedical services. Value clarification workshop for providers from referral facilities will be conducted to make them more responsive to MARPS.

Fisher-Folks Interventions: 312 Beach Management Units (BMUS) are located around Lake Victoria out of which 292 are in Nyanza while are in 20 Western. Each BMU has between 450 and 1000 members. Behavioral interventions targeting fisher folks will be delivered through peer education. Periodic biomedical services of HTC and VMMC outreaches will be conducted at popular BMUs. 1740-trained Peer Educators (140 for Western and 1600 for Nyanza) will meet monthly to submit reports, share experiences and plan. Additional 1000 peers will be trained in PEs. By the end of the year, 2,740 Peer Educators will reach about 350,000 people with repeat-prevention messages, condom promotion and referrals for STI management, HTC and VMMC services in Nyanza and Western.

Workplace Interventions: 1500 additional workplace Peer Educators from 30 work sites will be trained in addition to 322 existing PEs in Nyanza and Western to create demand for health service. To the ratio of 1 PE to 14, 226,800 people will be reached with prevention messages, condom promotion and referrals for STI management and biomedical services. To ensure sustained institutional support at the workplaces, the project will conduct two breakfast meetings for Chief Executives from targeted companies.

Low-Income Women: Community outreaches, one-on-one peer education, and small group discussions will be used to facilitate behavior change among women.

The project is supporting comprehensive adult HIV care and treatment in 48 comprehensive ART sites in Nyanza and 66 sites in Western. This will be scaled up to 62 and 75 ART sites in FY 2012. The target population in the zone is 149,250 comprising all adults testing HIV positive and referred into care with coverage of 17.1% in Nyanza and 43.4% in Western provinces.

The package of care and treatment services provided through the project include cotrimoxazole prophylaxis provision, TB screening during all client visits, CD4 testing for initiation and monitoring, lab tests for ART initiation and monitoring (such as HB, urinalysis and creatinine testing) according to national guidelines, food by prescription (FBP) and supply of ARV commodities at ART sites.

For clients enrolled into care and treatment the project supports clinical appointment and drug therapy adherence counseling sessions at the point of enrollment and continually thereafter by HCWs and project supported peer educators. The project helps clients enroll into psychosocial support groups for adherence counseling and stigma reduction support. Home visits by peer educators help follow-up clients with adherence challenges.

To support client retention in care and treatment the project provides daily appointment diaries at the clinic that are used to track daily clinic appointments. At the end of the clinic day, the missed appointments are immediately notified to the peer educators who initiate defaulter tracing by making telephone calls to the clients, carrying out home visits and notifying patient support group leaders. The project is introducing a new modality which features an SMS reminder system to notify patients expected clinic appointments and which offers patient education on ART. Client retention to date is at 78% in Nyanza and 89% in Western.

For effective monitoring of care and treatment services at the ART sites, the project facilitates PHMT and DHMT integrated support supervision on a quarterly and as-needed basis. Training needs are addressed by supporting on-site and off-site mentorship. The project is supporting district mentorship teams to offer continual mentorship at site level within a district. The project will introduce on-site HCWs modular training at district hospitals with minimal interruption to service provision.

The project carries out quarterly performance data review meetings for the ART sites which form the basis of continuous quality improvement initiatives. The performance data reviews are incorporated in annual M&E plans and involves clinicians, site managers and M& E staff.

The project supports peadiatric ART services in 48 and 66 sites in Nyanza and Western provinces respectively. The total current cohort as at September 2011 is 5,306 and those newly enrolled is 1,139. The current peadiatric ART cohort is 9% of total ART in the zone. The services will be scaled-up to 62 in Nyanza and 75 sites in Western in FY 2012. The total cumulative ART pediatric cohort is expected to reach 10,120 with a current ART peadiatric population of 8,800 and 1,800 new enrollments.

The project supports on-going on-site and off-site mentorship, exchange visits of newly initiated site clinicians to established peadiatric ART sites and continued site mentorship by the district mentorship teams to new sites. The goal of the mentorship is to better support early identification and initiation of ART in children as per national guidelines.

The project will support early infant diagnosis DBS PCR networks, CD4 testing networks for CD4% availability, and viral load monitoring for suspected treatment failure cases. MCH integration with pediatric care and treatment for infants and children < 18 months will be supported to promote early identification and retention in care and treatment. Linkages to food by prescription for children with malnutrition will be supported at all supported sites.

Retention rates will be improved through the identification and follow-up of HIV exposed infants by peer educators, regular review of PMTCT and HEI registers, home visits and enrollment into support groups. The project will support adolescent clubs/ support groups, adolescent youth friendly services and health education at facilities and focused adolescent adherence counseling and support.

Quarterly PHMT and DHMT support supervision visits will be facilitated as well as program specific support supervision visits to monitor availability of peadiatric ARV commodities, treatment algorithms and linkages and referrals to nutritional support, peadiatric psychosocial counseling and community support.

Performance review will be done through quarterly data review and performance meetings and quality improvement assessments at facilities.