The goal of the APHIAplus Nairobi/Coast project is to support the public, NGO and for-profit sectors in Nairobi and Coast Provinces to provide sustainable, integrated, quality health services to Kenyans, resulting in improved health. Through strategic partnerships, the country-led project will capitalize on existing opportunities to make a lasting contribution to improved health outcomes. All activities are aligned with existing GOK policies, guidelines, strategies and priorities. Activities are also aligned to the PF as they will address issues of health systems strengthening, integrated service provision and demand creation.

APHIAplus will implement integrated programs that include HIV, RH, child survival and malaria. In doing so, efficiencies will be realized in investments in equipment, infrastructure and training as services are co-located and the same staff and facilities are utilized in service delivery. They will also work towards providing TA on task shifting to increase health worker efficiencies. Additionally, they will collaborate with the national work groups exploring options of sustainable financing, such as health insurance schemes and promoting integration of the private sector in service delivery. APHIAplus will provide TA to the GOK programs at the provincial, district and service delivery levels to ensure GOK ownership. Furthermore, they will support strengthening systems, including working with District and Provincial Health Management Teams, and strengthening country ownership and building capacity for a sustainable, long-term GOK response to the HIV pandemic. This partner will procure 8 vehicles using past year funds but none with FY12 funds. This activity supports the GHI/LLC and is funded primarily with pipeline in this budget cycle.

APHIAPlus Nairobi-Coast HBHC programs support a comprehensive package of care and support services to promote health, improve quality of life, prevent HIV transmission and delay HIV disease progression in PLWHA. The package includes prevention and treatment of OIs, malaria and diarrhea (including provision of commodities such as pharmaceuticals, insecticide-treated nets, safe water interventions and related laboratory services); nutrition assessment, counseling and support; and pain and symptom relief. Involvement of the community and organizations of PLWHA will continue through psychosocial support groups, employment as peer educators, HIV treatment awareness activities, wraparound food programs, and income-generating activities.

APHIAplus will offer an integrated package of care services to all HIV+ patients at the health facility level, including clinical assessment for ART eligibility; lab monitoring; psychosocial counseling, including support for HIV status disclosure, positive living and referral to support groups; adherence counseling and support; nutritional assessment, counseling and supplementation; PwP; family planning; support for family testing for spouses/partners and children; opportunistic infection diagnosis and treatment, including TB; pain management, and increased access to opioids for registered palliative care centers. APHIAplus will work closely with the regional Nutrition and HIV Program (NHP) participating in scale up and implementation support - trainings, equipment, inventory management, and early identification of malnutrition using MUACs for early referrals. APHIAplus will also increase linkages to and implementation of food security and livelihoods interventions as they graduate patients out of therapeutic nutritional care.

In collaboration with facility in-charges multi-disciplinary teams will be established for HIV care and support and treatment. The project will strengthen linkages between health facility committees and the community health committees/CUs for referral. Facilities will be supported to achieve high patient retention and greater adherence by expanding interventions, such as referral desks that increase health literacy, ensuring availability of psychosocial support, and improving on defaulter tracing. Facility PwP package provision will be promoted at all outlets. STI screening and treatment and the provision of FP will also be integrated.

At community level, support will be provided for training PLHIV (including MSW, FSW, discordant couples and OVC caregivers) on health literacy and PwP thus promoting treatment adherence, positive living and good nutrition for PLHIV. CHWs will be trained on CHBC, PwP, SGBV, defaulter tracing and pediatric counseling. The project will assist support groups, including assistance with regular updates. HH economic strengthening initiatives will improve food support at community level. The project will purchase HBC supplies and fund monthly transport allowance for CHWs. CHWs will be supported to establish support groups (targeting pregnant women, youth, MARPs) for peer-to-peer psychosocial support and treatment adherence.

The project will build on the GOK systems for data collection and reporting at all levels to strengthen data quality and management. The project will support DHRIOs and DASCOs with technical assistance. In FY12 persons reported as receiving basic care and support will receive at least one clinical service, plus at least one service.

Pathfinder is an International Organization implementing the APHIAplus program in Nairobi and Coast provinces. APHIAplus works with GOK, CBOs, FBOs, NGOs and communities to serve OVC (in and out of school) and their families, implementing community-based activities aimed at reducing their vulnerability to HIV/AIDS and helping them become productive members of society. In COP12, APHIAplus will build on the Quality Improvement Initiative spearheaded by GOK and will support dissemination of service standards to the point of service delivery. This project targets children 0-18 affected and infected by HIV in Nairobi and Coast provinces. APHIAplus uses an evidence-based community-strengthening approach, as working within community structures is shown to have a more lasting effect on the livelihoods of OVC and project sustainability. APHIAplus will continue to support the GOK to undertake service mapping that will facilitate informed decision making and support coordination of OVC stakeholders.

The goal is to support local implementing partners (IPs) and GOK to deliver services for OVC to address lack of educational opportunities, social and emotional support, inadequate health care, malnutrition, and susceptibility to abuse and exploitation. APHIAplus will provide sustainable, high-quality services to OVC, including: strengthening capacity of families to cope with their situation; strengthening community-based responses; increasing capacity of children to meet their own needs; and raising awareness within communities to create supportive environments for OVC.

APHIAplus fosters close relationships with the Department of Children Services, the Ministry of Gender, Children and Social Development, the National Council for Children Service, the OVC Secretariat, the Nairobi and Mombasa City Councils. APHIAplus also collaborates closely with the Ministries of Education, Youth, Health, and Agriculture. CBOs and FBOs will link with community units (CUs), which will contribute significantly to the sustainability of the project. CUs and IPs will support OVC and their caregivers in accessing health, education, and legal services, and support groups. Activities will be tailored for age and gender, and adolescents will receive information on reproductive health, life skills, and income generation. The investment in accessible health services for OVCs will benefit overall access to comprehensive care within the health system. Health services include growth monitoring of the under-fives, deworming and vitamin A supplementation, and immunization campaigns. For HIV positive children, OVC support groups will improve ART adherence. Support groups for children of all ages will be strengthened and more created where necessary.

Technical support includes planning, budgeting, and delivering quality services (protection, health, food and nutrition, education, psychosocial support, shelter and care and economic empowerment) to OVC guided by priorities at the child, household and community levels, which aligns with PEPFARs support to OVC through the 6+1 core program areas. APHIA will also help the GOK disseminate policies like the Early Childhood Development policy and the School Health policy, and ensure that stakeholders understand and implement them. In COP12, PEPFAR will support GoK efforts in rolling out and disseminating the recently finalized OVC service standards, and mainstreaming OVC QI standards in service deliver.

APHIAplus Nairobi-Coasts overall objective of the HIV/TB care project is to decrease the prevalence of TB in Nairobi and Coast provinces and integrate care of co-infected patients into a comprehensive program that meets the objectives of the Division of Leprosy, Tuberculosis and Lung Diseases (DLTLD) and NASCOP. This activity will support and strengthen the Global Stop TB Strategy, which Kenya has adopted, emphasizing effective DOTS delivery with focus on HIV-associated and drug-resistant TB, health system strengthening (particularly primary care and laboratories) and closer engagement with patients and communities.

Support for expanding TB/HIV services at facility and community levels is stipulated in the national policies and strategic plans. HIV/TB co-infection is approximately 48% of new TB patients. APHIAplus will address challenges in Nairobi and Coast provinces, which include multi-drug resistant TB, poor nutritional support for TB clients, limited HIV/TB integration, and pediatric TB diagnosis and management. Interventions target MARPS, vulnerable children, PLHIV, slum dwellers and transport workers as target groups. Activities aim to improve early identification of TB and diagnosis, intensify case finding, case management, and improve the cure rate, reporting rate, and infection prevention and control.

TB/HIV integration support includes provision of TB screening tools, defaulter tracing to avoid drug resistance, contact tracing, and transportation of sputum for TB culture and drug sensitivity test (DST) for failed, retreatment, relapsed cases or those returning to treatment after a period of default. The number of diagnostic sites in both provinces (currently 107 in Nairobi and 88 in Coast) will be increased. APHIAplus will support training of service providers, renovations, nutritional support, provision of equipment, staffing, and collaboration with GOK officials. Community desks and health talks are planned at facility level. Treatment support groups will help in defaulter tracing while community forums will help in passing prevention messages. CHWs will be involved and ICF tools will be piloted among OVC.

Support to GOK includes mentorship, support supervision, CME, and OJT, orientations of health workers and CHWs on MDR-TB, IPC and training of CHWs on defaulter tracing. In collaboration with P/DHMTs, needs for facilitators (numbers, refresher training) will be identified and addressed by linkages with national mechanisms. Standardization of CMEs is essential. This project will result in increased demand creation for TB/HIV services, increased access to PITC and ARVs, improved infection prevention and control at the facilities, TB intensified case finding integration into HBCT, CCC, OPD, improved medical and pediatric wards and improved pediatric TB diagnosis and treatment.

APHIAplus will monitor and evaluate this program using identification of M&E tools, distribution of the tools to facilities, orientation of services providers on the use of tools, record keeping, data analysis and use for decision making, data sharing/review forums, supervision by PTLC and DTLC and logistical support to strengthen MDR TB surveillance.

APHIAplus Nairobi Coasts pediatric care and support program aims to optimize the continuum of care for HIV exposed and infected infants (HEI) and children through provision of clinical, psychosocial, spiritual, social and prevention services. 141,275 adults and 4,159 children are now on ART treatment in both provinces. APHIAplus will build upon and continue to prioritize the identification of exposed and infected children through EID for those <18 months of age, PITC in clinical settings, family testing through clinical and community HTC strategies, and the launch and use of the combined mother-child card. Activities will involve the intensified identification of HIV-exposed and infected children both at the facility and community level, and collection of samples for DBS and strengthening of DBS networks to all facilities offering PMTCT services. DBS collection will be closely linked to immunization schedule and regular growth & nutritional monitoring. Exposed children will be followed until their status is confirmed, and are then proactively linked to pediatric care services and ART if infected. The project will help decentralize services so patients get treatment where they are presenting for care.

APHIAplus will support virological testing for 1,616 HIV exposed children. Out of the infants tested those who test positive, 243 newly enrolled will be put on ART while 1,571 will be continuing treatment. A total of 3,780 will continue receiving comprehensive care services. In addition, 52,875 eligible children will be supported to access food and nutrition services. APHIAplus supports holistic care and support services and the availability of a high quality package that includes prevention and treatment of OIs and malaria and diarrhea, including provision of commodities such as pharmaceuticals, insecticide-treated nets, safe water interventions and related laboratory services; nutrition assessment, counseling and support; and pain and symptom relief.

Mentorship of service providers will support the expansion of service outlets providing pediatric HIV care and treatment services. Facilities will be supported to achieve high patient retention and greater adherence by expanding interventions such as referral desks, increased health literacy, availability of psychosocial support, and improvement on defaulter tracing. Lab networking for CD4 and DNA PCR testing for EID in HEI will be supported through skills building of lab technicians on HIV lab services and transportation of lab samples and results.

CCC family days will be supported through provision of edutainment and lunch; OJT will be undertaken for HIV counselors on Hero book to empower children on coping skills for positive living and better treatment adherence. CHWs will be trained on CHBC, PwP, SGBV, defaulter tracing and pediatric counseling. The project will assist support groups, and economic strengthening initiatives will strengthen food support. The project will purchase HBC supplies and fund monthly transport allowance for CHWs. CHWs will be supported to establish support groups (targeting pregnant women, youth, MARPs, including for YLHIV) where clients will be encouraged to form pairs for peer-to-peer psychosocial support and treatment adherence.

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 APHIAplus Nairobi-Coast VMMC program is one part of a comprehensive prevention package, which is part of a larger package of integrated support at health facilities and communities, holistically addressing HIV prevention, treatment and care. Nairobi provinces VMMC three year target is 120,000, of which APHIAplus will circumcise 14,285 men in COP12. APHIAplus currently supports five facilities in Nairobi province to provide comprehensive VMMC services to males aged 15-49 years, with an increased focus on recruitment of hard-to-reach older men population. APHIAplus will also support the establishment of two more sites in Nairobi in this coming year. APHIAplus will collaborate with Nyanza Reproductive Health Society, who has been training VMMC service providers for Kenya using approved curricula, to ensure APHIAplus staff is trained to highest standards. The target population and their partners will also receive key messages on HIV prevention and family planning as part of an integrated approach.

Community mobilization will take place in the targeted communities where male circumcision is low and where cost remains a barrier to access of services. VMMC messages will be disseminated and mobilizers trained to create demand. Women and girls will be targeted with information and mobilization, as their vital role in decision making and influence regarding VMMC in Kenya is widely recognized. VMMC awareness will be raised during the community days and in opinion leaders forums. Focus group discussions will be used to dispel myths and misconceptions about VMMC in communities and to brainstorm ways of working around this to remove barriers to access to care. The HCM VMMC video will be screened and this will be followed by small group discussions to ensure that the right messages are imparted.

Dedicated teams are hired on renewable 6-month assignments. Teams consist of a clinical officer, a nurse, a counselor and a hygiene officer. They will mentor other facility staff to ensure sustainability, ownership and continuity of services. Outreach services will be provided to improve access where distance is a barrier whereas the project will participate in the provincial RRI. Minor renovations are in the process at the public facilities. Circumcision kits will be provided by the project and national partners. The project ensures high standards of clinical care and infection prevention, providing TA, supportive supervision, and quality assurance visits. Whole site sensitization of service providers will be conducted to improve interfacility referral and to improve attitude of service providers.

APHIAplus Nairobi Coast will develop an intensive M&E plan in order to ensure the highest quality services are delivered. Activities will include routine site visits, reporting checks, and training of workers in data collection. Adverse events will be closely monitored and steps taken to improve the rate of such events. The partner will ensure standardization of data collection forms and consent forms across all sites and according to national and World Health Organization guidance. This activity supports the Kenya Partnership Framework by using evidence-based, data driven approaches, efficiency of activities, and sustainability of all interventions. The goals and objectives of the partnership framework include providing facilities, personnel, and technical leadership for VMMC facilities, and to support community mobilization and outreach approaches.

APHIAplus Nairobi-Coast covers Nairobi and Coast provinces and targets general populations, men and women, (especially concurrent partnerships and discordant couples), in and out of school youth, teachers, most-at-risk populations (MARPs), and more with evidence-based intervention (EBI) HIV/AIDS prevention programs that promote abstinence and/or being faithful, and link to condom and counseling and testing programs where appropriate.

In-school small group programs for 10-18 year olds will emphasize support systems to focus on long-term goals, self-esteem and life skills. For example, APHIAplus supports the Kenya Girl Guides Association, which implements a life skills program that targets boys and girls. Girl Guides, young leaders and Guide Leaders will be trained on promoting abstinence, including delay of sexual activity or secondary abstinence and related social and community activities. Gender-sensitive messages that discourage cross-generational and transactional sex, sexual violence and stigma will be passed, giving young people skills to help sustain desirable behaviors. Diverse small-group, evidence-based approaches will be utilized: peer education, outreaches, songs, poems, drama, educational rallies/ fun days, art/essay competitions, etc. Life Skills Promoters will train peer educators to use dialogue groups to conduct peer education sessions using nationally approved curriculum and age-appropriate workbooks and reference materials. Teachers and parents will be involved in programs as much as possible. Programs for adults and youth out of school (15-49), will consist of AB EBI with emphasis on being faithful and reduction of multiple and concurrent sexual partnerships, a main driver of the Kenyan epidemic.

Small group sessions will be carried out by facilitators and CHWs, who will be trained on BCC methodologies. Around 3 million people in Nairobi and Coast live in low income areas such as urban slums and rural areas. Through APHIAplus interventions this population will be targeted directly with at least two in-depth contacts per target in 2012. APHIAplus will implement comprehensive prevention with positives programs by working with PLWHA support groups, linking them to comprehensive care centers and other services, and delivering key messages about living positively. These activities will provide assistance to patient support groups and post-test clubs in VCT centers to encourage abstinence and to empower support group participants to become peer and advocacy leaders in prevention at the community level.

Individual, small group or community level interventions that explicitly address norms about masculinity related to HIV/AIDs will be conducted in Nairobi and Coast, including men-as-champions programs and gender-based violence prevention forums. APHIAplus programs also include interventions that explicitly aim to increase access to income and productive resources for women and girls impacted by HIV/AIDs.

Intensive M&E will include support supervision visits, audit checks, training of facilitators and monitors on data collection and data entry, and progress review meetings with community health workers and community based organizations.

In Nairobi and Coast, coverage for HIV testing and counseling (HTC) is relatively high, for both women (Nairobi 83%; Coast 91%) and men (Nairobi 79%; Coast 87%) (KDHS 2008). In the last year APHIAplus Nairobi-Coast reached over 350,000 people with HIV Testing and Counseling (HTC). But in both provinces, coverage is less a problem than achieving sustained quality of HTC, ensuring that most-at-risk populations (MARPs) properly access HTC services and that those testing positive are effectively linked with care. APHIAplus will ensure that HTC services in Nairobi and Coast provinces are readily available, high quality, and meet needs of clients, and are in line with national guidelines.

The project will support various service delivery models for HTC (facility based, PITC, mobile VCT, door-to-door outreaches, couple testing, RRIs) and focus on increasing access and acceptability for men and even greater access for MARPs. The project will support the Provincial and District Health Management Teams (P/DHMT) to strengthen integration of RH/FP and TB screening into HTC services through supporting out and in-reaches. The project will focus on strengthening integration of HIV testing of individuals infected with TB and TB/HIV cross referral systems.

Continuing Medical Education (CME) and orientation sessions will be conducted to ensure that service providers receive updates on HTC guidelines and protocols. Counselor supervision will be supported on a monthly basis in all districts and will prevent burn out. At community level, HTC messages will be integrated into small group communication sessions and in magnet theatre outreaches. The project will train select CHWs, MARPs, and youth as counselors. During outreaches, CHWs and peer educators will target MARPs (CSW, IDU and MSM), youth and OVC and their caregivers for HTC services. The project will support provincial HTC Rapid Results Initiatives (RRI) campaigns at least twice a year.

Pediatric HIV testing will be supported, especially among OVC. HTC will be integrated in services provided by the Tunza franchise, to further improve access. Operational objectives are that all patients tested and found to be positive for HIV are referred for care and treatment.

In order to help DHMTs focus on data, systems and processes, support will be given to increase availability of registers, to use data to analyze service delivery processes, to involve facility teams in data improvement efforts. This will help service providers in setting realistic targets and particularly in setting focused targets: youth, couples, newly tested clients etc.

APHIAplus will provide supervision to ensure that all HTC services adhere to national and international standards of algorithm used, confidentiality, counseling, and consent. Through guidance from the national level, HTC laboratory proficiency and laboratory quality assurance will be strengthened. During technical support, attention will be paid to integration of HTC in other services as appropriate (e.g. MNCH) and to the fact that HTC serves as an entry-to-HIV care and as a support for HIV preventive behaviors.

Target Population/ Approx $ Amount/ # Reached

CSW/ $1,400,000/ 14000

MSM/ $100,000/ 2000

Youth 15-24/ $450,000/ 40000

Men 30-44/ $175,000/ 15000

Discordant couples/ $60,000/ 6000

PWP/ $350,000/ 70000

APHIAplus Nairobi Coast will target the populations listed above in Nairobi and Coast provinces with an integrated comprehensive prevention approach that includes small group and individual community outreach evidence-based behavioral interventions (EBI) to promote character formation, abstinence among youth, fidelity, partner reduction, and correct and consistent condom use by sexually active persons targeting populations at risk for transmission or acquisition of HIV. These programs will be tailored to the urban concentration found in these provinces, and will include focus on efficiency of activities, meaningful involvement of PLWHA, and sustainability of programs.

APHIAplus will ensure that community health workers and clinical staff are trained to provide HIV/AIDS prevention programs that promote prevention other than abstinence and being faithful. They will work with PLWHA, with a special focus on youth, support groups, linking them to comprehensive care centers and other services, and empowering participants to become leaders in prevention at the community level. Youth programs will target both in and out of school young people, including peer education, vocational/life skills building, mentorship programs, linkage and referral to youth friendly health services, reduction of harmful gender norms and gender based violence (GBV) prevention, and close collaboration with HIV Free Generation programming to combine the reach of mass media with the intensity of interpersonal communication.

Examples of specific EBI programs used are an adapted form of the Sister to Sister program, addressing low condom use, safe sexual behavior, and concurrent partnerships, among other components, and the Healthy Images of Man (HIM) program, which promotes male involvement in health. Testing and counseling and condom use will be promoted across all adult target groups and audiences.

Aphiaplus will support peer education interventions with at risk youth, transport workers, CSWs and MSM, disseminating prevention messages and linking them to STI, CT, care and support services available at public facilities and at drop in centers. Activities include targeted promotion of correct, consistent condom use and distribution to high-risk populations, stigma reduction, and partner trust, disclosure, and multiple concurrent partners. Quality of STI services will be improved by working through the MOH and other partners.

APHIAplus will continue to expand its programming for GBV survivors with integrated activities including awareness raising for communities, medical personnel, police, leaders, and men/women around womens rights and legal recourse, building capacity of local communities to recognize and fight GBV, and supporting GBV recovery centers and shelters.

The project will work closely with the GOK and other implementing partners to help establish or support provincial MARP TWGs and partner with MARP, youth, and PLWHA groups and encourage their active participation in programming.

Activities for monitoring and evaluation will include support supervision visits, audit checks, training of facilitators and monitors on data collection and entry and progress review meetings with community health workers and community based organizations.

APHIAplus Nairobi-Coasts injecting drug user (IDU) and non-injecting drug user (NIDU) program aims to reduce the spread of HIV among the high-risk populations of drug and alcohol users, both male and female, with evidence-based behavioral, structural, and biological interventions in Nairobi and Coast provinces. There is paucity of data on substance abusers in both provinces, but there are known clusters of users in both Coast and Nairobi provinces. The IDU program has an increased focus due to GOKs recent adoption of new guidelines regarding needle exchange and medication-assisted treatment (MAT). APHIAplus will work with both GOK and all other partners working with drug users to minimize overlap and maximize results. The program will utilize both recovering drug users and non-drug-users to make contact with addicts to establish behavior plans to reduce their risk of HIV, as well as reach out to male and female sex workers with anti-drug interventions. Other activities will include a comprehensive mapping exercise of IDU/NIDUs in the different regions of Kenya in collaboration with other partners, which will allow existing programs to strengthen their efforts. Programs will include medically assisted treatment, addiction recovery treatment services, and improving skills in the area of HIV outreach behavior change interventions. The APHIAplus program will continue to ensure effective referrals for relevant services, including HIV counseling and testing, HIV care and treatment services and male circumcision services.

Behavioral interventions: (i) Comprehensive peer education and outreach. Peer educators will be recruited from former addicts who are familiar with the wide user networks and are trusted by addicts. They will be trained on the Education Through Listening model to conduct facilitative peer education; (ii) Risk assessment, reduction counseling and skills building:-trained counselors and outreach workers will be making contact with addicts and conduct active harm reduction counseling and provide commodities like condoms, bleach, and alcohol swabs; and (iii) Linking IDUs to treatment, rehabilitation, and needle exchange programs.

Biomedical interventions: (i) The peer educators and outreach workers will refer IDUs for integrated services. The outreach workers will conduct mobile clinics near places where IDU congregate. Services offered will include HTC; STI screening, treatment and referrals; TB screenings and referrals; and hep. B screening and management; (ii) Comprehensive condom promotion, demonstration and distribution by peer educators, outreach workers and hotspots managers; (iii) Linking to needle exchange programs; (iv) In Coast, local relevant GOK facilities that offer drug abuse treatment will be supported to offer MAT. (v) Support MARPs-friendly provision of PEP in facilities for users who are victims of GBV.

Structural interventions: (i) Setting up IDU/DU-friendly drop in centers that offer HIV services and information to IDUs; (ii) Setting up of a network of recovering addicts for psychosocial support and counseling; (iii) Family and social services will be offered to recovering addicts to link them with their relatives for easier reintegration into society.

APHIAplus technical teams will provide TA, supportive supervision, and data management capacity building to subpartners, ensuring high quality, MARP-friendly services and accurate data collection and use.

APHIAplus NairobiCoast supports facilities in Nairobi and Coast provinces to provide a comprehensive antenatal package for all pregnant women including screening, prevention and treatment of any infections, nutritional support, prophylactic ARVs, Infant and Young Child Feeding (IYCF) support, and provider-initiated HIV counseling and testing (PITC) of women, their partners, and family members. The family-centered approach to care and treatment (C&T) will improve post natal follow up, and help ensure that all HIV-infected pregnant women are enrolled into HIV C&T. To improve access to HIV services, APHIAplus will support the integration of HIV C&T into MCH for the mother and family by strengthening referral lab networks for CD4, decentralization and task-shifting. This family-centered approach will improve C&T retention. APHIAplus will use national referral tools to link mothers and families to palliative care, including TB services and home-based care; ART; malaria prevention activities; FP services; and income-generating activities.

APHIAplus will collaborate with other partners to support Early Infant Diagnosis (EID) and HIV-exposed infant (HEI) follow up by integrating the PMTCT services with well child and immunization services. APHIAplus will build upon existing ICYF strategies such as involvement of men, grandmothers, PLHIV peer educators, mother-to-mother support groups, and other community leaders at community level and explore the use of ARVs at facility level to make breastfeeding safer. Support to service providers will include mentorship, continuous medical education (CMEs), on-the-job training (OJT) and orientation sessions. Attention will focus on integration of family planning into PMTCT; provision of more efficacious regimes to HIV pregnant women and provision or referral for HAART; adherence through counseling and support from community health workers (CHW); HIV prevention during pregnancy and during lactation; early infant diagnosis (EID) and follow up of HEI; and enrolment of HEI in care and treatment. OJT will be provided on dried blood spot (DBS) harvesting. The lab transport network will be supported so that DBS specimens can reach the labs and that facilities receive the results.

Technical assistance and support supervision will build capacities of HCW. PMTCT protocols will be disseminated, and standardization of services will rely on national guidelines from MOH. The project will support the distribution and proper use of the mother-child booklet and of MOH monitoring tools, and give routine TA to ensure high quality data collection and evaluation. At community level, support will be provided to the DHMT to orient CHWs on PMTCT, EID, and IYCF. In select communities, mentor mothers will be supported to strengthen promotion of PMTCT and IYCF to pregnant women, offer psychosocial support, and link mothers to support structures.

Mobilization will be done during community dialogue days and outreaches to encourage mothers to attend ANC and to know their status. IEC material will be distributed to promote PMTCT services. Absence of male involvement remains an effective barrier to uptake of PMTCT services. Male involvement will be improved using the Healthy Images of Manhood (HIM) approach. APHIAplus will use multiple approaches to reach women currently not accessing ANC due to challenges related to culture, stigma and distance.

APHIAplus Nairobi Coast will continue to strengthen facilities to provide quality HIV treatment services in Nairobi and Coast provinces. Activities include infrastructure improvement, training clinicians and other providers, clinical monitoring, lab services, community-adherence activities and management of opportunistic infections (OI). APHIAplus emphasizes improving access to care and treatment for pregnant women. Currently there is need to initiate around 40,000 more patients on ARV in both provinces, and APHIAplus plans to contribute to roughly 25% of that in COP12, about 90% adults.

Multi-disciplinary teams will be established for HIV care and treatment. While a national mechanism will support technical training of health workers, all other capacity building measures will be supported by the project: exchange visits, mentorship, on-the-job training, continuous medical education (CMEs), whole site training, orientation sessions, on-site TA, and dissemination of clinical guidelines. Lab networks will be strengthened and networked to provide HIV monitoring tests (CD4 tests, hematology and liver function). APHIAplus will support viral load testing for suspected treatment failure cases through the network, and strengthen the case management of 2nd line patients to minimize failure, as 3rd regimen is expensive and not readily available.

At community level, APHIAplus will build capacity and create systems to strengthen facility-community linkages by sharing and implementing best practices. Patient follow up in the community will be critical to enhance adherence. APHIAplus will support communities to improve referrals and linkages to facilities, and follow up to ensure loss to follow up is minimal and adherence rates above recommended levels. The project works with PLWHA, promoting treatment adherence, positive living and good nutrition. CHWs will establish support groups (including for YLHIV) within which clients will be encouraged to form pairs for peer-to-peer psychosocial support and treatment adherence. The project will assist support groups or post-test clubs, including assistance with regular updates. Topical updates will be conducted in monthly support group meetings by PLHIV advocates and service providers from referral facilities. Education through listening methodology will be used in small group discussion on various HIV care and treatment messages.

The project will help strengthen linkages between the levels of care by supporting provincial, district and facility management committees, stakeholder forums, establishment of community desks at facilities and having CHWs based in facilities. The project supports the provinces through 3 QI approaches: supportive supervision, mentorship and quality improvement approaches. The multi-disciplinary mentorship team will work with provincial and district mentors to maintain strong management capabilities at facility level.

The project will strengthen data collection, management and use. EMR will be established and strengthened to improve program reporting. EMR will improve patient tracking and be a major resource for the CQI teams. The EMR will improve facility reports in terms of accuracy, completeness and timeliness. The partner will encourage data use at the facility level in order to improve service delivery. In both provinces, the project will work in close collaboration with DHRIOs and DASCOs to whom support and technical assistance will be targeted.

APHIAplus Nairobi Coasts pediatric treatment program works in Nairobi and Coast provinces to provide ART treatment to children, focusing on prioritizing the identification of exposed and infected children through PMTCT and EID for those <18 months of age, conducting PITC in clinical settings, family-testing through clinical and community strategies, and launch and use of the combined mother-child card. 4,159 children are now on ART treatment in both provinces. Expansion will continue in order to fill gaps in comprehensive HIV care and treatment, and in pediatric HIV service delivery. The project, through establishment of family friendly facilities, will support initiation of 1,088 children on treatment in the coming year. EID and pediatric CT will be enhanced to reach more children. APHIAplus will strengthen pediatric TB case finding, diagnosis and treatment, and will increase availability of the cryptococcal antigen test. Nutritional assessment using the WHO height and weight charts will provide a key pillar in monitoring the wellness of pediatric patients.

Mentorship of service providers will support expansion of service outlets. The project will focus on capacity building to improve service provider confidence in management of young children, especially prescribing of ARVs. Facilities will be supported to achieve high patient retention and greater adherence by expanding interventions, such as referral desks, improved health literacy, ensuring availability of psychosocial support, and defaulter tracing. Caregivers will be given treatment literacy training. High volume facilities will introduce the hero book, a psychosocial support program aimed at facilitating pediatric disclosure and adherence.

Orientations, sensitizations, CMEs, OJT and mentorship will ensure continuous capacity building at facility level. Lab networking for CD4 and DNA PCR testing for EID in HIV exposed infants will be supported through skills building of laboratory technicians, and support will be provided for transporting lab samples and results. At community level, CHWs will be trained on defaulter tracing and pediatric counseling. CHWs will facilitate the formation of support groups targeting children, especially adolescents. The project will support P/DHMTs to supervise and monitor facility based service delivery, and project staff will contribute to joint supportive supervision and provision of technical support on HIV/TB, and wrap around services with special focus on pediatric services.

APHIAplus will provide a package of basic care services to exposed/infected/affected children through supported facility, community, and home-based basic care services. Services include nutrition assessment, growth monitoring, safe water interventions, malaria prevention, OI management, psycho-social support, TB screening, and CTX at the service delivery points. Infected children will be provided with a basic care package including a safe water system, CTX for OI prophylaxis, an insecticide-treated bed net, and multivitamins.

The project supports the provinces through 3 QI approaches: supportive supervision, mentorship and quality improvement approaches. The project will strengthen data collection, management and use of data, working in close collaboration with district health teams. The M&E system will build on and improve existing tools. APHIAplus will also support paper based and electronic versions of record keeping at the CCC in line with NASCOP guidelines.