APHIAplus Northern Arid Lands is a five-year project funded by USAID to be implemented between June 2012 and June 2017 in North Eastern Province and select districts in Coast, Upper Eastern and Upper Rift Valley Provinces. The project is designed to support integrated service delivery and address social determinants of health by working with existing structures at the provincial, county, facility and community levels and building their capacity as necessary to ensure efficiency and effectiveness. The project will work to ensure access to and continuation of services in an area prone to drought, famine, insecurity and other disasters for populations that are nomadic and largely hard to reach. It 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. It also supports the Let's Live Campaign aimed at ensuring good health outcomes for mothers, new borns and children under 5 years in families infected and affected by HIV/AIDS. This project, which covers a very large geographic region, is expected to procure 8 vehicles in FY12. This activity will be funded primarily with pipeline funds in this budget cycle.

Care & Support Services for OVC: The services will enable OVC enjoy the basic human rights that include right to food and nutrition, health care, psychosocial support, shelter, education and vocational training and legal protection. Similarly people living with HIV (PLWH) enrolled and provided with nutritional support, shelter, medical and health care, legal protection and psychosocial support. To reach to the OVC and PLWH with care and support, the project will sub-contract the Local Implementing Partners (LIPs), train and provide them with grants for OVC/HBC services. In 2012, the project plans to sub-contract LIPs to reach OVCs and HBC clients in Garissa, Wajir, Mandera, Rana River, Marsabit, Turkana and Isiolo counties. OVC and PLWH will receive care and support at a household level to foster community and family participation as this approach has shown to reduce stigma and discrimination. Those to benefit from the project as OVC will constitute children aged 0-17 years while ensuring both girls and boys have equal chances of benefiting from the project. Those aged 18 years and above will be considered as beneficiaries on home based care and support. Client retention and referrals: The project will maintain a data base of OVC/HBC clients. Project staff will make periodic follow-ups to ensure retention on the program. To ensure that the OVC and HBC clients on the program receive quality services, the project will train the LIP project staff on QI standards. The care & treatment team will be involved for HIV care and support. Sustainability: The project will support the beneficiaries to engage in viable income generating activities (IGA) through training on group dynamics, identification of viable IGAs and marketing strategies. The project staff will conduct quarterly supportive supervision, review OVC/HBC data records and make random visits to the beneficiaries to assess quality of services that are received by the OVC/HBC clients.

APHIAplus will continue support the to Department of Childrens Services (DCS), to strengthen Area Advisory Councils (AAC) that have been established, build the capacity of new AACs where they do not exist at the district level and to help decentralize the system to the community level. APHIAplus aims to reach OVC households in the zone with care packages addressing needs related to health (including HIV prevention), education, targeted food and nutritional assistance, psychosocial support, shelter, protection, and household economic strengthening. Quality care implies that an appropriate mix of services and support are provided to ensure children affected by HIV/AIDs grow and develop as valued members of their families and communities. APHIAplus will apply the QI approach that engages teams of OVC care providers and other staff at the point of service delivery to evaluate their own performance and develop plans on how they can perform their work better.

This activity will occur in garissa, Wajir, Mandera, Tana River, Samburu, Isiolo and Turkana counties. Support for TB-HIV activity is centered on the DLTLD and NASCOP collaborative activities. The PTLC/PASCO and the DTLCs and DASCOs lead the processes at the provincial and district levels respectively. Support for intensified case finding through provision and mentorship on use MOH, screening tools at the CCC and MCH, Mentorship on TB HIV integration models, provision of job aids and IEC materials, scaling up ART uptake among TB-HIV co-infected patients and carrying out CMEs on infection prevention/control. Support to the implementation of the minimum package for infection prevention and control ensuring cross ventilation in all the clinical rooms and health talks is included.

On-the-job training for service providers as well as sensitizations/Continuing medical education sessions for up-dates conitnues. TB-HIV collaborative meetings and strengthening integration of TB and HIV services are priorities. Participation in the quarterly review and planning meetings with the DTLCs, DMLTs and DASCOs continue to be an important factor in ensuring that we address government priorities. Support will continue for active TB case finding through monthly integrated TB/HIV outreaches in urban centers. This includes on site sputum collection, and testing. Testing for HIV in TB clinics and TB in HIV clinics will continue and improvement of HIV/TB data management.

In The Northern Arid land area a mentorship program will be expanded to cover all treatment sites in Garissa, Mandera, Wajir, Turkana, Samburu, Isiolo and tana River Counties. To scale up uptake of pediatric HIV services, a mentorship program that takes into account special aspects of children living with HIV is essential. I The mentorship program has paediatric components that address issues like paediatric psychosocial care, management of opportunistic infections like TB, growth and neurodevelopmental screening, and management of treatment failure.

Adherence and psychosocial support services for children include innovative use of colour-coded labeling of syrups and syringes for the un-educated parents and care givers. Enrollment of children into psychosocial support groups is done according to their age groups thereby taking into account their cognitive development. The adolescent support groups are linked with other youth-friendly services in the facility. Support for care-givers support groups to run concurrently with the children support groups so that adherence measures can be reinforced. Other measures include structuring the parents or care givers clinic days to coincide with the childrens appointments. Integration of HIV services in the MCH ensures follow up of the mother and child in one clinic to minimize time spent in the health facilities. This also increases retention by minimizing defaulting. Follow up of the HIV exposed infants and the PMTCT program continues to be integrated with CCC services to ensure no missed opportunities. Efforts are in place to scale up EID services in tandem with PMTCT services. Other activities are to provide drugs, food and other commodities for pediatric clients (HIV exposed infants, HIV infected children and adolescents). Project will support the needs of adolescents with HIV (PwP, support groups, support for transitioning into adult services, adherence support), supervision, improved quality of care and strengthening of health services, promoting integration with routine pediatric care, nutrition services and maternal health services. Laboratory support and diagnostics for pediatric clients will be strengthened. Additional resources ( $300,000) will be used for the procurement of zinc tablets under LLC, to support the management of diarrheal diseases using ORT amongst children under 5 infected or affected by HIV/AIDS. Further, there are hard to reach population groups in NAL who do not utilize health services in facilities. This additional resources will provide integrated outreach health and referral services for the children in those communities who are infected or affected by HIV/AIDS . 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 projects principal strategy for rapid scale up of VMMC services in Turkan County will be to:

1. Coordinate with the Ministries of Health and other VMMC implementing partners in these districts to ensure strong coordination of interventions and avoid duplication of effort. The project will participate in national, provincial and district-level VMMC Task Force Meetings. Through collaboration with the Provincial Medical offices and the USAID capacity project VMMC teams have been deployed in Turkana and received training through the Nyanza Reproductive Health Services.

2. Conduct regular outreach campaigns based at health facilities, in tents to circumcise large numbers of men in line with the Ministries VMMC strategy. APHIAplus will utilize the MOVE approach to VMMC, which is focused on maximizing efficiency in the delivery of high quality VMMC services.

All the interventions will adopt the Comprehensive Prevention Program approach. They will be the approved Evidence Based Interventions (EBIs) or those that are curriculum based. The project will support AB activities within the framework of the Comprehensive School Health Program which is supported by the Ministries of Public Health and Sanitation and Education. This program will be rolled in schools, and out of school youth groups in the project intervention areas. These EBIs are an integrated set of planned, sequential, school affiliated strategies, activities and services designed to promote the optimal physical, emotional, social and educational development of learners/education sector actors. This program component will target young people aged 10-24 years both in school, out of school and in tertiary institutions. They will be taken through Life skill sessions using the approved EBIs, such as Healthy Choices, the KIE approved life skills curriculum and the KARHP curriculum. These will be complemented with interventions such as Shuga and other HFG activities. These interventions provide a set of Life Skills and Adolescent Reproductive Health Education that empowers young people make informed decisions and help delay onset of sexual activity and or practice of secondary virginity which may otherwise lead to increased HIV infections amongst youth. These interventions will be implemented in countiessuch as Garissa, Tana River, Wajir, Isiolo, Samburu, Mandera, Marsabit and Turkana.. The project will print and distribute the appropriate curriculum and will support the Ministry of Education officials to conduct supportive supervision in the institutions targeted. The targeted youth will, as appropriate, be linked to the relevant biomedical services such as counseling and testing and condoms. Each school/institution will be supported to undertake a self-assessment and develop an appropriate action plan that will be reviewed annually to assess level of achievement.

North Eastern province has a HIV prevalence of 0.9%, Eastern 3.5 percent and Rift Valley 4.7% according to KDHS 2008- 2009. This activity will be focused in eight counties in this region namely Garissa, Wajir, Mandera, TanaRiver, Marsabit, Isiolo, Turkana and Samburu. HTC services are provided using both PITC and CITC approaches. PITC services are not yet comprehensively provided in all counties under this project .Community HTC is provided through outreaches, mobile VCT, door to door testing and moon light outreaches. These activities target the general population but with special focus on first time testers and couples. MARPS receive services through targeted outreaches. Moonlight HTC is utilized to reach the subpopulations. Quality assurance for HTC is ensured by linking all facilities to the NHRL to ensure that they participate in the EQA exercise. The DMLTs are supported to organize for quarterly proficiency testing activities within their districts to refresh the providers on laboratory practices. Facilities have regular visits by the District laboratory and counselor supervisors to ensure quality testing is going on at all service delivery points. HTC providers receive regular update meetings to keep them appraised with new HIV testing information and dissemination of guidelines. The national algorithm for testing is utilized at all facilities and the national reporting tools and reporting structures are utilized. The facility MDTs will be tasked to document follow up and tracking for clients referred to the CCC.The community units are utilized to create demand for services both at the facility and at the community outreaches. Gender based violence activities are carried out both at the facility and community levels. At the facility level, Post rape care services are provided at the Outpatient department where the clients report. Examination and prophylaxis together with trauma counseling form the PRC package. Update for HCWs on management of survivors of sexual violence is provided regularly and trauma counselors receive supervision on quarterly basis. Sensitization on GBV to community leaders childrens officers and other stakeholders provides them with information for GBV prevention and response. Community units are sensitized to ensure they know where to refer survivors and what a survivor should do or not do when raped. Stakeholders meetings are held to create a forum where stakeholders can share their interventions and also discuss strengthening the medico legal linkages.

The project will target individuals or groups whose behaviour puts them at very high risk of HIV infection. This will cover the Northern Arid Lands area: Tana River, Isiolo, Garissa, Marsabit, Wajir, Samburu, Mandera and Turkana counties. The target group includes female and male sex workers in urban and peri urban area, youth out of school and comunity groups like morans in Samburu amongst others. Other interventions include the the Community Strategy. The identification process to map most at risk populatons will be extended to the new areaas in Tana River and Turkana counties. The project will buy in into the national MARPs mapping exercise and collect specific information that will be useful in programming for MARPs. The interventions for MARPs will be in line with the NASCOP guidelines and meet the minimum standards set. That will include behavioral, biomedical and structural interventions such as health education, provision of condoms, counseling and testing, STI screening and treatment and linkages and partnership (NHIF,MFI, GoK, alternative livelihood skills development). The Community Strategy will continue to be prioritized in this region using appropriate models because of the vast geopgraphical terrain. Schhol based programs through health clubs and parent fora will be important entry points for education and risk reduction. The Community units will be increased to 50 benefitting an estimated population of 1 million people. The interventions will be guided by the Minimum standards as defined by NASCOP and the KEPH and will be integrated with the appropriate services. MARPs, Workplaces and Community units will be linked to service delivery points as well as integrated outreaches to support hard to reach areas. The activities in CS will be reported through the National CBHIS system, while the MARPs and Workplaces within the KEPMS.

Human resources for health continues to be a big challenge in the NAL zone covering Garissa, Wajir, mandera, Tana River, Isiolo, Marsabit and Turkana for this activity. Most facilities have either one or two qualified staff. There are facilities PMTCT skills are absent. The project will continue to work with the national USAID capacity Project and the Ministry of Public Health and Saniatation to address the issue of additional stafff ofr this region. The project will collaborate with the new USAID Trianing project to train staff on the new PMTCT guidelines. Couple counseling and testing uptake is low in PMTCT settings. Formation of mother-to-mother support grouos in low volume faciklties is hindred by few numbers of HIV positive mothers and long distances between homes. So this activity will be limited to district hospitals and high volume facilties. Increasing coverage will be through increasing number of sites offering PMTCT minimum package of care; PMTCT and pediatric mentorship activities; Integrated Support Supervision. Linkages with the KEMRI reference Laboratory will help improve the timely submission of EID results and the Clinton Health Access Inititiative will support the project to get access to the web based EID resutls for selected sites. Efficiencies will be achieved through coordination with the transport network of Care and treatment team in the DBS sample transportation; use SMS for DBS results notification; Integration of activities within MCH: PPFP, FP in ANC, Use online updates on latest PMTCT guidelines on new changes; Use of champions as mentors at facility level; Global E-learning on PMTCT/EID; Encourage SBA for PMTCT; by motivation e.g provision of mama packs to women; Mentor mothers for defaulter tracing; CMEs,and OJTs for newly recruited health workers; Mentoring SS; Transitioning to FBO; ARVs, Counseling time, CD4, Viral load, FBC, UECs, LFTs; TB & STI screening and treatment; Documentation; SS; Job aids and mobilization costs. Additional resources ( $200,000) from Let's live Campaign (LLC) will be geared at training of HCW on maternal and newborn care, hence increase their skills in offering antenatal care, delivery and newborn services. This will help to improve the quality of services and ensure better health outcomes for HIV positive women and their new borns.. Activities will also aim at significantly increasing cervical cancer screening for high- risk women aged 30 - 49 .

An effort will be made to narrow the gap between the number of clients testing positive and those actually enrolling into care and treatment in both provinces. This will be done through various strategies that will include facilitated referral by non-clinical counsellors/ volunteers and CHWs within the facilities, use of community referral documents and through follow up of the clients testing positive. The clients testing positive will also be linked to support groups in their areas for psychosocial support as well as adherence counselling and defaulter tracing.

The project will continue to expand the integration of HIV services in the MCH, TB clinics and OPD. The project will also link with the ongoing pilot QI/QA intervention supported by URC and NASCOP in select districts of Nyanza province, and roll out best practices to other districts.

The decentralization of integrated services HIV/FP/RH/MCH will be supported by the rapid expansion of and continued support for the highly reliable, cost-effective laboratory network model i for the referral of specimens to comprehensive laboratories in level 4 and 5 facilities from the lower level satellite facilities. A clinical systems mentorship (CSM) program jointly conducted by MOH mentors, Kenya Pediatrics Association in and the APHIAplus NAL mentors will continue to be expanded in the counties of Garissa, Wajir, Mandera, Tana River, Marsabit, Isiolo, Sambvuru and Turkana. The mentorship teams have a mutually agreed work plan/schedule of visits to health facilities which are shared with the recipient facilities well in advance.

Multi-disciplinary teams (MDTs) are the entry points.

The three main facets of clinical systems mentorship process are:

1. Preceptorship,

2. Chart reviews and

3. Clinical case discussions.

Clinical case discussions: challenging patient presentations serves to generate interesting cases to support learning and sharing of ideas (Case-based learning).

Supported defaulter tracing and prevention strategies include provision of HIV treatment literacy, adherence monitoring, and use of phone tracing.

DHMTs and the PHMTs will be supported to conduct quarterly integrated supportive supervision. This builds the capacity of MOH to manage services ensure there is sustainability- country managed project.

APHIAplus will scale-up pediatric care and treatment in the region. 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.

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.