The Centre for Health Solutions (CHS) has been awarded a cooperative agreement as a follow on to the Columbia Track 1 activity in Central Province. CHS aims to build the capacity of 4 districts in Central Province to ensure sustainable universal access to high quality HIV prevention, care and treatment services, with a focus on integration within the broader health and development context through an evidence-based, cost-effective, and sustainable model of care. In line with the Kenya GHI Strategy, they will strengthen MCH services, support laboratory capacity for diagnosis of endemic conditions, and promote good governance by supporting training in governance and leadership.

Cost efficiency will be addressed through integration of services, reduction of the technical teams with increased capacity building of the MOH staff, use of existing evidence-based efficient strategies, task shifting, implementing more facility-based training and mentorship as opposed to offsite training, evaluating cost effective strategies for defaulter management, lab networking, and mobilization.

Implementation will be through joint programming with MOH staff. Key focus will be to invest in MOH systems. Training and mentorship will be facilitated by MOH staff. M&E strategy will include correct use of national tools. National commodity and lab systems will be supported by ensuring regular supplies via the central supply chain.

The transition strategy will primarily be to the MOH through progressively increased program leadership and responsibility through the District/Provincial Health Management Teams, escalating from the 3rd year.

CHS will purchase 1 vehicle to be used for transport of program officers for supportive supervision and mentorship. This activity supports GHI/LLC.

Center for Health Solutions (CHS) will support HIV care and support services in Central Province, with an estimated adult HIV prevalence of 3.4% compared to the national 7.1%. Since 2010, CHS has been supporting these activities as a local transition partner to Columbia Universitys International Center for AIDS Care and Treatment Programs-Kenya (ICAP) in 52 treatment sites in Central Province. In 2011, CHS won a PEPFAR award to support the Implementation of HIV Care, Prevention and Treatment Activities in 44 facilities in Central Province. As of March 2011 SAPR results, CHS had enrolled 57,267 patients into care with 29,594 active in care.

CHS 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 22,317 current adult patients in FY12 and 26,512 patients in FY13.

CHS will offer comprehensive care and support package of services including HIV testing to partner and family members of index patient 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.

CHS in collaboration with MoH will support targeted capacity building (training and mentorship) for health care workers and offer continuous medical education. CHS will identify areas with staff shortages and support recruitment of additional staff as well as support good commodities management practices to ensure uninterrupted supply of commodities.

CHS will also support ongoing community interventions for HIV infected individuals, including peer education and use of support groups to provide adherence messaging. Effective and efficient defaulter tracing and follow up will continue to be supported and strengthened 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 and/or food security programs will be implemented.

CHS will adopt strategies to ensure access and provision of friendly services to youth, elderly and disabled populations. Strategies to increase access of care services by men will be employed, including supporting male peer educators, mentors and support groups, and supporting women to disclose and bring their male partners for testing and care and treatment.

CHS will continue to strengthen data collection and reporting at all levels to improve reporting to NASCOP and PEPFAR. CHS will adopt the new generation indicators support the development and use of electronic medical records system in accordance with NASCOPs guidelines. CHS will adapt the quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV care and support services and integrate them into routinely collected data and use the results to evaluate and improve clinical outcomes. CHS will do cohort analysis and report retention rates as required by the NASCOP.

Center for Health Solutions (CHS) will support four districts in Central province, which has a population of about 4.4 million people, and reported 10,623 TB patients in 2010. Over 10,000 TB patients received HIV testing and 3,531 TB/HIV co-infected patients were identified. 97% and 47% received cotrimoxazole prophylaxis and ART respectively. Since 2010, CHS has been supporting TB/HIV activities as a local transition partner to Columbia Universitys International Center for AIDS Care and Treatment Programs-Kenya (ICAP) in 52 treatment sites in Central province.

In the next two years covering COP 2012 and 2013, CHS, which has just won a CDC award to support HIV activities including TB/HIV in 44 facilities, will intensify efforts to detect TB cases through clinical exams, laboratory investigations and ensure successful TB treatment through provision of appropriate treatment. CHS 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. CHS 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, CHS will ensure that at least 95% of TB patients are screened for HIV and 95% TB-HIV co-infected patients are put on cotrimoxazole and ARVs as early as possible regardless of the CD4 count as per the national guidelines. CHS 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. 200 HCWs in FY12 and 150 HCWs in FY13 will be trained as needed.

To reduce the burden of TB in HIV infected patients, CHS will support intensified TB screening for 19,837 in FY12 and 23,566 in FY13, HIV infected persons identified in their HIV care settings. 992 co-infected patients identified in FY12 and 1,178 co-infected patients identified 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, CHS will ensure that the national IC guidelines are available at all sites and training of staff on IC is done. CHS 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, CHS 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. CHS will also support scaling up of drug-resistant treatment sites thus expanding access to MDRTB treatment.

CHS 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, CHS will support reporting of selected custom indicators to assist with program management, evaluation and monitoring.

Centre for Health Solutions (CHS) will support pediatric care activities in Central Province. Since 2010, CHS has been supporting pediatrics activities as a local transition partner to Columbia Universitys International Center for AIDS Care and Treatment Programs-Kenya (ICAP) in 52 treatment sites in Central Province. In 2011, CHS won a PEPFAR award to support the Implementation of HIV Care, Prevention and Treatment activities in 44 facilities in Central Province.

By March 2011, CHS had 6,000 children enrolled in care with 3,263 receiving HIV care.

In FY 12, CHS will provide care and support services to 2,332 children currently on care and increase to 2,820 on care during FY 13.

CHS will provide comprehensive, integrated quality services and scale up to ensure 2,310 HIV exposed infants are put on ARV prophylaxis and all HIV exposed children access pediatric care services.

The focus of pediatric care services will continue to be provision of comprehensive, integrated quality services including strengthening the use of the Mother-baby booklet, early infant diagnosis, universal provider initiated testing and counseling, and ensure those identified HIV infected are linked to care and ART services.

CHS will ensure children enrolled in care receive quality clinical care services including clinical history and physical examination; WHO staging, CD4 testing, and other basic tests; opportunistic infection diagnosis, prophylaxis and management; TB screening; pain and symptom relief and management; and psychosocial support. Additional key care services will include nutritional assessment, counseling and support based on the WHO and IYCF guidelines (including 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 (WASH) in the community and in health facilities; and malaria screening, treatment, and provision of long lasting insecticide treated nets in malaria endemic areas.

CHS will support integration of HIV services into routine child health care 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. Exposed children management and follow up will continue to be supported and will include enrollment, HIV testing (PCR-DNA and antibody testing) as per the national guidelines, provision of Nevirapine throughout the breastfeeding period, follow up and retention, and linkages of those positive to care and ART services.

CHS will support hospital and community activities to support the needs of the HIV infected adolescents: support groups to enhance disclosure and adherence messaging, PwP, substance abuse counseling, support for transitioning into adult services, and teaching life skills.

Commodity access and infrastructure development will continue to be supported, including relevant trainings.

CHS will strengthen pediatric data collection and reporting at all levels to increase and improve reporting to NASCOP and PEPFAR.

Target population: CHS will support HIV testing and counseling services in all health facilities in Nyeri, Muranga, Nyandarua and Kiambu counties in central province. Target population will include all patients, their family members and caretakers who access out and in patient services at all the health facilities in the 4 counties.

HTC Approaches: The program will utilize provider initiated opt out approach and the services will be offered within all out patient departments, TB clinics, FP, ANCs, special clinics, HIV clinics (targeting family members) and in patient departments. The counseling and testing will either be done within the consultation rooms by trained clinicians, or in counseling rooms by lay counselors within the outpatient departments if space will be available or at the laboratories.

Targets and achievements: In COP 2012, CHS will target to provide HTC services to a total of 255,000 persons of which 20% will be tested as couples and 10% will be children below the age of 15.

Testing algorithm: National algorithm is being used.

Referrals and linkages: In order to strengthen referrals, CHS will put in place several important strategies. They include: use of peer educators as patient escorts from one hospital department to the CCC; same day enrollment of clients to CCCs; use of an integrated defaulter tracing system for tracing patients who default on care or ART upon enrollment; introduction of documented referral system by use of the NASCOP referral booklet; use of mobile phones to follow up whether the client was actually enrolled.

Quality management: In order to improve and monitor quality of HTC services, CHS will put in place the following strategies: Training and continuing education of HTC providers; strict adherence to the standard operating procedures outlined in the national HTC guidelines; proper handling (storage and transportation) of HIV rapid kits as per the guidelines; putting in place a functional QA systems as provided for in the national HTC guidelines; participation in EQA- proficiency testing and finally conducting support supervisory visits.

Monitoring and evaluation: CHS will use all ministry of health tools to capture HTC data, both for couples and individual patients. These include HTC lab Register and Monthly summary tool (MOH 711 and MOH 731). MOH approved HTC lab registers have been introduced at all HIV testing points except PMTCT.

Promotional activities for HTC: All patients attending the supported facilities will be 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 will be given individualized invitations though the index clients and available avenues for testing including individualized home testing.

CHS implements comprehensive prevention, care and treatment programs in Central province. In FY 2012/13, CHS will expand HIV prevention services to include evidence based behavioral interventions (EBIs) 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 EBIs 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.

CHS 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 centers 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. HIV Prevalence in Central province is (3.6%). CHS will reach 12571 (60%) PLHIV in FY2012 and 17453 (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.

CHS 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 CHS 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).

Center for Health Solutions (CHS) will support PMTCT services in Kiambu and Kirinyaga district in Central Province. Since 2010, CHS has been supporting these activities as a local transition partner to Columbia Universitys International Center for AIDS Care and Treatment Programs-Kenya (ICAP) in the same region. In 2011 CHS won a PEPFAR award to support the comprehensive HIV services including PMTCT activities in Central Province. By end of March 2011 SAPR CHS had counseled and tested 15,850 pregnant women and given ARV prophylaxis to 1,325 HIV positive pregnant women and 399 infants.

In FY12, CHS will offer HIV counseling and testing to 65,285 pregnant women at ANC and give ARV prophylaxis to 2,211 HIV infected pregnant women. The HIV infected women will receive a CD4 test after undergoing a WHO clinical staging. CHS will give HAART to all eligible HIV+ pregnant women in line with the revised PMTCT national guidelines. In FY13, CHS will increase the number of pregnant women counseled to 68,549, offer ARV prophylaxis to 2,685 pregnant women and 2310 infants, and do EID for 2,310 infants.

CHS will focus on 4 prongs of PMTCT: primary prevention; prevention of unwanted pregnancies; ARV prophylaxis to all HIV+ 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 HTC, clinical/lab 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. CHS will incorporate TB screening into routine antenatal care.

CHS will reach 20,565 of 1st 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. CHS will support integration of ART in MCH clinics, access to FP/RH services, establish or strengthen infection control and waste management activities.

CHS 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.

CHS will support safe infant feeding practices as per national guidelines and enrollment and follow up of 2,310 of babies born to HIV infected mothers to access CTX, ARV prophylaxis, and EID services using the HIV exposed infant register till 18 months. CHS will facilitate ART initiation for those who test positive before 2 years.

CHS 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 (training 60 HCP in FY12 and equal number in FY13), enhancing data quality and streamlining M&E gaps including orientation of new MOH ANC/maternity registers, and utility 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.

CHS will train HCWs on PMTCT and provide orientation on 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, referral and linkages.

Center for Health Solutions (CHS) will support four districts in Central Province, which has a population of about 4.4 million people and an estimated adult HIV prevalence of 3.6% compared to the national 7.1%. Since 2010, CHS has been supporting HIV treatment activities as a local transition partner to Columbia Universitys International Center for AIDS Care and Treatment Programs-Kenya (ICAP) in 52 treatment sites in Central Province. In 2011, CHS won a PEPFAR award to support the Implementation and Expansion of High Quality HIV Care, Prevention and Treatment Activities in 44 facilities located in four districts in Central Province. As of March 2011 SAPR results, ICAP/CHS has enrolled 31,003 patients on ART with 16,649 active on treatment.

CHS will continue to support HIV adult treatment services in the 44 treatment facilities in Central province in the next two years. In FY12, CHS will ensure provision of HIV treatment to16585patients currently receiving ART, including 3990new patients. The number of adults currently on treatment will increase to 19,581 during the FY13. The number currently on treatment is lower than SAPR 11 because some of the sites will be transitioned to University of Nairobi.

CHS will work with the Ministry of Health (MoH) at all levels to jointly plan, coordinate and implement HIV treatment services. CHS will offer training to 200 health care workers in ART provision using the NASCOP ART training curriculum in compliance with National Guidelines and mentorship to the sites. CHS will support recruitment of additional staff as needed.

CHS will support provision of comprehensive package of services to all HIV+ patients at health facility level including clinical assessment for ART eligibility; provision of ART for those eligible; laboratory monitoring with biannual CD4 testing and viral load testing for patients failing treatment; cotrimoxazole prophylaxis; psychosocial counseling; referral to support groups; adherence counseling; nutritional assessment and supplementation; prevention with positives (PwP); support for family testing for spouses/partners and children; supportive disclosure; family planning counseling and provision or referral of services; STI diagnosis and treatment; and improved OI diagnosis and treatment, including TB screening, diagnosis, and treatment.

Ongoing community interventions for HIV+ individuals, including peer education and use of support groups to provide adherence messaging, defaulter tracing and follow up will continue to be supported to improve retention in all facilities. CHS will do cohort analysis and report retention rates as required by the national program and discuss the analysis results with facility staff in order to improve program performance.

CHS will adapt the quality of care indicators (CQI, HIVQUAL) for monitoring the quality of HIV treatment services and integrate them into routinely collected data and use the results to evaluate and improve clinical outcomes. CHS will adopt strategies to ensure access and provision of friendly HIV treatment services to all including supporting peer educators, mentors, support groups, and supporting patients to disclose and bring their partners for testing and care and treatment.

CHS will continue to strengthen data collection and reporting at all levels to increase and improve reporting to NASCOP and PEPFAR. Use of an electronic medical records system will be supported and strengthened.

Center for Health Solutions (CHS) will support pediatric HV care and treatment services in Central Province. Central Province has an estimated population of 4.4 million people with an estimated adult HIV prevalence of 3.6% compared to the national 7.1%. Since 2010, Center for Health Solutions (CHS) has been supporting HIV treatment activities as a local transition partner to Columbia Universitys International Center for AIDS Care and Treatment Programs-Kenya (ICAP) in 52 treatment sites. As of March 2011 SAPR results, ICAP/CHS had supported a cumulative 3,627 paediatric on ART and 2,059 were active.

In FY12, CHS will jointly 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 1,739 pediatrics currently receiving ART and 348 new pediatrics resulting to cumulative 2,083 pediatrics ever initiated on ART. In FY 13, this number will increase to 2,174 pediatrics currently receiving ART and new 314 resulting to cumulative 2,397 pediatrics ever initiated on ART.

CHS 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; PITC to all children and their care givers attending Child welfare clinics; support family focused approach; community outreach efforts; and integration of HIV services in other MNCH services.

CHS will support hospital and community activities to support the needs of the HIV infected adolescents: 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.

CHS will support in-service training of 200 and 150 HCWs in FY 12 and 13 respectively, continuous mentorship and capacity building of trained health care workers on specialized pediatric treatment including management of ARV treatment failure and complicated drug adverse reactions. CHS will 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.

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