1.Goals and objectives:HIV Program is centered in Kericho, the primary location for the USAMRU-Kenya HIV research activities, closely integrated with comprehensive HIV prevention and treatment services, thereby providing quality HIV care, treatment and prevention to the community and our research population in a previously underserved geographic region.The program is aligned with GHI, national policies, guidelines and strategies; closely collaborates with MoH; and draws synergies from other related programs such as nutrition, PMI, child survival, safe motherhood, and FP; while addressing pertinent gender issues.

2.Cost-efficiency strategy: partnership and leveraging resources and infrastructure of already existing local institutions; tapping into pooled national procurement systems; integration and system strengthening for synergy and sustained impact; as well as undertaking cost-efficiency studies to develop best practices.

3.Transition to country partners:The SRV Program partners with the health ministries, private hospitals, FBOs, NGOs & CBOs through capacity building and systems strengthening to ensure sustainability, ownership and seamless transition to these local partners.

4.Vehicle information:Partners needed sturdy, all-terrain vehicles to facilitate coordination and supervision of program implementation across 14 districts in SRV. Since 2004, vehicles procured include: 2 (2005) and 1(2007) for office and field travels; 5 (2009) to support program activities at MoH partner sites; 3 replacements, 2 for supplies and 2 for field travels, procured in 2010. None requested in current COP. This activity supports the GHI/LLC and is funded primarily with FY12 funds in this budget cycle.

HJF SRV will continue to implement adult care and support in the South Rift Valley and part of North Rift Valley in > 100 facilities of which 11 are main hospitals and the rest being level 2 and 3 facilities, in line with the GoK decentralization policy. The COP 12 PEPFAR funds will be used to support adolescents, adults and women in the general population , marginalized and MARPS such as sex workers, prisoners to access care and support services both in the community and the facility. The total number being targeted to receive a minimum of one clinical service is 22,597 and 28,170 in FY 12 and FY 13 respectively.

Early identification and linkage to care will continue to be emphasized in an effort to reduce morbidity and mortality. This will be achieved by working closely with counseling and testing programs (HTC) using the different strategies employed. Facilities will be encouraged to ensure early linkage to care at all points of diagnosis both at the facility level and community level. Initial assessment and counseling will be done by the health care workers and, where feasible, also by peer counselors to promote status acceptance and retention in care.

Integration of care and support services will be promoted at all levels and all adolescents and adults living with HIV will be offered the comprehensive package of care, as outlined in the GoK ART guidelines, including: psychosocial and spiritual support; linkage to support groups; universal prophylaxis for Cotrimoxazole and provision of other OI drugs; adherence counseling; nutritional assessment, counseling, and where necessary supplementation; early screening, diagnosis and treatment of OI infections and STIs; pwp package in clinical and community settings); sexual and reproductive health services; defaulter tracing; alcohol and substance use counseling and support; support of and linkage to economic empowerment projects; end-of-life care and other interventions in an effort to improve and prolong the quality of life for infected and affected individuals. Cervical cancer prevention, screening and treatment will be supported in line with the GoK strategy and all women in the HIV Clinics will be screened for cervical cancer at least once a year. Selected level 4 facilities will be supported to be referral centers of excellence.

Efforts will continue to be made to improve patient retention through strengthening of the existing linkages i.e. intra-/inter-facility, and facility-community linkages. This will be achieved through emphasis on complete documentation of patient social history, use of existing community health care workers supported by the GoK, support of home and community based care component of the community strategy, patient education in the support groups, and outreach services to the community. The capacity of health care workers will also be built through in-service training, continuous medical education and mentorship to improve the quality of care offered to the adolescents and adults living with HIV and also to be able to refer these individual to services required e.g. to a high level facility for specialized care.

Monitoring of quality of care will be done through joint supportive supervision with GoK officers on the ground, continued mentorship, joint quality of care review meeting. This will involve use of existing registers and reporting tools, in house program evaluation tools and will be done in collaboration with the facility staff and leadership.

Henry Jackson Foundation (HJF) implements Orphans and Vulnerable Children (OVC) program in the South Rift Valley Province in Kericho and Bomet and part of Narok counties. HJF and its partners are currently serving over 12,000 OVCs in SRV.

Goals of the project:

The major goal of the program is to mitigate against the impact of HIV and AIDS and prevent inequity and other challenges like stigma, lack of care and support, lack of food, shelter, health care and poor access to education.

Secondly, the program aims at helping children and adolescents grow and develop into healthy, well adjusted and productive members of society by ensuring that the needs of each OVC enrolled into the program are addressed. This is in line with the US five year Global HIV/AIDS strategy to rapidly scale up compassionate care to OVC and the Government of Kenya (GoK) OVC guidelines. It aims at optimizing quality of life for HIV infected and affected OVCs and their families throughout the continuum of illness through referrals of OVCs for treatment, provision of psychosocial, spiritual, social, nutritional, economic empowerment, and prevention services. The program will target OVCs from infancy to late childhood/ adolescence (0-17). The services will be offered indiscriminately for both males and females. It will also target people affected by HIV and AIDS by focusing on existing caregivers. In FY 2012, the program will support 13,359 OVCs.

Strategies/Activities:

HJF will continue to directly care for and support the OVCs by working in three levels: child level (by provision of food /nutrition, shelter renovation, health care, access to education, psychosocial support, legal protection, and economic empowerment); caregiver level (by training caregivers on care of OVCs); and community level (by use of existing community structures) to make sure children live within their cultural context and family set up. The programs will continue working with the relevant government ministries of education, health, and community based organizations, and other stakeholders in support of OVC program. The mechanism has strengthened partnerships with the local government systems and other community organizations in providing comprehensive and quality services to OVCs.

Strengths:

The integration of the OVC program with care and treatment programs and other prevention programs such as VMMC, HTC, and AB, will support community ownership and sustainability of the program. The programs have been able to leverage some support from the National AIDS Control Council. They have also used the multi-sector approach by working closely with the relevant ministries of health, gender and education. They have been able to link children and families to prevention, care and treatment programs and support through the capacity building of CBOs to facilitate care for more OVCs.

Challenges:

There are more OVCs than the programs can support hence the need for more funding.

Monitoring and Evaluation will be done through supportive supervision and technical assistance visits. Routine data collection and reporting tools will be used.

The HJF SRV will target all males and females in general population including children, pregnant women, and MARPs like prisoners etc in South Rift and part of North Rift Valley by working with Provincial/ District Leprosy and TB Coordinators (P/DTLCs) to co-ordinate, monitor and implement TB services.

Integration of ART in TB clinics will continue to be supported in Level 4 facilities; while lower level facilities will integrate TB services into their HIV or general outpatient clinics.

TB ICF will be done and documented using the national TB screening tool, at facility and community level, including high risk contacts for PLHIV with TB. Public health officers and cough monitors will be utilized in the community to identify and link suspected cases to a facility for further work up and diagnosis. About 80% of PLHIV will be screened for TB in HIV clinics, with 5% expected to initiate TB treatment.

All individuals with TB or suspected TB in facilities will be offered PITC; those positive will be linked to care and ART initiated immediately in line with MoH guidelines. SRV will target 75% (the current DLTLD target is 50%) to be initiated on ART. All TB/HIV Co-infected will be offered comprehensive care package including: DOTS, cotrimoxazole prophylaxis and PwP messaging to improve patient outcomes.

Isoniazid Preventive Therapy will be implemented, in a phased approach, in level 4 facilities with capacity to rule out active TB. Effective intra-/ inter-facility, and facilitycommunity linkages and referral networks will be further strengthened so that all PLHIV benefit from IPT.

TB infection control (IC) activities in TB and HIV Clinics will be promoted and supported per MoH guidelines.

Health care workers selected by DHMT, will be trained or sensitized on TB/HIV including IPT, ICF, and TB/HIV per MoH curricula to improve their capacity in TB/HIV management to: prevent new TB infections, reduce morbidity and mortality, and control MDR/XDR TB development.

Laboratory infrastructure and services like TB diagnostic capabilities using sputum smear microscopy, fluorescent microscopy will continue to be supported; with focus on quality including QA/QC. TB sputum for culture and suspected MDR cases will be sent to the Central Reference Lab. SRV will support use of Gene Xpert technology based on phased plan at the national level where procurement and placement of these machines in selected hospitals will be done.

Data is collected and reported using MoH tools; SRV will intensify use of PDA for collecting and disseminating TB/HIV reports. Continued joint support supervision, and quarterly review meetings with the DTLC and facility staff, will be supported to improve data quality and data use for decision making.

In FY 11, SRV achieved 86% treatment success rate for smear-positive disease (vs. WHO targets of 85%); TB treatment sites increased from 117 to 132 and TB diagnostic sites 70 to 89; HIV testing among TB patients- 84% to 90%; CTX prophylaxis for co-infected patients- 90% to 98% and initiation of ARVs in Co-infected patients 45% to 56%. SRV assisted MoH improve its sputum smear microscopy network through training, mentorship, and strengthening of EQA programs. Concurrently, DST for TB re-treatment cases improved from 42% in FY 10 to 63% in FY 11. Standardized TB screening (ICF tool) tools for HIV patients were successfully rolled out. SRV also contributed to the development of National TB policies and guidelines.

HJF SRV will target all children aged 18 years and below, who will receive a minimum of one clinical service, 3,490 and 3,842 pediatrics will be reached in FY 12 and FY 13 respectively in SRV and part of North Rift Province; 95% will receive cotrimoxazole prophylaxis.

Early identification of HIV exposure and infection status remains key to effective and prompt linkage to care and treatment. To achieve this, children will be offered PITC services in all health facilities as a routine for timely linkage to care and treatment.

Exposed Infants will be followed up as per the MoH HIV Exposed Infant algorithm. HIV positive infants will be actively followed up for early initiation of ART as per ART guidelines. The mother- baby booklet will be used to link the infant to the MNCH, Care and ART clinics. HIV exposed infants and infected infants will be followed up and offered comprehensive package including: ARV prophylaxis, timely initiation of ART for those who are eligible, appropriate infant feeding options, growth and development monitoring, immunization as per Kenya Expanded Immunization Program (KEPI). All HIV exposed infants, infected infants, children, and adolescents will be offered: TB screening; IPT for those at high risk; regular screening, diagnosis and treatment of OIs; routine nutritional counseling, assessment and supplementation; clinical and laboratory monitoring such as hematology, chemistries, CD4%, targeted VL and resistance testing, where necessary; family testing, psychosocial and spiritual support to the child and family members; training of caregivers on basic principles of treatment and palliative care, Linkage to other facility-based and community programs such OVC programs; PMI for the mother to access ITNs, Food-by-prescription programs including other children in the household, pediatric and adolescent support groups, etc. Facilities will be encouraged to have clinic days for the pediatrics and adolescents while ART is being integrated into the MNCH clinic. There is ongoing decentralization of pediatric services and creation of child friendly clinics up to the lower level facilities. Support for pediatric equipments to improve child survival will continue.

With effective programs, more children are surviving to adolescence. Since the adolescents have special needs and challenges there is need for more support for HIV infected adolescents: Facilities are encouraged to have adolescent clinic days following a successful model at Kericho District Hospital. HCWs are trained on pediatric psychosocial counseling to support the care giver on disclosure, formation of pediatric and adolescents support groups, to prepare the adolescent and caregiver for the transition into adult care services etc, linking adolescents to other programs such as youth friendly centers etc. The program will support implementation of the care of adolescents package as per MoH guidelines.

Lab diagnostic systems are in place to support pediatric friendly parameters such as CD4%, VL and where necessary resistance testing. QA/QC will be supported. Laboratory networks and referrals will be strengthened to support sending of specimens and results to and from identified labs such as KEMRI WRP CRC lab.

On-site support supervision, mentorship and clinical pediatric services review, M&E will be supported to improve quality of care and to support HCWs to document, collect and report quality data for pediatric care programs.

HJF SRV will target to offer Laboratory services to all males, females and children in the general population drawn from South Rift valley and part of North Rift Valley.

HJF SRV will work closely with the Government of Kenya Ministry of Health and implementing Partners to co-ordinate, monitor and implement quality Laboratory services in the region.

Leveraging on the existing research lab infrastructure, some assays will be offered centrally at the KEMRI/WRP Clinical Research Centre (CRC) Lab for specialized HIV diagnostics and monitoring tests, opportunistic infections and emerging diseases. In addition, and to promote country ownership, sustainability, decentralization and integration into existing systems, MoH and other partner hospital labs will be supported to perform routine assays. The number of Laboratories offering CD4 testing, chemistry and hematology (plus other body fluids) will be increased to ease and improve access to service delivery in a timely manner especially for expectant mothers requiring ART early in order to eliminate MTCT (eMTCT). The KEMRI/WRP CRC lab will continue offering PCR DNA for Early Infant Diagnosis (EID) and other specialized tests to the greater Rift Valley region.

Building upon existing strengths, more Laboratories will be networked to improve on geographical coverage, turn-around-time (TAT) and cost-efficiency and ensure adequate back up as necessary.

HJF SRV plans to support five Laboratories to be assessed for Accreditation using the WHO AFRO stepwise format with the applications of Strengthening Laboratory Management Towards Accreditation (SLMTA) approach.

The trainings planned, including Laboratory ART Monitoring, and SLMTA are geared towards offering quality services and improvement of project implementations. Laboratories will be enrolled in local as well as external quality assurance systems and WRP CRC Laboratory will offer biannual quality assessment activities.

Monitoring and evaluations of all the activities and tests will be done by District Laboratory Managers with support of HJF SRV Laboratory coordinator and visiting Laboratory advisors and specialists within the DoD network.

Henry Jackson Foundation (HJF) South Rift Valley (SRV) SI program will provide technical, Monitoring & evaluation (M & E) and data management support to the South Rift Valley HIV Program. The program covers the south Rift Valley and parts of North Rift region of Kenya which includes Kericho County, Bomet County, Nandi County and part of Narok County, with a population of more than 3 million Kenyans accessing HIV prevention, care, and treatment services. The SI program will be supporting partner sites which are based at the Government of Kenya Ministry of Health District Hospitals and local health clinics as well as community based programs offering OVC support, HIV prevention and palliative care. COP 12 funds will be used to build the capacity of M & E staff through relevant M & E trainings and data analysis aimed at improving service delivery.The SI program will support District Health Records officers (DHRIOs) and data clerks in 11 treatment partner sites and 3 community based programs with equipment, Data management M & E support including M&E trainings, roll out of national reporting tools, mentorship, participation in data review meetings, data analysis, dissemination and use of data for decision making at the facilities, Data quality Audits and support supervision.The SI program will support the coordination of data management and data quality management in the PEPFAR Sites. As part of supporting Government of Kenya (GoK) systems, SI program will be rolling out Electronic Medical Records system (EMR) in 7 district hospitals, 2 Faith based and 2 Plantation hospitals. EMR roll out to high volume satellites will be considered as EMR use stabilizes in the main facilities.In each of the Partner Hospitals, HJF SRV SI program will help in the roll out and use of the District Health and Information system (DHIS) as part of strengthening one national reporting system by GoK. HJF SRV SI program will support internet infrastructure provision and Information Technology capacity building at the District Hospitals to enable health workers access and use the DHIS system; and also improve existing communication systems.

Henry Jackson Foundation (HJF) implements VMMC program activities in South Rift Valley Province in the tea estates of the following counties; Kericho, Nandi, Bomet and Narok (Transmara East and West Districts in the mining industry) targeting the non-circumcising communities including Luos, Tesos, Turkanas etc. In FY12, program will provide VMMC services to 12,879 individuals, most of whom will be 15 years and above, at existing MoH and plantation hospitals. The targets, in line with the PEPFAR NGIs, are laid out at the start of the year and tracked on monthly basis by program managers. The VMMC minimum package includes: HTC; risk assessment and reduction counseling; STI screening and treatment; referrals as appropriate for ART, psychosocial support, post test club; education on wound healing; and then circumcision.

Supportive supervision:

The program managers and other program technical experts will conduct monthly site support supervision. Also the program in collaboration with NASCOP will conduct quarterly site support supervision that includes observed practice. The areas identified to have gaps will be addressed.

Quality Assurance:

HJF has put in place for all the VMMC sites the following: use of approved VMMC national curriculum; emphasis on importance of fidelity to the respective curriculum; use of trained and certified facilitators to train clinical officers, nurses, and Medical officers who are the VMMC service providers; observed practice of the implementation is done soon after the training; use of standardized national data collection tools; and regular field site support visits by trained program staff to check on the VMMC service delivery. Reviewing of the clients is effective since most of the clients are a cohort living in the tea plantation. Monitoring and evaluation will be conducted with approved national monitoring tools. Field staff will send reports on a monthly basis which are compiled into quarterly reports and submitted to DoD SRV.

Communication activities:

VMMC communication activities will include dissemination of IEC materials targeting both males and females (to support their husbands and sons) to go for VMMC services.

HTC is a core element of VMMC services and it is offered on sites. MC is integrated with other services and is offered as part of the comprehensive prevention package.

Training programs and materials used:

HJF works in collaboration with NASCOP which provides VMMC trainings using certified national trainers and approved national curriculum and materials. NASCOP certifies the trained VMMC service providers.

Demand creation activities: In the implementation of VMMC, the program will work in collaboration with the district Ministries of Health and Public Health and Sanitation. Also the community gatekeepers will be sensitized and given information, which will then encourage the other community members (both males and females) through snowball approach to buy the idea and own the program.

Linkage to care and treatment:

Since the services are offered in the existing MoH and plantation hospitals, the VMMC positive clients are linked and referred for care and treatment in the same facilities using the NASCOP referral tools. A regular analysis of referral status between HTC program on site and care and treatment are done to monitor linkages and correctives measure taken where gaps exist.

HJF will contribute to the prevention of medical transmission of HIV (and other blood borne pathogens) through sharps and other medical waste management. It will support training and behavior change communication aimed at improving injection safety, phlebotomy, lancet and other high risk procedures for health workers. It will also strengthen post-exposure prophylaxis (PEP) services for health workers encountering accidental exposure to blood borne pathogens. It will promote safe medical waste management (MWM) practices by supporting dissemination of necessary policies and guidelines; training of health workers; ensuring commodities security; decreasing the use of unnecessary injections and supporting installation and maintenance of environmentally friendly medical waste management equipment.

HJF will implement its activities in DOD supported Sites and will ensure that all counties within its supported area are covered. It will target health workers, and communities as recipients of health services and those at risk of injury. It will support installation of six (6) MWM systems, and support to train at least five (5) biomedical engineers in MWM equipments to maintain and repair the equipments.

Importance will be put on integrating Bio-safety, MWM, universal precautions and infection prevention and control (IPC) measures into existing HIV programs like care & treatment, prevention, counseling & testing and other health programs such as family planning, immunizations and other clinical services. It will support these programs to have a plan and budget to address medical waste and infection control.

HJF will facilitate training of health workers through a training of trainer (TOT) model to create a pool of trainers and leaders in MWM and IPC. It will facilitate training of biomedical engineers who will ensure efficient and sustainable operation of cost-effective MWM systems. Additionally it will strengthen the County MoH coordination structures such as the County IPC committee to make them fully operational and be able to sustain county oversight for the future.

HJF will collaborate with the MoH/FBO/Private Hospitals to leverage resources for waste management from key partners. It will also explore viable public private partnerships (PPP) eg Tea companies that support safe MWM.

Quality assurance and improvements will be a key component of this program. HJF will ensure this by rolling out a strong monitoring and evaluation system with indicators for tracking along the lifespan of the project. It will also support a sharps injury surveillance system that will be used to improve programming.

Henry Jackson Foundation (HJF) works in the South Rift Valley Province in Kericho, Bomet, Nandi and 10% of Narok County (i.e. Transmara East and West Districts) to serve youths in and out of school with abstinence and being faithful evidence-informed behavioral interventions (EBIs), Families Matters Program and Health Choices 1. The estimated population of adolescents aged 10-14 years in the counties as per 2009 Census is 413,298 distributed as follows: 99,735(Nandi), 100,147 (Bomet), 97,629 (Kericho) and 115,787(Narok). In FY 12, the program will reach 118,156 individuals; including 58,729 youth aged 10-14.

FMP is an EBI targeting parents, guardians, and other primary caregivers of preadolescents aged 9-12 years. It is delivered in 5 weekly sessions to allow parents to practice skills learnt. It aims at promoting positive parenting practices, monitoring, positive reinforcement, effective parent-child communication on sexual topics and sexual risk reduction. FMP seeks to delay onset of sexual debut by training parents to deliver primary prevention messages to their children. FMP is linked to other EBIs including VMMC and HTC.

Healthy Choices 1(HC1) targets in-school youth of 10-14 years and aims to delay sexual debut by providing knowledge and skills to negotiate abstinence, avoid negative peer pressure, avoid or handle risky situations, and to improve communication with a trusted adult. It can be delivered in 4 sessions of two hours each or 8 sessions of 1 hour each. HC1 is linked to other EBIs including VMMC.

Some of the HVAB funding will be used to promote abstinence and/or be faithful messages in the EBIs targeting the following priority populations: 15-19-year olds (44,995), discordant couples (3,329), men aged 30-44 (8,159) and persons living with HIV (2,944).

Quality Assurance: HJF has put in place the following measures for all its sites: use of approved national curricula; emphasis on importance of fidelity; use of trained and certified pair of gender balanced facilitators; trainings on EBIs are conducted by certified national trainers; observed practice of implementation is done soon after training; use of standardized, national data tools at every stage of EBI implementation; and regular field visits for support supervision by trained program staff to check on delivery of EBIs.

The implementation of the EBIs for each targeted populations is integrated with other services, such as condom promotions, HIV Counseling and Testing, Voluntary Medical Male Circumcision (VMMC), ART etc. The proposed activities and EBIs are guided by the goals and objectives of the project. Targets for each of the interventions are laid out at the start of the project year and tracked on a monthly basis through respective monthly reports. Results are analyzed on a quarterly basis. The targets are in line with the PEPFAR Next Generation Indicators (NGIs). Monitoring and evaluation will be conducted with EBI approved data capture / monitoring tools. HJF and its partner sites will send reports on a monthly basis; these reports will be compiled into an overall report quarterly and submitted to DOD SRV.

Target population:

HJF implements comprehensive HIV prevention services in Kericho, Bomet, Nandi and Narok (Transmara East and West Districts) counties of South Rift Valley Province.

Targeted as per KDHS, are youth and general population including discordant couples, couples, men in rural settings and those infected but unaware of their HIV status, and MARPs (Female sex workers and Truckers). HJF will expand the HTC scope and approach to minimize missed opportunities and accelerate HTC coverage to achieve the universal 80% knowledge of HIV status among individuals 15-64 years. HIV prevalence among the general population in Rift Valley is 6.3%. HTC coverage in the last year among men was 16% and 25% for women.

HTC approaches:

Client Initiated Counseling and Testing (CITC) and Provider Initiated Counseling and Testing (PITC) provided in health care facilities and community settings (mobile/outreach services, door-to-door, stand alone VCT, and targeted HTC campaigns) based on population density, HIV prevalence and HTC coverage.

Targets and achievements:

Last year, HJF provided HTC services to over 424,846 (vs target of 165,000) through: PITC 42%; campaigns and outreaches 20%; mobile HTC 30% and the rest (8%) through VCT and home based HTC approaches. The program supported capacity building of 230 HTC service providers including HTC refresher training (proficiency testing, national re-testing recommendations and data collection tools), CITC, PITC, and couple HTC. In FY 2012, the program will provide HTC services to 261,522 individuals, of whom 60% will be new testers, 20% couples, 15% MARPs and the rest will be through VMMC and other populations.

Proportion allocation of funding:

20% of the budget supports HTC among the MARPS and 6% for VMMC provided as part of the combination HIV prevention package.

For effective linkage and referrals, a directory of existing HIV care and treatment facilities is maintained; and referrals done using the NASCOP tool. Regular analysis of referral status between the HTC sites and care and treatment facilities is undertaken and necessary corrective measures taken. A follow up system is in place to track clients tested at HTC sites; and HJF collaborates with Ministries of Health to ensure that all HIV infected individuals and their familys access care and support services in the community setting.HIV negative individuals will be referred for other prevention services such as VMMC.

Quality management:

HTC service providers are trained and certified by NASCOP. Quality Assurance systems are in place including counselor support supervision, proficiency testing and Dry Blood Spot (DBS) is taken for every 20th client. For service standardization, timers as well as job aids are used. Monthly HTC counselor supervision is done by program technical experts/managers in collaboration with the respective District Health Management Teams.

Monitoring and evaluation:

The program uses national tools for data recording and reporting. The Indicators collected include individuals receiving HIV testing disaggregated by age, sex, MARPs and couples.

Sensitization and mobilization is done through the use of Peer led networks among MARPs who motivate the peers to access the range of HIV prevention services. The community gatekeepers are also involved to give information on availability of HIV prevention services to the other community members.

HJF implements MARPs services in Kericho, Bomet, Nandi and 10% of Narok (i.e. Transmara East and West Districts) counties of south Rift Valley.

The total target population in FY12 is 98,960 which include: Female Sex Workers (3,328), truckers (150), general population (27,668), youth 15-19 (10,015), youth aged 20-24 (38,213), and PWP clinical (19,586), each sub-population to be reached with minimum package. The activities will target high risk sexual behavior prevalent among these populations such as incorrect and inconsistent condom use particularly with regular sex partners and concurrent partners.

HJF and its partners will work with FSWs and truckers to select, recruit and train them as peer educators. A sub-population identified as peer leaders will be further trained on peer education and facilitation skills, and will help cascade the peer education. They will train Small groups of 25 individuals identified by the peer educators based on gender and age to enhance active participations. During the peer sessions, mobilization and linkage/referrals for other services like STI treatment, HIV care and treatment services, HTC and VMMC will be offered. All the groups of peer educators will undergo 5 sessions on various SRH topical issues, with follow up sessions after 6 months for each group. Gender based violence, poor ARV drug adherence issues, excessive alcohol, drug and substance abuse, among other behavioral risk factors will be included as part of the elements of the sessions.

HJF will support implementation of the HIV Combination Prevention Interventions for FSWs as per National Guidelines for the package of services for SWs which captures evidence-informed behavioral, biomedical and structural interventions. Some of the behavioral interventions include condom and lubricant demonstration and distribution, peer education and outreaches, risk assessment, risk reduction counseling and skills building. The specific EBIs for this group will be RESPECT, Sister-to-Sister and Safe in the City. Biomedical interventions include STI screening and treatment, HTC, Pre-exposure prophylaxis, TB screening and linkage/referral for treatment, HIV care and treatment, RH services, and Emergency contraception.

HJF will implement EBAN, which is an EBIs for discordant couples. Its aimed at lowering the rate of risky behavior and promoting safe sex through increased condom uptake among HIV-discordant couples; and provided as part of the integrated services.

The in and out of school Youth aged 15 19 years and 20-24 will be reached with Healthy Choices II (HCII) which aims at delaying sexual debut, promote secondary abstinence or have protected sexual intercourse. It helps in handling peer pressure, learning ones HIV status, and give knowledge and skills on correct and consistent condom use.

To facilitate Quality Assurance HJF and its partners will provide mentorships, learning on the job, Continuous Medical Education (CMEs), exchange visits for best practices and bench marking. In areas where knowledge or skill gaps are identified, they will be addressed through mentorship and refresher courses. Quarterly support supervision with NASCOP and DOD SRV technical managers will be done to promote quality of services offered.

For M&E purposes, HJF will ensure that all the data collected by service providers/facilitators will be entered into standard database and periodically analyzed and sent to DOD SRV

The SRV program has scaled-up PMTCT services to 15 districts in south and north Rift Valley region. In COP 11: 84,200 pregnant women presented for their first antenatal visit; 99% were tested and received results. 80% of the 2,737 women who tested positive, and 67% of the exposed infants received ARV prophylaxis. In COP 12 and COP 13, the program aims to test a total of 92,984 and 97,633 expectant women respectively. 2,735 and 3,322 positive women are expected to be identified and put on ARVs, while 2,052 and 2,857 exposed infants are expected to be put on prophylaxis for the two years respectively. The KEMRI/WRP CRC laboratory in Kericho will provide HIV PCR EID services to the whole of Rift Valley province and Kisumu West district in Nyanza.

The cost per target for FY10 was $22. This amount included support for the Kericho EID lab which is a National activity and the actual cost per patient is considerably lower. This cost will come down further as the program limits expansion and reaps from prior infrastructural investments.

The SRV program will train 300 and retrain 400 health workers on the more efficacious regimens as well as other courses aimed at improved service delivery in the MCH clinic and maternity. In addition, technical assistance and on job training will be provided by HJF Technical staff.

Monitoring: The program will continue to work with Provincial and District Health Management Teams (P/DHMTs) to ensure that all the facilities are able to offer the minimum package of PMTCT. Coordination with GoK will ensure sustainability and ownership. Program data will be reviewed quarterly with the service providers, and identified weaknesses improved. The program has planned various program evaluations to assess effectiveness of the PMTCT and EID programs.

Best practices: The SRV program will offer testing and counseling to all women attending ANC clinics, through task shifting including use of lay counselors to offer counseling services. All service providers will be trained on the new PMTCT guidelines. Continuous mentorship and on job training will be offered through the district mentors and the DHMTs. All sites will have access to CD4 testing by use of various strategies including a CD4 networker. Follow up will be reinforced through the use of support groups, CHWs and cough monitors as appropriate to assist with defaulter tracing. All exposed infants will be entered into a data base by the clinical mentor, followed up, and those positive started on care.

Demand creation: The program will participate in community meetings to sensitize the community on ANC and PMTCT Specifically, Male involvement will been encouraged through the roll out of Saturday male clinics in selected health facilities in the region. The women will be given cards with their ANC number to be used by their partner when testing, to enable the health worker to link the results for the couple.

Linkages: The SRV PMTCT activities will be implemented in the setting of a comprehensive HIV/AIDS prevention, care and treatment program. PMTCT clients will be linked directly to Treatment for ARVs; ; CT will be conducted on male partners and children of women in the MCH clinics. The women will also be screened for TB and linked to TB/HIV services. Linkages between PMTCT service and care outlets will be strengthened to improve utilization of care opportunities created through PEPFAR funding, including support for food and nutrition among other services.

HJF SRV will continue to provide treatment to all male and female adolescents and adults aged 15 years and above in the general population and MARPs such as sex workers, prisoners to reach a target of 21,190 and 22,315 currently on ART in FY 12 and FY 13 respectively.

As more PLHIV are initiated on ART due to adoption of new guidelines at a cut off of 350 and other eligibility criteria, COP 12 funds will be used to improve efficiencies by putting measures such as continued decentralization of ART services, task shifting, mentorship, support supervision and program review meetings.

A comprehensive treatment package will be offered to these PLHIV which will include: psychosocial support, clinical monitoring, PwP package, universal Cotrimoxazole prophylaxis, nutritional counseling assessment and supplementation and Laboratory monitoring. The current clinical outcome measures are: Improved health outcomes defined by viral suppression, improvements in immunological status (increase in CD4 cell count); clinical parameters (stable or decrease in WHO stage, increase in weight/body mass index, stable or improved hemoglobin, and stable renal and liver function tests); and participant-reported improvement in health status. Selected level 4 facilities will be supported to be referral centers of excellence.

Strategies will be put in place to improve patient retention and adherence through: Continued patient education (group and individual education), proper documentation of the patients social history for effective follow up and defaulter tracing, encouraging PLHIV to have treatment partners, linkage to support groups and the community through the existing community units and community health care workers. The outcomes of such strategies are: improved health outcomes, reduced morbidity and mortality and reduced chances of developing resistance. The retention rate in SRV is currently >80% which reflects the retention at the national level.

Integration of services will be emphasized in all facilities: TB/HIV services including TB screening and Isoniazid prophylaxis; ART in MCH; counseling and /or provision or referral to Family planning services ; and cervical cancer screening in the HIV clinics.

The funds will be used to support: in-service ART trainings using the national approved curricula and Mentorship programs. Health care workers (HCWs) will be encouraged to hold CMEs, on job trainings and regular clinical review meetings to discuss challenging cases. Treatment failure retreats will be held in a forum where HCWs drawn from different hospitals meet to discuss treatment failure cases.

Support supervision to the facilities will be done jointly with MoH and in each visit; provision of quality treatment will be emphasized.

Accurate documentation of patient information in the files, MoH data collection and reporting tools will be supported for improved patient follow up and management. Facilities will be supported to hold regular data review meetings to improve data utilization for decision making. The new generation indicators will be collected and reviewed at least quarterly with the Strategic information, monitoring and evaluation team.

To promote local ownership and program sustainability, facility Health Management Teams develop their own work plans and scope of work with Technical Assistance from HJF staff. Performance is monitored and evaluated quarterly using in-house tools; this is done jointly with the HJF SRV technical staff.

HJF SRV will support all male and female HIV-Infected children below 15 years of age, targeting 2, 673 and 2,982 children currently on ART in FY 12 & FY 13 respectively. Strategies to scale up pediatric treatment include: Offering PITC to all children presenting to facilities for whatever reason, both in in-patient and out-patient clinics; encouraging the mother or care giver to bring all the other siblings to be tested for HIV; and decentralization of pediatric ART services to all clinics offering ART services.

The capacity of HCWs to offer pediatric treatment will be strengthened through in-service training using nationally approved curricula, mentorship, encouraging the facilities to hold clinical review meetings and on-job training. Technical Assistance (TA) will be offered through telephone and e-mail follow up where clinics are encouraged to do case summaries and share with SRV program team. Treatment failure retreats are organized by the Technical Staff in the SRV program for facilities to share challenging cases with colleagues, including expert clinicians; such forums have instilled confidence in HCWs as regards pediatric treatment.

HCWs will be supported to improve documentation on patient files and other tools, for effective follow up and linkage. Support supervision will be carried out jointly with the DHMT and HMT.

Adherence in pediatric population remains a challenge due to frequent change of caregivers, lack of social support etc. Efforts will be made to address these challenges through: Having dedicated pediatric clinic days, child friendly clinics, formation of age appropriate pediatric support groups; empowering care givers through trainings on disclosure and Families Matter Program under AB program on prevention messages; leveraging on the AB program in schools to sensitize teachers on HIV issues; male involvement in PMTCT, using family centered approach in pediatric treatment; linking the children to OVC programs and Youth Friendly Centers for the adolescents.

Integrated pediatric services will be supported e.g. integration of ART in the MCH clinics, pediatric TB screening in all clinics including HIV clinics, treatment of those co-infected with TB in the TB clinic with each child accessing a comprehensive treatment package.

A robust EID network to collect and transport DBS specimens from all facilities offering PMTCT to KEMRI/WRP CRC- Kericho lab is in place, and will be further supported to ensure that the results also get back to the facility on time to inform and improve clinical outcomes of the infants. A lab network system is in place where all specimens for CD4%, Viral Load ,other monitoring tests and where necessary, resistance testing are sent to various labs and results get back to the facilities in a short turn-around time. These labs are enrolled in EQA, personnel trained and mentored to assure of quality lab results.

Efforts are made to address issues affecting adolescent treatment e.g. formation of adolescent support groups to sensitize them on life skills by leveraging on AB program curriculum, training of care givers to be able to handle adolescent issues, establish adolescent friendly clinics having been successfully modeled at Kericho District Hospital and also early preparations and counseling of adolescents for transition into adult treatment service.

HCWs are encouraged to document best practices and submit abstracts to conferences including national treatment conferences.