PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:
+ Prime partner HJF MRI has been competitively selected to implement the activity.
+DNA Polymerase Chain Reaction for HIV testing for Early Infant Diagnosis (EID) will be supported for all
facilities implementing PMTCT services in the Rift Valley Province through the new partner and the Kenya
Medical Research Institute/Walter Reed Project Clinical Research Center Kericho laboratory.
SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS
In COP 2009, a total of 300 health workers will be trained to address the shortage of skilled human
resources. In addition, training of mentor mothers, peer educators and community health workers will be
emphasized to enhance effective task shifting.
COP 2008
Geographic coverage has been expanded to include Kisumu West district in Nyanza province. DNA
Polymerase Chain Reaction for HIV testing for early infant diagnosis will be supported for all facilities
implementing PMTCT services in the Rift Valley through the Walter Reed Project research laboratory.
1. LIST OF RELATED ACTIVITIES
This activity relates to activities in Counseling and Testing, HIV/AIDS Treatment: ARV services, Palliative
Care: TB/HIV, Palliative Care: Basic Health Care and Support OVC and APHIA II Rift Valley.
2. ACTIVITY DESCRIPTION
Since August 2001, the Kenya Medical Research Institute /Department of Defense (KEMRI/DOD) had been
implementing a Prevention of Mother-to-Child Transmission of HIV infection (PMTCT) program in the
Kericho District of the south Rift Valley Province. With Emergency Plan (EP) support, KEMRI/DOD has
scaled-up PMTCT services in 10 other districts of south Rift Valley Province (SRV) and will continue to
scale up in Kisumu West District (KWD) of Nyanza province. The number of PMTCT sites has increased
from three to over 205 and as a result 157,571 pregnant women had received PMTCT Counseling and
Testing (CT) by end of March 2008. In the period between October 2007 and March 2008, 29,197 pregnant
women presented for their first antenatal visit, of which 28,952 received their HIV test results. Among them,
970 women were identified as HIV-infected and 847 women and 739 of their HIV exposed infants received
ARV prophylaxis. Male involvement has been encouraged through the development of Saturday male
clinics in some health facilities in the region. Even though the PMTCT program has been successful;
inadequate numbers of trained Health Workers (HW), limited working space, poor infrastructure, weak
logistics and supply chain management, inadequate management, as well as stigma and discrimination in
the communities continues to limit the full utilization of PMTCT services and further access to care and
treatment by the HIV-infected women and family members. Low levels of male involvement, lack of
appropriate infant feeding options, and limited access to Family Planning (FP) information and services are
further barriers. The SRV Province and KWD has 274 health facilities and 216 are currently providing
PMTCT services. In 2009 COP, HJF MRI-SRV will continue to work with Provincial and District Ministries of
Health (MOH) Health Management Teams (HMT) to address these barriers in an effort to scale up PMTCT
services to a total of 250 health facilities. The coordination with Government of Kenya in the implementation
of this activity will ensure sustainability and quality of the services. Of the 112,722 expected pregnancies in
SRV and KWD; HIV CT services will be provided to 97,435 (86%) pregnant women during the antenatal,
intra-partum, and immediate postpartum period. Additionally of the 5,102 total expected HIV infected
pregnant women, 4,377 (86%) HIV-infected pregnant women and 4,074 (80%) of their babies will receive
ARV prophylaxis. All HIV +ve pregnant women will be staged clinically and immunologically by WHO criteria
and CD4 cell count testing respectively. Women in WHO stage 3 & 4 and all those with CD4 cell count less
than 350 will be initiated on ART. Those in WHO stage 1 & 2 with CD4 cell count greater than 350 will be
initiated on AZT from 28 weeks gestation. Of the targeted 4,377 HIV-positive pregnant women 1,313 (30%)
will get a minimum of Single dose nevirapine (SdNVP), 2,189 (50%) will receive short course AZT from 28
weeks of pregnancy and SdNVP, and 875 (20%) will get ART. All the HIV +ve pregnant women who
receive SdNVP will be given AZT and 3TC combination for one week post natally to cover the Nevirapine
"tail" to reduce the development of NVP resistance. All exposed babies will receive SdNVP, 3TC for one
week and AZT for six weeks. Nevirapine tablets will be dispensed to all HIV+ pregnant women at first
contact to minimize missed opportunities. All HIV +ve pregnant women and their infected or exposed
babies will be started on cotrimoxazole (CTX) prophylaxis till they are confirmed HIV negative. All pregnant
women will be given Malaria Intermittent Presumptive Treatment (IPT) and Insecticide Treated Nets (ITN). A
total of 300 health workers will be trained to address the shortage of skilled human resources. In addition,
technical assistance will be provided by 2 additional locally employed staff. Priority areas in 09 COP include
provision of a package of services consisting of expanding CT to achieve universal coverage, complete
ANC profile and birth planning, improved obstetric care, HIV staging in both ANC and delivery units, ARV
and OI prophylaxis, scaling up of more efficacious ARV prophylactic regimens, ART for eligible women,
facilitating HIV EID; counseling and support on maternal, infant and young child nutrition; TB screening for
HIV-positive pregnant women. CT within the PMTCT program will be extended to 19,827 (20%) male sexual
partners of the pregnant women through the Men as Partners (MAP) initiative, Provider Initiated Testing and
Counseling (PITC) in FP and Child Welfare Clinics (CWC); and improving access to FP services. Emphasis
will be placed on primary prevention for the majority of women identified as HIV -ve through PMTCT
programs. We plan to enhance greater involvement of people living with HIV and AIDS (GIPA) through the
facility and community based psychosocial support groups, Mentor Mothers, PwP and MAP. This will link
mothers and their families to palliative care including TB services and home-based care, ART PMI malaria
prevention activities, FP services and income generating activities. Dry Blood Spots (DBS) will be used for
Polymerase Chain Reaction (PCR) testing for the HIV exposed or infected children. Follow-up and referral
as appropriate of the HIV-infected women, their HIV exposed children, and their sexual partners will be
supported. Counseling and support for infant and young child nutrition will be provided. FP services will be
supported through wrap around programs. The KEMRI/WRP CRC laboratory in Kericho will provide HIV
PCR diagnostic testing services to the whole of Rift Valley province. All HIV-positive children below 18
months will be started on ART as soon as they are diagnosed irrespective of CD4 cell counts and WHO
clinical staging within the MCH settings.
3. CONTRIBUTIONS TO OVERALL PROGRAM AREA
Activity Narrative: This KEMRI/WRP activity will contribute to approximately 7.6% of the total, direct PMTCT Emergency Plan
targets of 1,300,000 pregnant women offered CT in FY 2009. This will also support government efforts of
ensuring that at least 80% of pregnant women have access to PMTCT services by the end of 2008 with a
50% reduction in pediatric HIV infections. Planned activities will improve equity in access to HIV prevention
and care and treatment services since the currently underserved rural communities will have better access.
KEMRI will work to ensure the availability of networks and linkages among medical sites where AIDS care
and treatment are provided for both adults and children.
4. LINKS TO OTHER ACTIVITIES
The PMTCT activities will relate to the following KEMRI-SRV comprehensive approach to HIV/AIDS care
and treatment: Palliative Care: Basic Health Care and Support, CT Treatment: ARV services, OVC, and
TB/HIV. The women will also be screened for TB as a direct link with TB/HIV services. Linkages between
PMTCT service and care outlets will be strengthened to improve utilization of care opportunities created
through PEPFAR funding.
5. POPULATIONS BEING TARGETED.
This activity targets adults of reproductive age, pregnant women, family planning clients, infants, and
People Living With HIV/AIDS (PLWHA) including HIV-positive pregnant women. Strategies to improve
quality of services will target MoH staff, doctors, nurses, midwives, and other health care workers such as
clinical officers and public health officers in both public and faith based facilities as well as the local
communities through training, Support Supervision, and Health Education.
6. KEY LEGISLATIVE ISSUES ADDRESSED.
This activity will increase gender equity in programming through PMTCT services targeted towards
pregnant women and their spouses. Women bear a high HIV burden through not only primary infection but
also as caregivers and impact of stigma and discrimination. Identifying these women through PMTCT will
provide an opportunity to access care for themselves, their spouses, and their infants - all targeting
improved pregnancy outcomes. Increased availability of PMTCT and PMTCT+ services will increase access
and help reduce stigma at community and facility levels. Men will be encouraged to come for CT services
and male PMTCT clinics will be expanded. Psychosocial Support Groups, mentor mothers and Peer
Counseling and Prevention with Positives (PwP) will be encouraged to improve on PMTCT uptake and to
also reduce fear of stigma and discrimination.
7. EMPHASIS AREAS
The major emphasis area in this activity is training health care workers and facilitating EID. Minor emphasis
will be placed on infrastructure, development of networks/linkages and referral systems, quality assurance,
quality improvement and supportive supervision.
New/Continuing Activity: Continuing Activity
Continuing Activity: 14902
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
14902 4804.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $2,021,145
Defense Research Institute
6967 4804.07 Department of Kenya Medical 4249 3476.07 South Rift Valley $1,141,540
4804 4804.06 Department of Kenya Medical 3476 3476.06 South Rift Valley $550,000
Emphasis Areas
Construction/Renovation
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Malaria (PMI)
* Safe Motherhood
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $350,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
This PHE activity, "How to Optimize PMTCT Effectiveness (HOPE) Project" was approved for inclusion in
the COP. The PHE tracking ID associated with this activity is KE.08.0203. This PHE is an FY08
Collaborative.
New/Continuing Activity: New Activity
Continuing Activity:
Estimated amount of funding that is planned for Public Health Evaluation $620,000
Program Budget Code: 02 - HVAB Sexual Prevention: AB
Total Planned Funding for Program Budget Code: $35,906,467
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Key Result 1: Strengthen programs with combination prevention interventions.
Key Result 2: Expand scope and coverage of targeted interventions for most-at-risk populations (MARPs).
Key Result 3: Support development and scale up of targeted comprehensive prevention approaches.
Key Result 4: Strengthen national HIV prevention planning and coordination through support to the National HIV Prevention Task
Force.
CURRENT PROGRAM CONTEXT
The Kenya Emergency Plan (EP) Sexual Transmission Prevention (STP) program continues to intensify prevention interventions
by increasing coverage, improving quality, and enhancing program efficacy to reduce the risk of HIV transmission. The STP
program consistently integrates prevention across all program areas through a combination of prevention interventions. Kenya's
approach targets both the general population as well as MARPs. In the country, personal risk perception has not increased
although HIV knowledge levels have. Data from the 2007 Kenya AIDS Indicator Survey (KAIS) indicate that four out of five adult
Kenyans do not accurately know their HIV status. Prevention education that emphasizes correct knowledge of status is therefore
an increasingly important building block to a comprehensive prevention strategy, and a standardized ABC+T (Testing) approach
will be pursued.
The HVAB program will continue to strengthen interventions contributing to abstinence, delayed sexual debut, and adoption of
secondary abstinence among young people. Addressing cross-generational sex and providing education regarding the associated
risk of early marriage will be a key focus, linked with income-generating activities (IGAs) to reduce risk determinants that increase
this vulnerability. The HVAB program employs a balanced approach that focuses on youth and adults with fidelity and testing
messages, as well as working in concert with the HVOP program to provide the right mix of age-appropriate interventions. The
HVOP program has sharpened its focus on promoting correct and consistent condom use among sexually active persons of
unknown HIV status or with known discordant HIV status, both to the general public and MARPs.
The 2008 UNAIDS Modes of Transmission (MOT) Study indicates that MARPs contribute more than one-third of new infections in
Kenya. Targeted interventions with a comprehensive package of services will be scaled-up for sub-populations at higher risk of
HIV infection, including commercial sex workers (CSW) and their clients; men who have sex with men (MSM) and their partners;
fishermen; casual heterosexual concurrent relationships; discordant couples; and prisoners.
The Prevention with Positives (PwP) strategy is incorporated across all HIV prevention, care and treatment interventions with a
particular emphasis on reaching discordant couples with education on safer sex and greater awareness that long-term
discordancy carries an increased risk due to frequency of exposure. An important milestone achieved this year was the launch
and rollout of the PwP clinical package. A standardized package of interventions is being developed for a PwP community
strategy. A National PwP Task Force has been established and work is underway on a toolkit to guide evidence-based, high-
quality interventions for people living with HIV (PLHIV). A minimum prevention package for CSW is being finalized and will be
rolled out by NGO and health ministry implementers. Standard guidelines will also be developed for youth programs and other
interventions.
Ongoing EP-supported youth programs will be invigorated through additional, collaborative activities with the Partnership for an
HIV-Free Generation. This initiative will enable the EP to leverage new public-private partnerships toward enhancing youth HIV
prevention and linking young people to economic opportunities to the greatest extent possible.
The majority of the HIV-positive population resides in rural areas of Kenya. Although there has not been a systematic mapping of
the coverage of prevention interventions, it is clear that additional efforts must target rural populations. Emerging data on
geographic prevalence has guided programming priorities, particularly for MARPs in Nyanza, Nairobi, Coast, and Rift Valley
provinces.
Gender considerations have been incorporated across the entire program portfolio. Specific interventions addressing male norms,
increased vulnerability of young women and girls, gender and sexual-based violence, and cross-generational sex are an important
focus for all programs.
A national communication campaign will help to scale up universal access to HIV prevention. National-level prevention leadership
is also being strengthened. Through the Capacity Project, the EP supports a Senior HIV Prevention Expert and a Youth Affairs
Officer at NACC. Similarly, the EP will support a National Officer at WHO to provide technical guidance in prevention. In 2008, the
EP STP program helped bring about formation of a high-level National HIV Prevention Task Force (NHPTF) led by the National
AIDS Control Council (NACC) to re-invigorate and steer national prevention efforts. An important expected output of the NHPTF is
to aid development of a new Kenya National AIDS Strategic Plan (KNASP) with a more robust prevention agenda that is well-
informed by KAIS, the Kenya Demographic and Health Survey 2008 (KDHS), the MOT study, and evidence-based practice.
Moreover, the new KNASP should incorporate consensus emerging from the 2008 National HIV Prevention Summit, which
emphasized that effective prevention strategies must embrace a combination approach and recognized the need to expand the
scale and quality of prevention interventions across the country.
STATISTICS
The 2007 KAIS documented national HIV prevalence of 7.8% among adults 15-49. There are significant gender disparities with
women having a higher prevalence (8.7%) than men (5.6%). Among youth, women aged 15-24 are four times more likely to be
HIV-positive than their male peers (6.1% versus 1.5%). KAIS also showed a marked variation between rural and urban residents,
with 70% of HIV-positive adults living in rural areas. Nationally, the highest prevalence was found within the 30-34 age bracket.
Geographically, prevalence remains highest in Nyanza Province at 15.3%. This is followed by Nairobi at 9%, Coast at 7.9%, and
Rift Valley at 7%, all significantly contrasting with the North Eastern Province at 1%. The number of HIV-positive adults in Rift
Valley (estimated 322,000) is greater than in Coast (estimated 135,000) and Nairobi (estimated 176,000) combined.
About two-thirds of HIV-positive Kenyan adults report currently being in a union, yet there is only 50% condom use among HIV-
positive sexually-active individuals. 10% of monogamous married couples and 14% of polygamous couples have one or more
partner infected with HIV. Ongoing HIV testing and counseling initiatives, including couple CT and home-based CT, have helped
to identify couple discordance.
An important sub-group that has previously not been targeted as "high-risk" is married individuals. Among HIV-positive people,
45% have a partner who is not currently infected. Discordance, particularly in marriage, presents a great risk.
SERVICES
The USG team of prevention technical experts from USAID, CDC, DoD, and Peace Corps jointly plans, reviews program
progress, and provides technical guidance to the entire Kenya prevention portfolio. This synergy will be enhanced in 2009 through
joint technical meetings for all implementing partners to exchange best practices, ensuring consistent prevention messaging and
reducing duplication of effort.
The Partnership for an HIV-Free Generation will work with the STP ITT to infuse corporate strategies to optimize access for youth
prevention services, such as an intensified campaign for CT for youth in Kenya. Through a PPP that includes Warner Bros. and
Intel, a computer game will be launched and piloted at youth centers to test the effectiveness of popular entertainment as a
medium to impact key behavioral outcomes. Services that closely link prevention and CT services will be strengthened. The
Ministries of Public Health & Sanitation and Medical Services will remain key partners in prevention activities, providing a nucleus
around which all other prevention services will be provided. The GoK's Community Strategy will be strengthened to provide
comprehensive prevention education and referral for services.
A comprehensive prevention package for CSW, developed with NASCOP leadership, will be rolled out as a standardized
approach to service provision. This will include peer education and risk reduction education, CT, STI screening and treatment,
condom promotion and distribution, and HIV care and treatment. Clients of CSWs will also be targeted. MARP prevention
interventions will be scaled up, guided by mapping services within prevention program areas, including sexual risk reduction
messages, condom promotion and provision, communication campaigns, couples counseling and testing, discordant couple
interventions, and support group activities.
Prevention education, including a national mass media campaign, will be intensified through the APHIA II Health Communication
and Marketing (HCM) program. Internews will train TV, radio, and print journalists to more actively and accurately report on HIV
prevention through media sources around Kenya. Increased male involvement in prevention efforts will include scaling up the Men
as Partners program to address gender stereotypes that predispose men to sexual risk behaviors, as well as sexual and gender-
based violence. An expanded program with uniformed services at the workplace, their families, and host communities, as well as
with prisoners, will reinforce safer sexual behavior and emphasize the benefits of reduction of multiple concurrent partners.
PEPFAR partners will also target fishing communities in Nyanza with combination interventions.
AB programs will expand coverage for youth and general population prevention activities to optimize coverage in locations not
previously reached. This will be achieved through a mix of life skills education, community education, peer education, and
interventions targeting couples and older adults to promote fidelity with knowledge of status and partner reduction. Specific gender
programs include an ongoing house girls' initiative and programs by the Kenya Girl Guides Association, linkages with IGAs
through the K-Rep microfinance program and with the Women's Justice and Empowerment Initiative for legal rights awareness
and improved post-rape medical services.
Alcohol and substance abuse prevention, including prevention education, counseling and referral, will continue to be integrated
within targeted primary prevention services.
Consultations will be held with the GoK, World Bank, DFID, and other development partners to assure commodity security
especially for male condoms in the country. Given limited supplies of lubricant gel in the country, a more effective means to
procuring these will be explored. New approaches to increasing access to and use of female condoms will also be pursued.
Overall, the STP team continues to examine geographic coverage to reduce duplication of efforts and ensure optimal coverage.
REFERRALS AND LINKAGES
Prevention has been integrated into other program areas, and key prevention messages are integrated with service provision.
Prevention programs will work to identify appropriate referral mechanisms so that prevention efforts translate to increased access
to CT, PMTCT, care and treatment, and vice versa. Where a comprehensive package of services is offered, an M&E system will
be incorporated into the package. EP-supported prevention programs will seek to leverage wrap-around services in family
planning in health care settings, including PMTCT, which are supported through the GoK, USAID Population funds, and other
partners.
POLICY
In 2008, the Ministry of Education will rollout a standardized, in-school curriculum on life-skills training and the EP will support its
implementation. The EP STP program is supporting the development and dissemination of prevention guidelines for MARPs,
including a comprehensive prevention package of services for sex workers and a PwP package. Data from KAIS, KDHS, and
MOT study will continue to inform prevention priorities as well as development of the next KNASP in 2009. Promotion of
Meaningful Involvement of People Living with HIV will be achieved through supporting prevention advocacy by PLHIV at various
levels. This will include interfacing with GoK through peer education and support group involvement.
CHALLENGES
A clearer operational definition of what an STP target "reached" entails is needed. Ambiguity arises from the broad range of
prevention interventions that are attributed to a "reach," which may range from a single intervention (e.g., a peer education
session) to a combined approach that may include life-skills curriculum training, theatre, counseling and testing targeting a single
individual or defined group.
As prevention programming expands its targeted interventions for MARPs, the per capita prevention cost will likely rise owing to
the intensity required to access hard-to-reach populations, as well as the mix of interventions in a comprehensive package;
however, over time, this such targeted interventions should help substantially diminish care and support costs, as fewer people
become infected.
SUSTAINABILITY
Training and the involvement of community members as the primary implementers sets a platform for sustaining programs beyond
EP funding. The EP will work to further empower and build the capacity of CBOs, PLHIV groups, and other indigenous groups to
achieve the organizational and technical capacity to carry out HIV prevention work in a sustainable fashion.
MONITORING AND EVALUATION
There is a close collaboration with GoK on a harmonized M&E system in the country. Also, through APHIA II Evaluation, a District
Education Monitoring and Management Information System will be implemented to assess the impact of HIV on the education
sector. Specific indicators will be developed with the SI program to monitor the integration of prevention across other program
areas.
WORK OF HOST GOVERNMENT AND OTHER DEVELOPMENT PARTNERS
The prevention program will work with the Kenya Institute of Education in streamlining the life-skills curriculum. It will also work
with NASCOP to roll out the comprehensive prevention packages, both through the provincial and district health management
teams, as well as through the work of USG-funded implementing partners. The National HIV Prevention Summit has been
established as an annual technical consultation for prevention stakeholders, led by the NACC and co-sponsored by the USG,
UNAIDS, and other key partners.
Table 3.3.02:
+ Prime Partner Henry Jackson Foundation Medical Research International (HJFMRI) has been
competitively selected to implement this activity in the place of KEMRI.
+ The geographical coverage has been expanded to include Nandi districts and Transmara District within
the South Rift Valley province.
This activity supports key cross -cutting attributions in education through supporting life skills training and
HIV prevention education within the context of education settings. This will be done in conjunction with the
Ministry of Education. It will involve training of peer educators among school going children, teachers and
parents who will be equipped with communication and leadership skills to enhance their ability to reach their
peers with HIV prevention messages. The cost implication will be at $15,000
N/A
The South Rift Valley (SRV) through KEMRI/WRP has provided HIV comprehensive care and support to six
districts in the South Rift Valley since 2005. Although HIV testing, care and support have been very
successful programs prevention efforts focusing on Abstinence/Being Faithful in the larger area have been
minimal. HIV prevention interventions for very vulnerable populations in this region has been traditionally
neglected therefore having minimal affects on the learning and subsequently adapting new behaviors that
will systematically and successfully limit the number of new infections that occur in this region on an annual
basis. In FY09, Henry Jackson Foundation Medical Research International, (HJFMRI/SRV) will scale up the
comprehensive HIV prevention program focusing on minimizing the risks for young people as well as
support the development of healthy relationships that will significantly reduce the risks related to the
acquisition of HIV. The HJFMRI/SRV AB program will focus its efforts in the activity in the expansion and
implementation of Families Matters! Program, WHY WAIT? A Family Enrichment Curriculum and Men as
Partners in HIV Prevention (MAPP). The interventions are evidence based curriculums that will be scaled-
up through out the seven districts in the south Rift Valley through local faith based organizations and
churches as well as in conjunction with the Ministry of Education. Families Matters! Program focuses on
augmenting the family unit as the major support in reducing the risks of HIV that young people face as well
as provides families with the skills and knowledge to discuss issues of HIV and human sexuality in a
positive and productive manner with their children. HJFMRI/SRV will also continue working with the
university student population at East Africa Baraton University through the on-going support of the I Choose
Life program by training 50 people in the program and reaching over 50,000 individuals. The HJFMRI/SRV
AB program will initiate a working relationship with the Kenya Girl Guides Associations Movement in the
Schools to promote HIV/AIDS prevention, through abstinence and/or being faithful by focusing in training
peer educators in life skills as well as identified teachers and community leaders in comprehensive
HIV/AIDS prevention curricula. Together these three programs will reach over 117,560 individuals with
HIV/AIDS prevention. The HJFMRI/SRV AB program will also be active participants in the development and
the implementation of the Healthy Youth Initiative (HYPE) as it is expanded nationally past the urban areas
of Kenya. HJFMRI/SRV will actively identify community based and faith based organizations that work with
the youth of south Rift Valley and engage them in the development of interventions that HYPE could
support and be effective with rural youth. The HJFMRI/SRV AB program will also partner with other
organizations in the implementation of the comprehensive HIV prevention interventions such as Kericho
Youth Center, AIC Litein and Tenwek Hospital.
This activity will contribute to the national Emergency Plan AB program by ensuring that all interventions
follow evidence-based approach to prevention that is informed by rigorous analysis of Kenya's epidemic.
The major focus of this activity will focus on the youth especially those at heightened risk of HIV by
strengthening the larger systems that these youth operate in through focusing on family and community
structures that will be supportive in evading HIV infection. A major focus will be on young girls that are at a
heightened risk of HIV by also focusing on the protection of the girl child from gender based violence or
coercion. The HJFMRI /SRV AB program will target a total of 117,560 individuals reached through
community outreach that promotes HIV/AIDS prevention through abstinence and/or being faithful and train
an additional 1,417 individuals in the promotion of HIV/AIDS prevention.
This activity is linked to other prevention activities in the DOD Emergency Plan prevention portfolio such as
the HJF MRI/SRV OP activity and the Live with Hope Center's AB and OP activity. They are also linked to
counseling and testing activities in the south Rift Valley with partners such as Tenwek Mission Hospital, Live
with Hope Center and HJFMRI/SRV. The links to these activities provide a comprehensive approach to
prevention from abstinence to the correct and consistent use of condoms as outlined in the PEPFAR
Guidance for ABC programs. The HJFMRI/SRV AB activity will also be linked with local Orphans and
Vulnerable Children (OVC) partners to ensure that all OVC receive age-appropriate HIV prevention
interventions, addressing the heightened risk this population is in to be abused or taken advantage of.
5. POPULATIONS TARGETED
This activity targets the general population from children to adults recognizing that prevention activities are
comprehensive and the development process of human sexual development is also an on-going transitional
process. Other populations that are targeted for this activity will be teachers and religious leaders through
the work that HJFMRI/SRV AB will do with faith based organizations as well as the local Ministry of
Education schools. This activity will also focus on street youth and orphans and vulnerable children,
recognizing the heightened risk that this population is exposed to due to their vulnerable situation.
6 & 7. EMPHASIS AREAS/KEY LEGISLATIVE ISSUES ADDRESSED
The HJFMRI/SRV AB activity will address issues in gender especially in the areas of addressing male
Activity Narrative: norms and behaviors through the MAPP program as well as increasing gender equity in HIV/AIDS programs
by focusing interventions at the family level through Families Matter!. Efforts will also be made in protecting
OVC and the girl child against violence and coercion. In-service trainings will also be an emphasis area to
ensure that the services and interventions are de-centralized and reach the most people.
Continuing Activity: 16997
16997 16997.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $360,000
Estimated amount of funding that is planned for Education $15,000
+ The geographical coverage has been expanded to include Nandi North and Nandi South districts and
Transmara District within the South Rift Valley province.
+ The target population has been scaled up to include touts, food vendors, and bicycle and motor cycle
riders. Based on the lessons learned during the FY07 activity, these groups form a large percentage of sex
work clientele otherwise known as the networks of sex workers.
This activity supports key cross-cutting attributions in Economic Strengthening. The activity will facilitate
education and awareness on income generation through linkage with experts in the field of micro credit and
micro enterprise and entrepreneurship. It will also facilitate registration of the groups with the social welfare
in order to access the services. The activity will cost $3,000.
The only changes to the program since approval in the 2007 COP are:
•Geographic coverage has been expanded to include Bomet District, Bureti District, Nandi North and Nandi
South;
•The target population has been expanded include discordant couples, personnel of public service vehicles,
university students at East Africa Baraton University and people living with HIV;
•$7,000 of this activity is programmed with funds from the $7 million FY 2008 plus up for the Healthy Youth
Programs Initiative;
•$137,500 of this activity is programmed with funds for the promotion, education and awareness of male
circumcision as a prevention intervention;
•Other changes include the following new interventions in the OP activity:
-Men as Partners in HIV Prevention
-Positive Prevention in Community Settings
-I Choose Life program for University Students
This activity relates to activities in Abstinence and Being Faithful (#6891) and Counseling and Testing
(#6968).
KEMRI/Walter Reed/SRV embarked on a new piloted initiative in South Rift Valley in the area of Condoms
and Other Prevention in 2007 in order to bring prevention to high-risk populations in two stop-over locations
along the Nariobi-Kisumu transport highway corridor within Kericho District. Both sites have been extremely
underserved in the area of prevention which has fueled the prevalence rate to increase among core
transmitters as well as the surrounding general communities. KEMRI South Rift Valley program has had a
comprehensive HIV care program for the residents of south Rift Valley since the 2005 Emergency Plan
which includes counseling and testing as well as HIV/AIDS treatment. These activities will be implemented
by Henry Jackson Foundation Medical Research International (HJFMRI) South Rift Valley. A significant
aspect of the existing HJFMRI/South Rift Valley HIV comprehensive care program which has been missing
is in the area of prevention, especially among high-risk populations. The reliance on conventional voluntary
counseling and testing (VCT) sites to address this need has not been a sufficient prevention intervention. In
FY 2009, Henry Jackson Foundation Medical Research International (HJFMRI) South Rift Valley (SRV) will
address this existing gap in HIV-AIDS prevention by targeting 134,883 individuals in South Rift Valley in
creating a sustainable prevention program which addresses the specific risk factors of commercial sex
workers (CSW), touts, food vendors, as well as other high-risk adults in South Rift Valley. The estimated
HIV prevalence rate is 7-8% among the general population, but the targeted group for this activity is
estimated to be higher than that. Even after personal knowledge of HIV status, there is a significant gap in
prevention activities due to the lack of personal knowledge and skills that assist an individual to change
behavior. HJFMRI/SRV will address this issue in South Rift Valley with condom promotion and STI
identification and management. HJFMRI/SRV OP Program will also target 343 people to be trained in
promoting HIV/AIDS prevention among high-risk adults. In FY09 HFFMRI/SRV OP program will expand the
above activities to the rest of the predominantly rural region specifically in the area of condom promotion.
HJFMRI/SRV's new activity in Condoms and Other Prevention will contribute to the overall objective of
reducing high-risk behaviors among high-risk adults. This activity will also empower and train 257
individuals in South Rift Valley in the promotion of routine testing of STIs as well as the promotion of
consistent and correct condom use. This activity will target 86,479 individuals with HIV prevention
messages as well as behavior change skills that significantly minimize their risk behaviors. 89 condom
dispensers will also be set up throughout the South Rift Valley.
4. LINKS TO OTHER ACTIVIITES
This activity is linked to Live with Hope's Abstinence and / or Being Faithful program (#6891) and
HJFMRI/SRV AB Program as other prevention activities occurring in South Rift Valley. Through
coordination the two programs will work closely together in identifying populations to reach with prevention.
Counseling and testing services through HJFMRI/SRV (#6968) will also be linked to this activity in the
promotion of gaining personal knowledge of HIV status as a key to prevention and access to care.
5. POPULATIONS BEING TARGETED
This activity will target adults in the general population with prevention messages as well as the most at-risk
populations of commercial sex workers and mobile populations; specifically truck drivers. Brothel owners
and bar maids will also be a targeted population for this activity. In FY 09, this activity will include touts, food
vendors, bicycle and motor cycle riders as well as prison officers and inmates.
6. KEY LEGISLATIVE ISSUES ADDRESSED
Activity Narrative: This activity will address adult men in educating them about the identification of male norms and behaviors
which may be risk factors in HIV-AIDS transmission. The project activities with CSWs will increase gender
equity in HIV-AIDS programs as well as increasing women's access to income and productive resources.
Stigma reduction will also be addressed through information, education and community mobilization.
The primary focus of HJFMRI/SRV in this activity will be to mobilize the community in the participation of
these prevention activities as well as reduce stigma in specific high-risk populations. This activity will also
dedicate part of its time to information, education and communication in the development of material that
serves as mass media prevention campaigns as well as in training of individuals to sustain the prevention
activities.
Continuing Activity: 14903
14903 8808.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $240,000
8808 8808.07 Department of Kenya Medical 4249 3476.07 South Rift Valley $375,000
Estimated amount of funding that is planned for Economic Strengthening $3,000
Table 3.3.03:
This activity supports key cross-cutting attributions in human capacity development through training of lay
and community health workers for task shifting. It will also develop local management and leadership skills
for community based groups. Of the allocated budget, at most 20% will be spent on this.
1. ACTIVITY DESCRIPTION
HJFMRI-South Rift Valley (SRV) has provided HIV comprehensive care and support to six districts in the
south Rift Valley since 2005. KEMRI- south Rift Valley has been working in targeted divisions among 6
districts in the rural settings within the Southern Rift Valley Province where approximately 80% of men are
circumcised, nearly ¾ by ‘traditional circumcisers'. In FY08 the HJFMRI- South Rift Valley ‘male
circumcision program was able to follow up on over 2000 boys aged between 10-17 years who underwent
male circumcision through prevention and STI counseling, and ABC Messaging. In FY09, HJFMRI-SRV
male circumcision will develop a comprehensive HIV prevention program that will focus on minimizing the
risks for young people as well as support the development of healthy relationships that will significantly
reduce the risks related to the acquisition of HIV. The HJFMRI-SRV male Circumcision program will focus
its efforts in the activity in the development and implementation of WHY WAIT? A Family Enrichment
Curriculum, Families Matter! Program (FMP); and Men as Partners in HIV Prevention (MAPP). These are
proven interventions designed on evidence based curriculums that will be scaled-up through out the seven
districts in the south Rift Valley through partnerships with the local communities, faith based organizations
and churches as well as in conjunction with the Ministry of Education. In FY09 the program will target to
reach and follow -up 5000 boys between the ages of 11-14 years, an important age group that can easily
be influenced by peer pressure; there exists an important window of opportunity before the boys become
sexually active and delay sexual debut. The HJFMRI-SRV circumcision program will develop and
disseminate Ministry of Health approved trainings and IEC Materials (brochures and Posters) to ensure that
Comprehensive HIV prevention messaging and interventions are included in the Circumcision ceremonies
while young men are in seclusion following circumcision. The HJFMRI-SRV CIRC program will train a total
of 400 people: 20 people in Families Matter! Program, 300 people in MAPP and 100 people in Why Wait?
curricula. Together these three programs will reach over 30,000 individuals with HIV/AIDS prevention who
are predominantly in the rural populations. In addition, the targeted surveillance will permit the ability to
gather information and better understand complications and adverse events associated with the current
provision of male circumcision in South Rift Valley and inform the policy making process. The FMP and
‘Why Wait' a Family Enrichment Curricula focus on augmenting the family unit and by extension the
individual social networks as the major support in reducing the risks of HIV that young people face as well
positive and productive manner with their children with an aim of delaying sexual debut and adoption of
healthy sexual behaviors..
2. CONTRIBUTIONS TO OVERALL PROGRAM AREA
This activity will contribute to the national Emergency Plan Male Circumcision program by ensuring that all
interventions follow evidence-based approach to prevention that is informed by rigorous analysis of Kenya's
epidemic. The major focus of this activity will focus on the youth especially those at heightened risk of HIV
by strengthening the larger systems that these youth operate in through focusing on family and community
coercion. The HJFMRI-SRV CIRC program will target a total of 30,000 individuals reached through a
comprehensive male circumcision HIV prevention package and train an additional 400 individuals in the
various HIV/AIDS prevention curricula.
3. LINKS TO OTHER ACTIVITIES
the HJFMRI-SRV AB, and OP activity and the Live with Hope Center's AB activity. They are also linked to
counseling and testing activities in the south Rift Valley. The links to these activities provide a
comprehensive approach to prevention from a male circumcision perspective as outlined in the PEPFAR
Guidance for ABC programs. The HJFMRI-SRV CIRC activity will also be linked with local Orphans and
4. POPULATIONS TARGETED
process. Other populations that are targeted for this activity will be teachers, community and religious
leaders through the work that HJFMRI-SRV CIRC will do with community-based and faith based
organizations as well as the local Ministry of Education schools. This activity will also focus on street youth
and orphans and vulnerable children, recognizing the heightened risk that this population is exposed to due
to their vulnerable situation.
5. EMPHASIS AREAS/KEY LEGISLATIVE ISSUES ADDRESSED
HJFMRI-SRV CIRC activity will address issues in gender especially in the areas of addressing male norms
and behaviors through the MAPP program as well as increasing gender equity in HIV/AIDS programs by
focusing interventions at the family level through FMP and Why Wait?- A family enrichment curriculum.
Efforts will also be made in protecting OVC and the girl child against violence and coercion. In-service
trainings will also be an emphasis area to ensure that the services and interventions are de-centralized and
reach the most people.
Continuing Activity: 16827
16827 16827.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $307,000
Estimated amount of funding that is planned for Human Capacity Development $80,000
Program Budget Code: 08 - HBHC Care: Adult Care and Support
Total Planned Funding for Program Budget Code: $41,349,738
Key Result 1: Provide HIV care and support services for 600,000 adults.
Key Result 2: Provide a Basic Care Kit (BCK) to 400,000 HIV-positive persons including a safe water system, cotrimoxazole
(CTX) for opportunistic infection (OI) prophylaxis, an insecticide-treated bed net, condoms, educational materials, and
multivitamins.
Key Result 3: Provide direct antiretroviral treatment (ART) support for 270,000 HIV-positive adults and indirect support for an
additional 10,000.
Key Result 4: Expand integration of prevention education and services in care and treatment programs.
Key Results 5: Expand provider-initiated, family, and couple HIV testing and counseling services in care and treatment settings.
Kenya's HIV care and ART services have significantly expanded in the last four years. The five-year Kenya Emergency Plan (EP)
goals were to support 300,000 in care and 250,000 on ART by September 2010. However, by July 2008, >500,000 adult Kenyans
had received facility and community HIV care services. The number of ART patients has increased from <5,000 in 2003 to over
200,000 (90% adults) by July 2008, and the number of ART sites has increased from 5 pilot sites to over 500 established sites.
Scale-up continues at a rapid pace, with >10,000 initiating care and 5,000 initiating ART monthly. This tremendous expansion is
attributed to increased funding and scale-up primarily through the EP with some Global Fund (GF) support. Other five-year plan
goals achieved include establishment of a national care and ART task force, revision of policy and guidelines for OI care and ART,
and the training of >15,000 health care workers (HCW) on care and ART.
According to the recently completed Kenya AIDS Indicator Survey (KAIS), there are ~1.4 million HIV-positive adults aged 15-64 in
the country, 390,000 of whom require ART. HIV testing and counseling (HTC) have not reached many of these persons, with 83%
of adult HIV-positive Kenyans not knowing their status. However, among those who knew their status, KAIS revealed high ART
(90%) and CTX (74%) coverage.
Two national surveys conducted in 2007 provided information about care and treatment services. An EP-supported longitudinal
national ART survey conducted at 30 ART sites in 2007 indicated that 78% of patients remained alive and on ART one year after
initiation; 12% were lost to follow-up, 5% died, 4% transferred care, and 1% discontinued ART. Further, 93% of those in follow-up
remained on their first-line regimen at their most recent visit. An HIV basic care service survey at 60 sites revealed that nutritional
advice was the most common type of care provided (98%), followed by secondary prevention (97%), HTC (90%), support groups
(75%), and adult ART (58%). Over 80% of facilities provided condoms and CTX; over 30% offered safe water and bed nets. Non-
opioid pain control was available at 83% of sites, although 5% of sites reported having opioids.
In 2009, the approximate number of HIV-positive Kenyans in EP-supported care and ART will reach 775,000 and 300,000
respectively (55% and 77% of total demand). Decentralization to lower-level health facilities, including health centers and
dispensaries, is anticipated to increase the number of care and treatment sites from 500 to 800, of which 700 provide ART. The
EP will directly support 90% of patients (including 270,000 on ART) and indirectly support nearly all patients. EP funds will train
over 2,000 HCW through classroom training and mentorship, and have already supported Kenyan adaptation of WHO mentorship
guidelines for nurses and clinical officers.
A key 2009 program emphasis is HTC expansion in HIV care settings, including provider-initiated testing and counseling (PITC) in
clinical facilities, and couple and family testing in facility and community settings. Implementing partners will leverage care and
ART program funds to provide HTC within their facilities and expand outreach activities to offer family members home- or facility-
based HTC. PITC will also be provided in hospices through support to the Kenya Hospice and Palliative Care Association
(KHEPCA).
All HIV-positive persons identified through VCT, PITC, couple, and family testing in facility and community settings will be referred
to a nearby health care facility for care and ART evaluation. Patients will have quarterly clinic visits, including CD4 testing twice
yearly, to determine ART eligibility or for treatment monitoring as per Kenyan guidelines.
By September 2010, ~600,000 (43%) of HIV-positive adults will receive EP-supported facility, community, and/or home-based
basic care services (family and couple HTC, TB screening, and CTX) from over 800 service delivery points; 300,000 will receive
both community and facility services. A subset, 400,000 (75%) who are in care but not yet on ART, will be prioritized to receive a
BCK; 200,000 (32%) will receive treatment of other OIs and 270,000 (42%) will receive ART. EP support will scale-up the
provision of the cryptococcal antigen test. Pain management will include non-opioids, acetaminophen and non-steroidal anti-
inflammatory drugs; opioids will be limited to registered palliative care centers. The USG will continue collaboration with KHEPCA
to advocate for policy changes to expand access to pain medication. The EP will continue to provide care and ART services to
hard-to-reach populations, and involve organizations of persons living with HIV (PLHIV) through psychosocial support groups,
PLHIV employment as peer educators, HIV treatment awareness activities, wrap-around food programs, and income-generating
Prevention with Positives (PwP) activities will be expanded in health care facilities and at the community level. A technical working
group, chaired by the National AIDS and STI Control Programme (NASCOP), has been established. In 2008, the first national
HCW PwP trainings-of-trainers occurred. Core clinical PwP activities include: partner/family member HTC, encouraged/assisted
disclosure, condom education and provision, STI screening/treatment, and referral to family planning services. Community PwP
materials will be developed and launched in 2009.
Currently, two pilot programs provide cervical cancer screening to a limited number of women through non-EP funding. The USG
team is assessing their protocols, financial investment, and site capacity to provide screening and treatment services and that of
their tertiary referral sites to provide radiation and/or chemotherapy. Based on the findings, a determination will be made as to
how best 2009 EP funds might support limited cervical cancer screening activities in HIV settings.
Over 60 health care facilities receive Food by Prescription (FBP) to distribute to eligible patients, and >50,000 adult patients have
benefited. Other nutritional support is provided through leveraging of private funds and food production programs. In 2009, the
FBP project will expand to support an additional 40,000 adults, bringing the total ever supported to 100,000. EP funds have
supported nutrition guidelines and protocol development, including entry and exit criteria using BMI and other parameters.
The EP will continue supporting 850 contract clinical staff at government and mission facilities, including clinical officers, nurses,
lab technologists, and pharmacists. Other implementing partners also employ additional staff. Yet, despite EP efforts and that of
other development partners, Kenyan health care facilities remain staffed at ~50% of optimal levels. Various approaches have
been suggested to task-shift HCW roles and responsibilities to other cadres and/or community members, and the MOH has
embarked upon a Community Strategy to ensure Kenyan communities have the capacity and motivation to take up an essential
role in health care delivery. EP funds will promote community ownership of and participation in health care delivery, including HIV
care and ART programs, which should help improve the quality of both general health services and HIV programs. Communities
will be empowered to contribute to policy setting, resource mobilization and allocation, and program development, implementation,
and evaluation.
HIV-positive patients identified through HTC services - including PMTCT, TB/HIV, VCT, PITC, and home-based counseling and
testing - will be linked to care and treatment services. HIV-positive pregnant women will be enrolled in care at Maternal and Child
Health (MCH) or HIV care clinics where they will start CTX and be evaluated for ART. Currently, ART is only available through
HIV care and ART sites; however, a small program will pilot ART in MCH sites. All patients enrolled in clinical HIV care programs
will receive TB screening during routine visits. A standardized TB screening tool for use in HIV settings has been developed and
will be implemented in collaboration with NASCOP and the TB program. HIV-positive men identified through HTC during voluntary
medical male circumcision (VMMC) activities will be linked to care; HIV-negative men in discordant relationships will be referred
for VMMC.
Kenya has developed and implemented national ART and OI prevention and treatment policies and guidelines. During 2009, ART
guidelines will undergo reassessment/revision, including a likely shift to a tenofovir-based first-line regimen. CTX and
multivitamins are recommended for all PLHIV. Policy on other HIV care components remains poorly defined, and, in 2009, EP
funds will support care policy development.
EP funds have supported development of a decentralization policy and mentorship guidelines to guide multi-tasking and task-
shifting to lower level health facilities, and implementation of these policies and guidelines will continue in 2009.
Over 80% of Kenya ART and care programs are within MOH facilities. In 2009, the EP will continue to support HCW didactic
trainings and mentorship. Implementing partners will be encouraged to integrate care and ART plans into the district annual
operations plans. In addition, partners will be encouraged to establish, support, and build the capacity of local, indigenous
organizations. Currently, two umbrella agreements support over 70 local indigenous organizations.
The concept paper for Kenya's PEPFAR Partnership Compact commits the Government of Kenya (GoK) to a minimum of 10%
annual increases in direct budget support for ARV procurement, which will enhance program sustainability.
Data collection and reporting will be strengthened at all levels to increase and improve reporting to NASCOP and PEPFAR. The
NASCOP Systems Subcommittee has adapted quality of care indicators to be incorporated into routine M&E reporting. TB
indicators will be incorporated into HIV care and ART reporting to capture active TB cases and ART uptake among HIV/TB co-
infected patients. The USG team will incorporate customized indicators, including those current, ever, and newly initiated in care,
and differentiate between adults and pediatric patients. Indicators to capture those receiving community and/or facility care will be
developed to avoid double-counting. In 2009, persons reported as receiving basic care and support will receive at least one
clinical service, as well as at least one service in another domain of palliative care.
Currently, implementing partners struggle with the existence of several electronic database systems to capture facility patient-level
care and ART data. A data assessment of the most commonly used systems occurred in November 2007, and a WHO-consultant
is assisting in data variable harmonization. EP funds will assist further development of patient-level computerized database
systems capable of reporting to both NASCOP and PEPFAR, moving toward consensus on a single or limited menu of electronic
systems.
A national survey to monitor emergence of HIV drug resistance (HIVDR) among ART patients has been planned using 2008
funds. These data and that of the early warning indicators will assist NASCOP and other national and international partners to
design strategies to improve ART outcomes, strengthen recommendations for optimal first- and second-line regimens, and
provide indications for time of regimen switch to optimize ART clinical management and minimize the emergence of HIVDR.
WORK OF HOST GOVERNMENT AND OTHER IMPLEMENTING PARTNERS
NASCOP coordinates all care and ART activities and oversees development and implementation of care and ART policy,
guidelines, and training curriculums in Kenya. A national care and ART taskforce, chaired by NASCOP and including
representation from the USG, WHO, UNAIDS, Medecins Sans Frontieres (MSF) and other development partners, meets quarterly
to deliberate on care and ART issues. In 2008, GF resources procured ARVs for ~75,000 and a limited number of OI drugs, and
GoK-procured first-line ARVs for ~25,000. MSF directly supports care and ART for over 15,000. The Clinton Foundation (CF)
procures second-line ARVs for adults and, in 2006, employed 1,120 nurses for a three-year placement in districts with severe
staffing shortages; the GoK is to absorb these nurses after expiry of the contract in 2009. WHO and UNAIDS provide technical
support to NASCOP and have assisted with the WHO guideline adaptation on IMAI and mentorship.
OUTSTANDING CHALLENGES/GAPS
Key remaining barriers include insufficient human resources, inadequate space, and inconsistent access to care and ART
commodities for further scale up. It is hoped that adoption of the Partnership Compact will help increase HCW staffing, and that
implementation of the GoK's Community Strategy, decentralization policy, and mentorship activities will promote multi-tasking and
task-shifting to expand ART availability to lower level facilities. Funds allocated to RPSO will permit the construction and
renovation of health care physical infrastructure, including laboratories, pharmacies, and care and treatment clinics.
Despite ART scale-up in Kenya, the GoK funding allocations to expand their ARV procurement and other commodities remains
low, and the distribution system is weak. In 2008, the GoK has allocated ~$7 million for ARV procurement to cover 25,000
patients on generic first-line regimens. However, this is insufficient to cover the current rate of scale-up and GoK plans to adopt
safer, more efficacious, and more expensive ARV regimens. GF Round 2 Phase 2 only procured ARVs to cover 42,500 patients
for a period of three years. Yet, as this target was quickly exceeded (~75,000), it is unclear how these extra patients will continue
to be covered. The USG team will continue to encourage the GoK to commit more funds for procurement of ARVs, as well as to
assure the security of other commodities.
Table 3.3.08:
+ the prime partner changes from KEMRI to HJF-MRI
+ all sections referring to pediatric care and support have been moved from this narrative to a new program
(PDCS Care)
+ emphasis areas will be expanded to include prevention with positives, nutrition management (Food By
Prescription) for moderate to severely malnourished clients on care and support, and task shifting and
involvement of PLWHA in defaulter tracing and other non-technical aspects of comprehensive ART.
+ number of service outlets providing HIV related palliative care (excluding TB) changes to 100
+ number of individuals provided with HIV related palliative care (excluding TB) changes to 4,800
+ number of individuals trained to provide HIV related palliative care (excluding TB) changes to 150
This activity supports key cross-cutting attributions in HCD through its on-site CME training for doctors,
nurses, clinical officers, pharmacists, nutritionists, and HIV program managers. 2.5% of the budgetary
allocation will be attributed to this activity.
It also supports Food & Nutrition tools and service delivery through meeting critical staff gaps and equipping
health facilities to be able to offer quality nutrition services. 2.5% of the budgetary allocation will be
attributed to this activity. The activity additionally supports nutrition commodities by leveraging on the INSTA
Food By Prescription Support program, currently being implemented in four partner hospitals (Longisa
District Hospital, AIC Litein Mission Hospital, Kericho District Hospital, & Kapsabet District Hospital). In FY
09, mechanisms will be put in place to expand this support to all the 100 palliative care service outlets in all
the 8 districts under the SRV program coverage. 2.5% of the budgetary allocation will be attributed to this
activity.
The only change to the program since approval in the 2007 COP is:
+geographic coverage has been expanded to include Kisumu West District in Nyanza Province and
Kipkelion District in Rift Valley, therefore increasing the geographic coverage from 6 to 8 districts.
This activity relates to HIV/AIDS Treatment/ARV services, Palliative Care: TB/HIV, Counseling and Testing,
Prevention, OVC and PMTCT.
The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed/KEMRI-HIV project in
collaboration with the Ministry of Health and Faith-based (including a local community based organization)
health care programs within 8 districts (2 new districts added to the previous 6 districts) in the South Rift
Valley and Nyanza Provinces of Kenya.
The South Rift Valley Program serves a population of approximately 2.7 million people, with a HIV
prevalence ranging from 5% to as high as 19% in some congregate settings. In 2006, about 100,000 adults
were estimated to be living with HIV. As of March 31, 2007, the South Rift Valley program was providing
basic health care and support services to 16,065 HIV infected patients, of whom 6021 were on ARVs. In
FY09 the program will reach 4,800 clients with facility based basic care services.
To ensure sustainability the program will work hand in hand with the Ministry of Health and NASCOP in
offering basic health care and support services. In FY08, concerted efforts were made to support quality
clinical care for HIV infected patients including routine patient follow up, laboratory monitoring, prevention
(including Co-trimoxazole Preventive Therapy) and treatment of opportunistic infections (OIs), and
treatment literacy and drug adherence. Nutritional (including multi-vitamin supplementation) support;
psychosocial care, including support groups to encourage positive living, disclosure counseling, and mental
health services; prevention with positives; family planning and STI services were supported. Regular
support supervision and technical assistance; and timely, efficient and accurate data collection, analysis
and dissemination were further consolidated.
In order to decongest the overcrowded district level facilities and enhance accessibility of basic care
services by the rural underserved population, decentralization of basic health care services and follow up of
stable patients at lower level facilities (health centers and dispensaries) will continue to be supported in
accordance with the network model. In FY09, this model will be expanded to support additional lower level
facilities throughout the 8 districts, bringing the number of facilities offering basic health care in the region to
100. By doing so, over 40% of the current patients seeking basic care services will be able to access the
services in nearby rural facilities. To support the scale up, 150 additional health workers will be trained on
basic health care and support.
In FY 2008, the South Rift Valley basic health care and support program supported Live with Hope Center
(LWHC) in their community home based care program which has been receiving Emergency Plan funds
since FY 2004. In FY 2009, the program will continue to serve and care for over 1,000 individuals in their
homes in the provision of home based basic health care as well as psychological support and counseling
through community clinical health workers as well as PLWHA community volunteers.
This activity will contribute substantively to Kenya's FY08 goal of providing facility based basic care and
support to 460,200 clients, by providing services to 33,000 individuals (7% of the overall FY 2008
Emergency Plan national target). The collaboration with MOH, other GOK offices and major stakeholders
will ensure these services are sustainable.
This activity is linked directly to the other KEMRI-SRV HIV/AIDS program initiatives in 8 districts in the SRV
and Nyanza provinces of Kenya. It is directly related to KEMRI-South Rift ARV services in the identification
and provision of palliative care to all HIV+ patients (including those not on ARVs). It is also linked to the
Activity Narrative: orphans and vulnerable children (OVC) program to ensure those HIV+ children in palliative care that require
additional services are adequately linked to receive the support.
5. POPULATION BEING TARGETED
The KEMRI-SRV basic health care and support program serves the civilian population in the SRV region.
The program will target primarily those people affected by HIV/AIDS including discordant couples,
caregivers as well as children since the main objective is to provide supplemental care to existing ART
services. Health care providers (both in public and private institutions) will also be targeted by increased
palliative care training to enhance their capacity to provide basic health care services. The work
accomplished by LWHC will be a demonstration of palliative care work with a community/faith based group
in Kericho district.
This activity will address increasing gender equity in HIV/AIDS programs by ensuring that both men and
women access basic health care and support services. Traditionally, women are more receptive to the
service but efforts will be made through a strong peer support network and counseling services to
encourage men to access services as well. Counselors will continue to be used to address psychosocial
issues that may contribute to the spread of HIV, including issues of disclosure and discordance among
partners. The effort of decentralization of services to lower level facilities through the network model will
continue to be strengthened and will help in reducing stigma and discrimination by the delivery of services
at the community level.
This activity includes emphasis on minor construction/renovation of health facilities to ensure adequate
space to offer basic care services; human capacity development including training and empowering the
health workers to provide basic health care and support services by supporting necessary commodities;
data collection, analysis and dissemination, which will further support program monitoring and evaluation;
collaboration with the MOH and NLTP to support family planning, malaria prophylaxis and treatment and
commodities for TB diagnosis and treatment; and increasing gender equity in HIV/AIDS programs, by
ensuring that equitable number of women, and targeting increased access of services by men.
Continuing Activity: 14904
14904 6922.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,050,000
Estimated amount of funding that is planned for Human Capacity Development $18,750
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $18,750
and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Commodities $18,750
+ The prime partner changes from KEMRI to HJF-MRI
+ All sections referring to pediatric ART have been moved from this narrative to a new program area (PDTX
Treatment)
Prescription) for moderate to severely malnourished clients on ART, and task shifting and involvement of
PLWHA in defaulter tracing and other non-technical aspects of comprehensive ART
+ Number of service outlets providing antiretroviral therapy changes to 68
+ Number of individuals newly initiating antiretroviral therapy during the reporting period changes to 6,000
+ Number of individuals who ever received antiretroviral therapy by the end of the reporting period changes
to 21,600
+ Number of individuals receiving antiretroviral therapy at the end of the reporting period changes to 18,000
+ Number of health workers trained to deliver antiretroviral therapy services according to national &/or
international standards changes to 150
09, mechanisms will be put in place to expand this support to all the 68 ART service outlets in all the 8
districts under the SRV program coverage. 2.5% of the budgetary allocation will be attributed to this activity.
This activity relates to activities in HBHC, TB/HIV, and HVCT.
basic health care and support services to 16,065 HIV infected patients, of whom 6021 were on ARVs. One
year later, the numbers had risen to 20,706 and 8339 on care and treatment respectively. In FY09 the
program targets to enroll 6,000 new clients into ART.
To ensure sustainability, the program built the technical and management capacity of all the hospitals
providing treatment by targeting 115 health care workers to be trained in ART (including pediatric AIDS
treatment) in FY 2007 & FY 08. In FY 09, 150 health workers will be trained to deliver adult antiretroviral
services according to national &/or international standards.
FY07 & FY 08 funds were used to encourage positive living, prevent HIV infection transmission or re-
infection, enhance community mobilization, reduce stigma and discrimination, and increase treatment
literacy and adherence. Funds were also used to continue and/or initiate technical assistance from 5 locally
employed staff.
Kericho District and Tenwek Mission hospitals will continue to be supported as referral units for the SRV for
patients requiring more specialized medical care, with Kericho District Hospital continuing to provide Quality
Assurance and Control oversight for diagnostics (HIV and Opportunistic Infection (OI)), monitoring, and
quality of treatment in the regional network for the rural health center facilities as well as the larger SRV.
To enable the facilities cope with the increasing number of patients and to improve accessibility of HIV
treatment services in the rural underserved populations, based on the network model initiated in FY 2006,
the program will continue to support the decentralization of treatment of stable patients to rural health
facilities by building the capacities for these facilities to offer HIV treatment services. In FY 2009, this model
will support a total of 68 health facilities in the delivery of ART services throughout the SRV.
This activity will continue contributing to the Emergency Plan result for increased number of individuals on
ARV treatment, and contribute to Kenya's 5 year strategy target by providing ARV services to over 21,600
individuals throughout the eight districts. It will strengthen the capacity of the health systems to offer ART
and strengthen the referral network for ARV treatment provision in collaboration with host government
workers, specifically with the National AIDS/STI Control Program (NASCOP) at the district level.
KEMRI-SRV ART activity is closely linked with KEMRI-SRV palliative care program for those individuals
who qualify for basic health care and support as well as with KEMRI-SRV PMTCT program in the provision
of comprehensive care for pregnant women who are HIV infected and qualify for treatment. This activity is
also linked with KEMRI-SRV counseling and testing (CT) programs as an entrance point for care. It is also
similarly linked to Tenwek and Live with Hope CT programs. It is also linked to KEMRI-SRV TB/HIV
program, and Samoei Community Response and Live with Hope's Orphans and Vulnerable Children (OVC)
programs in Kericho District.
Activity Narrative: 5. POPULATION BEING TARGETED
The KEMRI-South Rift Valley adult treatment program will target the general population including adults,
and family planning clients as well as people affected by HIV/AIDS through HIV/AIDS-affected families,
OVC, and people living with HIV/AIDS. New rural health care facilities will increase coverage and access to
all these targeted populations. Health care providers, both in the private and public sector, will also be
targeted by increased ART training thus increasing the number of clients able to be served more efficiently.
The KEMRI-South Rift Valley HIV program will increase gender equity in HIV programming by ensuring that
equitable numbers of women including children are receiving treatment. The activities will address stigma
associated with HIV status through information, education, and communication materials targeted to health
care providers, caregivers, and communities.
This activity includes emphasis in training, strategic information, human resources, targeted evaluations,
and commodity procurement. SRV will procure supplies for HIV diagnoses and staging (e.g. CD4 counts) as
well as safety monitoring for HIV treatment (e.g. hemoglobin, liver transaminases). It will also obtain medical
supplies for providing HIV treatment services and procure and train additional staff as needed to ensure
quality care is delivered in light of their increasing workload as more patients are recruited.
Continuing Activity: 14908
14908 6973.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $7,170,714
Estimated amount of funding that is planned for Human Capacity Development $161,250
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $161,250
Estimated amount of funding that is planned for Food and Nutrition: Commodities $161,250
Table 3.3.09:
This PHE activity, "Utility of Viral Load Monitoring In Addition to Routine CD4 + WHO Clinical Staging In
Patients Receiving Antiretroviral Therapy in the South Rift Valley of Kenya" was approved for inclusion in
the COP. The PHE tracking ID associated with this activity is KE.07.0044. A copy of the progress report is
included in the Supporting Documents section.
Continuing Activity: 17878
17878 17878.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $400,000
Estimated amount of funding that is planned for Public Health Evaluation $150,000
Program Budget Code: 10 - PDCS Care: Pediatric Care and Support
Total Planned Funding for Program Budget Code: $2,750,000
Key Result 1: Provide direct HIV care and support services for 75,000 children, and indirect support for an additional 6,000
children.
Key Result 2: Provide Basic Care Kits (BCK) to 40,000 HIV-positive children including a safe water system, cotrimoxazole (CTX)
for opportunistic infection (OI) prophylaxis, an insecticide-treated bed net, and multivitamins.
Key Result 3: Provide direct antiretroviral treatment (ART) support for 30,000 HIV-positive children, and indirect support for an
additional 12,000.
Key Result 4: Expand the integration of pediatric HIV services with maternal and child health (MCH) services, strengthen linkages
and referrals across PMTCT, TB programs, wrap-around services, community, and OVC services.
Key Result 5: Expand HIV testing and counseling (HTC) for infants, children, adolescents, and their families.
Through the Emergency Plan (EP), USG agencies support a clinical care model focusing on pediatric support centers that offer a
broad range of services, including HTC, clinical monitoring, diagnosis and treatment of OIs, nutritional supplements, referrals to
pediatric support groups, and linkages to OVC support. Community-based support will complement these efforts through
psychosocial activities and paralegal services.
The Kenya Five-Year EP strategy proposed expansion of the depth and breadth of pediatric ART capacity, as well as the
development of community and facility-based pediatric ART programs with an emphasis on OVC. This strategy fosters an
environment where older youth are treatment advocates for younger ones, and targets infected young adults as prime ART
candidates. Although the strategy does not include pediatric targets, the five-year EP goals are to support the care of 300,000
patients and 250,000 on ART by September 2010 of which 10% were to be children. More than 56,000 Kenyan children have
received facility and community HIV care services as of July 2008.
Kenya has rapidly expanded pediatric HIV care and ART services since 2004, increasing the number of Kenyan children receiving
ART from < 2,000 in September 2004 to 16,000 in March 2008. This significant increase is attributed to increased funding and
scale-up primarily through the EP, Clinton Foundation, Global Fund support, and the tireless efforts of many committed
individuals.
According to the National AIDS and STI Control Programme, there are 100,000 HIV-positive children in Kenya, 50,000 of who
currently require ART. Since 2006, Kenya has scaled-up early infant diagnosis (EID) using dry-blood spot/DNA PCR testing with
34,000 children tested through three reference laboratories that had networked 1,214 sites as of June 2008.
As of June 2008, over 56,000 children had accessed USG-supported pediatric HIV care services at 554 sites, including national
referral, provincial, district, faith-based, and private hospitals, as well as health centers. These sites are distributed across Kenya
with 23% located in Nyanza Province, where an estimated 30% of HIV-positive children reside.
As of March 2008, 350 of 500 ART sites provided pediatric ART to 16,000 children; 60% are Government of Kenya (GoK)
facilities. At minimum, every district hospital is equipped to provide pediatric ART. Based on data from one district facility, Kericho
District Hospital, 75% of children receiving HIV care and treatment are ?5 years of age, whereas children <1 year of age
constitute 8%, and children ranging from 2-4 years of age account for 17%. A national pediatric ART survey will provide further
information on pediatric ART outcomes.
In 2009, the total number of Kenyan children in care and on ART will reach 75,000 and 30,000 respectively. EP support will
strengthen service delivery systems including referrals. The number of sites providing pediatric care will increase to 1,200;
approximately 700 of these sites will offer ART. The EP will provide direct support to >80% of these pediatric ART sites and
indirect support to nearly all care sites.
In 2009, the EP will prioritize identification of exposed/infected children <5 years of age. Improved diagnosis and treatment will be
achieved through EID for those <18 months of age, PITC in clinical settings, family-testing through clinical and community HTC
strategies, and the launch and use of the combined mother-child card.
EP funds will expand networked EID sites to more than 2,000 that have the collective capacity to test at least 60,000 children
(60% of all exposed children will be identified in PMTCT settings). PITC will be offered to all HIV-exposed children by increasing
HTC for children of enrolled adult patients as well as through the use of the new mother-child health card. The card will assist in
identifying exposed infants in MCH clinics. HIV-positive infants identified through DNA PCR testing will be started on ART
irrespective of CD4 count or WHO staging. Exposed children will be followed until their status is confirmed and they are linked to
pediatric care services as well as ART for those that are HIV-positive. Per MOH guidelines, EP will support CTX for confirmed HIV
-positive children and for all exposed children until their HIV status can be conclusively determined.
By September 2010, EP funds will provide a package of basic care services to 75,000 HIV exposed/infected/affected children
through facility, community, and/or home-based care services; 30% will receive both community and facility-based services.
Services include nutrition assessment, growth monitoring, safe water interventions, malaria prevention, OI management, psycho-
social support, TB screening, and CTX at service delivery points. A subset of 40,000 will receive a BCK together with their parents
and/or guardians. The EP will strengthen pediatric TB case finding, diagnosis and treatment, and will increase availability of the
cryptococcal antigen test.
In 2009, EP funding will strengthen community care services. EP facility-based partners will strengthen relationships with
community-based organizations to facilitate community linkages. EP partners will provide or establish linkages with HIV
community care services through Community Health Extension Workers (CHEW) or Community Health Workers (CHW). CHEW
or CHW activities will include pediatric and family HTC, patient referrals, tracking, and enrollment into clinical care for all identified
HIV-positive children. In addition, CHEW and CHW will be involved in monitoring usage of BCK and assisting with refills, pediatric
and family medication adherence counseling and monitoring, and patient education regarding general health issues.
In 2009, consistent with the evidence suggesting the need for early diagnosis and treatment, the MOH will offer ART for all HIV-
positive children <18 months of age regardless of CD4 to improve treatment outcomes among infants. It is estimated that 40% of
the 75,000 children provided with HIV basic care services will receive ART. Several MCH programs are currently piloting ART
provision for HIV-positive mothers and infants; this approach will be assessed and expanded if proven successful.
Over 60 health facilities and organizations provide nutritional support to children; more than 5,000 children >6 months of age have
received nutritional supplements. Other nutritional support is provided through leveraging of private funds and innovative food
production programs. In 2009, 10,000 children will receive therapeutic nutrition or supplementary feeding support. All enrolled
children will receive anthropometric status assessment, nutritional education, and counseling. All EP-funded programs will
continue to advocate for and support exclusive breastfeeding for infants for the first six months of life with appropriate weaning
and nutrition education to all affected families, which will build upon the EP-supported development of national infant and young
child nutrition guidelines.
In 2009, the Kenya Pediatric Association will provide additional pediatric training and mentorship for health care workers. EP
funds will train over 3,000 HCW through classroom training and mentorship.
HIV-positive children identified through HTC services will be linked to care and treatment services. Exposed children identified
through PMTCT will be enrolled into care at MCH or HIV clinics. The mother-child card will be used at all PMTCT sites to ensure
the child is enrolled into care and receives all routine health services. Growth and child health will be monitored together with
provision of CTX and ART for infected children. Exposed children will be provided with CTX prophylaxis until HIV-positive status is
excluded.
Care and ART clinics will expand pediatric TB screening. TB clinics will offer HTC among children with TB and improve referral
mechanisms. HIV-positive children identified in OVC programs will be referred to pediatric ART sites for staging and treatment
and those enrolled in facility programs will be referred to OVC programs for additional services.
In 2009, the MOH will initiate a national pediatric care and treatment strategy to define stakeholder roles in the care and treatment
of HIV-positive children. It will identify pediatric care locations and the roles and responsibilities among the various members (e.g.,
caregivers, psychosocial care providers, community, and health facilities) involved in care delivery. Every pediatric patient will
have a multi-disciplinary care plan involving all care providers.
In line with the MOH Second National Health Sector Strategic Plan (2006-2010), a key emphasis will be the decentralization of
pediatric care and ART services to lower level facilities for ART initiation and follow-up. Such facilities will be strengthened to offer
comprehensive pediatric HIV care and ART services. EP funds will be used to develop regional activities such as quality
assurance, clinical mentoring, and supervision based upon the network model.
The lack of a clear policy on HTC in children and pediatric HTC guidelines remains a barrier to early identification of HIV-positive
children. In 2009, the EP will support the development of updated HTC guidelines for HIV-exposed children, for sick children in
whom HIV is suspected, and their families. EP funds will also support the development of pediatric specific ART guidelines by
adopting and adapting the updated WHO pediatric recommendations.
USG will continue advocating for other development partners and the MOH to play a greater role in pediatric HIV care and
treatment. EP funds will build MOH capacity to provide pediatric HIV care and treatment. In 2009, EP funds will continue to
support KPA, an indigenous organization, to conduct HCW pediatric trainings and mentorship. Currently, two EP umbrella
cooperative agreements support over 70 local indigenous organizations. Implementing partners will be encouraged to integrate
pediatric care and ART plans into the annual district operations plans and health facility work-plans. In addition, they will be
encouraged to establish, support, and to build the capacity of indigenous organizations. EP will work closely with the Kenya
Medical Training Colleges and the Universities to introduce pre-service training of health care providers in pediatric care and
treatment to reduce the need for in-service training which is not sustainable in the long term.
M&E systems will be strengthened at facility and regional levels to improve NASCOP and EP reporting. Quality indicators (e.g.
percentage of HIV-exposed children enrolled into care) will be incorporated into routine M&E activities. In 2009, pediatric specific
indicators disaggregated by age will be developed to measure the quality of pediatric programs. Indicators to capture the number
of children receiving community, OVC services, and/or facility-based care will be developed to avoid double-counting. In 2009,
children reported as receiving basic care and support will receive at least one clinical service, plus at least one service in another
domain of care and support (psycho-social, spiritual, social, or preventive).
All EP pediatric care and treatment activities are closely coordinated with NASCOP. The national pediatric care and ART
taskforce chaired by NASCOP, whose membership includes USG, CF, WHO, UNAIDS, Medecins Sans Frontieres, and other
development partners, meets quarterly to deliberate on pediatric care and treatment issues. CF procures all pediatric ARVs and
OI drugs, supports the EID testing networks, and pediatric ART provider trainings. WHO and UNAIDS provide technical support to
NASCOP. GF resources will support limited pediatric OI drug procurement.
Key remaining barriers specific to the provision of pediatric care and treatment activities include disclosure, stigma, lack of HCW
confidence in pediatric ART initiation, suboptimal adherence to medication, and difficulties providing continuity of care due to
multiple and changing caregivers. The Mwangalizi (accompagnateurs) pilot project, which trains and employs HIV-positive women
and other experienced adults to improve continuity of caregivers presenting with children at clinic visits, is being simultaneously
implemented and assessed; if effective, it will be expanded. The new mentorship and decentralization guidelines will promote
HCW capacity for initiation of pediatric ART and will increase access to ART. The development of pediatric specific HTC
guidelines is expected to improve care, reduce stigma and increase disclosure. Adolescent care, treatment, adherence and
disclosure remain a challenge, as does sexual and reproductive health needs for HIV-infected adolescents. Child psychosocial
support groups and involvement of a multi-disciplinary team of experts may help to address this challenge
Other barriers include insufficient human resources, inadequate space, and inconsistent access to care and ART commodities for
further scale-up. It is hoped that adoption of the Partnership Compact will assist in increasing HCW staffing and that
implementation of the GoK Community Strategy and mentorship activities will promote multi-tasking and task-shifting to expand
ART availability to lower-level facilities. Funds allocated to RPSO will permit renovation of pediatric-friendly care and treatment
clinics that will enhance play therapy. The USG team will continue to encourage the GoK to commit more funds for procurement of
ARVs, as well as to assure the security of other commodities.
Table 3.3.10:
ACTIVITY UNCHANGED FROM COP 2008:
This activity supports key cross-cutting attributions in human capacity development through in service
training of health care workers including clinical officers, nurses and doctors in the provision of pediatric
basic health care and support services as well as early infant diagnosis. 2.5% of the budgetary allocation
will be attributed to this activity. This activity will also support pediatric nutritional assessment and
counseling before and during ART. 5% of the budgetary allocation will be attributed to this activity.
Procurement of pediatric weighing scales, stadiometers, MUAC tapes and other equipment required to carry
out effective nutritional assessment will be supported. Micronutrient supplementation according to WHO
guidance will be provided. 5% of the budgetary allocation will be attributed to this activity.
The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed Project in collaboration with
the Ministry of Health and Faith-based (including a local community based organization) health care
programs within 7 districts in South Rift Valley Province (Transmara, Bomet, Bureti, Kericho, Kipkelion,
Nandi South, & Nandi North) and one district (Kisumu West) in Nyanza Province. The South Rift Valley
Program serves a population of approximately 2.7 million people, with a HIV prevalence ranging from 5% to
as high as 19% in some congregate settings. In 2006, about 100,000 adults were estimated to be living with
HIV, and about 15,000 being children under 15 years. Only about 2,300 (15.1%) of the HIV positive children
had access to HIV services. The SRV program will seek to address this gap in HIV services in this
vulnerable population. The scope of care services to be provided will range from early infant diagnosis, to
linkage to care & treatment for the HIV positive for clinical monitoring, prevention and treatment of OIs &
other HIV related ailments, malaria, pneumonia, diarrhea, and pain symptom management. The program
will also provide other components of the minimum package of pediatric basic health care and support
including provision of cotrimoxazole prophylaxis, nutritional assessment and support including
supplementation & treatment for nutrient deficiencies, deworming, and psychosocial counseling & support.
In order to increase the number of HIV positive children accessing care, the program will strengthen the
linkages between PMTCT Programs and pediatric care & treatment, pediatric training and sensitization for
early infant diagnosis, routine testing of children, laboratory capacity building and system strengthening for
Early Infant Diagnosis (EID). HIV diagnosis in babies will be done at six weeks after birth by collecting Dry
Blood Samples (DBS). A new focus will be on routine testing of sick children in pediatric medical settings
which is expected to rapidly identify large numbers of HIV positive children and provide possibility of direct
links to treatment and care. Adherence to care will be supported through extensive training of health care
providers on pediatric psychosocial counseling and support. As of March 31st, 2008, the South Rift Valley
program had enrolled a total of 2,327 children into its HIV care & treatment program, out of whom 1,552
were on basic health care and support, and 775 were on ARVs. In FY 09 the program targets to reach
5,400 children with the basic care and support services. To be able to do this and to and ensure
sustainability the program will work hand in hand with the Ministry of Health and NASCOP. A total of 68
health facilities will be supported to offer quality pediatric care services. Of these facilities, 12 are partner
main hospitals (8 district hospitals, 2 plantation, & 2 mission hospitals). In order to avoid congesting the
already overcrowded district level facilities and enhance accessibility of basic care services by the rural
underserved population, decentralization of basic health care services and follow up of stable patients at
lower level facilities (health centers and dispensaries) will be supported in accordance with the network
model, that has been successfully used in adult care and support. The health facility support will include
minor renovations to create children friendly care and support centers, procurement of necessary
equipment, and supplies. The human resource requirements will be reviewed as necessary. To support the
scale up, 150 health workers will be trained on basic health care and support, including EID, nutrition, and
psychosocial counseling and support. Regular support supervision and technical assistance; and timely,
efficient and accurate data collection, analysis and dissemination will also be consolidated.
This activity will contribute substantively to Kenya's FY 09 goal of providing basic care and support to
76,900 children, by providing services to 5,400 individuals (7% of the overall FY 2008 Emergency Plan
national target). The collaboration with MOH, other GOK offices and major stakeholders will ensure these
services are sustainable.
This activity is linked directly to the other SRV HIV/AIDS program initiatives in 8 districts in the SRV and
Nyanza provinces of Kenya. It is directly related to South Rift ARV services in the identification and
provision of palliative care to all HIV+ patients (including those not on ARVs). It is also linked to the SRV
PMTCT program, where children will be identified, and those diagnosed as HIV infected linked to care &
treatment. In addition, it is linked to the orphans and vulnerable children (OVC) program to ensure those
HIV+ children in palliative care that require additional services are adequately linked to receive the support.
4. POPULATION BEING TARGETED
The SRV pediatric basic health care and support program serves the predominantly rural population in the 8
districts. The program will target primarily those children affected by HIV/AIDS since the main objective is to
provide supplemental care to existing ART services. Health care providers (both in public and private
institutions) will also be targeted by increased basic health care training to enhance their capacity to provide
quality care services.
5. EMPHASIS AREAS
Major emphasis is on commodity procurement (drugs for opportunistic infections, nutritional supplements
and pain relief) with minor emphasis in the areas of human resources, training and infrastructure.
Activity Narrative:
Estimated amount of funding that is planned for Human Capacity Development $3,750
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $7,500
Estimated amount of funding that is planned for Food and Nutrition: Commodities $7,500
ART services as well as early infant diagnosis, and basic health care. 2.5% of the budgetary allocation will
be attributed to this activity. This activity will also support pediatric nutritional assessment and counseling
before and during ART. 5% of the budgetary allocation will be attributed to this activity. Procurement of
pediatric weighing scales, stadiometers, MUAC tapes and other equipment required to carry out effective
nutritional assessment will be supported. Micronutrient supplementation according to WHO guidance will be
provided. 5% of the budgetary allocation will be attributed to this activity.
vulnerable population, by facilitating their access to the life saving antiretroviral treatment (ART). This will be
a continuum of the pediatric basic care and support package, whereby in addition to clinical monitoring,
prevention and treatment of OIs & other HIV related ailments, malaria, pneumonia, diarrhea, and pain
symptom management, the children will be put on ART. The program will also continue providing other
components of the minimum package of pediatric basic health care and support including provision of
cotrimoxazole prophylaxis, nutritional assessment and support including supplementation & treatment for
nutrient deficiencies, deworming, and psychosocial counseling & support. Adherence counseling and
support will be offered, which in Kericho District Hospital will leverage on the activities of the ‘Muangalizi'
project. The ‘Muangalizi' project seeks to improve adherence to clinic appointments and ART for those HIV
infected children enrolled for ART, through support to the caretaker. In order to increase the number of
HIV positive children accessing treatment, the program will strengthen the linkages between PMTCT
Programs and pediatric care & treatment, pediatric ART training and sensitization for early infant diagnosis,
routine testing of children, and laboratory capacity building and system strengthening for Early Infant
Diagnosis (EID). HIV diagnosis in babies will be done at six weeks after birth by collecting Dry Blood
Samples (DBS). A new focus will be on routine testing of sick children in pediatric medical settings which is
expected to rapidly identify large numbers of HIV positive children and provide possibility of direct links to
treatment. As of March 31st, 2008, the South Rift Valley program had enrolled a total of 2,327 children into
its HIV care & treatment program, out of whom 1,552 were on basic health care and support, and 775 were
on ARVs. In FY 09 the program targets to provide ART services to 600 children newly initiating ART, to
make a total of 2,160 children ever started and 1,800 receiving ART at the end of the reporting period. To
be able to do this and to and ensure sustainability the program will work hand in hand with the Ministry of
Health and NASCOP. A total of 68 health facilities will be supported to offer quality pediatric ART services.
Of these facilities, 12 are partner main hospitals (8 district hospitals, 2 plantation, & 2 mission hospitals). In
order to avoid congesting the already overcrowded district level facilities and enhance accessibility of ART
services by the rural underserved population, decentralization of ART services and follow up of stable
patients at lower level facilities (health centers) will be supported in accordance with the network model,
which has been successfully used in adult ART. The health facility support will include minor renovations to
create children friendly ART centers, procurement of necessary equipment, and supplies. The human
resource requirements will be reviewed as necessary. To support the scale up, 150 health workers will be
trained on pediatric ART, including EID, nutrition, and psychosocial & adherence counseling and support.
Regular support supervision and technical assistance, and timely, efficient and accurate data collection,
analysis and dissemination will also be consolidated.
This activity will contribute substantively to Kenya's FY 09 goal of providing ART to 43,092 children, by
providing services to 2,160 individuals (5% of the overall FY 2009 Emergency Plan national target). The
collaboration with MOH, other GOK offices and major stakeholders will ensure these services are
sustainable.
Nyanza provinces of Kenya. It is directly related to South Rift pediatric basic care and support services in
the provision of ART to all HIV infected children who qualify for ART. It is also linked to the SRV PMTCT
program, where HIV infected children will be identified, and those diagnosed as HIV infected linked to care
& treatment. In addition, it is linked to the orphans and vulnerable children (OVC) program to ensure those
HIV infected children in basic care that require ART services are adequately linked. The ART program also
links with the ‘Mwangalizi' pediatric ART adherence support project in Kericho District Hospital.
The SRV pediatric ART program serves the predominantly rural population in the 8 districts. The program
will target primarily those children affected by HIV/AIDS since the main objective is to provide ART services.
Health care providers (both in public and private institutions) will also be targeted by increased pediatric
ART training to enhance their capacity to provide quality ART services.
Major emphasis is on commodity procurement (ART, drugs for opportunistic infections, nutritional
supplements and pain relief) with minor emphasis in the areas of human resources, training and
infrastructure.
Estimated amount of funding that is planned for Human Capacity Development $17,500
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $35,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $35,000
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $19,230,846
Key Result 1: Reduce the tuberculosis (TB) burden by providing TB screening for 50% of HIV-positive persons at enrollment into
care.
Key Result 2: Reduce the HIV burden by providing HIV testing to over 90% of TB patients, their partners and families.
Key Result 3: Improve referral and tracking mechanisms between HIV and TB service delivery points.
Key Result 4: Strengthen Multiple Drug Resistant TB (MDR-TB) surveillance through expanded program and laboratory capacity
for TB case-finding, diagnostics, and drug susceptibility testing (DST).
Key Result 5: Optimize coordination of USG and other sources of TB and HIV funding.
In Kenya, TB is the leading cause of death of people living with HIV (PLHIV), and HIV is the greatest driver behind the nearly
three-fold rise in Kenya's TB burden over the last ten years. TB/HIV is a priority program area for the Division of Leprosy,
Tuberculosis and Lung Disease (DLTLD), the National AIDS and STI Control Program (NASCOP), the Emergency Plan (EP),
WHO, and other partners. In the Five-Year Strategy, the EP emphasized identifying persons in need of ART through wide-scale
diagnostic HIV testing and counseling of TB patients. The EP has supported development of new HIV testing guidelines and a
training curriculum to equip providers with essential skills, as well as supporting Kenya's overall TB/HIV national strategy. As part
of their national mandates, DLTLD and NASCOP guide TB and HIV policies and coordinate implementation of collaborative
activities through national, regional, and district coordinating bodies.
Free TB and HIV services are delivered to patients in Kenyan public and mission hospitals. Since 2004, TB/HIV activities have
advanced on the national agenda and are well articulated in the National TB Strategic Plan. National, provincial and district
TB/HIV coordinating bodies have been formed and guidelines on HIV testing for TB patients have been widely distributed and
implemented. USG technical support contributed to the distribution and widespread use of the TB/HIV training curriculum and an
integrated TB/HIV monitoring tool. From 2005-2008, facilities offering TB treatment increased from 1,600 to 1,909, and those
offeringTB diagnosis from 619 to 930. More than 80% of TB patients receive HIV testing, and 80-90% of co-infected patients
receive cotrimoxazole (CTX) therapy. Approximately 80% of co-infected TB patients are eligible for ART; at least 30% receive
ART before completion of TB treatment.
The EP has recently supported TB/HIV media campaigns to empower health workers to deliver quality TB and HIV services,
encouraged increased and intensified case-finding in HIV care settings, and have expanded secondary prevention activities
(Prevention with Positives [PwP]) to reduce the national TB and HIV burdens. EP funds have further supported the development
of TB infection control (IC) policy guidelines and training of MOH personnel.
Kenya's national TB burden remains high. TB case notification rose six-fold from 53/100,000 persons in 1990 to 338/100,000 in
2007. The number of TB patients is projected to increase to 120,000 in 2009 and to 130,000 in 2010. Kenya has 1,909 TB
treatment sites; 930 (49%) provide TB diagnostic services. Directly observed therapy (DOTS) coverage is universal, with
treatment observed by either a provider or a treatment partner. In 2007, Kenya achieved a TB case detection rate of 70% and
treatment success rate of 85%. The national HIV prevalence among TB patients in 2007 was 48%, but exceeded 80% in some
settings. The percentage of MDR-TB patients is estimated at <1%, however drug susceptibility testing was only performed in 40%
of the 9% re-treatment cases in 2007.
USG has a TB/HIV coordinator at each implementing agency and supports TB/HIV activities through funding and technical
support. USG technical staff participate in policy work groups and provide technical assistance to the host government and
implementing partners. In 2009, EP funds will support the placement of a TB/HIV staff member at NASCOP to improve TB/HIV
coordination. HIV testing for TB patients is the standard of care and efforts will be made to ensure that consistent and quality
counseling and testing messages continue to be improved. Approximately 80% of co-infected TB patients are eligible for ART by
WHO staging criteria, and 30-50% receive ART before completion of TB treatment depending on the facility. In the next phase,
Kenya plans to achieve the following goals: over 90% of TB patients will be tested for HIV and 100% and 50% of all eligible TB
patients will be placed on CTX and ART, respectively.
In 2008-09, provision of ART in TB clinics will be piloted in collaboration with NASCOP and DLTLD. DLTLD, in collaboration with
NASCOP, will incorporate and expand PwP activities as part of strengthening contact tracing practices in TB control, and
contributing to the overall national strategy to achieve HIV control. Initiating at pilot sites and expanding toward national coverage,
PwP will be implemented in TB clinics targeting the large number of HIV-POSITIVE TB patients served. EP funds will support
expanded use of Community Health Workers (CHW) to identify and refer suspected TB patients, assist with family TB/HIV
screening, and provide adherence support and patient education.
Kenya will continue to prioritize intensified TB case-finding and TB infection control at all HIV entry points. TB screening in HIV
care and treatment settings is occurring in most settings. In 2009, concerted efforts will be made to standardize such screening
through the distribution and implementation of national guidelines for TB screening and referrals in HIV care settings. The TB and
HIV programs will also develop IC implementation procedures for health care facilities, targeting two provinces for a phased
rollout. Besides assisting to formulate IC policy, the EP will support assessment of TB IC prevention and control procedures in
selected facilities to establish gaps and needs and develop IC work and evaluation plans to protect patients and health workers at
specific sites, including prisons. Currently, four organizations (EDARP, AMPATH, AMREF, and MSF) implement isoniazid
preventive therapy (IPT) under close monitoring by DLTLD. Further expansion is anticipated in 2009 on a case-by-case basis,
depending on facility capacity to diagnose TB, sustain patient adherence, and document treatment outcomes.
In addition, the EP will continue to assist Kenya's response to the threat of MDR-TB by improving national laboratory surveillance
capacity, promoting best TB care practices, and treating drug-resistant patients. Presently, the EP is strengthening the national
Central Reference TB Laboratory (CRL) culture and drug sensitivity testing (DST) capacity through improvements in physical
infrastructure, culture diagnostics, and development of a laboratory information system. Through EP support, Kenya plans to
optimize DST for TB re-treatment cases according to national guidelines and expand national coverage of external quality
assessments (EQA) for sputum microscopy services from the present 20% to 50% by 2010. The EP will support ongoing
decentralization and strengthening of DST capacity in regional laboratories, including those supported by KEMRI, DOD, and
AMPATH. These efforts, complemented by those of other partners, will provide better insight into the MDR-TB burden and
contribute to planning for sustained control. In 2009, DLTLD plans to pilot MDR-TB treatment on an ambulatory basis as part of
implementing the national strategy.
The EP continues its contribution to expanding fluorescence microscopy (FM), which did not exist in Kenya in 2003. EP funds
have since procured and placed seven microscopes in five regions, and, in 2009, they will procure an additional five microscopes
for other high-volume regional sites.
The USG and DLTLD consider TB/HIV work in the prisons as an essential component of the national agenda. Through a yet to be
determined new partner, the EP will support improvement and expansion of quality TB/HIV care and treatment services from 12
high-volume prisons and expansion of such services to an additional 5 in collaboration with Kenya Prisons Services, DLTLD, and
NASCOP.
Kenya recently launched international standards for TB care, which seeks to facilitate engagement of all providers in accepted
levels of care in public and private practice. In 2007, the private sector registered 1,804 TB cases, and the EP is building on this
reporting to promote best practices pivotal to prevention of HIV and MDR-TB.
Approximately 10% of registered TB patients in Kenya are children. In 2008, NASCOP, DLTLD, WHO, USG, and other
stakeholders consulted on how to improve pediatric TB/HIV management. Pediatric TB screening and surveillance evaluation is
planned soon. Information from these activities will strengthen both pre-service and in-service trainings to improve pediatric case
identification. In 2009, through intensified case finding of adults, more children will be screened and tested for both TB and HIV.
Co-infected children will receive both TB and HIV treatment; HIV-positive children without active TB will receive CTX, IPT, and
ART if eligible.
In 2009, the EP will support procurement of TB and HIV laboratory commodities, including rapid test kits, through SCMS and
drugs (ART and CTX) through in-country mechanisms.
REFERRALS, LINKAGES, MONITORING AND EVALUATION
Kenya TB registers include TB/HIV variables. Moreover, a program evaluation is underway to monitor referrals to HIV services
and establish proportions of co-infected patients enrolled in HIV care and receiving CTX and ART, with the overall goal of
establishing a joint TB/HIV co-management review to reconcile referrals through standardized reporting systems, including
adequate feedback mechanisms.
Currently, only 26% of TB treatment points offer ART. HIV care and ART registers need to develop TB variables to capture TB
screening, diagnosis, referral, and treatment among their patients. Decentralizing ART services will improve access for eligible TB
patients served in lower levels of care. Facilities and community groups will be encouraged to collaborate and provide a two-way
referral or communication system to coordinate outreach activities to identify and support TB/HIV patients.
In 2008, EP support piloted electronic data collection tools to improve accuracy and efficiency in recording and reporting of
TB/HIV patients, as well as to allow for facility-based program evaluation. In 2009, the EP will support expanding this pilot to assist
Kenya in establishing a national electronic TB/HIV reporting system. In addition to required EP indicators, TB/HIV implementers
will be encouraged to document some or all of the following custom indicators as part of strengthening TB and HIV programs: (1)
number and percent of HIV-positive patients in HIV care screened for TB; (2) number and percent of TB suspects/patients tested
for HIV; (3) number and percent of HIV-positive registered TB patients/suspects; (4) number and percent of HIV-positive TB
patients receiving CTX; and (5) number and percent of HIV-positive TB patients receiving ART.
Kenya's National HIV/AIDS Strategic Plan (KNASP) includes expanded programming for TB/HIV activities coordinated by a
national committee established by the Ministry of Health (MOH), in which USG technical staff participates. In response to the 2005
Maputo Declaration calling for extraordinary measures by African governments to contain HIV and TB, the MOH has submitted a
Cabinet Paper seeking legislation to declare TB a national emergency. If enacted, this legislation will promote increased
mobilization of TB control resources. Policy considerations include how HIV and TB programs can best support cross-cutting
laboratory services at regional and district levels, and how EP funds can best support human resource needs. Kenya plans to
establish policies for TB-screening and diagnosis for all patients receiving HIV services in ART, PMTCT, and VCT clinics, as well
as in hospital wards. USG agencies also participate in working policy committees for PwP, TB infection control in HIV care
settings, IPT, laboratory services, MDR-TB control, TB/HIV monitoring systems, human resource plans, and TB care standards in
all settings, including pediatric services.
Greater sustainability will, in part, be achieved through encouraging implementing partners to be part of the national, regional, and
district TB/HIV work plans that support local government infrastructure, human capacity development, commodity distribution, and
national health management information systems.
USG agencies work in a complementary manner with the DLTLD, NASCOP, WHO, the National Public Health Laboratory
Services (NPHLS), and all implementing partners through the National TB Interagency Coordinating Committee and the National
TB/HIV Coordinating Committee. Kenya has recently received Round 6 TB Global Fund support, which will be used to upgrade 50
TB diagnostic facilities annually, conduct training for TB/HIV trainers, and train 80 health workers in 5 districts each year. Kenya
applied for Round 8 Global Fund TB funding (2009 to 2013) to support collaborative TB/HIV activities and a national TB
prevalence survey; however, the Global Fund Board recently announced that Kenya's Round 8 applications for HIV, TB, and
Malaria all had not been approved. In 2006-07, through a centrally-funded OGAC/WHO collaboration, Kenya received additional
funding for expanded TB/HIV activities in 30 districts; support for these activities will be mainstreamed into 2009 EP and other non
-EP funding. To maximize USG resources, both PEPFAR and USAID TB support are factored in an updated 2009 Joint Country
TB/HIV program work plan. In 2009, the TB Control Assistance Program will provide support for TB/HIV collaborative activities,
and DOTS expansion.
A principal challenge facing Kenya is to maintain the high coverage (>80%) of HIV testing among TB patients. This will be
managed in part through sustained advocacy; enhanced coordination of partnerships and funding; sustained staff hiring, training
and retention; improved field supervisions; and enhanced commodity security. Another challenge is the provision of optimal
TB/HIV services for the pediatric population. One strategy to address this issue has been described above. Recurrent challenges
include insufficient human resources, weak laboratory infrastructure, and slow disbursement of Global Fund support.
Table 3.3.12:
+ prime partner was changed from Kenya Medical Research Institute to Henry Jackson Foundation (HJF)
which was competitively selected to implement the activity .
+ TB Community services and outreach will be enhanced to complement the facility based TB prevention,
diagnostic, and treatment activities.
+ number of service outlets providing clinical prophylaxis &/or treatment for TB to HIV infected individuals
changes to 40
+ number of HIV infected individuals attending HIV care or treatment services that are receiving treatment
for TB disease changes to 1,500
+ number of individuals trained to provide clinical treatment for TB to HIV infected individuals changes to 50
+ number of registered TB patients who received counseling and testing for HIV and received their results at
a USG-supported TB service outlets
This activity supports key cross-cutting attributions in human capacity development through its on-site CME
training for health care workers to provide TB/HIV services. This will also include enhancing the capacity of
the government's DTLCs to improve supervision, coordination and general management of TB/HIV services
in the districts. 2.5% of the budgetary allocation will be attributed to this activity.
health facilities to be able to offer quality nutrition services to TB patients. 2.5% of the budgetary allocation
will be attributed to this activity. The activity additionally supports nutrition commodities by leveraging on the
INSTA Food by Prescription Support program, for TB/HIV co-infected patients with moderate to severe
malnutrition. 2.5% of the budgetary allocation will be attributed to this activity.
This activity relates to HIV/AIDS Treatment/ARV services, Basic Health Care and Support, Community Care
Services, Counseling and Testing, Prevention, OVC and PMTCT .
The South Rift Valley (SRV) Program is a broad initiative by the Walter Reed HIV project in collaboration
with the Ministry of Health and Faith-based health care programs within 8 districts in the South Rift Valley
(SRV) and Nyanza Provinces of Kenya. The program serves a population of approximately 2.7 million
people, with a HIV prevalence ranging from 5% to as high as 19%, and a TB prevalence of about 300 per
100,000 population. On average about 30-50% of TB patients are co-infected with HIV.
In FY09 the SRV Program will continue to strengthen and scale up the ongoing FY08 TB/HIV activities in
the 8 districts, in the following key areas: 1) Reduce burden of HIV among TB patients/suspects and their
partners and families through expanded HIV testing, delivery of Cotrimoxazole (CTX), ARVs and positive
HIV prevention in TB settings; 2) Reduce burden of TB among PLWHA through intensified TB screening
and TB infection control in HIV Care settings; 3) Strengthen collaboration of TB and HIV services including
joint planning, coordination and support supervision, monitoring and evaluation, and patient referral and
tracking systems; 4) Contribute to the overall national program agenda to strengthen local and international
partnerships in delivery of TB/HIV services, and strengthen capacity for quality diagnostic and treatment TB
services for PLWHA and containment of emerging threat of MDR-TB. Through this concerted effort, in
FY09, the SRV program will strive to achieve 95% HIV testing for TB patients, 100% provision of CTX to co-
infected patients, and 50% provision of ART to those eligible. To achieve this, in FY09, the program will
train an additional 50 health workers to provide TB/HIV services in 40 health facilities in the region; provide
HIV testing to 3,000 TB patients; and offer TB and HIV services to 1,500 TB/HIV co-infected patients.
Additionally, 16,500 patients accessing HIV services in the region will be screened for TB, and those found
positive provided with TB treatment.
In FY09, Integrated TB/HIV Clinic will be strengthened in all the 8 district hospitals in the region. The model
is unique in that TB/HIV co-infected patients are managed by one care provider. In this model, all TB
patients are offered HIV testing, recognition and management of STIs and HIV prevention messages. Those
with TB/HIV co-infection receive CTX and comprehensive HIV care, support and treatment.
The program will continue to support lower level facilities to provide or link patients to TB/HIV services. The
district hospital will continue to be strengthened as the referral unit for TB/HIV patients requiring specialized
diagnostic, treatment or in-patient services from the lower level facilities.
Working in collaboration with the Division of Leprosy Tuberculosis and Lung Diseases (DLTLD) to ensure
sustainability, the program will continue to support improvement of the capacities of the laboratories in
smear microscopy, and Kericho district hospital lab will continue to offer quality assurance in smear
microscopy (augmented by fluorescent microscopy) in the region. Additionally the program will continue to
strengthen optimized referral of specimen for TB culture and sensitivity to the upcoming TB culture lab;
efficient and timely supply of TB drugs to all the TB treatment sites; regular support supervision and
technical assistance to all the health facilities offering TB and HIV services; use of standardized national
registers and reporting tools; and timely, efficient and accurate data collection, analysis and dissemination.
SRV will contribute towards the provision of integrated TB/HIV care by reducing TB morbidity and mortality
in HIV-infected individuals and reducing HIV-related morbidity and mortality in TB patients. Planned
activities will further contribute to the overall national program agenda to strengthen local and international
partnerships in delivery of TB/HIV services and containment of emerging threat of MDR-TB.
This activity is linked to SRV ARV services throughout the 8 districts; SRV Counseling and Testing, with a
primary focus on provider initiated testing and counseling; Tenwek Mission Hospital's CT activity and the
Activity Narrative: SRV PMTCT program, as part of comprehensive care services offered to HIV infected pregnant women. It
also links to the new program areas of Community Care services by providing a continuum of TB services
from the health facility to the community; as well as the Pediatric Care and Treatment programs by
providing TB prevention, diagnostic & treatment services to children in care or ART.
The SRV program supports the predominantly rural population in 8 districts in Rift Valley and Nyanza
provinces. This activity will target the general population of both adults and children, but primarily those
infected with TB or HIV, including discordant couples. Trainings under this activity will focus on health care
workers both in the public and private sectors. All TB/HIV activities will be implemented in accordance and
in collaboration with host government programs, namely the National AIDS/STI Control Program (NASCOP)
and the Division of Leprosy Tuberculosis and Lung Diseases DLTLD)
The SRV TB/HIV activity will address increasing gender equity in HIV/AIDS programs, by ensuring that
equitable number of women and children are receiving treatment. The activities will address stigma
associated with TB/HIV status through information, education and communication materials targeted at
health care providers, caregivers, patients and communities.
space to offer TB/HIV services; human capacity development including TB/HIV training and empowering the
health workers to provide TB/HIV services by supporting necessary commodities; data collection, analysis
and dissemination, which will further support program monitoring and evaluation; collaboration with the
NLTP program who support commodities for TB diagnosis and treatment; and increasing gender equity in
HIV/AIDS programs, by ensuring that equitable number of women and children are receiving treatment, and
targeting increased access of services by men.
Continuing Activity: 14905
14905 6975.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,200,000
+ Prime Partner Henry Jackson Foundation International (HJFMRI) South Rift Valley has been competitively
selected to implement this activity in the place of KEMRI.
+The Muangalizi component of the program will be enhanced to include post disclosure support to
normalize the experience of HIV in the family, with a focus on households looking after HIV positive children
under the Muangalizi model.
+ The activity will also support the evaluation of the Muangalizi pilot in collaboration with the other 4 USG
supported and participating sites to facilitate lessons learnt and identification and documentation of the
effectiveness of different approaches to facilitate scale up.
This activity relates to activities in Counseling and Testing (#6968), Antiretroviral Therapy program (#6973),
Abstinence and/or being faithful (#6981), Counseling and Testing (#6979) and Orphans and Vulnerable
Children (#7035).
This activity was begun with 2007 plus-up funds and is part of a five-site effort to strengthen the link
between clinical and household settings for HIV+ children. All sites meet regularly with a sixth entity,
AED/Capable Partners, for real-time sharing of lessons learned and review the effectiveness of different
approaches in preparation for scale-up. The Mwangalizi model is being tested in response to concern
expressed by clinicians that assuring optimal care for HIV+ OVC was difficult in many instance because
they were accompanied to different clinic visits by different relatives or community members, necessitating
constant re-education of adults managing care of children. Central to the approach is recruitment of adult
patients who are successfully managing their own care to accompany pediatric patients to all clinic visits
when a consistent caregiver from the household is not available. These "accompagnateurs" will be trained
to be on watch for development of side effects or complications, remunerated for their time, and expected to
perform home visits to monitor medication consumption. They will also be expected to develop an ongoing
and supportive relationship with the OVC household, assess the social environment and refer for needed
services, and seek wherever possible to identify a household or community contact who can be prepared to
assume the long-term responsibility of being a treatment advocate for the child. Sites were carefully
selected to represent a cross section of Nairobi and coastal urban slum (Eastern Deanery, Coptic, and
Bomu), peri-urban (AMPATH/Eldoret, Bomu) and rural (Kericho District Hospital) communities. Standard
measures of household and clinician satisfaction with the value-added by the accompagnateur,
accompagnatuer satisfaction with the experience, and clinical progress of OVC participating in the program
will be tracked. Numbers of OVC served are captured under care and treatment activities. The HJFMRI-
South Rift Valley program will also leverage additional funding available through the Muangalizi project to
reach an additional 500 OVC with comprehensive care packages through existing faith based organizations
such as Tenwek Mission Community Health and AIC Litein's community health program. Kericho District
Hospital has been providing HIV treatment and care since 2004. The number of pediatrics receiving the
services as at the end of March 2008 was 723. A total of 285 are on ARVs whereas 438 are on care. The
Mwangalizi concept was founded on the premise that HIV positive children experience better health
outcomes when there is a continuum of care between the health facility and the home in the form of
consistent follow up and clinic accompaniment by a caregiver or Mwangalizi. The psycho-social needs of
the older OVC will also be an area of expansion in FY 2009 by establishing support groups and Kids clubs
that are developed by OVC/youth that will be trained in peer counseling and support as well as HIV
prevention and issues of sexual reproductive health.
HJFMRI-SRV OVC Program will ensure that OVC continue to receive care and support from their original
community. This approach is supported by the Kenya Emergency Plan in which the needs of the OVC in
terms of consistent care are identified at the community level and subsequently cared for. Mwangalizi will
continue working with the children by strengthening the linkage between clinical and household settings for
better quality and continuum of care. This intervention is not an expansion of the OVC programming and will
serve all HIV positive children who are currently or will one day be on ART.
This activity is linked with HJFMRI South Rift Valley Antiretroviral Therapy (ARV) program (#6973), as the
Mwangalizi are encouraged to be members of the clinics' ART program or are other HIV positive individuals
who are living positively. It is also linked with HJFMRI-South Rift Valley Counseling and Testing (CT)
program (#6968). In addition, HJFMRI's program South Rift Valley will provide counseling and testing to
willing caregivers and households of the OVC and all HIV positive children in hopes of having more people
knowing their status. HJFMRI-South Rift Valley will also work with South Rift Valley Abstinence and Being
Faithful and Live with Hope Center (LWHC) Abstinence and Be Faithful Programs (#6981) to ensure that
the OVC receive correct HIV prevention information that will reduce their vulnerability for HIV infection.
HJFMRI South Rift Valley will target people affected by HIV/AIDS by focusing their training activities on
caregivers to support the OVC and providing psychosocial support to HIV positive children and HIV/AIDS-
affected families which includes widows/widowers and other caregivers. Community leaders and teachers
will also be targeted as HJFMRI South Rift Valley will work closely with them in an effort to fight stigma and
discrimination towards children infected with HIV, which often leads to neglect and or lack of appropriate
care which leads to non adherence to ART and clinic appointments among the children.
In accordance with the Emergency Plan FY 2009 approach to OVC care and support, HJFMRI-South Rift
Valley OVC Mwangalizi model will be an integral part of a community wrap around service that will address
the needs of the whole child. Every child enrolled at the Kericho District Hospital ART clinic under the
auspices of HJFMRI-South Rift Valley will be ensured a consistent follow up as well as psychosocial
support.
Activity Narrative: 7. EMPHASIS AREAS
HJFMRI-South Rift Valley OVC Program will focus their attention on increasing the involvement of
community members in addressing factors that hinder the HIV positive children from receiving optimal
clinical care. Another emphasis of HJFMRI-South Rift Valley's efforts will be establishing and strengthening
the capacity of caregivers to facilitate disclosure in a sensitive and culturally appropriate manner.
Continuing Activity: 14906
14906 12478.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $300,000
12478 12478.07 Department of Kenya Medical 4249 3476.07 South Rift Valley $150,000
* Reducing violence and coercion
Program Budget Code: 14 - HVCT Prevention: Counseling and Testing
Total Planned Funding for Program Budget Code: $32,980,007
Key Result 1: Through Emergency Plan (EP) support, at least 5 million Kenyans will be counseled and tested for HIV in 2009,
using the different approaches.
Key Result 2: Scale up provider initiated HIV testing and counseling in health facilities (PITC), testing 1.5 million patients and
family members to make HIV testing part of routine care in health facilities.
Key Result 3: Implement HIV testing campaigns at national and sub-national levels, with USG supporting 1 million of 3 million to
be tested, in order to expand knowledge of HIV status and promote stigma reduction, including 500,000 in PITC.
Key Result 4: Increase emphasis on couple and family testing in all HIV testing and counseling services, including PMTCT and
ART clinics so that at least 500,000 couples are tested together in either community or health facility settings.
Key Result 5: Use recent national survey findings to guide expansion of Home-based HIV Testing and Counseling (HBTC) to high
HIV burden regions, testing at least 1 million people to increase access to HIV prevention, care and treatment.
The Government of Kenya (GoK) is committed to the achievement of Universal Access to HIV Testing and Counselling (HTC) and
has set a target that 80% of adult Kenyans and all exposed children will have been tested for HIV by 2010. Kenya's national
testing target will enhance access to prevention as well as care and treatment services. HTC services will therefore be expanded
vertically and horizontally, through multiple delivery modes, and in all strata of society, across age and gender.
In order to increase the pace of expansion of HTC services in the country, all EP-funded programs will be encouraged to
incorporate HTC into their activities. Other prevention, care, and treatment programs have the potential to leverage resources to
integrate HTC services by strengthening referral systems and enhancing collaboration across programs.
Data from the 2007 Kenya AIDS Indicator Survey (KAIS) show that there has been a significant increase in knowledge of HIV
status in Kenya. At least 36% of Kenyans have ever been tested, up from 14% in 2003 (KDHS, 2003). The proportion of those
who have ever been tested has more than doubled in the four years since the onset of PEPFAR. The same data show that this
increase is greater among women than men, largely due to expansion of PMTCT services. Predictably, the increase is also
greater in urban versus rural areas. Despite the impressive increase in coverage, the majority of adult Kenyans have never been
tested for HIV. Among HIV-positive persons in Kenya, nearly 80% are unaware of their correct status and have thus not benefited
from the rapidly expanding EP-supported prevention, care and treatment services. Moreover, there is a high rate of couple
discordance in Kenya, with 45% of married HIV-positive persons having an HIV-negative spouse or co-habitating partner.
Nyanza Province still has the highest HIV prevalence (15.3%) in Kenya, followed by Nairobi (9%). North Eastern Province has the
lowest prevalence (1%). In 2009, EP HTC resources will be more deliberately focused on regions with the highest prevalence. In
these regions, population-level activities, such as HBCT, will be expanded to improve access to HTC services and also as a key
strategy to encourage couple HTC. Particular emphasis will also be placed on the early identification of HIV-positive individuals
through expansion of PITC in health facilities. In the other regions, more targeted approaches, such as mobile and workplace
HTC, will be employed.
In 2009, it is anticipated that EP funds will be used to provide HTC services for five million people. We anticipate that EP funding
will directly support well over half of Kenya's national HTC services in 2009 in both health facility and community settings. Health
facility settings include PMTCT and tuberculosis (TB) settings, whereas community settings include mobile and outreach HCT as
well as home based HTC. In 2009, EP will also support indirect activities, such as procurement of test kits and media campaigns.
Overall, EP support will facilitate the achievement of 80% of Kenya's national target, either directly or indirectly, by 2010.
In health facilities, HTC services are primarily provided through in-patient services and selected out-patient sites. KAIS showed
that the majority (72%) of those who had ever been tested received HTC services in a government or private health facility. The
goal of HTC in health facilities is the integration of HTC into the general health system, so that HTC becomes part of the basic
health care package. HTC services in health facilities are chiefly provided by health care workers. In order to improve the attitude
of health care workers toward HIV, greater sensitization and training activities will be implemented. This includes expanding
access to HTC and Post-Exposure Prophylaxis (PEP) for health workers. Health worker professional associations, welfare groups,
and training institutions will also be engaged. Rapidly expanding Voluntary Medical Male Circumcision (VMMC) interventions will
consistently include PITC as part of their comprehensive prevention activities.
In the community, HTC is provided either at home, in a mobile HTC site, at the workplace, or at free-standing HTC sites. HTC can
be provided in any community facility that adheres to national standards. Experience from pilots in Kenya and elsewhere have
shown that HBCT is less expensive than stand-alone fixed services and effectively reaches couples and those in lower economic
strata. For these reasons, HBTC will be expanded in areas of high prevalence and low knowledge of HIV status in 2009.
According to KAIS, 85% of Kenyans nationally are willing to be counseled and tested for HIV in their homes and, HBTC programs
in Kenya have shown very high rates of acceptance. This unique community approach has ensured that couples and families are
tested together which enhances family and community support for HIV prevention, care, and treatment.
Couple HTC will remain an important area of focus in 2009. Training and mentorship for couple HTC will be expanded in all health
facility or community service points. Specific partners will be funded to facilitate training and mentorship for couple HTC and
development of information booklets and other IEC materials to support couples. In addition, a national media campaign targeting
couples will be launched and executed in 2009. A national indicator for couple HTC will be adopted and monitored by all HTC and
PMTCT partners, to further emphasize - and measure - its status as a national priority.
KAIS data also demonstrates that among youth aged 15 to 24, HIV prevalence is four times higher among women than same-
aged men. To help address this, EP support for youth-friendly HTC centers and services will be strengthened and expanded in
2009. Prevention partners will also leverage public-private partnership resources, in collaboration with the Partnership for an HIV-
Free Generation, to promote youth HTC. Ongoing linkages and expanded leveraging of HTC services within Orphan and
Vulnerable Children (OVC) activities will also ensure children access HIV testing and are linked appropriately into care and
treatment.
In 2008, the national HTC training curriculum was standardized and harmonized into a single modular training package. In 2009,
this will be rolled out nationally, necessitating updating of national trainers and printing of the new training materials.
In 2009, APHIA II Health Communication and Marketing (HCM) will continue to promote HTC interventions through their national
media campaigns. Community-based mobilization and local promotion through radio will remain important interventions to ensure
community awareness of HTC activities.
Kenya's new National HTC Guidelines are aimed at improving referral and linkage from HTC services to comprehensive HIV
prevention, care, and treatment, as well as other health services. The Guidelines promote a shift from anonymous to confidential
HTC and prioritize integration of HTC into other health services, as well as incorporation of other services into HTC. To make
operational these broad national strategies, the EP will support HTC in all health facilities, including TB, STI, and in-patient
services. All EP-funded care and treatment partners will be encouraged to implement HTC within their geographical areas, both
within health facilities and at the community level. All prevention partners will similarly be encouraged to include HTC in their
Working closely with the Ministries of Public Health & Sanitation (MPHS) and Medical Services (MMS), and other stakeholders,
the EP will further strengthen key referral systems through review of referral tools, printing and distribution of such tools, and
conducting regular assessments of the system.
New national HTC guidelines were released in 2008 and further dissemination will occur in 2009. The National AIDS and STI
Control Program (NASCOP), in conjunction with international organizations and the USG, developed the guidelines to harmonize
approaches in line with international policy recommendations. In 2009, new training curricula and other operational tools will be
produced to improve quality of services.
EP funds will contribute to the procurement of test kits to complement planned procurements through Global Fund (GFATM) and
the Japanese International Cooperation Agency (JICA). As a substantial contribution to national scale-up, the EP will secure
sufficient test kits for at least five million individuals to be tested and counselled in 2009.
Capacity building and systems strengthening of local indigenous partners in HTC remains an important part of EP-supported
activities. HTC activities in Kenya are developed in partnership with the GoK to ensure full integration into the larger health plan.
PITC activities and services are implemented through staff from local MPHS/MMS facilities to promote sustainability. In 2009,
PITC training will be incorporated in all medical training colleges so that all new health care professionals are trained in HTC.
The EP program in Kenya supports and works closely with MPHS/MMS at national and regional levels to strengthen data
management and reporting through provision of technical guidance and review and printing of data collections tools. EP will also
provide critical staff support to MPHS/MMS with short- and longer-term deployment of epidemiologists and behavioral scientists to
assist and strengthen program evaluation. The EP will also continue to support system development such as the electronic
medical records and e-health.
In 2009, the EP will continue to work closely with MPHS and MMS, as well as other key stakeholders. The EP will support national
capacity for coordination and supervision to strengthen field capacity in implementing programs. This support will focus on (1)
policy development and review, (2) monitoring and evaluation, and (3) commodity security. At the national level, the USG will work
with NASCOP and the Kenya Medical Supply Agency (KEMSA). In the field, the USG will work closely with Provincial and District
Health Management Teams to ensure HTC services are implemented according to national guidelines and standards.
ACHIEVEMENTS AND OUTSTANDING CHALLENGES/GAPS
To date, the greatest achievement of the Kenyan HTC program is the broad scope of HTC approaches, which expands the
opportunities and options through which people may learn their HIV status. Areas requiring more efforts include (1) expanding
couple HTC to deal with high rates of discordance; (2) reaching more children and youth with HTC; (3) urgently addressing the
discrepancy between men and women being tested and counseled, especially in rural areas; and (4) improving the quality of HTC
services provided.
Table 3.3.14:
+ The HJFMRI-South Rift Valley CT Program will now include the targets and budgetary allocation for Live
With Hope Center and Tenwek Mission Hospital.
+ The number of individuals counseled and tested according to national and international guidelines is
210,000 individuals.
+ geographic coverage has been expanded to include Kisumu West district in Nyanza Province and
Kipkelion district in Rift Valley Province
+ the target population has been expanded to include the general population in home based counseling and
testing
The Henry Jackson Foundation Medical Research International- South Rift Valley Counseling and testing
activities will relate to HIV/AIDS treatment/ARV services, TB/HIV, Abstinence/Being Faithful, Orphans and
Vulnerable children and Condoms and Other Prevention.
In FY 2009, Henry Jackson Foundation Medical Research International (HJFMRI) South Rift Valley will
continue to provide HIV counseling and testing (CT) services in partnership with the Ministry of Health
(MOH) in seven districts in the south Rift Valley Province and one district in Nyanza province. Together the
eight districts represent a collection of 70 MOH district hospitals, sub-district hospitals, and health facilities
as well Live With Hope Center, Tenwek Mission Hospital, AIC Litein Mission Hospital and Kericho Youth
Center that will be equipped and supported to serve as nationally registered CT sites in reaching
communities with Counseling and Testing services. In FY 2009, the eight districts will provide CT services
to over 210,000 people in the traditional voluntary counseling and testing (VCT) sites as well as through the
provider initiated testing and counseling (PITC), Mobile/Moon Light VCT and Household/Family Testing
strategies. Twenty (20) individuals will be trained in voluntary counseling and testing, while (fifty) 50
clinicians will be trained in Provider Initiated Tested Counseling; to enable them provide PITC in health
facilities. An additional twenty (20) will be trained in couple counseling & Testing and an additional 10 will be
trained in home based counseling and testing. In implementing this, HJFMRI-South Rift Valley will work
closely with the district AIDS/STI coordinators (DASCO) in order to strengthen coordination and referral,
especially between CT and care services. Technical assistance will be provided by 3 locally employed staff.
The combination of client-initiated (VCT) and provider-initiated CT services will significantly contribute to an
increased proportion of Kenyans learning their HIV status in the south Rift Valley Province, which has a
population of greater than 2.5 million and a HIV prevalence rate of approximately 7%. HJFMRI-South Rift
Valley CT Program will also continue to maintain the 1 youth friendly stand alone site in Kericho which
combines recreational services as well as CT services in this very dynamic approach to behavior change
and HIV prevention among the youth. The center was established in partnership with Kericho District
Hospital with support from PEPFAR in FY 2004, and has successfully assisted over 1000 youth between
the ages of 15-24 per month to learn their HIV status. The center also offers youth-friendly mobile VCT
services in collaboration with mobile reproductive health clinics in the larger district. HJFMRI will also
continue to work in developing mobile VCT activities in conjunction with MOH to reach populations of the
districts who have poor or no access CT services. This will be the primary method used in Transmara
District, because part of the population in the district has a nomadic lifestyle and also there are parts of the
district that are hard-to-reach. The prevalence rate in this district which borders Tanzania is estimated to be
around 8-9% but accessibility of HIV services is extremely limited. HJFMRI south Rift Valley Mobile VCT
activities will reach at least 90,000 individuals in FY 2009 in the eight districts served by HJFMRI. This
number will part of the annual CT target for HJFMRI south Rift, referred to above.
3. CONTRIBUTION TO OVERALL PROGRAM AREA
The South Rift Valley Province is one of the areas in Kenya that have large rural populations which account
for 70% of all HIV infections (KAIS 2007). These rural areas will be the main target of the CT initiative in FY
2009. Together with the MOH, HJFMRI-South Rift Valley will provide high quality CT services both to the
Tea farming community and to the general community through mobile/Moonlight CT services. Currently,
mobile CT services are conducted weekly and reach between 100 and 250 clients per week. In order to
meet the needs of rural Kenya, KEMRI-South Rift Valley CT Program will assist the MOH to scale up mobile
CT services in these areas. These coordinated CT activities will successfully provide VCT as well as PITC
to over 200,000 Kenyans in the south Rift Valley Province. This combined effort to extend quality CT
services to this geographical area will successfully contribute to 7% of 2009 Emergency Plan CT targets for
Kenya.
KEMRI-South Rift Valley will be instrumental in contributing to the national objectives of extending CT to
hospital patients and TB patients in both the inpatient and outpatient clinical settings. The youth recreational
center and VCT site in Kericho will continue to consistently target out of school and in-school youth, a
special population that has become a national focus in the provision of VCT services through scaling up
their services to reach rural youth in Kericho and Kipkelion districts.
This activity is linked to HJFMRI-south Rift Valley ARV services by ensuring that every individual who has
tested positive for HIV in the CT service is linked to care and treatment. This activity is also linked to
HJFMRI-south Rift Valley TB/HIV to ensure that every person who tests positive for TB is given the
opportunity to test for HIV in the PITC setting. This activity is also linked to prevention activities by Live with
Hope AB, and KEMRI-South Rift Valley AB and KEMRI-south Rift Condoms and Other Prevention program.
KEMRI SRV CT activity will target the general population, including children and youth. Mobile VCT
services will target migratory populations in Transmara and other hard-to reach populations. HJFMRI is
working in partnership with the MOH offices in eight districts and therefore will be in a position to train public
health care workers in PITC in the clinical settings as well as private health care workers in AIC Litein
Activity Narrative: Mission, Tenwek Mission Hospital, Kericho Youth Center and Live With Hope Center. HJFMRI, in FY 2009,
will train and equip 50 public health care workers in PITC in order to support the national scale-up of CT in
clinical settings within Kenya. The youth center in Kericho will also target its CT services to out-of school
youth as well as other most at risk youth like street youth. AIC Litein shall also put efforts into reaching
people with disabilities particularly the deaf. In general, VCT activities provide CT services to the most at-
risk populations. CT activities are done collaboratively with National AIDS control Program staff at the local
level.
HJFMRI-South Rift Valley, in partnership with the MOH and other partners, will improve gender equity in
accessibility of CT services within the eight districts in South Rift Valley. CT will be an important intervention
strategy in challenging current sexual norms that have contributed to the risks of contracting HIV in many of
the rural communities. Through information and education material stigma surrounding issues of knowing
HIV one's status will also be addressed.
HJFMRI South Rift Valley efforts in CT will be divided between community mobilization/participation, human
resources, information and communication, infrastructure, and training. HJFMRI-SRV will improve the
awareness of its CT services by focusing a part of its efforts in community mobilization and participation.
Other efforts will also go towards the training of 50 health care workers in the provision of CT services in the
clinical setting. Many of the health care settings do not have the existing space to provide CT services and
therefore some of the efforts in FY 2009 will be to make minor renovations in the already existing
infrastructure of the medical health facilities.
Continuing Activity: 14907
14907 4828.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,280,000
6968 4828.07 Department of Kenya Medical 4249 3476.07 South Rift Valley $750,000
4828 4828.06 Department of Kenya Medical 3476 3476.06 South Rift Valley $560,000
+ KMOD becomes a sub partner to HJFMRI/South Rift Valley.
+ The new coverage areas include Kisumu West, Nakuru Provincial General Hospital to provide Quality
Assurance/Quality Control activities.
+ Scaling up EID to cover the whole of Rift Valley region.
+ Expanding testing services to include microbiology, mycology and drug resistance.
This activity supports the key cross cutting attribution of human capacity development through training 160
laboratory technicians/technologists in hematology, chemistry, CD4 and QA/QC with emphasis on
interpretation of results generated in the laboratories. This will be achieved through pre-service/ in-service
training, workshops and seminars facilitated by internal and external experts. Further training of a laboratory
auditor will improve the overall quality of services and general evaluation of the program. This activity will
also support one lab technologist for higher national diploma training in molecular diagnosis and one in
microbiology at Kenya Medical Training College or equivalent. Laboratories in all the sites will be
strengthened on requisite Quality Assurance procedures, laboratory procedures and management, use of
SOPs and implementation of QA/QC systems for the follow up of about 40,000 HIV patients thus
contributing to the overall national target of treating 550,000 people by the year 2010.
Under the US DOD, the Kenya Medical Research Institute (KEMRI)/ South Rift valley (SRV)/Kisumu West
and Kenya Ministry of Defense (KMOD) PEPFAR Program have been providing laboratory support for HIV
care to approximately 32,000 patients, of which 15000 have started ART. This laboratory support has been
provided in two forms: through the Regional laboratory and direct district level/ facility support.
Statistics: There are a total of 17 functional/running labs under the DOD PEPFAR Program. 8 labs have the
capacity to do CD 4 tests while 17 have the capacity to either perform hematologies or chemistries or both.
We plan to empower 18 laboratories to be able to perform QA for rapid tests being performed in all the
testing facilities. Kenya Medical Research Institute/ Walter Reed Project Clinical Research Center
(KEMRI/WRP CRC), Kericho laboratory is currently the only facility performing EID for the whole Rift Valley
region.
Services: From the inception of the EP Program, the KEMRI/WRP CRC, has been used as a nodal point for
training and empowerment of all the laboratories in the 18 treatment facilities in the Program. Initially, only
KEMRI/WRP CRC lab had the potential of doing all the HIV/ART monitoring tests, but this has been
transferred to most of the treatment facilities except for the CD4 tests that are done in only 7 sites. This was
easily achieved through procurement of necessary equipments for hematology, chemistries and CD4 for all
the treatment facilities within the EP program.
Due to this rapid growth and expansion of the lab services, it became necessary to hire four lab officers who
could coordinate the laboratory activities within the Program through training, development of SOPs and
adherence to good clinical laboratory practices. This has improved services in most of the laboratories while
improving standards within these laboratories.
Though some laboratories have been supported for the last four years using the laboratory annual
allocations, this has so far been supplemented by procurements done centrally through SCMS.
TB diagnostic services (ZN microscopy) are being expanded from the current 47 to 100 besides putting up a
TB culture lab at KEMRI/WRPCRC, Kericho. Support to this activity will provide accurate and timely
diagnosis of TB in about 32,000 HIV positive patients in the SRV and Kisumu west. It will also serve as a
reference lab for the whole Rift Valley region.
Among other tests to be expanded include diagnostic tests for other opportunistic infections including
mycology and parasitology besides strengthening simple ZN and fluorescent microscopies. Strengthening
of capabilities within KEMRI/WRPCRC laboratory for mycology and parasitology will ease a rollover to other
treatment facilities through trainings, SOP development and QA/QC coordination.
Other concurrent services provided to all the laboratories include biannual validation and verification studies
for all equipments, quarterly submissions of split samples for QA/QC and finally biannual participation in
external quality assurance in hematology, flowcytometry and chemistry.
To be able to maintain good service provision, service contracts have been/will be provided for all
equipments in all the USG supported sites. This ensures continuity of services while prolonging the life
spans of equipments in use within the Program.
With the accreditation of the KEMRI/WRP CRC laboratory in Kericho by the College of American
Pathologists (CAP), it has become necessary to utilize the expertise within this facility to develop the
Nakuru Provincial General Hospital (PGH) laboratory to attain its rightful identity besides attaining good
standards. This will be attained through provision of trainings, SOP development, QA/QC coordination and
overall technical assistance. This will in the long run enable the PGH laboratory to oversee some of the
QA/QC aspects currently performed by the KEMRI/WRPCRC laboratory for the region.
Kombewa-District Hospital in Kisumu West District is another new site requiring further support for
laboratory renovation, human resource, equipments, and reagents. The patient uptake in this area is high
and will need adequate support for quality provision of services.
In preparation for emerging drug resistant strains, the KEMRI/WRP CRC lab is building capacity using its
current expertise in viral load and DNA molecular tests to perform drug resistance tests for all clients
suspected to be failing on their drug regimens in the whole Rift Valley region. Further funding will be
needed to support this Program for reagents, consumables and equipment servicing. A specialist in
molecular diagnosis will be needed to facilitate and run these services.
Referrals and Linkages: The CRC lab is the reference lab for all the HIV/ART monitoring services within the
Program. Kericho District Hospital (KDH) laboratory has also been developed to handle all referred
specimens from the other sites except services within the military premises. Health Centers, dispensaries
Activity Narrative: and some private institutions send samples to any of the treatment facilities of their convenience for
analysis for hematology and chemistries. All sites that have no capacity to perform CD4s refer them to
either KEMRI/WRPCRC or any of the 7 facilities with flow cytometry equipments. The current approach is to
empower KDH to perform all HIV/ART monitoring tests while KEMRI/WRP CRC acts as a back up site and
main facilitator of QA/QC and validations. Armed Forces Memorial Hospital (AFMH) will also be empowered
to have referral capabilities for the military clients. All samples are logged in a laboratory book and once
analyzed; results are dispatched to the sending institution through any of the following methods:
•Securicor courier services
•Direct deliveries to near by sites
•Telephone calls for all critical or positive CRAG results
For EID, samples are directly relayed to KEMRI/WRP CRC laboratory from the collecting sites while others
would deliver to a treatment facility (whichever is convenient) for subsequent dispatch to KEMRI/WRP CRC.
Most sites use Securicor courier service recommended by the Clinton Foundation to deliver samples to the
KEMRI/WRP CRC lab. Once samples have been analyzed, results are dispatched using either the
Securicor courier service or directly delivered to the nearby sites. On the second day of delivery of results, a
follow up call is made to a point of contact at the sample collection site to confirm if the results have been
fully received. Further follow up to the client is not made. This does not apply to other samples unless a
complaint arises. A questionnaire has been developed to capture such deficits if any arises which is usually
distributed to sites on a quarterly basis. Analysis of the questionnaire is done by an independent department
(IT) before results are submitted to the lab for use. An SOP has been developed for reporting and
interpretation of the questionnaire results.
Finally, the development of protocols for quality assurance schemes and off-loading such activities as
individual sites develop capacity will continue. Given the close collaboration and working relationship with
KDH, Nakuru PGH, AFMH, these sites will continue to be developed to offer backups for safety labs, flow
cytometries, QA/QC support to other treatment facilities.
2. CONTRIBUTIONS TO OVERALL PROGRAMME AREA
In FY09, this activity will contribute to training 160 laboratory technicians/technologists in hematology,
chemistry, CD4 and QA/QC with emphasis on interpretation of results generated in the laboratories. This
will be achieved through pre-service/ in-service training, workshops and seminars facilitated by internal and
external experts. Further training of a laboratory auditor will improve the overall quality of services and
general evaluation of the Program. This activity will also support one lab technologist for higher national
diploma training in molecular diagnosis and one in microbiology at Kenya Medical Training College or
equivalent. Laboratories in all the sites will be strengthened on requisite Quality Assurance procedures,
laboratory procedures and management, use of SOPs and implementation of QA/QC systems for the follow
up of about 40,000 HIV patients thus contributing to the overall national target of treating 550000 people by
the year 2010.
This activity relates to KEMRI-SRV/Kisumu West/ KMOD activities in HIV/AIDS treatment: ARV services,
palliative care: TB/HIV, palliative care: basic health care and support, counseling and testing, and
prevention of mother-to-child transmission.
4. POPULATIONS BEING TARGETED
The target population for this activity is primarily people living with HIV/AIDS that are identified through the
care and treatment centre's in the KEMRI- SRV/Kisumu West/ KMOD portfolio.
5. EMPHASIS AREAS/ KEY LEGISLATIVE ISSUES ADDRESSED
The activity includes emphasis on renovations, maintenance of laboratory equipments in the ministry of
health lab facilities as well as minimal work at CRC laboratory. Other emphasis areas will also include
human capacity development both in pre-service training and in-service training. This activity will also be
part of wrap around programs in health in the area of safe motherhood and TB.
Continuing Activity: 16508
16508 16508.08 Department of Kenya Medical 6968 3476.08 South Rift Valley $1,575,000
Estimated amount of funding that is planned for Human Capacity Development $60,000
Table 3.3.16:
+ In FY 2009 the fund will be used to strengthen the reporting systems from the health centers to the district
level, this will be done by enhancing email systems and purchase of motor bikes.
+ Facilitation of data clerks salary who are currently working at the sites.
+ The funds will be used for health care worker trainings on, Data Quality, Data use and importance of data.
This activity supports key cross-cutting attributions in human capacity development through training of data
handling personnel in data management, health management information system, data collection, reporting
tools, analysis, monitoring and evaluation in support of HMIS for program data, and building the capacity of
South Rift to analyze and utilize surveillance, survey and other strategic information. The data handling
personnel will work closely with program managers and health care workers to help in monitoring of
activities, prepare work plans, make field visits to assess implementation progress and evaluate the rate of
activity scale up and prepare and submit timely reports
1.ACTIVITY DESCRIPTION
This activity will strengthen the provincial and district level Health Management
Information Systems (HMIS) currently in use by MOH at health facilities and Community Based Program
Activity Reporting (COBPAR) currently being rolled by NACC through Constituency AIDS Control
Committees (CACC), through three key components.
Component 1:
Support South Rift Valley and MOH program data collection processes for performance reporting needs
(quarterly, semi-annual, annual). This component will support a participatory, coordinated and efficient data
collection, analysis, use and provision of information to track achievement of South Rift Valley and MOH's
district level objectives, and inform decisions at the local, district and provincial levels, using standardized
M&E/HMIS tools approved by the MOH.
Component 2:
Strengthen community and facility based reporting systems being rolled out by NACC and NASCOP. The
component will support South Rift Valley and MOH to measure progress towards its contribution to the
overall country's emergency plan, National Health Sector Strategic Plan II and Kenya National HIV/AIDS
Strategic Plan goals and results frameworks. Specific activities will include building capacity of the 6 districts
and their heath facilities to collect, report, analyze, and use both routine facility and non-facility data for
planning and program improvement.
Component 3:
Take lead role in coordinating M&E activities in the province to meet the information needs of the
Emergency Plan, MOH, NACC and other stakeholders, in line with the "three ones" principle. South Rift
Valley will organize district-level consensus building forums on M&E issues, distribute standardized data
collection and reporting tools, conduct regular data quality assurance processes at all data generation
points, train 200 facility based data point staff on the new data collection/reporting tools and data use for
improving program performance, and hold quarterly and annual stakeholders' information dissemination
meetings.
South Rift Valley will be held accountable for tangible results, especially in increased use of harmonized
data collection and reporting tools at health facilities developed by MOH, increased data use in planning
and at dissemination workshops to various stakeholders, increased supportive-supervisory visits and
routine data quality assessments at all data collection points by M&E/HMIS officers, and improved
coordination of M&E activities in South rift Valley. These efforts should result into demonstrated evidence in
increased national level reporting by up to 60% from health facilities to NASCOP national database.
2.CONTRIBUTIONS TO OVERALL PROGRAM AREA
The activity builds on activities that support the national M&E systems as well as contributing to the
Emergency Plan's training outputs. In overall, the activity will provide technical assistance to the six districts
and their health facilities in strategic information in addition to supporting the training of 200 facility based
data point staff, SI, program managers in M&E/HMIS, reporting and data use for program management.
3.LINKS TO OTHER ACTIVITIES
This activity links to South Rift Valley activities in the areas of MTCT, HVCT, HVTB, HKID, HBHC and HTXS
by providing linkages between the patient data monitoring system and PEPFAR and national reporting
systems through better data generated at each of the treatment sites. In addition, this activity will link to the
HVSI activities to be carried out by NASCOP.
4.POPULATIONS BEING TARGETED
This activity targets host government workers and other health care workers like M&E and HMIS officers for
data collection, analysis, reporting and use at both health facilities and community level. Program managers
are as well targeted for orientation on the role of M&E program management.
5.EMPHASIS AREAS
The major emphasis area is Health Management Information Systems (HMIS) and minor areas include
Monitoring, evaluation, or reporting (or program level data collection), Information Technology (IT) and
Communications Infrastructure and Other SI Activities.
Estimated amount of funding that is planned for Human Capacity Development $300,000
Table 3.3.17:
