APHIAplus Western Kenya is a five-year project funded by USAID to be implemented between January 2011 and December 2015 by a consortium led by PATH and comprising EGPAF, JHPIEGO, World Vision, and BroadReach. The project is designed to work with existing structures and build capacity at the provincial, district, facility, and community levels to achieve fully integrated service delivery in Nyanza and Western Provinces. The project team maximizes Kenyan ownership and aligns the aims of the project with the strategies of the USG and the GOK. The project will build the capacity of partners throughout the life of the project, and continuously transfer more responsibility to manage resources and project activities. APHIAplus builds on the lessons learned during APHIA II, expands successful approaches to high-need districts, and provides more support for interventions addressing the social and economic barriers to healthy lives.The project is divided into two main result areas which contribute to USAID-Kenyas strategic objective of Improved health outcomes and impacts through sustainable country-led programs and partnerships. This project focuses on improving and expanding health services from Level 5 to Level 1 and increasing the demand for those services. The project also focuses on reducing the barriers that prevent communities from accessing health care and living healthy lives. APHIAplus Western Kenya has purchased seven vehicles in COP10 to support program activities Western and Nyanza Provinces. The vehicles include 3 Toyota Prados (KBQ 974C, KBQ 975C, KBQ 315J) and 4 Toyota Land Cruisers (KBQ 993C, KBQ 992C, KBQ 302J, KBQ 315J, KBQ 243P). This activity supports GHI/LLC and is funded with both FY12 and pipeline funds in this budget cycle.

The project will support a minimum package for home and community based care in line with NASCOP guidelines. The services will include nursing care and palliative care; clinical care with an emphasis on treatment literacy and sustainability; family care and support (including psychosocial support, access to reproductive health services, and initiatives to strengthen food security and proper nutrition); trainings for health care workers, CHWs and peer educators; and establishing proper linkages and referrals to ensure clients access additional services as necessary. The services will be provided in both provinces. The services will be provided through CHWs and peer educators from patient support groups, youth groups, MARPS, and other organized community groups.The CHWs and peer educators shall be trained on key interventions including cPWP, treatment literacy, elimination of mother to child transmission (PMTCT), adherence to ART, stigma reduction skills, disclosure and behavior change communication, palliative care, defaulter tracing and nutrition. Likewise the project will identify and train TB ambassadors of hope. Nutritional centers will be established to demonstrate best practices. The CHWs and peer educators shall further be trained on IGAs and financial management, and data collection and reporting.The project will strengthen the referral system from health facility to home and back again. The system will ensure that clients and care givers understand the treatment plans and the care that is expected at home and when to return to the health facility for follow up. It will ensure that clients and care givers have access to community support groups, spiritual support, laboratory services, HTC and other services as needed. It will link OVCs to relevant CBOs under its support for necessary care and support. Likewise the project will establish sustainable IGAs among the different patient support groups and individual clients. It will link such groups to microfinance institutions as well as training them in financial management to ensure sustainability of their initiatives.Monthly DHMT support supervision visits will be facilitated. HBC focal persons will be facilitated to conduct targeted supervision based on identified need. Quarterly stakeholder meetings will be carried out to review implementation of the services and address emerging issues.The project will support data collection and reporting using standard tools as per NASCOP/ NACC guidelines. It will facilitate HBC focal persons under the guidance of DASCOs/ PASCOs to coordinate the flow of data from community to district, provincial and national levels. The data shall also be used for decision making at all levels.

The activities will be implemented by World Vision Kenya, through sub-contracted local CBOs in both provinces to reach over 200,000 OVCs and their households. Moderately vulnerable households will access asset growth and protection mechanisms by promoting Village Savings and Loans Associations (VSLA) among low income women and youth. Moderate and low vulnerability households will be linked to formal microfinance institutions operating within their community. OVCs out of school will be given individually-appropriate and market-driven vocational training.

To increase food production, the project will work through line ministries to promote drought resistant crops targeting 2000 households in Nyanza and 1000 in Western. Kitchen garden training will target 1000 HH with OVC in Western and 2000 in Nyanza emphasizing nutritious indigenous vegetables. The project will link with other programs including USG Feed the Future and other ABEO programs including KHCP/Fintrac and Land-O-Lake, to leverage efforts on maize production, dairy and small holder horticulture. Cooking demonstrations to empower the households on the best utilization methods of the food crops. Positive Deviance/ Hearth (PD/Hearth) model for improving nutrition will be scaled up.

Access to education, life skills, & literacy initiatives will be increased for highly marginalized children, youth, & adults by strengthening community based education structures, linking community based structures to education service providers, supporting the highly vulnerable OVC with school fees and mentoring the girl child and boy child on life skills.

To enhance access to improved water supply & sanitation and reduce incidence of diarrhea, the project will promote provision of safe water through protection of identified springs at community level using the existing local administration and CBO structures in areas with low coverage. The project will provide VIP latrines in schools and install PVC water tanks to ensure that school children access quality drinking water. The project will scale up community led total sanitation.

The project will assist the Department of Childrens Services (DCS) to build the capacity of 30 location AACs. Community groups will be strengthened to monitor and offer services to children. The project will conduct focused trainings based on identified gaps and social workers will train home visitors. The project will continue using the Child Status Index (CSI) tool in assessing and tracking priority services for vulnerable children. The tool will be used for biannual assessment of OVC needs and for subsequent follow-up monitoring.

Over the last one year, the project supported over 125,000 OVCs with core benefits. School levies were paid for over 5200 OVCs. The main challenge was related to a lag period in getting CBOs on board to implement the OVC program. This has however been finalized and 64 CBOs subgranted to offer the service.

CBOs will collect OVC data and provide monthly performance reports to the project. Data Quality Assessment will be conducted quarterly using the OVC DQA tool in all the sub granted CBOs

The project supports TB activities in 66 health facilities in 16 districts in Nyanza and 276 health facilities in 31 districts in Western. The activities are in line with the Division of Leprosy, Tuberculosis and Lung Disease (DLTLD) strategic objectives. The support includes early identification and referral of TB patients through dissemination of TB ICF tools and mentorship on the use of the tools. Case detection of TB is intensified through static and outreach services, comprehensive care centres, ART sites, and PMTCT/MCH services. To increase the level of community involvement in provision of quality TB services, Community Health Extension Workers (CHEWs) and Community Health Workers (CHWs) are trained on community involvement in TB care. The CHWS identify and refer suspected TB cases, conduct defaulter tracing and help supervise TB and ART treatment for those co-infected using directly observed treatment (DOTS). Additional trainings for the CHWs include nutrition, MDR TB, community infection prevention and prevention with positives (PwP).The project also supports mentorship and orientation of laboratory personnel on AAFB microscopy, quality improvement initiatives and laboratory networking for sputum tests. DOTS for MDR TB patients is supported by facilitating HCWs and CHWs to visit clients, paying for lab investigations and provision of nutritional support to the client.

The project supports integration of HIV and TB services through mentorship and technical updates for HCWs on TB/HIV and the 5 Is (Intensive Case Finding, Integration of TB/HIV services, Infection Prevention and Control, Immediate ART, and Isoniazid Preventive Therapy) using the orientation package developed by NASCOP/DLTLD. In addition, the project supports joint TB/HIV support supervision, the provincial and district steering committees and stakeholders forums.The project compiles monthly TB/HIV data from the facilities using the national TB and HIV M&E tools (MOH711 and TB/HIV register) through the respective District Health Records Information Officers. Feedback is provided to the facility in-charges during their monthly meetings. The DLTLD has implemented the use of PDAs for TB data collection in Nyanza province. The project will scale this up to include 5 districts in Western province through OJT and trainees follow up. The project will support the orientation of HCWs on the Management and Organizational Sustainability Tool (MOST HVTB tool). This will strengthen program management, implementation and expansion of the Stop TB strategy.

In the past one year the project has supported joint provincial/district health management teams to conduct joint supervision and TB/HIV stakeholder meetings. During the supervision, the following areas were identified as needing assistance: documentation, control procedures, contact and TB screening, and TB/HIV integration. These areas will be addressed in 2012 through mentorship, orientation and dissemination of the appropriate tools.

The project supports peadiatric care and treatment in 48 sites in Nyanza and 66 in Western. This support will be scaled up to 62 and 75 sites in Nyanza and Western respectively in 2012.The project will provide commodities at sites to support early infant diagnosis DBS PCR testing, HIV counseling and testing for older children and adolescents, and CD4 testing - including CD4% - in order to allow appropriate care and treatment services. In addition, the project will provide cotrimoxazole prophylaxis, nevirapine prophylaxis for infants and food by prescription for the malnourished children.

The project will continue to establish and facilitate existing peadiatric and adolescent support groups to promote adherence, peadiatric disclosure and psychosocial support for older children and adolescents. The peadiatric and adolescent services will be linked to and/or provided at the comprehensive care centre (CCC) for the continuum of chronic HIV care and treatment. Infant care will be integrated at MCH to offer seamless routinue MCH services like immunization and growth monitoring as well as HIV services.

HCWs will be supported with onsite and off-site mentorship as well as technical exchange visits for improved service provision. The project will facilitate quarterly PHMT and DHMT support supervision to sites for routinue monitoring of service delivery as well as program-specific supportive supervision. QA/QI initiatives using the HIVQUAL model will be introduced to monitor quality of care indicators at all project sites.

The project will carry out quarterly data performance review meetings and routinue continuous quality improvement initiatives at sites. These resources will also provide integrated outreach and clinical diagnostic assistance using IMCI, for improved referral and health services for the children in those communities who are infected or affected by HIV/AIDS.

The project plans to perform 25,000 male circumcisions in COP12. This target will be realized through static service delivery, outreaches and MOVE campaigns. The services will be provided at 21 health facilities in Nyanza and four in Western. These facilities are spread in 10 districts across the region.The services will conform to WHO and national guidelines and include trainings, supplies, equipment and client follow up. Project staff will work with DHMTs/HMTs to provide supportive supervision to VMMC sites. Supervision will be guided by a checklist that ensures the services conform to WHO and national standards.As part of the comprehensive MC package, testing and counseling will be provided on site to all clients on voluntary basis. Confidentiality will be observed during these sessions. This service will be extended to spouses or guardians/parents accompanying clients.MC will be part of a comprehensive package for HIV prevention. Clients will have the benefit of receiving other HIV preventive information and services which include HTC, diagnosis and treatment of STIs, provision of condoms, and information on abstinence and faithfulness to uninfected partners. Clients will be linked to other HIV services including care and treatment services as necessary.VMMC trainings will be provided using WHO and National VMMC guidelines. Training for MC under local anesthesia will be in two stages; theory sessions (knowledge), and practical (skills). This will be followed by continuous assessments and mentorship before confirmation on competency and certification by NASCOP.The project will employ several approaches for demand creation. CHWs will be trained and equipped with relevant messages to promote MC in their communities. Peer groups will also be supported to reach youth, men and women with correct BCC messages. Community opinion leaders such as councils of elders and other leaders will continuously be used. Radio spots will be used to air interactive sessions to encourage dialogue on the services. The project shall also use magnet theatre groups to pass the messages during outreaches and during accelerated VMMC activities. Relevant IEC material shall be provided to health facilities and communities.MC sites will be supplied with M&E tools. HRIOs will be supported to collect complete and timely MC data and transmit it to district levels.

The AB activities will target the general population, adults, youth in-and out-of school, teachers and MARPS with HIV/AIDS evidence-based prevention interventions that promote abstinence and/or being faithful. Particular focus will be young men and women aged 15-35,to reduce multiple concurrent partnerships.For youth in school, Life Skills and Peer Education activities will be scaled up. This will include provision of KARHP Tuko Pamoja Teachers session guides as well as Pupils Peer Educators manuals to schools. The project will conduct Reaching Adolescents Via combined prevention (RAVE) activities in 280 secondary schools (140 in Western and 140 in Nyanza). Magnet Theater and small group discussions will be used to engage the youth in thoughtful reflection of their behaviors and risk perception, moving them along the continuum of behavioral change. The intervention is expected to reach at least 10,000 youth with prevention messages including HIV counseling and testing. The project will support the Kenya Girl Guides and the Kenya Scouting Association to rollout life skills activities in schools. The project will scale up peer education activities initiated by I Choose Life at Maseno University and Masinde Muliro University of Science and Technology. The project will link with HIV Free Generation (HFG), to train peer facilitators on a discussion revolving around the SHUGA video series, to engage in annual talent contests, and the to establish and maintain Youth-bases a multipurpose virtual youth center. For youth out of school, additional peer facilitators will be trained on interventions such as the Stay Alive in the Box (SAIB) that has been championed by the HFG project. In all these activities, emphasis shall be placed on delayed sexual debut, or secondary abstinence for those already sexually active.Workplace interventions, community outreaches (including magnet theatre), mobile HIV testing and counseling services, among others, will be used to convey abstinence/ and or being faithful messages to other populations. Local implementing partners will be strengthened to provide the interventions especially at community level. The project will also continue working with patient support groups to promote abstinence among HIV positive patients. Relevant IEC material will be provided to these populations.All the activities will take into consideration gender-programming and messaging. Peer educators will refer their peers for other services including VMMC, HTC and treatment for STIs.The project is reviewing data collection tools and reporting to conform with 2009 NGI guidelines. It will orient project staff and subcontracted LIPs on the tools and reporting procedures. The project will ensure routine site visits for the activities.

The project supports HTC activities in 66 and 396 sites in Nyanza and Western provinces respectively. It will scale the support to 70 and 140 sites in Nyanza and Western respectively in the next one year. Target populations for APHIAplus Western Kenya include couples in the general population, particularly those who have never been tested before, most at-risk persons (MARPs), and pregnant women.Strategies to reach these target populations with HIV counseling and testing include supporting the MOH to provide Client Initiated HIV Testing and Counseling (CITC), Provider Initiated HIV Testing and Counseling (PITC), Home-Based Testing and Counseling (HB-HTC), and to conduct targeted special outreaches to bring HTC services closer to priority populations (e.g. outreaches for hard-to-reach communities, fishing communities). The Project also supports HTC services in ANC and TB clinics and engages lay counselors in priority high-volume facilities.The Project supported the testing of 148,906 Kenyans in its first year in Nyanza and 346,430 in Western, constituting coverage of 13.4%and 64.6% in Nyanza and Western provinces respectively. Of the total, 218,262 were done through PITC (124,081 in ANC clinic; 8481 in TB clinic), 102,432 through CITC, and 6580 through home-based HTC. Through the aforementioned approaches, the project expects to support the MOH to counsel and test over 629,564 Kenyans in 2012. Similar to achievements in year 1, the project expects approximately 390,000 to be achieved through PITC (162,200 in ANC clinic; 20,700 in TB clinic), 11,664 through CITC, 30,000 through home-based HTC and 15,000 through special outreaches.The project supports the Ministry of Healths recommended algorithm for serial testing. Referrals and linkages to services for clients who test positive are facilitated through community health workers. Monitoring for linkages is facilitated through community-facility linkage meetings. To improve quality HTC services (both testing and counseling), the project facilitates provider and supervisor orientations on external quality assurance (EQA), on-job training for HTC, updates, regular coaching, and supportive supervision. Technical review meetings are held quarterly to discuss HTC performance, issues and promising practices. Dissemination of promising practices and lessons learned is an output of the performance review meetings.To improve monitoring and evaluation of HTC, the project provides orientations to healthcare workers on M&E. In 2012, the project will support orientations to healthcare workers on the new HTC guidelines rolled out by NASCOP and the new HTC register MOH 362, which captures disaggregated indicators (eg couple, disability, MARPS).Project support for demand generation and mobilization for HTC is done through two principle strategies: routine mobilization and community education done by community health workers, and project support for high-profile HTC campaigns and events (e.g. HTC Rapid Results Initiative, and World AIDS Day).

The project will use a combination approach to HIV prevention that incorporates behavioral, biomedical, and structural interventions targeting specific populations in defined geographic settings in Nyanza and Western. Tailored prevention messages targeting needs of individuals and communities will be used to generate demand for service while promoting healthy seeking behavior and risk reduction. Peer education, dialogue groups and use of multimedia channels like magnet theatre, focused outreaches, road shows, print materials and radio will be used.Drivers of vulnerability, reduction of STIs, HIV acquisition and transmission, condom promotion among MARPS and vulnerable populations like fisher folks, low income women and migrant workers will be addressed.MARPSFemale Sex Workers: 240 bar managers and stakeholders from 10 priority sites will be sensitized on the national MARP strategy prior to selection of 1000 FSWs for Peer Education training. Each trained peer educator will regularly reach 14 peers with repeat-prevention messages aimed at risk reduction, condom promotion and making referrals for service uptake.140,000 (1000 x 14 x 10) people will be reached in Nyanza and Western in FY12.Men who have Sex with Men (MSM): An updated inventory of MSM hotspots in Kisumu will be developed. Implementation of MSM Intervention will continue using capture-recapture and snowball methods. Sensitizations, selection and training of peer educators based on National Guidelines for Sex workers shall be conducted. Structured repeat-peer education sessions, outreaches and referrals will follow. As per EBI programming, one peer educator will reach 14 peers with prevention messages. In year 2, 14,000 people (100 x 14 x 10 months) will be reached with repeat-prevention messages, condom promotion and referrals for STI management and biomedical services. Value clarification workshop for providers from referral facilities will be conducted to make them more responsive to MARPS.Fisher-Folks Interventions: 312 Beach Management Units (BMUS) are located around Lake Victoria out of which 292 are in Nyanza while are in 20 Western. Each BMU has between 450 and 1000 members. Behavioral interventions targeting fisher folks will be delivered through peer education. Periodic biomedical services of HTC and VMMC outreaches will be conducted at popular BMUs. 1740-trained Peer Educators (140 for Western and 1600 for Nyanza) will meet monthly to submit reports, share experiences and plan. Additional 1000 peers will be trained in PEs. By the end of the year, 2,740 Peer Educators will reach about 350,000 people with repeat-prevention messages, condom promotion and referrals for STI management, HTC and VMMC services in Nyanza and Western.Workplace Interventions: 1500 additional workplace Peer Educators from 30 work sites will be trained in addition to 322 existing PEs in Nyanza and Western to create demand for health service. To the ratio of 1 PE to 14, 226,800 people will be reached with prevention messages, condom promotion and referrals for STI management and biomedical services. To ensure sustained institutional support at the workplaces, the project will conduct two breakfast meetings for Chief Executives from targeted companies.Low-Income Women: Community outreaches, one-on-one peer education, and small group discussions will be used to facilitate behavior change among women.

The project supports PMTCT activities in Western Kenya with 114 and 376 sites in Nyanza and Western provinces respectively. In the next one year, these will be scaled up to 126 sites in Nyanza and 378 in Western. In the following year, they will be scaled up to 130 sites in Nyanza and 380 in Western. Between January-September 2011, the project has reached 21,204 pregnant women in Nyanza and 102,877 pregnant women in Western with counseling and testing at PMTCT service points. The project expects to reach 51,000 mothers in Nyanza and 275,200 in Western in the next two years. For PMTCT services the project supports HIV counseling and testing using the national algorithms to all first time ANC clients, provides cotrimoxazole prophylaxis to all HIV positive clients, CD4 testing for all HIV positive clients, adherence counseling and support, efficacious PMTCT prophylaxis and HAART as per national guidelines. It encourages enrollment into PMTCT psychosocial support groups and supports client (HEI) defaulter tracing by peer educators at sites.To monitor PMTCT service provision the project supports quarterly integrated support supervision and regular program specific support supervision. The project supports scale up and decentralization of PMTCT services by identifying suitable satellite sites that can be supported by district central sites for ARV commodities.The project is supporting integration of PMTCT services into MCH to offer a one-stop shop for PMTCT interventions for mother baby pair as well as routine MCH activities. These integrated services are linked to chronic care services at the CCC for adults and children through facilitated referrals. The project supports laboratory networking for CD4 testing for infected mothers as well as DBS for the HEI, together with appropriate linkages to treatment services.The project supports male involvement activities as well to improve uptake of PMTCT services and reduce the number of defaulting ANC clients, improve couple counseling and testing and increase male enrollment into care and treatment.To address capacity building gaps the project supports on-site and off-site mentorship efforts and has rolled out district mentoring teams to support continual mentorship efforts. During quarterly facility PMTCT performance review meetings, the performance of PMTCT cascade indicators is reviewed and recommendations made. Dissemination of best practices is an output of the performance review meetings.

The project is supporting comprehensive adult HIV care and treatment in 48 comprehensive ART sites in Nyanza and 66 sites in Western. This will be scaled up to 62 and 75 ART sites in FY 2012. The target population in the zone is 149,250 comprising all adults testing HIV positive and referred into care with coverage of 17.1% in Nyanza and 43.4% in Western provinces.The package of care and treatment services provided through the project include cotrimoxazole prophylaxis provision, TB screening during all client visits, CD4 testing for initiation and monitoring, lab tests for ART initiation and monitoring (such as HB, urinalysis and creatinine testing) according to national guidelines, food by prescription (FBP) and supply of ARV commodities at ART sites.For clients enrolled into care and treatment the project supports clinical appointment and drug therapy adherence counseling sessions at the point of enrollment and continually thereafter by HCWs and project supported peer educators. The project helps clients enroll into psychosocial support groups for adherence counseling and stigma reduction support. Home visits by peer educators help follow-up clients with adherence challenges.To support client retention in care and treatment the project provides daily appointment diaries at the clinic that are used to track daily clinic appointments. At the end of the clinic day, the missed appointments are immediately notified to the peer educators who initiate defaulter tracing by making telephone calls to the clients, carrying out home visits and notifying patient support group leaders. The project is introducing a new modality which features an SMS reminder system to notify patients expected clinic appointments and which offers patient education on ART. Client retention to date is at 78% in Nyanza and 89% in Western.For effective monitoring of care and treatment services at the ART sites, the project facilitates PHMT and DHMT integrated support supervision on a quarterly and as-needed basis. Training needs are addressed by supporting on-site and off-site mentorship. The project is supporting district mentorship teams to offer continual mentorship at site level within a district. The project will introduce on-site HCWs modular training at district hospitals with minimal interruption to service provision.The project carries out quarterly performance data review meetings for the ART sites which form the basis of continuous quality improvement initiatives. The performance data reviews are incorporated in annual M&E plans and involves clinicians, site managers and M& E staff.

The project supports peadiatric ART services in 48 and 66 sites in Nyanza and Western provinces respectively. The total current cohort as at September 2011 is 5,306 and those newly enrolled is 1,139. The current peadiatric ART cohort is 9% of total ART in the zone. The services will be scaled-up to 62 in Nyanza and 75 sites in Western in FY 2012. The total cumulative ART pediatric cohort is expected to reach 10,120 with a current ART peadiatric population of 8,800 and 1,800 new enrollments.

The project supports on-going on-site and off-site mentorship, exchange visits of newly initiated site clinicians to established peadiatric ART sites and continued site mentorship by the district mentorship teams to new sites. The goal of the mentorship is to better support early identification and initiation of ART in children as per national guidelines.

The project will support early infant diagnosis DBS PCR networks, CD4 testing networks for CD4% availability, and viral load monitoring for suspected treatment failure cases. MCH integration with pediatric care and treatment for infants and children < 18 months will be supported to promote early identification and retention in care and treatment. Linkages to food by prescription for children with malnutrition will be supported at all supported sites.

Retention rates will be improved through the identification and follow-up of HIV exposed infants by peer educators, regular review of PMTCT and HEI registers, home visits and enrollment into support groups. The project will support adolescent clubs/ support groups, adolescent youth friendly services and health education at facilities and focused adolescent adherence counseling and support.

Quarterly PHMT and DHMT support supervision visits will be facilitated as well as program specific support supervision visits to monitor availability of peadiatric ARV commodities, treatment algorithms and linkages and referrals to nutritional support, peadiatric psychosocial counseling and community support.

Performance review will be done through quarterly data review and performance meetings and quality improvement assessments at facilities.