The APHIAPLUS KAMILI (A+K) offers a standardized menu of supportive activities in HIV care and treatment as well as family health and malaria across Eastern and Central Provinces. The approach is demand-driven tailoring the specific package of activities implemented at the district level according to the given districts needs. The technical strategies are built on best practices and government guidelines. The A+K team works through the provincial and district health management teams.

The project supports provision of a comprehensive package of TB/HIV care and treatment services for adults and pediatric clients in public/private/FBO facilities and empowers the service providers to own and effectively manage an integrated quality TB/HIV care and treatment service. Lab transport networks will connect the lower level facilities to central sites. Limited numbers and training of staff is the key challenge faced across the two provinces. A+K will enhance service provider skills using on-site approaches, trouble-shooting programmatic areas and linking HIV services with FP and MNCH.

Strengthening the existing 112 community units will be the key focus in 2012. Other services from HIV testing and counseling through PMTCT services and HIV treatment and care will also be key activities linking the community to facilities as needed.

The monitoring and reporting capacity of the health care providers, local implementing partners and Community Health Extension Workers on correct data capture, aggregation, processing and reporting will be enhanced through mentorship, OJT and supportive supervision. A+K plans to procure 5 vehicles and 17 motorbikes with FY11 pipeline funding. This activity supports GHI/LLC and will be funded primarily with pipeline funds in this budget cycle.

PLWHIV will receive prevention care and treatment services at health facility and community levels. At community level, HBC care and support services will aim at enabling the PLWH access basic services that will include food and nutrition, medical and nursing care to treat cases of opportunistic infections, STIs and tuberculosis, psychosocial support, shelter and legal support. In 2012, the project will sub-contract a total of 32 LIPs (17 in Eastern and 15 in Central). These LIPs will be locally based NGOs, Faith Based Organizations or CBOs with capacity to provide HBC care and support .At the facility level, through the 118 HIV care and treatment facilities supported by project, PLWHV will receive adherence support and those who default clinic visits will be traced to their homes. The psychosocial support groups at the facilities will address the age/gender-adjusted needs by clustering the groups into adolescent, pediatrics, care givers, adults and PMTCT groups. HBC clients within the psychosocial support groups will be empowered on prevention, stigma reduction, cPwP and positive living. The empowered clients will graduate to the community-based psychosocial support groups and serve as champions of prevention. These community support groups will promote community-facility linkages for prevention and treatment, retention, RH/FP, cervical cancer screening, PMTCT, clinical care service and two-way referral system. HBC clients and their support groups will also be linked to community-based nutrition and income generating initiatives such as food banks and MFIs respectively for sustainability. The project will maintain a data base of all the HBC clients served. The project staff will make periodic follow-up of HBC clients to ensure that they are retained in the program to continue receiving the prevention, care and treatment services. CHWs will collect data at a household level to document the type of services received by the client. Community referral tools will be provided to community units and health facilities to facilitate a two-way referral system. The project staff and the LIPs will closely work with the community units and trained CHWs for service coordination, monitoring and evaluation.

Care & Support Services for OVC will them enjoy the basic human rights that include right to food and nutrition, health care, psychosocial support, shelter, education and vocational training and legal protection. To reach the OVC with care and support, the project will sub-contract the Local Implementing Partners (LIPs), train and provide them with grants for OVC/HBC services. In 2012, the project plans to sub-contract a total of 32 LIPs (17 in Eastern and 15 in Central) and reach 123,000 OVC (75,000 in Eastern and 48,000 in Central) and 30,000 HBC clients (8,000 in Central and 22,000 in Eastern). OVC and PLWH will receive care and support at a household level to foster community and family participation as this approach has been shown to reduce stigma and discrimination. Those to benefit from the project as OVC will constitute children aged 0-17 years while ensuring both girls and boys have equal chances of benefiting from the project. Those aged 18 years and above will be considered as beneficiaries on home based care and support. The project will maintain a data base of OVC/HBC clients. Project staff will make periodic follow-ups to ensure retention on the program. The project OVC/HBC staff and the LIPs will work closely with the community units and trained CHWs will be assigned to OVC/HBC households. OVC who test HIV positive will be counseled and referred to health facilities for treatment. To ensure that the OVC and HBC clients on the program receive quality services, the project will train the LIP project staff on QI standards. The LIP will cascade the training to lower levels to reach QI teams. The project staff will also conduct random visits to OVC and HBC clients at their households and schools to verify the type of services provided. The project will support the beneficiaries to engage in viable income generating activities (IGA) through training on group dynamics, identification of viable IGAs and marketing strategies. The project will also encourage the OVC care-givers and PLWH to form and register groups and link the groups to micro-finance institutions to access credit for starting IGAs. In partnership with the line ministries, the partner will support the OVC households in growing drought resistant and high protein food crops to boost food security. The project plans to partner with the LIPs in establishing community food crops to sell cereals at subsidized costs. Data will be collect at a household level by CHWs on type of services received by the OVC and HBC clients on the program. The project staff will conduct quarterly supportive supervision, review OVC/HBC data records and make random visits to the beneficiaries to assess quality of services that are received by the OVC/HBC clients.

Support for TB-HIV activity is centered on the DLTLD and NASCOP collaborative activities. The PTLC/PASCO and the DTLCs and DASCOs lead the processes at the provincial and district levels respectively. Support for intensified case finding through provision and mentorship on use MOH, screening tools at the CCC and MCH, Mentorship on TB HIV integration models, provision of job aids and IEC materials, scaling up ART uptake among TB-HIV co-infected patients and carrying out CMEs on infection prevention/control. We also support implementation of minimum package for infection prevention and control including cough monitors, fast tracking of coughers, ensuring cross ventilation in all the clinical rooms and giving health talks on cough etiquette.

We do carry on-the-job training for service providers as well as sensitizations/CMEs on up-dates.

In this second year more focus is laid on supporting the TB-HIV collaborative meetings and strengthening integration of TB and HIV services. Participation in the quarterly review and planning meetings with the DTLCs, DMLTs and DASCOs continue to be an important factor in ensuring that we address government priorities. HIV testing in the TB clinics has been well over 90% whereas TB screening in the CCC clinic has been averaging 60-70%. Focus will be on scaling up TB screening to about 90-95%.

To scale up uptake of pediatric HIV services, we support a mentorship program that takes into account special aspects of children living with HIV. In decentralization, all the facilities providing HIV care and treatment services have been supported to offer pediatric services. The mentorship program has paediatric components that address issues like paediatric psychosocial care, management of opportunistic infections like TB, growth and neurodevelopmental screening, and management of treatment failure.

Adherence and psychosocial support services for children include innovative use of colour-coded labeling of syrups and syringes for the un-educated parents and care givers. Enrollment of children into psychosocial support groups is done according to their age groups thereby taking into account their cognitive development. The adolescent support groups are linked with other youth-friendly services in the facility. Support for care-givers support groups to run concurrently with the children support groups so that adherence measures can be reinforced. Other measures include structuring the parents or care givers clinic days to coincide with the childrens appointments. Integration of HIV services in the MCH ensures follow up of the mother and child in one clinic to minimize time spent in the health facilities. This also increases retention by minimizing defaulting. We envision complete integration of MCH and HIV services during the project life. Those missing appointments are linked with the integrated defaulter tracing mechanism through community health strategy and the care takers psychosocial support groups. Follow up of the HIV exposed infants and the PMTCT program continues to be integrated with CCC services to ensure no missed opportunities. Efforts are in place to scale up EID services in tandem with PMTCT services. Family and partner testing is an approach employed at the CCC and the MCH to increase case detection rate among children in the families living with HIV. Provision of PITC services in the pediatric wards minimizes missed opportunities and encourages linkage between CCCs and the in-patient wards. In the Multi-disciplinary team meetings, one of the agenda is usually to address needs of special populations mainly children. Facilities with more than 10 children are structured to have a special clinic day for children so that they are fully investigated then. The standards of care assessment (SOCs) have a portion for children and adolescents separate from the adults SOCs. The target population/geographic coverage will contribute to scaling up pediatric participation in treatment programs, including pediatric targets. Other activities are to provide drugs, food and other commodities for pediatric clients (HIV exposed infants, HIV infected children and adolescents). Project will support the needs of adolescents with HIV (PwP, support groups, support for transitioning into adult services, adherence support), supervision, improved quality of care and strengthening of health services, promoting integration with routine pediatric care, nutrition services and maternal health services. We wil strengthen laboratory support and diagnostics for pediatric clients. 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 will support AB activities within the framework of the Comprehensive School Health Program which is supported by the Ministries of Public Health and Sanitation and Education. This program will be rolled in schools, tertiary colleges and out of school youth groups in the project intervention areas. These EBIs are an integrated set of planned, sequential, school affiliated strategies, activities and services designed to promote the optimal physical, emotional, social and educational development of learners/education sector actors. This program component will target young people aged 10-24 years both in school, out of school and in tertiary institutions. They will be taken through Life skill sessions using the approved EBIs, such as Healthy Choices, the KIE approved life skills curriculum and the KARHP curriculum. These will be complemented with interventions such as Shuga and other HFG activities. These interventions provide a set of Life Skills and Adolescent Reproductive Health Education that empowers young people make informed decisions and help delay onset of sexual activity and or practice of secondary virginity which may otherwise lead to increased HIV infections amongst youth. These interventions will be implemented in districts such as Tharaka Nithi, Embu Mbeere, Kitui Mwingi and Makueni, Kirinyaga, Nyeri and Kiambu. The project will print and distribute the appropriate curriculum and will support the Ministry of Education officials to conduct supportive supervision in the institutions targeted. The targeted youth will, as appropriate, be linked to the relevant biomedical services such as counseling and testing and condoms. Each school/institution will be supported to undertake a self-assessment and develop an appropriate action plan that will be reviewed annually to assess level of achievement. All the interventions will adopt the Comprehensive Prevention Program approach. They will be the approved Evidence Based Interventions (EBIs) or those that are curriculum based some of which are adapted from those locally developed by PATH in various USAID funded projects (IMPACT, AMKENI, Scouting for Solutions, KARHP) and from the Centre for Disease Control and Prevention (CDC) compendia for EBIs.

HTC services are supported in 16 Districts in Eastern Province and fourteen districts in Central Province. Eastern has a HIV prevalence of 4% for women and 3% for men while Central is at 6% for women and 3% for men according to KDHS 2008- 2009.HTC services are provided using both PITC and CITC approaches. PITC services are provided at all public and some faith based facilities both in Inpatient and outpatient departments .Community HTC is provided through outreaches, mobile VCT, door to door testing and workplace outreaches. These activities target the general population but with special focus on first time testers and couples. MARPS receive services through targeted outreaches. Working with the BCC team, MARPS are mobilized using the peer led approach and receive combined prevention intervention which include HIV testing and screening for STIs. Moonlight HTC is utilized to reach the subpopulations. Quality assurance for HTC is ensured by linking all facilities to the NHRL to ensure that they participate in the EQA exercise. The DMLTs are supported to organize for quarterly proficiency testing activities within their districts to refresh the providers on laboratory practices. Facilities have regular visits by the District laboratory and counselor supervisors to ensure quality testing is going on at all service delivery points. HTC providers receive regular update meetings to keep them appraised with new HIV testing information and dissemination of guidelines. Ninety HTC providers had refresher training on couple HTC while Three hundred and fifty three HCWs were updated on the retesting guidelines and National Quality management guidelines for HTC. The national algorithm for testing is utilized at all facilities and the national reporting tools and reporting structures are utilized. Referral and linkages to care services will be strengthened by use of the referral forms which the client takes to CCC and a copy left at the testing point. Telephone follow-up to the clients will also be done The facility MDTs will be tasked to document follow up and tracking for clients referred to the CCC.The community units are utilized to create demand for services both at the facility and at the community outreaches. Gender based violence activities are carried out both at the facility and community levels. At the facility level, Post rape care services are provided at the Outpatient department where the clients report. Examination and prophylaxis together with trauma counseling form the PRC package. Update for HCWs on management of survivors of sexual violence is provided regularly and trauma counselors receive supervision on quarterly basis. Sensitization on GBV to community leaders police officers, childrens officers and other stakeholders provides them with information for GBV prevention and response. Community units are sensitized to ensure they know where to refer survivors and what a survivor should do or not do when raped. Stakeholders meetings are held to create a forum where stakeholders can share their interventions and also discuss strengthening the medico legal linkages.

The project will target individuals or groups whose behaviour puts them at very high risk of HIV infection.

These include female and male sex workers, IDUs, MSM, truckers, discordant couples, migrant workers, prisoners and other incarcerated individuals and urban slum populations. Other interventions include the comprehensive workplaces wellness program and the community strategy (CS). Mapping of bars and hotspots will be carried out in both Central and Eastern provinces. The project will support the national MARPs mapping exercise and collect specific information that will be useful in programming for MARPs. The interventions for MARPs will be in line with the NASCOP guidelines and meet the minimum standards set. That will include behavioral, biomedical and structural interventions such as health education, provision of condoms, counseling and testing, STI screening and treatment and linkages and partnership (NHIF, MFI, GoK, alternative livelihood skills development). The MARPs program will target the transport corridor specifically Chumvi and Sultan Hamud, urban slums and sex workers in Embu, Meru, Nyeri and Thika and six prison populations. The workplace program will target the big agricultural firms in the Mt Kenya region, specifically the KTDA factories, flower farms and the industrial town of Thika. The CS will continue to be prioritized in the hard to reach and marginalized areas of the Zone such as lower eastern and Mbeere in Eastern and in Kyeni, Thika East and Kirinyaga counties. The community units will be increased to 200 benefitting an estimated population of 1 million people. The interventions will be guided by the minimum standards as defined by NASCOP and the KEPH and will be integrated with the appropriate services. MARPs, Workplaces and community units will be linked to service delivery points as well as integrated outreaches to support hard to reach areas. The activities in CS will be reported through the National CBHIS system, while the MARPs and workplaces within the KEPMS.

Geographical coverage for PMTCT interventions is 17 districts in upper Eastern (289 sites) and in Central Provinces 12 districts (133 sites). Current accomplishments include mapping of all PMTCT sites, formation of PSSG, orientation of the HCW on current PMTCT guidelines; mentorship on PMTCT/EID rolled out; orientation of HCW on DBS sample collection; support for BFI certification; CMEs on PMTCT/EID; targeted SS in PMTCT ; provision of logistical support for lab networking; Support for DBS sample transportation; distribution of PMTCT/EID tools; PMTCT Counselors have undergone orientation in couple testing and identification and support of Champions. Our set Targets are: 80 % of facilities offer minimum package of PMTCT; 95 % HIV exposed infants receive Prophylaxis in MTCT; 2000 HIV positive pregnant women receive ARV prophylaxis; 82% of HIV exposed infants receive EID test within 2 months of birth; 80% of PMTCT supported facilities offer EID services; 90% of facilities visited at least once a quarter; 85% of facilities using SBMR in PMTCT for improved quality of services; 100% of facilities receive mentoring visits; 20% of facilities offer integrated services: PMTCT/RH/FP. The detailed plans for achieving targets include using CMEs, OJT, mentorship, SS, formation and support of PSSGs, Lab networking for EID services; use of Integrated MCH Model; Use SBMR in PMTCT /EID services; male involvement supported; Identifying and recognizing champions; acceleration of Nutrition HINI/HII; Community PMTCT by mobilization, couple testing, CHWs for defaulter tracing; Integrated MNCH outreaches with support supervision; distribution of PMTCT/EID tools- e.g. HEI registers; share best practices; SMS platform for PMTC Messages; Counselor SS; Linkage of HIV +ve pregnant mothers/infants to replacement feeding programs; Increase Couple PMTCT sessions; and support graduation ceremony for HEI at 18 months before linkage to Care &Treatment team. The project shall measure progress by the No of HIV exposed infants who are negative at 18 months, tracking HEI follow up to care and treatment sites after 18 months; PCR at 18 Months; No of HEI exclusively breastfed infants at 6 months; No of infants receiving measles vaccine at 6 months; No of HIV women receiving nutrition assessments for food supplementation; HIV positive women of modern FP and dual methods; HIV positive women accessing CECAP services. Increasing coverage will be through increasing number of sites offering PMTCT minimum package of care; decentralize PMTCT mentorship activities to lower facilities; SBMR in PMTCT and nursing process to improve quality of PMTCT/EID services; Integrated Support Supervision. Reducing costs will be by riding on transport network of Care and treatment team in the DBS sample transportation; use SMS for DBS results notification; Integration of activities within MCH: PPFP, FP in ANC, CECAP, TB screening; Use online updates on latest PMTCT guidelines on new changes; Use of champions as mentors at facility level; Global E-learning on PMTCT/EID; Encourage SBA for PMTCT; by motivation e.g provision of mama packs to women; Mentor mothers for defaulter tracing; Synchronize DBS sample collection with KEPI schedule; Staff recognition; Whole market approach in CMEs, OJTs, Mentoring SS; Transitioning to FBO; ARVs, Counseling time, CD4, Viral load, FBC, UECs, LFTs; TB & STI screening and treatment; CECAP; Documentation; SS; Job aids and mobilization cots.

The project will support implementation of a quality, chronic care model for the care of PLWHIV in 118 health facilities in eastern and central provinces. The supported facilities will cover both public (94) and private facilities (private for profit-7, and private not for profit-17) in a whole market approach. Support to these facilities will entail a government-led technical mentorship utilizing a multidisciplinary team of GOK and Aphiaplus mentors who have a structured mentorship schedule of visits. The project will also support the facilities with basic furniture, job aids, stationery and other tools to facilitate service delivery. Other areas of support include technical and financial support to establish and maintain a laboratory network for CD4 and viral load sample transport from the lower level facilities to the central laboratories. This ensures that patients attended at the dispensaries and health centres have access to laboratory investigations only available in the district hospitals. At the clinic level, the project will continue to offer financial and technical support to the MDTs to manage the clinic and integrate HIV services with the other health services at the facility. Multidisciplinary teams monitor quality of care to the patients by carrying out a biannual assessment of standards of care (SOC) which are derived from the national guidelines. Defaulter prevention and defaulter tracing mechanisms will be strengthened to ensure patients retention to care and treatment while establishing intra-facility and community linkages. Support to strengthen pharmaceutical and laboratory commodity management serves to minimize acute stock outs as well as mitigating expiry of commodities at the facility. The project will offer technical support through district-based and community-based CME/CPD sessions, On-job training and couching. The project seeks to empower patients through psychosocial support groups, health education, supporting prevention by implementation of PWP package and also the peer educator program. Each facility MDT is supported to recruit two peer educators (expert patients) from among their clients who help to champion adherence and prevention strategies. District and provincial health management teams are supported financially to carry out integrated quarterly support supervision. The project also aims at convening an annual forum for the supported facilities to share best practices. The excelling facilities/champions shall be given recognition. Through this the project encourages health completion among the facilities and service providers as they strive to shine in service delivery.

To scale up uptake of pediatric HIV services, we support a mentorship program that takes into account special aspects of children living with HIV. In decentralization, all the facilities providing HIV care and treatment services have been supported to offer pediatric services. The mentorship program has paediatric components that address issues like paediatric psychosocial care, management of opportunistic infections like TB, growth and neurodevelopmental screening, and management of treatment failure.

Adherence and psychosocial support services for children include innovative use of colour-coded labeling of syrups and syringes for the un-educated parents and care givers. Enrollment of children into psychosocial support groups is done according to their age groups thereby taking into account their cognitive development. The adolescent support groups are linked with other youth-friendly services in the facility. Support for care-givers support groups to run concurrently with the children support groups so that adherence measures can be reinforced.

Other measures include structuring the parents or care givers clinic days to coincide with the childrens appointments.

Integration of HIV services in the MCH ensures follow up of the mother and child in one clinic to minimize time spent in the health facilities. This also increases retention by minimizing defaulting. We envision complete integration of MCH and HIV services during the project life. Those missing appointments are linked with the integrated defaulter tracing mechanism through community health strategy and the care takers psychosocial support groups.

Follow up of the HIV exposed infants and the PMTCT program continues to be integrated with CCC services to ensure no missed opportunities. Efforts are in place to scale up EID services in tandem with PMTCT services. Family and partner testing is an approach employed at the CCC and the MCH to increase case detection rate among children in the families living with HIV. Provision of PITC services in the pediatric wards minimizes missed opportunities and encourages linkage between CCCs and the in-patient wards.

In the Multi-disciplinary team meetings, one of the agenda is usually to address needs of special populations mainly children. Facilities with more than 10 children are structured to have a special clinic day for children so that they are fully investigated then. The standards of care assessment (SOCs) have a portion for children and adolescents separate from the adults SOCs.