USAID KENYA

HIV Service Delivery Support Activity (HSDSA) Cluster2

Quarterly Progress Report

April to June 2018

A health care worker facilitates a support group meeting in Turkana County

Date of Submission: July 30, 2018

This publication was by prepared by FHI 360 for review by United States Agency for International Development USAID KENYA (HIV Service Delivery Support Activity Cluster 2)

FY 2018 Q2 Progress Report 01 April – 30 June 2018

Contract No: 72061518C00002

Prepared for Dr. James Batuka United States Agency for International Development/Kenya C/O American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya

Prepared by:

Family Health International (FHI 360) The Chancery, 2nd Floor P.O Box 38835-00623, Valley Road Nairobi, Kenya

The authors’ views expressed in this report do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

ii | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report TABLE OF CONTENTS

LIST OF FIGURES ...... IV I. HSDSA CLUSTER 2 EXECUTIVE SUMMARY ...... VII II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 13 OBJECTIVE 1: INCREASED AVAILABILITY AND USE OF COMBINATION PREVENTION SERVICES FOR PRIORITY POPULATIONS ...... 13

OBJECTIVE 2: INCREASED UPTAKE OF TARGETED HIV TESTING SERVICES (HTS) ...... 18

OBJECTIVE 3: IMPROVED LINKAGE TO TREATMENT FOR INDIVIDUALS NEWLY TESTING POSITIVE FOR HIV ...... 24

OBJECTIVE 4: INCREASED UPTAKE OF AND ADHERENCE TO QUALITY HIV TREATMENT SERVICES .... 30

OBJECTIVE 5: LONG TERM FOLLOW-UP OF PATIENTS RECEIVING CARE AND TREATMENT SERVICES INCLUDING LAB AND LOGISTICAL SUPPORT ...... 45

OBJECTIVE 6: STRENGTHENED SUPPORT FOR FACILITY AND COUNTY MANAGEMENT OF HIV RESPONSE ...... 52 III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT) ...... 67 IV. CONSTRAINTS AND OPPORTUNITIES ...... 67 V. PERFORMANCE MONITORING ...... 68 VI. PROGRESS ON GENDER STRATEGY ...... 71 VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 71 VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 71 IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 72 X. PROGRESS ON USAID FORWARD ...... 72 XI. SUSTAINABILITY AND EXIT STRATEGY ...... 72 XII. SUBSQUENT QUARTER’S (JULY – SEPT 2018) WORK PLAN ...... 73 XIII. FINANCIAL INFORMATION ...... 76 XIV. ACTIVITY ADMINISTRATION ...... 78 XV. SUCCESS STORIES ...... 78 XVI. ANNEXES AND ATTACHMENTS ...... 81

iii | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report LIST OF FIGURES

FIGURE 1: PERFORMANCE ON VMMC APRIL TO JUNE 2018 ...... 14 FIGURE 2; PERFORMANCE ON VMMC BY AGE- NAKURU VS TURKANA COUNTIES ...... 16 FIGURE 3: SGBV SERVICE OUTCOMES FOR Q3 FY18 ...... 17 FIGURE 4: HIV TESTING PERFORMANCE AS AT END OF Q3 FY18 ...... 18 FIGURE 5: Q3 CUMULATIVE HIV POSITIVE PERSONS IDENTIFIED VS 2018 TARGETS ...... 19 FIGURE 6: HIV TESTING AND LINKAGE TO ART CASCADE ...... 20 FIGURE 7: PARTNER NOTIFICATION SERVICES/SEXUAL NETWORK TESTING OUTCOMES ...... 22 FIGURE 8: PERCENTAGE OF POSITIVE CLIENTS LINKED TO ART ...... 25 FIGURE 9: TB CASCADE APR – JUN FY18 ...... 28 FIGURE 10: GENEXPERT UTILIZATION RATES ...... 29 FIGURE 11: COUNTY ARV REPORTING RATES APR-JUNE 2018 ...... 31 FIGURE 12: PMTCT STAT ACHIEVEMENTS AGAINST ANNUAL TARGETS ...... 37 FIGURE 13: PMTCT MATERNAL CASCADE FOR THE PERIOD OCT 17-JUNE 18 ...... 39 FIGURE 14: HEI POSITIVITY RATES 2016 TO 2018 ...... 40 FIGURE 15: HEI WITH A TEST DONE WITHIN 2 MONTHS ...... 40 FIGURE 16: EID TEST DONE WITHIN 12 MONTHS ...... 41 FIGURE 17: CUMULATIVE FY18 HEI POSITIVITY AND ART INITIATION RATE ...... 41 FIGURE 18: INFANT CASCADE FOR THE PERIOD OCT 17-JUNE 2018 ...... 43 FIGURE 19: ONE-YEAR HEI COHORT ANALYSIS, APR TO JUNE 2017 COHORT OUTCOMES ...... 43 FIGURE 20: MATERNAL 12-MONTH COHORT ANALYSIS ...... 44 FIGURE 21: CURRENT ON TREATMENT ACHIEVEMENTS AGAINST TARGETS - QUARTER 3 FY 18 ...... 45 FIGURE 22: HSDSA CLUSTER 2 HIV TREATMENT CASCADE ...... 46 FIGURE 23: ADOLESCENT SUPPORT GROUP OUTCOMES ...... 47 FIGURE 24: VIRAL LOAD SUPPRESSION RATES APR-JUN 2018 ...... 49 FIGURE 25: VIRAL SUPPRESSION RATE BY GENDER ...... 49 FIGURE 26: QUARTERLY VIRAL SUPPRESSION PER AGE GROUP ...... 50 FIGURE 27: STF CASCADE FROM SELECT SITES – Q3 ...... 51 FIGURE 28; DHIS2 REPORTING RATES - BARINGO COUNTY ...... 55 FIGURE 29: Q2 AND Q3 TOOLS ASSESSMENT - BARINGO COUNTY (N=27)...... 56 FIGURE 30: DHIS2 REPORTING RATES - KAJIADO COUNTY ...... 57 FIGURE 31: DHIS2 REPORTING RATES - LAIKIPIA COUNTY ...... 57 FIGURE 32: TOOLS ASSESSMENT STATUS (APR-JUN 18) - NAKURU COUNTY ...... 58 FIGURE 33: NAKURU COUNTY REPORTING RATES (JAN-MAR VS APR-JUNE 2018) ...... 59 FIGURE 34: DHIS2 REPORTING RATES - NAROK COUNTY ...... 60 FIGURE 35: DHIS2 REPORTING RATES - SAMBURU COUNTY ...... 61 FIGURE 36: TURKANA COUNTY REPORTING RATES JAN-MARCH VS APR-JUN '18 ...... 62 FIGURE 37: LAIKIPIA COUNTY EID TAT IN DAYS JAN-MARCH/APRIL-JUNE 2018 ...... 63 FIGURE 38: NAKURU COUNTY VL AND EID TAT JAN-MARCH VS APR JUNE 2018 ...... 64 FIGURE 39: TURKANA COUNTY VL AND EID TAT JAN-MARCH VS APR JUNE 2018 ...... 65 FIGURE 40: BARINGO Q2 AND Q3 2018 GAP ANALYSIS GAPS (N=28) ...... 65 FIGURE 41: DATA VARIATION TRENDS FOR SELECTED INDICATORS JAN`18 - JUNE`2018...... 65 FIGURE 42: NAKURU COUNTY CONSISTENCY SCORED AND PRP [N=33 SITES ...... 66 FIGURE 43: NAKURU COUNTY TRENDS OF FACILITIES WITH DATA QUALITY GAPS JAN-JUNE '18 ...... 66 FIGURE 44: DHIS2 MOH 731-2 PMTCT REPORTING RATES (OCT 17' TO APR-JUN 18') ...... 69 FIGURE 45: VARIANCE BETWEEN RECOUNTED VS REPORTED DATA APR 17 TO MAR 18 ...... 70 FIGURE 46: OVERALL PRP PERFORMANCE VS CONSISTENCY SCORES APR 13' TO JUN 18' ...... 71 FIGURE 47: HSDSA BUDGET OBLIGATIONS VS. CURRENT AND PROJECTED EXPENDITURES ...... 76

iv | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report ACRONYMS AND ABBREVIATIONS

AGYW - Adolescent Girls and Young Women ANC - Antenatal Care APR - Annual Performance Report ART - Antiretroviral Therapy AWP - Annual Work Plans AYP - Adolescent and Young People CAG - Community ART Groups CCC - Comprehensive Care Centre CD4 - Cluster of Differentiation 4 CHMT - County Health Management Teams CRS - Catholic Relief Services DBS - Dried Blood Spot DHIS2 - District Health Information System 2 EBI - Evidence-based Behavioral Interventions EDITT - Electronic Dispensing and Inventory Tracking Tool EID - Early Infant Diagnosis EMR - Electronic Medical Records eMTCT - Elimination of Mother to Child Transmission FP - Family Planning GOK - Government of Kenya GUC - Grants Under Contract HCMP - Health Commodity Management Plan HCW - Health Care Worker HEI - HIV-Exposed Infant HIV/AIDS - Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HRH - Human Resources for Health HSDSA - HIV Service Delivery Sup Activity HTS - HIV Testing Services ICF - Intensified Case Finding IEC - Information Education and Communication iHRIS - Integrated Human Resource Information System M&E - Monitoring and Evaluation MCH - Maternal and Child Health MOH - Ministry of Health NASCOP - National AIDs and STI Control Program NCD - Non-Communicable Diseases PBB - Performance Based Budgeting PEPFAR - U.S. President’s Emergency Plan for AIDS Relief PGH - Provincial General Hospital PHDP - Positive Health, Dignity and Prevention PITC - Provider Initiated Testing and Counselling PLHIV - People Living with HIV PMTCT - Prevention of Mother-to-Child Transmission PrEP - Pre-Exposure Prophylaxis QA/QI - Quality Assurance/ Quality Improvement QIT - Quality Improvement Team REMS - Routine Efficiency Monitoring System RTK - Rapid Test Kits SCHMT - Sub County Health Management Teams SGBV - Sexual and Gender Based Violence SILC - Savings and Internal Lending Community v | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report SIMS - Site Improvement Monitoring System TA - Technical Assistance TQA - Technical Quality Assessment USAID - United States Agency for International Development USG - United States Government VL - Viral Load VMMC - Voluntary Medical Male Circumcision WI-HER - Women Influencing Health, Education and Rule of Law WIT - Work Improvement Team

vi | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report I. HSDSA CLUSTER 2 EXECUTIVE SUMMARY HIV Service Delivery Support Activity (HSDSA) Cluster 2 is a contract between the United States Agency for International Development (USAID) and Family Health International(FHI 360) covering the period December 8, 2017 to December 7, 2022. The Activity goal is to increase access and coverage for HIV prevention, care and treatment services toward achieving the “90-90-90” targets and achieving epidemic control with focused capacity building to bolster county ownership and management of the HIV/AIDS response. The Activity aims at improving health outcomes and impacts through sustainable programs and partnerships for public health services at the facility, community, Sub-County and County levels. HSDSA Cluster 2 is implemented in seven counties namely Baringo, Kajiado, Laikipia, Nakuru, Narok, Samburu and Turkana. This report explicates project achievements for quarter 3 (April - June) of FY18.

HSDSA Introductory Meetings with County Health Management Teams (CHMT): The project senior management team held separate meetings with senior health executives and managers in each of the seven counties to formally introduce HSDSA Cluster 2. A summary of the project description was provided in each meeting covering technical objectives, scope, funding mechanism, staffing, partners among other key areas. The meetings were informed of the change in funding mechanism from a cooperative agreement (under former APHIAplus project) to a contract, hence the impetus for proper prior planning, timely submission of requests and need for funder approvals on a variety of items. The meetings further discussed county level performance and accountability for results through joint monitoring and supportive supervision to ensure effective HIV patient identification and retention.

Development of Joint Work Plans (JWPs) with the Ministry of Health (MOH): During the quarter under review, the project held joint work plan (JWP) meetings with County Health Management Teams (CHMTs), Sub-County Health Management Teams (SCHMTs) and Facility Health Management Teams (HMTs) to agree on activities that would be implemented for the period between May and September 30, 2018. A total of 121(7 CHMTs, 34 SCHMTs and 80 Facility HMTs) JWPs were developed. The JWPs support Ministry of Health (MOH) activities which contribute significantly towards achieving the UNAIDS 90-90-90 targets through strengthened quality service delivery and health system strengthening.

County Quarterly Performance Progress Review Meeting: The project management team held review meetings with project staff for the seven counties. The review meetings focused on strategies of achieving the UNAIDS 90-90-90 targets for the annual period and other key deliverables outlined in the year one approved workplan. While there was demonstrated progress towards meeting the annual targets, much effort was still required for the following indicators; PMTCT testing, PMTCT positive identification, ART new enrolment, differentiated care, retention in care, viral load suppression rate and scale up of special clinics with accompanying relevant documentation. To scale up performance on these key indicators, customized strategies were developed focusing on facility testing optimization, partner notification testing for clients newly testing HIV positive, establishment of suspected treatment failures clinics, establishment of adolescents and pediatric weekend clinics, male clinics and weekend clinics among others. Partner Notification Services (PNS) has proved to be a successful approach to improving identification of People Living with HIV (PLHIV) in the community with a positive yield of 12% -14% in the reporting period. The project will continue scaling up this strategy to increase on the positive yield in the subsequent quarter.

USAID Implementing Partners HIV Care and Treatment Meetings: The meeting hosted by USAID/Kenya and East Africa brought together all implementing partners to address

vii | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report underperformance in Antiretroviral Therapy (ART) indicators for the January to March implementation period based on results from data review. Partners were tasked to introduce new strategies that would ensure achievement of year 2018 targets though adoption of best practices and establishing monitoring systems that can track performance on key indicators on a day to day basis.

HSDSA Facility-Based Staff Meetings: The Activity held introductory meetings with all facility- based health care workers (HCW) supported by HSDSA. The staff were provided an in-depth orientation on the Activity including its mandate, coverage, technical approaches and performance expectation. The meetings brought together all cadres of HCWs to forge a common understanding of the expected deliverables. These meetings were done in collaboration with county department of health services who were also present.

County Health Stakeholders Meeting: Nakuru County held a two-day stakeholder meeting hosted by the county health management team. The meeting discussed key activities by each partner in a view to enhance collaborative activities on key areas and avoid duplication of effort from different partners. The county appointed Dr Daniel Wainaina, Deputy Director of Medical services, to coordinate partner activities within the region. In addition, the county health strategic plan was presented for partners to align their activities and budgets.

During this forum, FHI 360 presented basic medical equipment purchased through USAID support to the county department of health executives led by Dr B. Osore, Director of Health Planning and Administration. The equipment, comprising of blood pressure machines, pediatric weighing scales, digital and infrared thermometers among others, was distributed to 61 health facilities to support HIV services.

Monthly Gap Analysis Meetings: The project Multi-Disciplinary Teams (MDTs) in each county held monthly gap analysis meetings to review service delivery gaps emanating from monthly MOH and project data. This entailed identification of data inconsistencies and missing reports among other gaps in HIV Testing Services (HTS), Prevention of Mother to Child Transmission (PMTCT), HIV Care and Treatment, Tuberculosis (TB)/HIV, and Early Infant Diagnosis (EID)/Viral Load (VL) services. Action plans were developed for addressing identified gaps prior to submission of final reports. Continuous identification and correction of data gaps has led to timely monitoring and reporting of project deliverables.

A. Qualitative Impact During this reporting period, the Activity supported the establishment of the HIV infant Tracking system in 10 facilities across 6 counties. Training of the PMTCT health care workers, mentor mothers, data clerks and laboratory staff was done on site. The HIT system aims to improve the turnaround time of viral load and PCR results and alert on appointments and track the mother baby pair up to 2 years. In the quarter under review, HSDSA trained 101 HCWs on HTS, ART and PMTCT revised reporting tools in Samburu county to improve the quality of reports in line with the revised guidelines.

B. Quantitative Impact Below is a summary of progress towards the achievement of the Project Performance Monitoring Plan (PPMP) targets. Details are provided in Section III of the report.

viii | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Table 1: Project Performance Monitoring Plan (PPMP) Code Indicator Year 2018 Quarterly Achievements Cumulative Percentage 2018 Oct - Jan - Mar Apr - Jun Year (%) Target Dec 2018 2018 Achievements Achieved 2017 vs Year 2018 Objective 1: Increased availability and use of combination prevention services 4 INVS_COMD Number of condoms dispensed 7,619,007 1,011,840 7,589,969 8,601,809 112% PP_PREV Percentage of priority population 5 reached with a defined package of services in 0% 0% 0% 0% 0% 0% HIV high burden counties TX_TB (NUM) Number of ART patients were 6 started on TB treatment during the reporting 968 575 418 368 1361 140% period VMMC_CIRC Number of males circumcised as 7 part of minimum package of MC for HIV 22326 4699 850 6827 12376 55% prevention program within the reporting period Objective 2: Increased uptake of targeted HIV testing services GEND_GBV Number of people receiving post 9 GBV clinical care based on a minimum package 7676 273 333 25 631 8% [persons provided with PEP by exposure type] HTC_TST Number of individuals who received HIV testing and counseling services for HIV and 10 716,176 191,022 230,057 229,518 650,597 90% received their test results [by age, sex and results, service delivery point at facility level] HTC_TST Positive: Number (Percentage) of 11 HIV+ individuals in each discrete geographic 15530 3045 3449 3350 9844 63% area identified through HIV testing services Percentage linkage of PLHIV to HIV care and 12 95% 84% 89% 88% 87% 87% treatment services PrEP_NEW Number of adults and adolescents who have received antiretroviral pre-exposure No target / 13 prophylaxis in the reporting period [PrEP] to 0 103 136 239 achieved prevent HIV infection value

Objective 3: Improved linkage to treatment for individuals newly testing positive for HIV Percentage of patients receiving CD4 on 16 90% 65% 65% 65% initiation of ART TB_ART Percentage of HIV positive new and 17 relapsed TB cases on ART during TB treatment 98% 96% 95% 94% 95% 95% [by sex] TB_STAT Number of new and relapsed 18 7484 2493 1697 1561 5751 76% registered TB cases with documented HIV status TX_CURR Number of adults and children currently receiving ART [by age, sex and 19 69000 53578 58805 59769 59769 86% pregnancy status]

TX_NEW Number of adults and children newly enrolled on ART [by age, sex and pregnancy 20 14653 2564 3069 2946 8579 58% status]

TX_RET Percentage of adults and children with HIV known to be alive and on treatment 12 21 90% 75% 69% 75% 73% 73% months after initiation of anti-retroviral therapy TX_TB (DEN) Number of ART patients who were screened for TB at least once during the 22 67620 48059 54491 58175 58175 86% reporting period

ix | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report Code Indicator Year 2018 Quarterly Achievements Cumulative Percentage 2018 Oct - Jan - Mar Apr - Jun Year (%) Target Dec 2018 2018 Achievements Achieved 2017 vs Year 2018 Objective 4: Increased uptake of and adherence to quality HIV treatment positive for HIV Percentage of infants born to HIV infected 24 mothers who receive prophylaxis to reduce 98% 98% 98% 98% 98% 98% MTCT Percentage of supported facilities have adequate 25 staff [>80 Percentage of full-time equivalents are 95% 48% 8% 28% 28% filled] to carry out core HIV service provision PMTCT_ARV Number of HIV positive pregnant women who received ARV to reduce 26 4457 733 900 923 2556 57% the risk of mother to child transmission [MTCT] during pregnancy and delivery PMTCT_CTX Number of infants born to HIV- infected women who were started on 27 4235 414 650 701 1765 41% cotrimoxazole [CTX] prophylaxis within two months of birth within the reporting period PMTCT_EID Number of infants born to HIV- 28 positive women who had a virological HIV test 4561 965 1210 1363 3538 77% done within 12 months of birth PMTCT_FO Percentage of final outcomes 29 among HIV exposed infants registered in the 90% Annual birth cohort Indicator PMTCT_STAT Mother-to-child transmission of 30 5% 3% 4% 3% 3% 3% HIV rate by 18 months of age in target counties PMTCT_STAT Number of pregnant women with known HIV status [includes women who 31 knew their status for HIV prior to ANC and 149896 21880 28609 29621 80110 53% those who tested for HIV and received their results] TX_NEW Pregnant HIV+ women: Percentage of 32 expected HIV+ women enrolled into 95% 15% 17% 16% 16% 16% care/treatment; Objective 5: Long term follow up of patients receiving care and treatment services including laboratory and logistics support IMIS Percentage of supported facilities with the 34 necessary commodities required for service 95% 68% 96% 82% 82% provision Percentage of sites reporting their stock status on 35 95% 80% 41% 47% 47% a timely-monthly basis TX_PVLS (DEN)Number (%) of adult and pediatric ART patients with a viral load result 36 66929 12178 15667 16663 44508 66% documented in the patient medical record within the past 12 months TX_PVLS (NUM) Percentage of ART patients virally suppressed with a viral load documented 37 90% 80% 79% 83% 81% 81% in the medical records in the past 12 months with a suppressed viral load [<1,000 copies/ml] Objective 6:Strengthened institutional accountability for the management of community, facility and county HIV response EMR_SITE Percentage of service delivery Annual 39 points that utilize a patient electronic medical 75% Indicator record system HRH_STAFF Number of health care workers No target / [regardless of funding source] at PEPFAR 40 0 842 950 1070 1070 achieved funded facility [with PEPFAR support value disaggregated]

x | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report Code Indicator Year 2018 Quarterly Achievements Cumulative Percentage 2018 Oct - Jan - Mar Apr - Jun Year (%) Target Dec 2018 2018 Achievements Achieved 2017 vs Year 2018

Number of county AWPs that reflect project 41 7 7 7 7 7 100% activities and activity budgets

Number of county governments that progress as 42 measured by the organization capacity 7 7 7 7 7 100% assessment tool Number of sub-counties effectively utilizing 43 program based budgeting to prioritize health and 39 41 Annual HIV needs Indicator Percentage of facilities submitting timely, 44 95% 91% 85% 92% 91% 91% complete and accurate information Percentage of high volume facilities that conduct 45 75% 68% 63% 49% 59% 59% quarterly data review and use forums

C. Constraints and Opportunities During the quarter, several constraints affected implementation of planned activities. The fact that some PEPFAR reporting requirements do not match with the current national reporting tools is a constraint towards continued strengthening of the national system. To meet this requirement, the project develops separate templates to collect the required data from supported sites. The Activity supports PMTCT services at 234 facilities out of the 800 offering this service in the region of coverage. This has affected the performance of PMTCT indicators as HSDSA support is limited to a small proportion of sites. To mitigate this, HSDSA will institute outreach services to additional PMTCT sites based on the client caseload in these sites. There exists a missed opportunity to offer comprehensive services, including Pre-Exposure Prophylaxis (PrEP) to Key Population (KP) clients seeking services at public Comprehensive Care Clinic (CCC) because they do not self-identify as KPs to avoid stigmatization. To address this, HSDSA trained FHI 360 LINKAGES project staff to foster service integration in the KP drop-in centres, provide information and link clients, upon request, to the link facility.

The Activity continues to make significant strides towards strengthening Electronic Medical Records (EMR) system. The Activity will continue collaborating with Palladium Group to institutionalize EMR system implementation at 83 high volume sites to improve the data quality and use of the system for patient management. The formation of USAID implementing partners forum is an opportunity to leverage support from other partners for synergies and avoid duplication of activities.

In the next quarter, the Activity will work closely with the HTS counselors in all HVFs to scale up identification through PNS in order to maximize the yield. Rollout of dual testing in ANC and maternity provides an opportunity for early identification and cost reduction for STI screening that will increase access to care for pregnant women. Collaboration with USAID funded Afya Timiza and Afya Uzazi is also an opportunity for the Activity to progress towards achievement of the PMTCT targets and reaching the population in need with comprehensive package of PMTCT services.

D. Subsequent Quarter’s Work Plan The Activity will continue to orient all the new staff hires in Turkana and Samburu Counties for quick transition into service delivery and meeting the project performance expectations. Health care workers in Turkana and Samburu will be trained on the new ART guidelines, revised NASCOP HIV tools, and partner notification services to equip them with necessary skills and knowledge for quality service

xi | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report provision. In addition, the Activity plans to roll out trainings on dual testing of HIV and Syphilis in all the seven counties to increase access to screening services and improve on early identification of HIV and Syphilis for timely intervention and reduction of MTCT.

The project will scale up partner notification services with close weekly monitoring of index client contacts testing aiming at 80% coverage. Implementation of the test and start guidelines will continue to be jointly monitored with MOH to ensure that positive clients identified are initiated on treatment within two weeks, with intensive follow up of those not linked and not initiated on ART after linkage. The project will conduct a Rapid Results Initiative (RRI) to account for all the clients that are not linked to treatment after identification as HIV positive or transitioned from treatment in the current FY.

Differentiated care models will continue to be strengthened and monitored to ensure they operate as per standards and achieve the expected outcomes. In addition, viral load monitoring for HIV positive patients, particularly pediatrics, will be intensified as well as follow up of treatment failures for adherence counselling, subsequent repeat viral load and switching to 2nd line regimen for those confirmed as failing treatment.

The project will also support the scale up of PrEP in all the seven counties. The Activity will support the scale up of special clinics to increase the quality of care for PLHIV. Through continuous mentorship and close monitoring of the clinics activities, proper documentation will be strengthened to capture outcomes of the supported special clinics.

xii | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report II. KEY ACHIEVEMENTS (Qualitative Impact)

OBJECTIVE 1: INCREASED AVAILABILITY AND USE OF COMBINATION PREVENTION SERVICES FOR PRIORITY POPULATIONS

Activity 1.1 Provide HIV prevention services to fisherfolk and other priority populations In Turkana County, HSDSA Cluster 2 held meetings with six landing beach management units (Kalokol, Lowarengak, Namukuse, Kataboi, Kangatosa and Eliye) to introduce project activities. This event was done in collaboration with relevant MOH facility in-charges and included demand creation for uptake of the evidenced based interventions (EBI), stepping stones, and identification of major landing beaches considering the migratory partners among the fisher folk. The project therefore identified Lowarengak, Longeche, Namukuse and Kalkol as the major landing beaches where the stepping stones EBI will be implemented in year one.

In partnership with AIC Lokichogio, a local implementing partner, HSDSA Cluster 2 created demand for HIV prevention services along Lake Turkana and more specifically Lowarengak and Kataboi landing beaches. This led to provision of Voluntary Medical Male Circumcision (VMMC) services to 1,199 fisher folk men out of whom 1,082(90%) were tested for HIV. In addition, 14 peers were identified to be trained on the Stepping Stones EBI to create demand for integrated HIV services, increase risk perception and behavior change among the fisher folk. In the subsequent quarter, the project will intensify the implementation of Stepping Stones EBI sessions in the community to create demand and uptake of HIV services and accelerate behavior change among the fisher community in the major landing beaches as identified.

Activity 1.2 Promote acceptability and availability of condoms Scale up counties: In the quarter under review, 51,466 (Kajiado- 8,571, Laikipia- 4,348, Nakuru- 32,747, Narok-3,487 and Turkana-2,313) people aged 15-49 years were reached with condom promotion messages. Thirty-nine male champions were identified and will be trained as peer educators on correct and consistent condom use, promotion, and redistribution to reach their agemates in all the seven counties. At total of 7,313,542 condoms were dispensed across all the supported sites in the period under review. Of these, 92,567 male condoms were supplied to institutions of higher learning, drop in centers and Salgaa truck park in Nakuru County. There were no stock outs reported during the quarter.

Sustained Counties (Baringo and Samburu): A total of 3,928 (Baringo- 3,030, and Samburu- 898) people aged 15-49 years were reached with condom promotion messages. All facilities were stocked with male condoms in the quarter under review and no stock out reported. There are three male champions in Baringo and Samburu who are trained to promote and distribute condoms to peers. At total of 953,991 condoms were dispensed (Baringo-711,237 and Samburu-242,754). The activity will continue to provide mentorship on condom inventory management through proper documentation on stock cards, reporting summary tools and uploading on District Health Information System (DHIS).

Activity 1.3 Support demand for and uptake of FP services During the reporting period, the Activity technical staff and health care providers continued to sensitize clients on long-acting and permanent Family Planning (FP) methods in addition to condom use as a dual method to prevent unintended pregnancy and HIV transmission. This was done during health talks and support group sessions. In addition, 587 HCWs from 153 public and private sector facilities were mentored on integration of Reproductive Health (RH)/HIV services in line with the MOH minimum package for RH/HIV and AIDS Guidelines (2012), and counseling of mothers for FP during post-natal care including immunization days. As a result, 137 facilities are now offering FP/HIV integrated services compared to 121 in the last quarter. A total of 32,410 clients were reached with integrated services that include HTS in FP clinic, cancer of the cervix screening and FP in CCC clinic. There was a stock out of implants at Rift Valley county referral hospital during the reporting period. Redistribution was done from other facilities within the county after data review, physical count and calculation of consumption rates.

Activity 1.4 Promote and provide Voluntary Medical Male Circumcision. The Activity continued to support Voluntary Medical Male circumcision (VMMC) services in two static facilities and four outreach sites in Nakuru County; and four static facilities and four mobile outreach sites in Turkana County through an implementing partner (AIC Lokichogio). Mobile outreach services were conducted in Nakuru sub counties to reach more clients in the informal sector and those working in the sisal and flower farms.

During the quarter under review, a total of 6,827 males were circumcised. This is 69% achievement against the quarterly target of 9,952 male circumcisions where Nakuru contributed 14% (949) and Turkana 86% (5,878) of the achievement. A further breakdown shows that males aged 10-14 years contributed 38%, males 15-19 years contributed 41%, while those in the 20-29 age group contributed 18% of circumcisions this quarter. The cumulative achievement for the Activity is 12,376, (55%) against an annual target of 22,326 male circumcisions. More focus was directed towards boys out of schools and adults in the community using champions and organized groups to reach them. Of the total circumcised, 4,861 (72%) clients returned for follow up within the 14 days. Those who did not turn up were tracked through phone calls to confirm their wellbeing and advised on wound care and importance of follow up in case of any complication. The chart below demonstrates the VMMC performance as at Q3.

No. Circumcised April - June 2018 7000 5878 6000

5000

4000 2818 3000

2000 1727 1333 1000 580 313 369 158 138 164 73 103 0 April May June Total Naivasha Turkana Nakuru

Figure 1: Performance on VMMC April to June 2018

During the reporting period 15 clients tested HIV positive in Turkana and were referred for care and treatment, while Nakuru reported none. There was no case of tetanus reported post- operative. A total of 11 moderate Adverse Events (AE) were reported but no severe cases were encountered. Three moderate AEs were found in Nakuru and 8 in Turkana; all were managed as per the national guidelines. All the AEs encountered were mainly due to: delayed healing as a result of poor hygiene, and swellings

14 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report due to failure to use underpants particularly in Turkana, and the general failure to follow post-operative instructions given at the clinic or outreach sites. The Activity did not apply any devices (Shang Ring) in circumcision procedures since they are yet to be introduced and MOH is yet to offer tetanus vaccine for the normal surgical circumcision.

The cumulative achievement for the Activity is 12,376, (55%) against an annual target of 22,326 MC. Nakuru contributed 48% (5,896) and achieved 112% of an annual target of 5,288, while Turkana contributed 52% (6,480) of the MCs and achieved 38% of the annual target of 17,038. Nakuru county has met the annual target for VMMC. This achievement is attributed to the concerted VMMC mobilization efforts in the informal sector and organized groups in the community and smaller towns during the December holiday period. The initiative targeted boys out of school, adults and the disadvantaged boys in the small towns of Molo, Njoro, Rongai and Naivasha. This was combined with additional mobilization in the sisal and flower farms using peer educators, community health workers and community leaders that included the chiefs. The fishing folks around Lakes Naivasha and Turkana were provided with information on HIV risk reduction, nutrition, family planning and the use of condoms. The 38% achievement in one quarter in Turkana is attributed to the intensive mobilization through the local implementing partner (AIC Lokichogio) using the locally recruited male circumcision champions in the community and the involvement of community leaders and organized groups in the sub-counties that created conducive environment to operate. The mobilizations strategy targeted boys out of school and adults around smaller towns in Kakuma, Kalobeyei lowarengak and Kataboi. To intensify VMMC services in Turkana, the project engaged two additional locum teams of service providers during the reporting period. The Activity will continue with intensive mobilization in the subsequent quarter in addition to conducting an RRI in the month of July and August so as to meet the annual target.

There were adequate VMMC commodities and supplies during the period under review in both counties and no shortages were experienced in consumables during the quarter. The planned external quality assessment by NASCOP was not carried out in the quarter under review, it is expected to be done in the next quarter. The main data quality issue encountered is the inability of the MOH 731 summary reporting tool to capture data in the finer age group and circumcision activity details as required for PEPFAR reporting. The project continues to customize M&E tools to address the challenge as well as other PEPFAR requirements that are not reported in the national system.

15 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

VMMC Perfomance per age group 3000 2,828 2,623 2,505 2500 2,389

2000

1500 Nakuru

Naivasha circumcisions 1000 893 Turkana 688 Total 322 500 247 202 14490 76 137 39 81 89 68 7 3943 3 8 3344 3 6 1625 0 1 2 3 0 10-14 15-19 20-24 25-29 30-34 35-39 40-49 50+ Age group

Figure 2; Performance on VMMC by age- Nakuru vs Turkana Counties

Activity 1.5 Increase access to PrEP for discordant couples and other high-risk populations The activity continued to support the County and Sub County teams with mentorship and forecasting and quantification of commodities. No stock out was experienced in the period under review. During the quarter, 191 discordant couples were newly identified and 136 (71%) were initiated on PrEP in accordance with the national guidelines compared to the 103 (60%) clients last quarter. Among those clients who were not started on PrEP; 13 are still undergoing preparation,16 opted to use condoms, 16 declined and 10 are still being followed up for linkage. The improvement in performance was due to consistent availability of the preferred regimen drugs, continued mentorship of HCWs on PrEP eligibility criteria and client counseling and education. Of those initiating PrEP, 90% were still active on the regimens by end of the reporting period. Out of the 103 clients initiated in the last quarter, 83 (81%) were still active bringing the to a total to 219 clients currently active on PrEP in the supported sites. Among the 20 (19%) inactive clients; 10 stopped after separating with partners while the other 10 defaulted and are being traced.

The activity mentored 56 HTS counselors on incorporating PrEP in pre- and post-test counseling with focus on linkage to PrEP services in CCC. The activity supported the printing of NASCOP developed PrEP and daily activity registers and this has improved PrEP uptake in some sub counties that were earlier not willing to implement the roll out of PrEP services. The Activity will continue scaling up PrEP services to supported sites through mentorship of providers and ensuring consistent availability of commodities and recording/reporting tools.

Activity 1.6 Gender Based Violence (GBV) prevention and response During the quarter under review the project worked with the MOH in 22 facilities to provide SGBV and post rape care (PRC) services. Supportive supervision was provided to ensure correct filling of PRC forms and registers and completion of the recommended five follow up visits by survivors of sexual violence in keeping with all the required services. The 28 clients served in the quarter under review received a package of services including post exposure prophylaxis (PEP), Emergency Contraception (EC), STI screening and treatment, HIV testing and counseling, trauma counseling and referral for other services within the facility, and externally received services from other service 16 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

providers like law enforcement authorities, including the police. Of the 28 clients initiated on PEP, nine were still on the prophylaxis by end of the reporting period, yet to complete the 28 days dose.

Below is the summary per county:

No. of Total no # Tested # HIV No. No. Given No. Initiated No. facilities of for HIV positive at eligible for ECP on PEP Completed County offering survivors 1st visit ECP PEP SGBV/PRC seen services

Baringo 5 2 2 0 2 2 2 1 Kajiado 4 13 11 0 8 5 12 9 Laikipia 2 0 2 0 1 1 2 2 Nakuru 9 11 11 0 4 3 10 5 Narok 0 0 0 0 0 0 0 0 Samburu 0 0 0 0 0 0 0 0 Turkana 2 2 2 0 1 1 2 2 Total 22 28 28 0 16 12 28 19 Figure 3: SGBV Service Outcomes for Q3 FY18

Activity 1.7 Social protection During the reporting period, 92 existing and newly established PLHIV support groups and 22 community ART groups were sensitized on the Savings and Internal Lending Communities (SILC) methodology in the seven counties. The Activity continued to use the directory of available social protection services that was used previously in the OVC project to make linkages and referrals for clients who required various services. The list was provided to 113 community health volunteers and case managers in the high-volume health facilities and mentorship on use of the tool done. A total of 2,052 HIV clients completed referrals to social protection services with 952 receiving Psychosocial support services and enrollment to SILC groups,181 received OVC services, 101 received legal services,364 who were identified with clinical malnutrition received food and nutrition services while 454 received social welfare services. Completion criteria was confirmation of services received and referral note brought back to the facility indicating services offered to the clients. The table below shows the performance per county. The project rolled out the establishment of psychosocial support services with referral to the community in Turkana and Samburu in the reporting period. Results from this initiative will be reported in subsequent period.

Table 2: Complete referrals to social protection services LEGAL FOOD/ SOCIAL County PSS/SG OVC SERVICES NUTRITION WELFARE Total M F T M F T M F T M F T M F T M F T Baringo 3 33 36 1 4 5 0 1 1 2 3 5 0 5 5 6 46 52 Kajiado 32 119 151 31 18 49 1 3 4 31 12 43 21 76 97 116 228 344 Laikipia 213 378 591 5 7 12 0 0 0 46 87 133 42 128 170 306 600 906 Nakuru 31 113 144 49 61 110 29 47 76 45 138 183 46 98 144 200 457 657 Narok 11 19 30 3 2 5 9 11 20 0 0 0 27 11 38 50 43 93 Samburu 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Turkana 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 290 662 952 89 92 181 39 62 101 124 240 364 136 318 454 678 1374 2052

17 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

OBJECTIVE 2: INCREASED UPTAKE OF TARGETED HIV TESTING SERVICES (HTS)

Activity 2.1 Increase access to facility-based HTS services In the quarter under review, the project supported 315 sites to provide HTS. Of these, 280 received Direct Service Delivery (DSD) support while another 35 received TA support. The sites in the scale up counties (Turkana, Nakuru, Kajiado, Laikipia and Narok) account for 95% of the DSD sites.

The project tested a total of 229,521 clients in the quarter under review. Of those tested 199,144(87%) were from the scale up counties and 30,377 from the sustained counties. A total of 81,793 (36%) of the tested clients were male and 147,725 (64%) were female. Among those tested, a total of 10,895(49% F) were children aged 0 – 10 years, 9,467(41% F) adolescents aged between 11-15 years and 209,156 (66.2% F) were above 15 years of age. A total of 1,977 infants were tested through EID and another 726 eligible males were tested during VMMC. In the five scale up counties (Nakuru, Narok, Kajiado, Laikipia and Turkana), a total 199,144 clients were tested in the quarter under review through the various entry points. The number of clients tested in the quarter in each County were: Nakuru 98,011, Narok 34,246, Kajiado 32,843, Laikipia 18,088, and Turkana 15,956. Overall, in the seven counties, at end of Q3, 672,181(93.8%) clients were tested against an annual target of 716,176. The figures 1 and 2 below demonstrates the county cumulative achievement for testing and positive yield against targets.

Q3 2018 HTS-TST Achievement vs Annual Targets

100% 30% 88% 88% 73% 177% 78% 120% 94% 90% 47,010 80% 52,864 52,101 93,049 98,964 672,181 28,785 70% 299,408 60% 50% 40% 159,211 30% 72,630 58,874 105,229 126,755 716,176 23,930 20% 169,547 10% 0% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Project

Target Achieved %

Figure 4: HIV testing performance as at end of Q3 FY18

Of the tested, 10,057 (1.49%) clients were identified positive, translating to a 65% achievement against an annual target of 15,530. The five scale up counties contributed a total of 591,295 of those tested, which was a 93% achievement of their cumulative target of 633,372. The individual county performance was: Nakuru 299,408(177%), Kajiado 93,049(88%) Turkana 47,010(30%) Laikipia 52,864(73%) and Narok 98,964(78%) respectively.

18 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Q3 2018 Positive Identified vs Annual Targets

100% 12% 468 65% 90% 62% 63% 50% 131% 47% 79% 609 939 80% 633 2,043 291 10057 70% 5,074 60% 50% 3,808 40% 1,225 1,987 30% 1,021 3,242 368 15530 20% 3,879 10% 0% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Project

Target Achieved %

Figure 5: Q3 Cumulative HIV positive persons identified vs 2018 Targets

Through the various entry points - IPD, PMTCT, EID and VCT- a total of 198,654 clients were tested. The breakdown of tested and those positive from these entry points in the reporting period are summarized in the table below.

Table 3: Testing and Positivity by entry point Entry Point Tested Positive Percentage yield OPD 120,897 1,665 1.4% IPD 18,268 330 1.8% PMTCT 30,877 391 1.3% TB 1,323 200 15% VCT 24,779 486 2% Index Client 2,182 276 13% STI 318 2 1.4 Total 198,654 3350 1.7%

In the reporting period, overall, a total of 3,350 clients were identified as positive, representing a positivity rate of 1.45%. Further, this represented 22% achievement against the annual positive target of 15,530. The project is however on course to meet the annual testing targets though more effort will be put in identification of positives through aggressive targeted testing for contacts of index client/ partner notification services, facility optimization at all entry points which include IPD, eligible in OPD using the HTS screening tool, CWC, malnutrition and TB clinics, to improve the positivity yield.

Out of those who were identified positive a total of 2,946 were successfully initiated on ART. This represented a linkage rate of 89% across all the counties as shown in the figure 6 below. In the scale- up counties a total of 3,030 clients tested positive and 2,682 were linked to ART, representing a linkage rate of 86% for the five scale-up counties while in the sustained counties, a total of 320 clients were identified as positive with 264(83%) of them linked to ART.

19 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Q3 Project Linkage Cascade

3883 4000 3350 2956 2946 86% 3000 100% 88% 2000 1000 0 Positive Q3 Positive Enrolled Started ART target Identified

Figure 6: HIV testing and linkage to ART cascade

The Activity continued to support a total of 240 HTS counselors across all the facilities in both scale up and sustained counties. In the facilities that had counselors (DSD) a total of 225,669 clients were tested with 3,292(1.46%) being positive. On the other hand, in TA sites, 3,852 clients were tested and 58(1.5%) tested positive. In these sites, mentorship focused on targeted testing including diagnostic testing and counselling especially due to shortage of staffs to conduct testing. The counselors benefited from 10 observed practice sessions and 22 counselor supervisions from the program staff and SCHMT. The sessions reached a total of 92 counselors in the reporting period. The key themes addressed in the supervision sessions included; correct documentation, correct timing of test, correct review of test kits batch numbers, adherence to the national testing algorithm and retesting for those identified positive. The gaps addressed were documented and will be followed up in the subsequent sessions to ensure impact and implementation.

In the quarter under review, a total of 10 counselors in 7 facilities benefitted from this support. In the reporting period a total of 202 HTS mentorship sessions were carried out reaching a total of 608 health care workers. The mentorship focused on facilitating health care workers to optimize facility testing, improve uptake of index client testing/ partner notification services and quality monitoring. The program further implemented family testing to reach partners and children of index clients in the scale up counties. Out of those eligible, a total of 401 children were tested and 11 were identified as positive representing a 2.7% positivity yield from index client testing among children. To achieve the HTS targets in line with “Test less, Yield more”, the Activity will focus on two main strategies namely; facility optimization and testing of contacts of index clients (family and sexual network testing) The activities that will be conducted include: matching of the number of sessional counselors to the workload in the facilities with a focus on high volume facilities, integrating testing into the various clinical areas like TB, STI clinic, Emergency department, nutrition service point, VMMC and MCH, use of the screening tool to be able to increase focused identification of clients eligible for testing in OPD, increasing the capacity of health care workers to carry out sexual network testing, documented referrals and linkage, accounting for each positive identified and scale up of Partner Notification Services (PNS) to all sites including Turkana and Samburu. with sessional counselors in all counties except Samburu and Turkana. In the subsequent quarter, trainings on PNS shall be done in Samburu and Turkana counties to improve on the positive yield.

The Activity will continue with other routine support activities to support increase in facility based HTC services including; continued paying of salaries for sessional counselors, provision of basic

20 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report supplies and recording and reporting tools, quality assurance support, training of counselors on HTS guidelines updates and provision of timers, mentorship of counselors who had unsatisfactory PT results, convening of continuum of care meetings to review missed opportunities in linkage of clients in the various CCC and provision of allowances for peer educators. Further, the counselors were also provided with updates on HTS guideline testing, new data tools and job aids in the reporting period.

The Activity supported the various counties to report, forecast and quantify adequate supplies of rapid test kits from KEMSA. The project supported at least one meeting per county, sub county and high- volume sites to sensitize HCWs on timely and quality reporting per County. Stock outs were experienced in Baringo and Laikipia counties during the reporting period, and this was addressed through rapid test kit re-distribution from the sites that had additional kits to support the facilities with a severe shortage. The stock outs were caused by delays in deliveries of ordered test kits. Further, the Activity continued to orient the Sub County Medical Lab Technologists to adequately forecast HTS service demand and request for rapid test kits using the Health Commodity Management Plan system (HCMP). A total of three SCMLTs were orientated in the reporting quarter. The Activity continued to support the Commodity TWGs to meet for the quantification exercise in addition to addressing other commodity challenges.

Intensify identification of HIV-positive children (under 15): During the quarter under review, 10,895 children under 15 years of age were tested for HIV excluding PCRs. Among those tested in the quarter under review, 131 were identified positives, translating to a positivity rate of 1.2%. In the same period 1,363 individual PCRs tests were analyzed of whom 35 were confirmed positive translating to a positivity rate of 2.6%. Of the 38 positives identified, 30 were newly enrolled and initiated on ART giving a linkage rate of 86% for this population. The performance is attributed to intensive case finding in MCH thus reaching to the HEIs, and targeted testing of children in IPD and CWC, with mentor mothers, mentor fathers and case managers ensuring effective linkage. The project team will continue with mentorship on targeted testing in children focusing in the CWC, IPD and children of index clients to improve on the positive yield. The project continued supporting index client testing as one of the modalities to improve identification of children. Through this modality, 401 children were tested of whom 11(2.7%) were identified positive.

A total of 103 PMTCT high volume facilities have systematic synchronization of EID with the immunization schedule. With this approach, expanded screening of all children in OPD, IPD and CWCs occurred using the mother baby booklet, immunization registers and the FHI 360 ‘See, Ask and Offer’ strategy followed by a DBS/PCR where indicated.

Mentorship of HCW was conducted on the revised HTS guidelines with an emphasis on effective linkages. Further, a total of 713 HCW in PMTCT implementing facilities were mentored on EID services and on how to facilitate fast tracking of results through continuous review of the NASCOP EID website and use of the toll-free SMS platform. To support this further, the program linked a total of 73 facilities to the five laboratory hubs (one per County in Nakuru, Kajiado, Narok, Laikipia and Baringo) to improve the turnaround time for results to five to seven days and improve on documentation. The lab hubs in addition facilitate quick printing of results. Samburu county will as well have a laboratory hub where 17 facilities will be linked by APR.

Intensify identification of HIV-positive adolescents (>15 years) and young people (15-24 years): In the reporting period, a total of 79,636 adolescent and young people (AYP) were reached with HTS. Of these, 548(0.68%) were identified positive. Of the tested AYP, 55,005(69%) were females of whom

21 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

482(0.87%) were positives. Females accounted for 88% (482) of the positive AYPs identified during the reporting period. Of the 548 identified positive, 407(74%) were linked to ART. The program also carried out family testing, Index client testing and Partner Notification Services. A total of 460 eligible adolescents and young people (10-24 yr. old) were elicited, of whom 225 (49%) were tested, with 18 (8%) being identified positive, and 18 (100%) linked to ART. Owing to the low yield in general facility testing for AYPs as shown above (0.68% positivity) the Activity will strengthen PNS and facility optimization through use of HTS screening tool to improve on the yield in this population in the subsequent periods. A total of 77 facilities provided adolescent friendly services in the quarter of which 62 provided weekend clinics and/or extended hours to reach and serve a large population of adolescents and young people. A total of 76 adolescent champions were situated in these clinics to offer comprehensive package of care and treatment services including HTS at the convenient times.

Activity 2.2 Index /sexual network/ family testing at the facility and community level Cumulatively, a total of 205 HTS counselors were trained on partner notification services, to equip them with the knowledge and skills to elicit contacts of index clients and have them tested to improve the yield. The Activity MDTs mentored the counselors to prioritize testing of contacts of index clients who are brought/referred to the facilities, and this encouraged clients who needed testing to come to the facilities for testing. As at end of the reporting period a total of 121 facilities offered PNS, up from 118 sites in the previous quarter. During this reporting period, the HTS counsellors identified, a total of 1,275 new clients, this resulted into 2,238 (915 female) contacts being elicited of whom 117 were known positives. 2,125 of the contacts were eligible for testing, 1096 (52%) were tested with 131(12%) being positive, and 128 (98%) were linked to ART.

The graph below represents a cascade PNS testing and outcomes.

PNS Outcomes Oct 17 to June 18 2500 2,238 2,125 2000

1500 1,275 95% 52% 1,096 1000

500 12% 131 98% 128 0 Tested Positive Contacts Contacts Eligible Contacts Tested Positive Linked Identified for Testing

Figure 7: Partner Notification Services/Sexual Network Testing Outcomes

22 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Activity 2.3. Link HIV-positive clients to care In the reporting quarter, the project identified a total of 3,350 positive patients and 2,946 (88%) were linked to ART. To improve on linkage referral and retention the project ensured availability and correct use of linkage registers in all facilities. All facilities in Nakuru, Baringo, Kajiado, Narok, and Laikipia had the linkage registers. However, gaps were still identified in availability of the registers and directories in Turkana and Samburu counties. The project continued distribution and dissemination of the registers and offering mentorship on their correct use. In addition, the project ensured the availability and use of directories across all supported sites. The directories were used to improve inter-facility and community referrals.

The project supported 103 link persons/ case managers in 100 high volume sites across the seven counties in the reporting period. The link persons and case managers stationed in facilities facilitated the linkage of the clients identified positive, provided continued posttest, pre-ART and adherence counselling in addition to updating the adherence calendar, adherence register, linkage register and further supported patients as treatment buddies in their treatment journey and following up those who miss scheduled clinic appointments.

Crude linkage of clients tested positive in the quarter under review was 88%. The difference between the total testing positive and those initiated new on ART in the quarter is 404. Of these clients, 130 were initiated ART in same facilities that are not project supported sites, 34 were referred for treatment in facilities of the clients’ choice and were confirmed to have been linked and started on treatment. This brings the effective linkage to 94% of the total identified positive in the reporting period. In addition, 39 were enrolled and still in preparation phase before treatment initiation, 188 declined linkage and are still on follow up, and 13 died before initiation. The project will continue to strengthen physical linkage using linkage officers and case managers who support continued post-test counselling to clients and follow up of those yet to be linked to treatment.

The program supported 98 facilities with mobile phones and airtime in the quarter. The phones and airtime were used by the linkage facilitator/case managers to facilitate complete referrals. In the quarter, the program supported 16 facilities with point of care CD4 devices across the seven counties. The devices were used to analyze 1,531 CD4 samples in the reporting period which represented 52% of the patients newly enrolled in care within the quarter as shown in the table below. Conventional CD4 platforms at Maralal CRH in Samburu county, Nakuru PGH, Naivasha, Subukia and Molo in Nakuru county, Kabarnet CRH in Baringo county, Oloitoktok and Kajiado CRH in Kajiado county and Nanyuki referral, Ndindika and Rumuruti in Laikipia county had stock out of CD4 reagents thus affected the number of samples analyzed contributing to the poor uptake of CD4 testing among the newly enrolled. The project facilitated networking of the samples to the nearby facility with POC CD4 for analysis.

23 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

County CD4 CD4 COUNT CD4 CD4 COUNT >250 <100 COUNT<250 Nakuru 838 76 133 629 Kajiado 279 49 73 157 Narok 163 26 34 103 Laikipia 55 5 10 40 Baringo 165 21 45 99 Samburu 22 2 7 13 Turkana 9 1 1 7 Table 4: CD sample outcomes

In the quarter under review, a total 8 ,044 clients were referred for various services both in the facility and community out of which 7 ,146 were complete referrals. A total of 2,052 were facility to community referrals and 5.094 were community to facility referrals.

To ensure provision of psychosocial support to clients in supported sites, the Activity supported 880 facility-based support groups. The support groups were of different types namely; adult, adolescent and PMTCT support groups. The support groups have contributed to the improvement of retention from 86% in previous quarter to 91% among clients enrolled in the PSSGs in the current reporting period and acted as a platform for the sharing of information on quality of care for the specific client category. In the support groups a total of 12,173 clients in the quarter also received quality PHDP services.

OBJECTIVE 3: IMPROVED LINKAGE TO TREATMENT FOR INDIVIDUALS NEWLY TESTING POSITIVE FOR HIV

In the reporting period, a total of 2,946 clients were initiated on ART in all the 175 supported sites across the seven counties. This represented 88% of those eligible for initiation on ART in the quarter. Thirty-nine clients were enrolled but still on treatment preparation phase. The graph below represents the overall cumulative project and county specific linkage to ART rates for the review. Cumulatively, 8,805 clients have been newly started on ART, an achievement of 60% against the annual target of 14,653. The five scale-up counties contributed 8,551(97%) of the cumulative new on treatment and 67% achievement against a scale up counties annual target of 13,231. In the subsequent quarter, the Activity will focus on partner notification services with aggressive testing of contacts of index clients, and facility optimization at all entry points using the HTS screening tool, with aim of improving the yield with improved linkages through escorted referrals to achieve the annual new on treatment target. The low linkage to ART in Kajiado County is attributed to clients being initiated on ART in same facilities that are non-Projected ART sites yet projected HTS sites.

24 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

HSDSA Cluster 2 Overall Crude Linkage to ART 120% 107%

100% 91% 92% 85% 88% 79% 78% 77% 80%

60%

40%

20%

0% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Project 633 2043 609 5074 939 291 468 10057

Figure 8: Percentage of positive clients linked to ART

The 2,946 patients that were new on treatment were distributed as follows in terms of age and sex: 156 (41% F) under 15 years, 407 (86% F) between 15-24 years, and 2,383 (62% F) above 24 years. By the end of the reporting period, the project supported a total of 59,808 patients as current on care with 59,769 (99.9%) of them on ART, translating to an achievement of 86.6% against an annual target for current on ART of 69,000 from 174 supported sites. Of clients currently on ART, 4,412 (7.4%) are children while 5,351 (9%) are AYPs. A total of 802 health workers were mentored on the new ART and PMTCT guidelines during the reporting period aimed at enabling HCWs to facilitate fast tracking of clients to initiation on ART as per the revised national guidelines. With this guidance facility were also mentored on ensuring baseline CD4 is done on enrolment of the clients and networking of the CD4 samples where POCs not available facilitated by the project to ensure same day testing for the new clients. All the 175 ART supported facilities have rolled out test and treat approach and differentiated care; the two main models adopted being spaced out appointments for clinical review and the community ART group models, both peer led, and health care worker led. The program supported linkage facilitators in 100 facilities (both ART and non-ART sites) who facilitate physical escort and linkage of clients where feasible. To support effective linkage further, the program is in the process of developing a linkage application that will work on a mobile platform. This app will help case managers track referral completion at various end points once the patient has completed the linkage process. The mobile app will be tested and rolled out in the subsequent reporting periods.

Scale up Counties (Nakuru, Kajiado, Laikipia, Turkana and Narok): The five scale-up counties had 2,626 clients started on ART in the quarter under review, translating to a cumulative 7,986 clients, (60% of annual target of 13,231) initiated on ART, 98.0% of the total initiated. A total of 55,412 clients (87.4% of annual target of 63,368) were on ART as at end of the reporting period, a contribution of 93.7% of the total clients on ART in the project. The project mentorship team reached 802 HCWs through CMEs and mentorship on ART related areas including the test and start guidelines, differentiated care, patient monitoring using VL and defaulter tracing.

Sustained counties (Samburu and Baringo): The counties had 264 clients initiated on ART translating to 763 started, a 53.6% cumulative achievement against an annual target of 1,422. A total of 4,357 (77.3% against annual target of 5,632) clients were on ART at end of reporting period. During

25 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report the reporting period, 1385 HCWs were reached with capacity building activities including CMEs, mentorship and OJT on HIV treatment for adults, children and adolescents.

Activity 3.1 No-missed-opportunity approach to ART enrollment The program supported all facilities to implement targeted same day initiation on ART. These facilities further conducted immediate adherence counseling as outlined in facility adherence calendar. Of the clients enrolled and initiated on treatment, 94% were initiated the same day while the remaining were initiated within 2-8 weeks of enrolment. TB/HIV coinfected clients contributed to the majority of those who took longer before initiation on treatment (up to 8 weeks) before initiation. To further support no missed opportunity approach in HTS, 109 high volume facilities have rolled out case management focusing on the newly enrolled, the defaulters traced back, suspected treatment failure clients and PMTCT mothers/mother-baby pair. The case management approach is being currently implemented in 109 (63% of all ART sites) ART facilities which include the 83 high volume sites, and this has assisted the follow up and intensified adherence of those newly initiated on ART. The staff supporting case management are expert clients, adherence counselors and the health care providers working in the CCC department. In addition, these facilities have assigned case managers to the wards to facilitate and coordinate ART preparation and initiation processes.

To strengthen integration of ART services within other departments, the project continued with mentorship and provision of basic infrastructure (furniture, basic renovation). A total of 233 PMTCT sites offered ART onsite across the seven counties. These sites offered ARV through physical linkage to CCC or issue ARVs on site but do not give the full complementary package. All the PMTCT high volume sites across all counties except Turkana and Samburu have fully integrated CCC services in MCH (mini CCCs). The project will continue in supporting integration of services to more sites in Turkana and Samburu in the subsequent quarter. To further integrate ART into other departments and reduce missed opportunities, ART was offered in TB department in 117 sites. To increase the ART clinic days and hours a total of 114 high volume facilities were supported to offer ART services for extended hours. The extended times included; all weekdays for a minimum of 8 hours (some facilities were not having clinics on daily basis), weekends, early morning and late afternoon appointments specifically targeting men and AYPs.

The program currently supports a total of 12 (Kajiado 2, Nakuru 4 and Narok 6) static outreach sites that are stations for providing ART to clients. The project plans to scale up to 20 static outreaches in the subsequent quarters across the seven counties. The project will in addition map out mobile outreach sites in Laikipia, Turkana and Samburu, where mobile populations exist due to nomadic lifestyle and farming.

Activity 3.2 Increase ART uptake among HIV-positive children and adolescents In the quarter under review, 156(41% F) children under 15 were newly initiated on ART. Of the 166 positives newly identified positive in the reporting period, 156 were initiated on treatment translating to a linkage rate of 94%. This was made possible by the escorted referrals done by the mentor mothers and linkage officers. In addition, for the HEIs confirmed positive, the project facilitated immediate access to results through printing and delivery of results and subsequent calling of the parents/guardians to come back to the facility with the child for initiation on treatment. The project provides the phones and airtime. The remaining 3 HEIs are being tracked for initiation on treatment. Currently, the project has 4,412 (48.1% F, 7.4% of total project) children below 15 years current on ART. A total of 407 (86% F) adolescents and young people aged between 15-24 were initiated on ART, while 5,351 (75.6% F, 9% of total project) AYPs are currently on ART as at the end of the

26 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report reporting period. The linkage to ART rate for this age group was 74% (548 positives identified), which is the lowest among all the age groups. To facilitate and strengthen linkage, and ART initiation in children, a total of 68 adolescent case managers/linkage facilitators were engaged to physically escort adolescents for immediate enrollment and ART initiation. To ensure quality service provision and retention of children and AYPs in care and treatment, the project facilitated chart abstraction and reviews for all ART files to review status of viral load monitoring and active defaulter tracing for children and adolescents who had defaulted from care. In the reporting period, the project supported 77 facilities with functional pediatric, adolescent and family clinics. The clinics provided comprehensive care services to the pediatric and adolescent patients and their care takers. During clinic days, the process of disclosure was assessed for the clients to improve disclosure rates. In Turkana and Samburu, the program identified 6 high volume facilities- based spaces and started the process of having them established to offer adolescent specific services. The project supported the facilities to hold weekend clinics for pediatric and adolescents, to reduce on missed opportunities for those going to school/college. In addition to the clinical review and receiving their refills, those eligible for collection of viral load test results had samples removed and sessions for disclosure, adherence, patient literacy conducted. The clients also engage in age appropriate fun activities such as playing football, volleyball and other games. To improve parent/ child treatment literacy, mentored 199 providers in the 77 facilities to facilitate age appropriate adherence counseling and disclosure.

Activity 3.3 TB/HIV co-infection services Early identification, treatment and prevention: The project supported TB identification and treatment activities in a total of 175 sites in the 7 counties. In the quarter under review, 53,456 clients in care were screened for TB symptoms at their last clinical visit. This was 89.4% of the 59,769 current on ART as at the end of the reporting period. The below 100% screening was mostly due to documentation issues with Health Care Workers (HCWs) at times not documenting screening in the standard MOH recording tools i.e. they record in the blue/green card and forget to document the same in the ICF tool. By end of third quarter, 8,805 (14.7%) of registered new and relapsed TB cases had their HIV status documented in the IM supported sites, translating to 56% of achievement against the annual target for testing and 54.7% achievement of TB case identified against an annual target of 7,484. Of the 1,053 coinfected clients, 993(94.3%) were started on ART. This translates to an achievement of 44% against an annual target of 2,276. Of the identified positives, KPs were (63%) while newly tested positives were 200 (37%). Coinfection rate in the scale up counties was 63% while for sustained counties was 34%. The sub optimal achievement is attributed to documentation especially of those already on treatment at time of TB diagnosis, and those referred/getting treatment from ART sites away from where they are collecting TB treatment. In addition, the clients initiated on treatment within the recommended eight weeks but after the reporting period are missed out. Data reporting cycle for SCTLCs for uploading to TIBU system also affects the reporting as the reporting dates are not consistent. The project continues to provide mentorship and OJT to improve on timely initiation of ART for TB/HIV co-infected persons, integration of ART in TB clinics and correct/timely documentation and reporting.

A total of 7,916 clients completed the 6-12 months IPT course during the reporting period. This is 95% of 8,332 who were expected to complete a course of TB preventive therapy. The performance was not a true under-performance but was more of a data capture and reporting issue. The previous MoH tools did not capture this indicator adequately thus resulting in under-reporting. The reporting challenge has been mitigated by the recent rolled out NASCOP reporting and recording tools which addressed this reporting gap. There were no stock outs during this reporting period. The project will

27 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report continue supporting recording of IPT into the DHIS2, provision of standard operating procedures(SOPs) and ensuring commodity security through correct and timely commodity forecasting. With a view of improving IPT uptake further, facilities were supported to integrate IPT in supported monthly data review meetings and 157 HCWs mentored on the commodity inventory management system. The project also liaised with USAID TB ARC project on sample collection and transportation for drug susceptibility testing for suspected cases of drug-resistant TB.

TB infection control assessments were carried out in all high-volume facilities during the reporting period. Some of the gaps identified included documentation challenges, lack of designated cough corners in some facilities, TB Infection Prevention Plans that were not up to date among others. These were addressed through mentorship, orientations and engaging facility management and MOH focal persons.

Activity TB Cascade (Apr-Jun 18)

1623 1560

96%

25% No ofNoPax 389 94% 367

TB Cases Detected TB Cases Tested TB Cases HIV+ve TB Cases on ART

Figure 9: TB Cascade Apr – Jun FY18

Scale up counties (Nakuru, Kajiado, Laikipia, Turkana and Narok): In the Apr to June 18 period, clients were screened for TB at least once. 1,560 of the new and relapsed TB patients had their HIV status established of whom 25% were coinfected; of these, 921 (96%) were initiated on ART. The project team continued with mentorship of HCWs on the 5Is (intensive case finding, IPT, immediate initiation on ART for coinfected patients, infection prevention and integration of services) to improve the quality of care for TB clients and improve on infection prevention. The project distributed ICF cards for facilities in need during the mentorship visits. Health care workers at 117 facilities were reached with CMEs and supportive supervision on timely initiation of ART for TB/HIV co-infected persons and integration of ART in TB

3.4 Expanding intervention to increase screening and diagnosis of TB Of the 59,769 clients eligible for TB screening 55,412 (92.7%) were screened using the national Intensive Case Finding (ICF) card. The percentage of eligible patients screened for TB per county was: Nakuru 8%, Narok 93.3%, Laikipia 99.96%, Kajiado 97.8%, Baringo 96.3%.

During the quarter under review, 6,003 GeneXpert samples were processed and results relayed back to facilities within a turnaround time (TAT) of 48 hours which is excellent performance above the

28 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report normal five to fourteen-day TAT. Of those processed in the reporting quarter, 755(12.5%) were confirmed positive cases and all were initiated on TB treatment. The percentage utilization of GeneXpert machines in each county was; Nakuru 54.7 %, Narok 71%, Kajiado 66%, Laikipia 66 %, Baringo 28% and Samburu 44%. This is against the national set target of 80%, but in comparison to previous quarters, the utilization in Nakuru, Kajiado and Samburu Counties improved. The figure below shows facilities that had a reduction in utilization. The reduction in utilization for Narok CRH, Nanyuki TRH and Kabarnet CRH is attributed to malfunctioning of the equipment and connectivity into the GeneXpert laboratory information management systems. The Activity has supported in replacement of the module at Narok CRH. To improve the uptake, the project will continue with capacity building of HCWs through mentorship and CMEs on use of GeneXpert for TB diagnosis, improved documentation and laboratory sample networking. In addition, the project will continue supporting sample networking for GeneXpert to the lab hubs through human courier and the hub and spoke model.

GENEXPERT UTILIZATION RATES

Jan-Mar 18 Apr-Jun 18

128

100

85

81

80 80

71

66 66

64

57

53

52

51.3

47

45

44

37

36.4

31

22

21

19 10

Figure 10: GeneXpert utilization rates

ICF tools, GeneXpert testing algorithms, and TB ART charts were among the job aids and SOPs disseminated to supported sites during the reporting period. The project prioritized the scaling up of TB screening in IPD and OPD, including CWCs, to increase identification of adult and pediatric TB cases and laboratory sample networking for GeneXpert. Other areas of focus were implementing segregation of coughers, fast-tracking TB diagnosis, use of referral directories to aid linkage of TB clients in private facilities and escorted referrals from TB clinics to CCCs. A total of 117 facilities had integrated ART within TB clinics, and TB into MCH and 76 facilities implemented patient follow-up by case managers including Directly Observed Treatment (DOT) using a scheduled tracker.

Activity 3.5 Reach children with TB screening and diagnosis. The project continued mentoring HCW on diagnosis of TB in children using GeneXpert as gold standard, and the procedure for getting sputum specimen for children. During the quarter under review, 227 pediatric sputum samples were analyzed using GeneXpert; 9 (3.9%) were TB positive. In the same

29 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report period, out of the children screened for TB using the ICF card, 27 were confirmed to be HIV coinfected. All were started on treatment for TB as well as ART. The project collaborated with the national TB program and TB ARC to provide easy to use pediatric formulations including pyridoxine. Mentorship of HCW was conducted to facilitate scale up of tuberculin skin test to aid diagnosis especially in children, improve index contact tracing by ICF for symptomatic children of index clients and children living with HIV. In addition, 96 facilities implemented integration of TB services into MCH and pediatric wards.

Activity 3.6 Link HIV-positive and TB clients with nutrition assessment. During the period under review, the Activity continued to provide mentorship to HCWs on nutritional assessment at every clinical visit with proper documentation done for Body Mass Index (BMI), Mid Upper Arm Circumference (MUAC), height and weight measurements in the standard recording tools and referral of malnourished clients to nutrition support programs as required. The project also provided 20 BMI charts, 23 pediatric weighing scales, 21 adult weighing scales, 29 adult MUAC tapes, 48 pediatric MUAC tapes,34 Nutrition SOPs and assorted nutrition job aids in the supported sites to aid in nutrition decision making at facility level. The Activity continued to support the mentorship of HCWs to conduct NACS to all HIV and TB patients as a routine, promote good dietary practices among PLHIVs/WRA/Children and high-impact nutrition interventions (HINI). Nutrition counselling was provided to all HIV patients routinely with messages tailored to unique client needs where necessary. Referrals were done for eligible patients to other services such as NHP plus Food by Prescription and linkage to community livelihood support initiatives done where required. Supported facilities were also linked to commodities with strengthened recording and reporting of nutrition services.

OBJECTIVE 4: INCREASED UPTAKE OF AND ADHERENCE TO QUALITY HIV TREATMENT SERVICES

The Activity continued to facilitate commodity security meetings in all the supported counties, guided by the developed terms of reference (TOR) for the meetings. The Activity facilitated rapid test kits (RTKs) allocation and quantification forums in five counties, and supported reporting system data review in Turkana and Samburu. All the sub-county medical lab technologists (SCMLT) and sub- county pharmacist were provided with data bundles for monthly commodity reporting using DHIS2, LMIS and HCMP. This has resulted in sustained reporting and timely request of ARVs leading to sustained availability of basic commodities for HIV services provision. HSDSA conducted a sensitization of county managers on commodity security, which resulted in execution of commodity TWG meetings and training of staff, in Samburu and Turkana counties, on reporting and requesting Antiretrovirals on DHIS2. The Activity will support the development and adoption of commodity security TOR in the two counties within the next quarter.

4.1 Health Commodities The five Scale up counties (Nakuru, Kajiado, Laikipia, Turkana and Narok) have functional commodity security TWG. Besides Narok, all the rest held quarterly TWG meetings. Narok county opted to focus on strengthening sub county TWG, which resulted in five sub counties holding meetings which focused on online commodity reporting. This has resulted in improved DHIS2 reporting rates and adherence to the NASCOP transition from LMIS reporting system. Similarly, sustained counties of Baringo and Samburu held similar meetings. The meetings focused on identifying and addressing key commodities management and reporting challenges in the context of the national guidelines include those on: quantification, forecasting, ordering, storage, redistribution, stock taking and

30 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report management, dispensing, expiry tracking, reporting tools and use of DHIS2 for reporting. The sessions also discussed HCW training and mentorship to build on needed skills in these areas.

A total of 66 HCWs from 41 facilities across seven counties were mentored on health commodities management focusing on; quantification on EMMS commodities, stock control, storage, timely reporting, proper disposal of health commodities. Monitoring of expiries by use of expiry tracking charts, RT/pharmacovigilance/ADRS reporting in LMIS and DHIS2 and using ADT systems. In the coming months, the Activity will conduct DHIS2 orientation for staff from ordering sites.

Strengthening Health Commodities inventory management and reporting systems: The activity continued to support the use of web-based ADT in 33 facilities [Kajiado (14), Laikipia (3), Narok ( 6), Baringo (3) and Nakuru (6)]. It supported upgrading in one facility in Nakuru county and there is a planned refresher orientation on web-based ADT and subsequently followed by accelerated upgrading. The web-based ADT has added value to quality of patient care since it accesses viral load results due to its interoperability with NASCOP EID/VL website. This has resulted in elimination of stockout in facilities and improved quality of care. The project plans to support scale up of the use of this system in more facilities in the next reporting period.

The Activity supported monthly quantification and request in 35 ART ordering sites in all supported counties as evidenced by monthly facility consumption data report and requests. In addition to mentorship, HSDSA provided pharmacists with airtime and data bundles for internet connectivity and supported monthly facility data review meetings at sub county level. This intervention facilitated efficient transition uploading of commodities reports in DHIS from LMIS as show in the below diagram.

HSDSA Cluster 2 ARV reporting rates performance 100%

80%

60%

40%

20%

0% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana

Apr-18 May-18 Jun-18

Figure 11: County ARV reporting rates Apr-June 2018

DHIS2 reporting having been newly introduced in this FY 18 has had challenges which the activity is working with counties in addressing. Key among the challenges is that not all staff in ordering sites have been allocated data entry rights and not all facilities are allocated data sets. The activity is planning to work closely with county pharmacists and HRIOs on orienting staff in Nakuru, Kajiado and Turkana counties. Laikipia and Samburu county was supported in the last month of the reporting period on DHIS2 orientation.

31 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

The project supported distribution of assorted job aids, SOPs and recording tools in 93 ART/PMTC sites (Nakuru 46, Laikipia 3 and Narok 6, Baringo 10, Kajiado 21, Turkana 7). The tools included: dosage charts, DAR for ARVs &OIs, FCDRR, FMAPS, and bin cards. Other job aids and SOPs included: Dispensing checklist, good dispensing practices, expiry tracking charts, good storage practices for health commodities, pharmacovigilance job aids and pediatric dosing charts/wheels.

To sustain gains made in DHIS2 reporting, the Activity plans to continue: providing mentorship to MOH staff on DHIS2 reporting; working closely with the county and sub county pharmacists, HRIOs and NASCOP to address challenges identified in allocation of data sets, allocation of data entry rights; and sharing feedback with KEMSA on aggregation consumption report. Redistribution of nutritional supplements and RTKs was done in Narok, Laikipia and ARVs in Turkana. The Activity supported provision and distribution of huduma chap cards and pill carriers among adolescents, children, youth, STF clients and stable clients to facilitate adherence.

In Turkana and Samburu Counties, the Activity has made steadfast engagement with the county, sub county and facility management teams. In Turkana, the project addressed emerging concerns relating to decentralization of ART ordering sites from Lodwar to Lokichar and redistribution of ARVs from Lodwar county referral hospital to other sites. DAR and FCDR copies were distributed to St Monica, St Catherine, St Mary’s Kalokol, AIC Kalokol, RCEA Lokichar, Katilu, Kianuk and Lokori PHC. The process of ART decentralization commenced in Turkana South in collaboration with SCHMT and county pharmacy team. The activity supported orientation of ten staff on DHIS2 drawn from ordering sites in Samburu. The Activity will continue to support HCW mentoring in these sites on commodity inventory management and monthly reporting on DHIS2 as guided by NASCOP. During the introduction meeting with County pharmacists in Turkana and Samburu, the project discussed action plans for establishment of commodities TWGs in the two counties. Turkana already has an active FP commodity TWG that has had challenges meeting regularly due to members having other County competing tasks. The project will support sensitization of County managers on commodity security and other aspects of commodity management in the next quarter geared towards establishment of one County commodity TWG and development of TORs for the TWGs in the subsequent quarter.

Finally, a baseline assessment for commodity services was conducted in all counties during the reporting period. This informed the implementation of some of the afore mentioned activities, thus resulting in increased access and availability of ART commodities.

Activity 4.2.1 Strengthen lab networking and services All ART sites are linked to laboratory networking and specimens are shipped through human courier whereby HCWs are reimbursed cost of transportation incurred for delivery of samples to lab hubs, this is supported through costed joint workplans between the project, HMTs and SCHMTs. During the reporting period the program supported shipment of samples as shown in the table below.

Table 5: Lab network/sample shipment COUNTY CD4 GeneXpert EID VIRAL LOAD Nakuru 838 2942 1158 9227 Kajiado 279 1017 438 2769 Narok 177 544 166 1103 Laikipia 55 505 145 1290 Baringo 165 655 109 1054 Samburu 25 340 31 279

32 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Turkana 9 0 119 941 Totals 1548 6003 2166 16663

There are five laboratory hubs within the region of HSDSA coverage, where laboratory data clerks have been engaged to conduct data entry; these are Nakuru PGH, Narok CRH, Kitengela SCH, Kabarnet CRH and Nanyuki TRH. Using the hub and spoke model, majority of the county ART sites are shipping both EID and Viral load samples to the linked laboratory hubs. The hubs are supporting 75 sites: Nakuru PGH-32, Kitengela SCH-9, Kabarnet CRH-7, Nanyuki Teaching and Referral Hospital- 4 and Narok CRH- 23. The introduction of Laboratory hubs has led to improved access and coverage to testing services. Also, the hubs have taken responsibility of preanalytical sample quality, hence reducing rejection of samples in the referral laboratories. The turnaround time has also reduced from the previous 20 days to an average of 10 days. Samples are shipped within 48 hours from the peripheral facilities to the laboratory hubs and referral laboratories. Specimens are packaged in accordance with the recommended sample shipment procedures and recommended biohazard guidelines. The average turnaround time (TAT) of samples from collection to delivery of results back to the facility is as follows: CD4 - 48hours, geneXpert - 48 hours, EID 10-14 days, viral load 10 - 18 days. The TAT of EID and viral load is high due to equipment down time in one referral laboratory and also the SMS platform for transmission of viral load and EID results/alerts was down.

The Activity technical officers continued with mentorship reaching 178 HCWs in the period. The mentorship focused on the use of VL for monitoring ART patients, improved patient literacy, color coding of patients’ files, synchronizing VL and EID sample collection with the clients’ appointments, timely reporting including submission of commodity reports through HCMP, and linking all ART and PMTCT sites to the lab network among other activities. The program supported five counties Kajiado, Narok, Nakuru, Samburu and Baringo in laboratory data reviews and quarterly commodity allocation/quantification of HIV RTKs. This has led to better forecasting and quantification thus no stockout reported in the quarter under review.

Activity 4.2.2 Laboratory quality and accreditation FHI 360 CDC laboratory systems strengthening program alongside HSDSA cluster 2 supported the following SLMTA and CQI facilities: Nakuru PGH, Langalanga SCH, Molo SCH, Olenguruone SCH, Naivasha SCH, Gilgil SCH, Njoro SCH, Rongai HC, Kapkures HC, Keringet SCH, Bahati SCH, Narok CRH, Ololulunga SCH, Kajiado CRH, Kitengela SCH, Loitoktok SCH, Ngong SCH, Ongata Rongai SCH, Baringo CRH, Marigat SCH, and Eldama Ravine SCH. SIMs assessments by project staff were done in the following sites Narok CRH, Mulot HC, Nairagie Enkare HC, Sogoo HC, Ololulunga SCH, Ongata Rongai SCH, Kitengela SCH, Ngong SCH, Kajiado CRH, St. Therese Dispensary, Embulbul Dispensary and Eldama Ravine SCH. The gaps identified were shared with the facility management and the laboratory staff during the debrief meetings. The non-conformities were on improper documentation of corrective actions, non-enrollment of some HIV core tests EQA program and stock out of laboratory commodities. The team developed a remedial action plan which will be followed up in the subsequent quarter.

4.3 Health Facility Staffing The project continued to support facility contracted staff in all 7 supported counties. It continued to engage a total of 1,070 facility-based staff (670 clinical staff and 400 expert clients/volunteers) on short hire basis pending completion of full transition to be managed by an HRH services management contractor expected to come on board in the next quarter. Table 6 below outlines the number of facility staff supported in the various counties disaggregated in various cadres providing HIV/AIDS services

33 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report and general support to county health systems. The project conducted rapid facility baseline assessment covering a sample of 46 facilities across all the 7 counties. The survey encompassed HRH assessments aspects including ; numbers of staff providing HIV/AIDS services, priority capacity building needs and performance management.

Table 6: Facility Staff Numbers by County and Cadre as at June 30, 2018 Grand Cadre of Facility Staff Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Total Adherence counselor 5 9 4 34 5 5 10 72 Adolescent champion 5 14 8 37 6 3 3 76 CHV 9 18 11 23 8 4 9 82 Clinical mentor 2 2 4 2 10 Data clerk 1 1 1 3 1 3 6 16 Expert client/link 8 18 6 45 9 5 12 103 desk/defaulter tracer HRIO 3 6 4 24 2 3 42 HTS Counselor 20 32 22 96 34 13 23 240 Hygiene assistant 4 4 Laboratory Technologist 2 7 4 10 3 6 32 Mentor father 5 8 3 20 2 2 40 Mentor mother 6 21 8 42 10 3 9 99 Nurse 6 15 6 47 15 2 18 109 Nutritionist 2 1 3 5 4 15 Pharmaceutical Technologist 4 4 2 13 3 2 28 RCO 4 14 12 50 11 11 102 Grand Total 82 170 94 457 115 38 114 1070

There is an overall increase of 111 in the number of contracted facility staff to stand at 1,070, up from 959 in the previous quarter. This is arising from additional lay workers recruited namely; Community Health Volunteers(CHVs) (47), Mentor Fathers (40), adolescent champions (21) and mentor mothers (15). The numbers in all other cadres remained unchanged from the previous quarter. The largest three facility staff cadres are: HTS counsellors at 240(22.4%), nurses at 109 (10.2%) and expert clients at 103(9.6%). The lowest three facility staff cadres include; hygiene assistants at 4(0.4% only found in Nakuru County), clinical mentors at 10(0.9%), nutritionists at 15(1.4%) and data clerks at 16(1.5%). Nakuru County has the highest number of project supported staff at 457(42.7%), an increase of 38 from previous quarter, followed by Kajiado at 170(15.9%) with an increase of 29, Narok at 115 (10.7%) with an increase of 14 and Turkana at 114(10.7%) with an increase of 8. Only Samburu County had a reduction of 5 facility staff from 43 in the previous to 38 in the reporting quarter.

In the reporting quarter, Nakuru, Kajiado Baringo and Turkana Counties continued with efforts towards the development of their HRH strategic plans for the period 2018-2022 with the support of Afya Uzazi and Afya Timiza. HSDSA provided TA and participated in workshops and meetings for the development of the HRH plans. Kajiado and Samburu have planned to initiate the HRH strategic plan development activities in the July- September quarter. The project is continuing to follow up with the counties for the formation, strengthening and routine meeting of HRH/integrated Human Resource Information System(iHRIS) TWGs to support key HRH activities including: development of HRH 2018-2022 strategic plans, Cluster HRH TWGs and County iHRIS TWG meetings. Further, HSDSA initiated actions towards the engagement of HRH services management sub-contractor to provide administrative services for contracted facility staff.

34 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Activity 4.3.1: Provide in-service training/continuous medical education During the reporting quarter, the projected supported capacity building of HCWs through 5,131 contact sessions with service provided across seven counties. The capacity building interventions included on-site and off-site activities such as: trainings, mentorship, OJT, and CMES. The top areas of focus were; ART care and treatment, HIV/TB, PMTCT, HTS, and RH/HIV among others outlined in the table below. The project plans to continue supporting capacity building of health care providers to improve their knowledge and skills to provide good quality of care for the clients they serve. The table below outlines the various types of capacity building activities and numbers of participants trained.

Quarter 3: April – June 2018 County

Type of Site/ Grand Technical Name of Capacity Building Activity Offsite Total

Skill

Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Mentorship No of HCWs mentored on HTS Site 67 89 70 290 61 2 29 610 No of HCWs mentored on PMTCT Site 96 97 68 308 93 2 49 715 No of HCWs mentored on PMTCT, Site 41 58 61 104 33 0 49 346 MCA, HCA, PMTCT reporting tools No of HCWs mentored on TB Site 169 96 64 259 139 0 42 769 No of HCWs mentored on ART Care and Site 104 108 67 307 142 9 65 901 Tx No of HCWs mentored on RH/HIV Site 68 87 64 261 62 0 45 587 No of CHVs mentored on early identification of pregnancy and use of Site 7 0 6 91 0 0 0 104 referral directories No of counsellors trained in pediatric and Site 6 6 0 558 0 0 0 570 adolescent psychosocial support No of HCW mentored on adolescent package of care and integration of Site 0 57 7 57 78 0 0 199 adolescent and youth friendly services Sub Total 558 598 407 2235 608 13 279 4698 Trainings/ HCWs trained on NASCOP reporting 0 60 0 0 0 71 0 131 Updates tools HCWs trained on Quality Improvement- 0 60 0 0 0 0 0 60 IQcare HCWs trained on PNS 0 60 0 0 33 0 0 93 No of HCWs counselors updated on the 0 0 0 0 34 0 0 34 new HTS guidelines/new data tools No of HCWs trained on revised WHO pediatric and adolescent HIV care and 0 0 0 0 29 0 0 29 treatment guidelines No of CHVs were trained on Community Management of Acute Malnutrition 0 0 0 0 9 0 0 9 (CMAM) No of HCWS trained on new ART 0 0 0 0 77 0 0 77 reporting tools Sub total 0 180 0 0 182 71 0 433 Grand Total 558 778 407 2235 790 71 279 5131

The outcome of these capacity building efforts is improved knowledge and skills among HCWs that is reflected in improved service delivery outputs and outcomes including: increased PMTCT clients retention reduced number of facilities experiencing commodities stock outs. Improved HEI cohort 35 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report analysis, improve retention of mother-baby pairs. Complete, timely and accurate recording and reporting, adoption of the huduma chap cards for facility fast track model (Narok) in some facilities. Accurate HCA reporting. Improved patient literacy and increased number of clients reached, color coding of patients’ files, synchronizing VL and EID sample collection with the clients’ appointments, timely reporting and improved linking of ART and PMTCT sites to the lab network. The project supported 307 HCWs in Nakuru to conduct periodic self-assessments and peer reviews and experience sharing sessions and supportive feedback from supervisors. In addition, 124 HCWs in 31 facilities (Nakuru 27, Baringo 4) were provided technical assistance in the design, implementation and evaluation of QI activities that address health care processes and systemic issues that affect service delivery against established standards.

4.4 Prevention of Mother-to-Child Transmission of HIV The Activity continued to support 234 PMTCT sites across the 7 counties with 171 (73%) of the sites in five scale-up counties of Kajiado, Laikipia, Nakuru, Narok and Turkana, while 63 are in the sustained counties of Baringo and Samburu. In the period under review, 29,624 clients had their HIV status known (of who 332 were newly identified) out of 29,633 clients that attended the 1st ANC visit leading to a testing uptake of 99% which was an improvement from 95% uptake in Q2 as there was no shortage of RTKs reported. This was achieved through working closely with the commodity TWG to ensure correct reporting, forecasting and quantification to mitigate against the testing interruptions and prioritization of ANC testing in instances of anticipated shortage of RTKs. The activity supported the following counties; Nakuru, Kajiado, Narok, Baringo and Samburu in HIV RTKs quarterly allocation meetings. The meetings were held to review commodity allocations hence reducing stock outs. One targeted outreach, in collaboration with Afya Uzazi project, took place in Labos, Marigat subcounty, Baringo county reaching a total of 29 women, out of whom 29 were tested for HIV and none was identified positive. The 29,624 clients that had their status known, including 610 known positives in ANC translate to an achievement of 79% against the quarter target of 37,474. Cumulatively, 82,735 clients had their HIV status known, including 1,667 known positives in ANC translating to an achievement of 55% against the annual target of 149,896.

The scale up counties, contributed 87% (71,971) of the clients with known status. Nakuru achieved 12,229 (89%) %), Kajiado 6,317 (84%) Narok 3,757 (81%) Turkana 1,245 (53%) and Laikipia 2,135 (60%)) of the quarterly targets. The sustained counties had Baringo with 2,318 (64%) and Samburu 1,623 (76%) during the reporting period. Cumulatively, the sustained counties had an achievement of 10,764 (47%) against an annual target of 22,875. The figure below demonstrates the overall project and county specific PMTCT STAT achievements against targets as at end of Q3.

36 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

100% 90% 80% 70% 60% 50% 40% 30% 59% 63% 55% 50% 55% 20% 45% 41% 41% 10% 0% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Project 14,504 30,109 14,303 54,730 18,452 8,371 9,427 149,896

Cumulative Achievement at Q3 Gap

Figure 12: PMTCT STAT achievements against annual targets

The overall under achievement is attributed to mothers seeking services from other MOH and private facilities that are more accessible to them. The project supports 234 PMTCT sites in the seven counties whereas facilities providing PMTCT services are over 800 across the seven counties. PMTCT services are decentralized including provision of ARVs thus mothers can access the services in facilities nearby to them. The effect of small private facilities who attend to ANC mothers yet do not report in DHIS2 also contribute to the seemingly low coverage. The target given assumes near 100% coverage of sites by the project which is not the case.

During FY18 Q1, 40,818 (82%) mothers attended 1st ANC against expected 49,866. The effects of the nurses’ strike, and elections contributed to this, but this has improved as from January 2018. As at June 2018, 136,415 mothers attended 1st ANC of whom 122,113(90%) had their status established in ANC only, but inclusive of L&D and postnatal, we had 100% mothers with status established. These is for all the over 800 sites within the project region of support, whereas the project specific sites which we report contributed 82,739 (68%) of the mothers with status established in ANC. Shortage of RTKs in Q2 across the counties contributed to the 90% achievement in testing. With inclusion of the total sites in the region of coverage, the coverage as at Q3 June is 81% of the expected pregnancies, which is within expected, but since we are not reporting on all sites, the coverage may seem to be very low at 55%.

In addition, low uptake of ANC and PMTCT services in communities in Turkana, Narok, Samburu parts of Laikipia, and pockets of Nakuru (Kuresoi and Gilgil) also contributed to the poor performance. This is mainly due to cultural beliefs, difficult terrain and long distances that limit access to health facilities. In these regions, the distances to facilities is approximately 30Kms, with very difficult terrain where public transport is not easily accessible thus women opt to get services from TBAs. Of the 29,624 women with known status, a total of 942 (3.2%) 2%) were identified as positive out of whom 923 (98%) were issued with maternal prophylaxis. Of those positive, 92% (869) were from the five scale up counties. Cumulatively, 2,657 pregnant women were identified as positive out of whom 2,614 (98%) were issued with maternal prophylaxis. 91 high yield sites contributed to 19,129(65%) of total clients tested and 658(71%) of the positives identified for the quarter. 165 data review meetings that included review of PMTCT data were held where variances in maternal and infant prophylaxis was discussed in addition to findings discussed in the projects gap analysis meetings for corrective action. 28 PMTCT TWGs meetings were held in 5 counties where PMTCT STF cases, HEI positive

37 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report audit, LTFU rates. Cohort analysis with focus on retention and active follow up of mother baby pairs up to 24 months was discussed.

Scale up counties (Nakuru, Narok, Kajiado, Laikipia and Turkana): The projects supported 191 PMTCT sites across the 5 counties (Nakuru 90, Narok 21, Kajiado 36, Laikipia 23, Turkana 21). In quarter 3 FY18, 25,686 clients had their HIV status known (of who 305 were newly identified) out of 25,691 clients that attended the 1st ANC visit leading to a testing uptake of 99.9%. The 25,686 clients that had their status known, including 564 known positives in ANC translate to an achievement of 81% against the quarter target of 31,755. Cumulatively, 71,974 clients had their HIV status known translating to an achievement of 57% against the annual target of 127,021. Of the 25,686 women with known status, 869 (3.4%) were positive out of whom 857 (99%) were issued with maternal prophylaxis. Cumulatively, of the 71,974 women with known status, 2,456 (3.4%) were positive out of whom 2,418 (98%) were issued with maternal prophylaxis, 58 data review meetings that included review of PMTCT data were held where variances in maternal and infant prophylaxis was discussed in addition to findings discussed in the projects gap analysis meetings for corrective action. In addition, Nakuru county STF TWG meeting was held where PMTCT STF cases were discussed and personalized planned actions agreed on all failing clients. In addition, the Activity shared the scheduled PMTCT STF clinic dates with the county NASCOP trained mentor and the CASCOs team for support during planned clinic days.

Sustained counties (Baringo and Samburu): The projects supported 42 PMTCT sites in the two counties (Baringo 20, Samburu 22). In quarter 3 FY18, 3,941 clients had their HIV status known (of who 27 were newly identified) out of 3,942 clients that attended the 1st ANC visit leading to a testing uptake of 100%. The 3,941 clients that had their status known, including 46 known positives in ANC translate to an achievement of 69% against the quarter target of 5,719. Cumulatively, 10,765 clients had their HIV status known translating to an achievement of 47% against the annual target of 22,875. Of the 3,941 women with known status 73 (1.9%) were positive out of whom 66 (90%) were issued with maternal prophylaxis. Cumulatively, of the 10,764 women with known status, 201 (1.9%) were positive out of whom 196 (98%) were issued with maternal prophylaxis. 6) data review meetings that included review of PMTCT data were held where variances in maternal and infant prophylaxis was discussed in addition to findings discussed in the projects gap analysis meetings for corrective action.

Activity 4.4.1 Increase uptake of PMTCT services including EID In Q3 YR 18 review period, a total of 942 (3.2%) were identified as positive out of whom 923 (98%) were issued with maternal prophylaxis. Cumulatively, 2,657 pregnant women were identified as positive out of whom 2,614 (98%) were issued with maternal prophylaxis - which is in line with 95% target of having positive women initiated on treatment. Cumulatively, a total of 43 women have missed prophylaxis. Out of the 26 that missed prophylaxis in the period October to March 2018, 11 have been traced back and put on prophylaxis in the post-natal period. Of the 19 missed opportunities in quarter 3, 2 picked ARVs from non-supported sites, 7 were issued in PNC while the rest declined. Active follow up and counseling is ongoing to have them initiated on treatment. The main reason for declining treatment is religious beliefs and denial due to stigma. The project will continue to mentor HCWs and mentor mothers on treatment preparation and support to enhance linkage and enrollment of all pregnant mothers to increase uptake of PMTCT interventions and reduction in MTCT rates. This will continue to be done through continuous health talks where information is provided to enhance disclosure, treatment support and linkage. A total of 2,280 pregnant and lactating women had a viral load done during the reporting period with 1,876 (82%) achieving viral suppression. 210 facilities were supported with appointment diaries, referral directories, defaulter tracking registers, provision of transport and airtime for physical tracking

38 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report to reduce the number of defaulters. There are 22 facilities with fast tracked services for males accompanying their spouses, special weekend and after-hours clinics targeting males. As a result, 1,000 males have been reached in the reporting period. In addition, 24 discordant couples in 13 facilities were identified in PMTCT and are on PrEP for the negative partner.

Scale up counties (Nakuru, Narok, Kajiado, Laikipia and Turkana): A total of 869 (3.4%) were identified as positive out of whom 857 (99%) were issued with maternal prophylaxis and infant prophylaxis. Cumulatively, 2,456 pregnant women were identified as positive out of whom 2,418 (98%) were issued with maternal prophylaxis. Cumulatively, 38 infants missed prophylaxis out of whom 11 were traced back while 27 are being followed up actively.

Sustained counties (Baringo and Samburu): A total of 73 (1.9%) were identified as positive out of whom 66 (90%) were issued with maternal prophylaxis and 65 infant prophylaxis. Cumulatively, 201 pregnant women were identified as positive out of whom 196 (98%) were issued with maternal prophylaxis and 195 were issued with infant prophylaxis.

HSDSA Cluster 2 Maternal Cacsacde (October 17 - June 18) 160000 149896

140000

120000

100000 82731 80000

60000

40000

20000 2657 2614 2280 1876 0 Target Tested Positive ARV VL done VL suppressed 100% 55% 3% 98% 87% 82%

Figure 13: PMTCT maternal cascade for the period Oct 17-June 18

A total of 134 HCWs were mentored on collection of DBS. Currently, 109 facilities have synchronized collection of EID samples according to immunization on schedules to improve uptake and reduce missed opportunities which is an improvement from 104 in the last quarter. A total of 2,166 EID samples of infants born to HIV positive women were analyzed out of which; 1,392 (64%) were initial samples, 739 (34%) were repeats, 34 (1.6%) were confirmatory PCRs and one was a discrepant PCR (tie breaker). Samples analyzed for HEIs within 12 months of birth from project DATIM sites were 1,363 (63 %), of which 1,077 (79%) were within 2 months, and 286 (21%) between 2 and 12 months. The 1,363 tests done within 12 months of birth translate to an achievement of 120 % against the quarterly target of 1,140. Samples for HEIs above 12 months were 359. Of those analyzed after 12 months, 14 (3.9%) were initial tests while 331 (92%) were repeats. The positivity rate for HEIs aged 2 months and below was 1.7%, for the HEIs between 2 and 12 months was 6% while for those above 12 months was 3.6%.

39 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

The Activity continues to support access to comprehensive package of PMTCT interventions uptake in supported sites. This has led to a gradual decrease in HEI positivity rates over the period as demonstrated in the figure 14 below.

Figure 14: HEI positivity rates 2016 to 2018

Cumulatively, in FY 18, A total of 6,162 EID samples of infants born to HIV positive women were analyzed out of which; 3,748 (61%) were initial samples, 2,299 (37%) were repeats, 113 (1.8%) were confirmatory PCRs and 6 were discrepant PCR (tie breaker). Samples analyzed for HEIs within 12 months of birth were 3,605 (59%), of which 2,685 (74%) were within 2 months, and 859 (24%) between 2 and 12 months. There has been a gradual increase in the HEIs with a test done within 2 months as in the figure 15 below.

Figure 15: HEI with a test done within 2 months

40 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Samples for HEIs above 12 months were 583 (9.5%) of the 6,162. Of the ones analyzed after 12 months, 39 (6.7%) were initial tests while 509 (87%) were repeats. The EID 3,605 tests done within 12 months of birth translate to an achievement of 79% against the annual target of 4,561 as shown in the figure below.

100%

80%

60% 103% 91% 40% 76% 79% 66% 68% 60% 55% 20%

0% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Project -20% 306 1,135 242 2,050 450 107 271 4,561 % Achievement as at End of Q3 Gap

Figure 16: EID test done within 12 months

The positivity rate for HEIs aged 2 months and below was 1.9%, for the HEIs between 2 and 12 months was 6.2% while for those above 12 months was 28%. The high positivity among HEIs above 2 months is attributed to late presentation of pregnant women who did not receive any PMTCT interventions for themselves and the baby during pregnancy. The figure below shows the Activity Overall under 12 months and below HEIs positivity and ART initiation rate.

Cumulative FY18 HEI positivity and ART initiation Rate 120% 100% 93% 93% 100% 86% 78% 82% 72% 80% 67%

60%

40%

20% 10% 6% 2% 4% 2% 4% 4% 3% 0% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Project 233 753 250 1857 268 59 185 3605

Positivity Rate % Started on ART

Figure 17: Cumulative FY18 HEI positivity and ART initiation Rate

41 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

HEI audit was conducted for all the 38 HEIs confirmed positive in the quarter and the outcome is as follows; 31(82%) enrolled, 3 died, 4 LTFU. The Positive HEI interrogation results were as follows: Twenty-eight (74%) of the mothers were newly identified positive while 10 were known positives at first contact with 12(32%) having a current viral load test result out of whom 8(67%) were virally suppressed. A total of 20 (53%) women were on HAART while 25(71%) received infant prophylaxis. Twenty of the women delivered in hospital (53%), out of whom none were through a caesarian section. Nineteen (50%) of the infants are up to date with immunization while 12 are defaulters. Seventeen (49%) were on exclusive breast feeding, 11 were on exclusive replacement feeding, while 7 were on mixed feeding. Cumulatively, out of 106 positives infants identified with exception of Q1 positives from Turkana and Samburu, 97(92%) were started on ART. HEI audit was conducted for all the 106 HEIs confirmed positive and the outcome is as follows; 97 enrolled, 4died, 5 LTFU. The Positive HEI interrogation results were as follows: Seventy-four (70%) of the mothers were newly identified positive while 32 were known positives at first contact with 29(27%) having a current viral load test result out of whom 16 (55%) were virally suppressed. A total of 64(60%) women were on HAART while 73(69%) received infant prophylaxis. Fifty-eight of the women delivered in hospital (55%), out of whom 16(15%) were through a caesarian section. 60(57%) of the infants are up to date with immunization, 35 are defaulters while 2 were not immunized (Loitoktok SCH and Kimana HC). Fifty (47%) were on exclusive breast feeding, 19 were on exclusive replacement feeding, while 35were on mixed feeding.

A total of 112 facilities that have integrated PMTCT in MCH in an effort to increase uptake and retention to care. The project continued to support mentor mother services in 91 high yield sites with a total of 100 mentor mothers. In addition, 40 mentor fathers and 68 adolescent champions (39 male, 29 female) have been engaged to strengthen male involvement at ANC. In the Kenya Mentor Mother Program (KMMP), 402 HIV positive women were enrolled while 11,470 HIV negative women were educated on HIV preventive measures and family testing services. The mentor mothers were mentored on; appointment management, defaulter tracing, charting of missed appointments and defaulter outcomes, feeding options, adherence counseling, viral load schedule and importance of suppression and pregnancy spacing. The number of new defaulters was 1,595 during the reporting period whereby 1,573 (99%) were reached and 1,317 (84%) cases were resolved. During the reporting period, there were support group sessions held in 86 facilities. Additionally, mentor mothers and peer facilitators supported the escort of HIV positive mothers for services such as lab and pharmacy to enhance linkage. Mentorship on the revised National ART guidelines reached 713 HCWs, with emphasis on patient monitoring, retention, and differentiated care models, to conduct cohort analysis using national cohort tools for maternal and HEI cohort analysis with feedback on outcomes discussed in QITs and monthly facility data review meetings. A HCWs have been mentored on commodity management, forecasting and reporting. There was no report of PMTCT commodities stock outs in all our supported facilities. A further 63 HCWs were sensitized on FP/HIV integration and provision of FP methods in ART settings through same room or physical linkage to the FP room service provision. 57 CHVs have been mentored on community mobilization, HTS, mentor mother approach and community MNCH/PMTCT.

In collaboration with the MOH, the project continued to support high volume private sector facilities to offer quality PMTCT services, through mentorship on revised ART/PMTCT and HTS in line with the new guidelines reaching 27 HCWs. 5roving linkage officers were engaged to ensure effective linkage to ART for clients testing HIV positive from the private facilities.

42 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

HSDSA Cluster 2 Infant Cacsace (Oct 17 - June 18)

5000 4561 4500 4000 3605 3500 3000 2500 2000 1500 1000 500 106 80 69 0 EID Target EIDs done EID pos HEI initiated on ART Baseline VL done 100% 79% 3% 75% 86%

Figure 18: Infant cascade for the period Oct 17-June 2018

Activity 4.4.2 Improve retention of mother-baby pairs A total of 603 HEIs were followed up for the 12 months’ cohort. Virologic testing was done for 478 79 %) infants within the recommended 6-8 weeks while 125 (21%) were aged above 2 months. Out of these, 14 infants tested HIV positive translating to a 3% positivity rate. Those active on follow up at 12 months were 457(76%), 89(14%) were missing at twelve months follow up, 10 (1.7%) died and 335.5%) transferred out to other health facilities as illustrated below.

Q3 HCA Outcomes (Apr - June 17', n=603) 1% 2% 5% 7%

85%

512 Active in follow-up 14 Identified as positive between 0 and 9 months 33 Transferred out between 0 and 9 months 39 Missing 9 month follow-up visit 5 Died between 0 and 9 months

Figure 19: One-year HEI Cohort analysis, Apr to June 2017 cohort outcomes

In the reporting period, 306 PMTCT clients who initiated ART one year (initiated April-June 2017) from select sites had a cohort analysis done. 54 (18%) clients transferred out, 53 (17%) were transfer- in translating to a net cohort of 305. Of these, 228 were retained in care, 65 (21%) were lost to follow up, 1 (0.3%) died translating to 75% retention rate. Viral load was done for 200 (66 %) clients and 190 (95%) achieved viral suppression as shown in the chart below.

43 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

One Year MCA Outcomes (Apr - June 17', n=302)

350 300 250 200 302 150 266 253 225 100 50 0 Net PMTCT Cohort Retained VL Done VL Suppressed 100% 82% 95% 89%

Figure 20: Maternal 12-month cohort analysis

The project has engaged 40 mentor fathers to strengthen male involvement and as motivation, screen for non-communicable diseases such as hypertension and diabetes in 20 facilities by APR.

Scale up counties (Nakuru, Narok, Kajiado, Laikipia and Turkana): A total of 559 HEIs were followed up for the 12 months’ cohort. Virologic testing was done for 450 (81%) infants within the recommended 6-8 weeks while 109 (19%) were aged above 2 months. Out of these, 17 infants tested HIV positive translating to a 3.8% positivity rate. Those active on follow up at 12 months were 424 (76%), 84 (15%) were missing at twelve months follow up, 8 (1.4%) died and 30 (5.4%) transferred out to other health facilities. 268 PMTCT clients initiated on ART one year (initiated April-June 2017) had a cohort analysis done during quarter under review. 45 (17%) clients transferred out, 48 (18 %) were transfer-ins bringing to a net cohort of 271. Of these, 58 (21%) were lost to follow up, 1 (0.4%) died while 205 were retained on treatment translating to 76% retention rate. Viral load was done for 178 (87%) clients and 169 (95 %) achieved viral suppression.

Sustained counties (Baringo and Samburu: A total of 44 HEIs were followed up for the 12 months’ cohort. Virologic testing was done for 28 (64%) infants within the recommended 6-8 weeks while 16 were aged above 2 months. Out of these, 1 infant tested HIV positive translating to a 3.4% positivity rate. Those active on follow up at 12 months were 33 (75%), 5(11%) were missing at twelve months follow up, 2 (4.5%) died and 3 (6.8%) transferred out to other health facilities. 38 PMTCT clients initiated on ART one year (initiated April-June 2017) had a cohort analysis done during quarter under review. 9 clients transferred out, 5 were transfer-ins bringing to a net cohort of 34 clients. 7 (18%) were lost to follow up none died while 23 were retained on treatment translating to 61 % retention rate. Viral load was done for 22 (96 %) clients and 21 (95 %) achieved viral suppression

Activity 4.4.3 PMTCT for AGYW Adolescent girls and young women (AGYW) aged 15-24 years constituted 47% (13,938 of the total PMTCT clients with known status, out of whom 349 (2.5%) were tested positive and all received maternal and infant prophylaxis. 48 facilities have integrated AYP-friendly services in existing ART clinics with AGYW clinic days where they receive the full package of care. There are 68 adolescent case managers engaged to support pregnant AGYW receiving ANC, provide HTS, and facilitate high- quality PMTCT services to those who test HIV- positive (including encouraging male involvement,

44 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

VMMC where indicated, family support, and adherence counseling). There were 70 AGYW support groups meetings held supported by case managers. 199 HCW were mentored on adolescent package of care and integration of adolescent and youth friendly services in the PMTCT sites.

OBJECTIVE 5: LONG TERM FOLLOW-UP OF PATIENTS RECEIVING CARE AND TREATMENT SERVICES INCLUDING LAB AND LOGISTICAL SUPPORT

A total of 59,769 patients from 174 facilities were on ART in the seven supported counties out of which 2,946 newly initiated on ART during the reporting period. This represents 87% achievement against the annual target of 69,000. The five scale up counties (Nakuru, Narok, Laikipia, Turkana and Kajiado) contributed 55,412 (93%) of the total current on ART clients, and 87% of the scale up counties annual target of 63,368. The sustained counties (Baringo and Samburu) contributed 4,357 clients currently on ART representing 7% of the total current on ART and 77% of the sustained counties’ annual target of 5,632.

Q3 current on treatment achievement against annual target 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 84% 83% 83% 98% 72% 62% 48% 87% 0% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Project Gap 639 1907 998 706 1501 636 2844 9231 Achieved 3,313 9,210 4,718 35,016 3,825 1,044 2,643 59,769

Achieved Gap

Figure 21: Current on treatment Achievements against targets - Quarter 3 FY 18

Of the 59,769 clients currently on ART, 40,673 (68%) were female and 19,096 (32% male). The age group break down was as follows: 4,412 (48% F) were below 15 years, those between 10-19 years were 3,829 (58% F), those between 15-24 years were 5,351 (76% F) and 50,006 (69% F) were 25 years and above.

The variance between the expected and the reported number of clients was 1,982 (35 sites have since accounted for 1,085 : defaulters - 846, lost to follow up - 76, transfer out - 112, dead - 50 and 1 stopped ARVs. The Activity will continue to strengthen appointment schedule with proactive reminders to scheduled clients in addition to intensified defaulter tracking mechanisms to improve on retention. In addition, the project will continue supporting deployment of health care workers and lay workers to support provision of quality HIV services and follow up of the clients. Scale up differentiated service delivery models to reach 80% of the stable clients will be an area of focus to improve retention in the seven supported counties. The project will also continue with patient literacy and adherence support to clients using the adherence calendar to reduce patient attrition. In the subsequent quarter, an RRI

45 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report will be rolled out to ensure all ART clients are accounted for. The HSDSA cluster 2 treatment cascade is represented in the graph below:

HSDSA Cluster 2 treatment cascade 80000 69000 70000 59769 60000 50000 44997 40000 36478 30000 75% 20000 81% 10000 0 Current on ART target Current on ART achieved VL done VL suppressed

Figure 22: HSDSA Cluster 2 HIV treatment cascade

Activity 5.1 Provide services aligned with Kenya Comprehensive Package of Care HSDSA cluster 2 reached over 2870 HCWs through mentorship during the reporting period. Mentorship sessions covered topics on; ART, TB, PMTCT, RH/HIV integration, PHDP, SGBV package of care, facilitation of lab networks (GeneXpert and cryptococcal antigen test) and assessment and linkage for non-communicable diseases for more holistic clinical encounters. Further, orientations on Kenya Comprehensive Package of Care was conducted reaching 1,385 HCWs at 79 facilities through 203 CME sessions. The project, in collaboration with county HMTs, continued to engage 959 facility based HCWs and support staff on contracts. The placement of these staff was based on a rapid facility staffing needs assessment, to ensure that staff are placed where there is most need. They facilitate provision of the comprehensive package of quality HIV care. Further details on human resources for health are in sections 4.3 and 6.1. SOPs and job aids focusing on the revised guidelines were distributed in the supported facilities.

A total of 59, 808 PLHIV were reached with preventive messages on recognizing the role of lifestyle modification in preventing Non-Communicable Diseases (NCD). A total of 109 facilities across the seven counties were supported with tools and mentorship of HCWs and triage team on how to screen at triaging for hypertension and diabetes and provide preventive messages with referral for treatment for those identified with the NCD or at risk was done. The project rolled out the FHI 360’s Chronic HIV Care Checklist in all supported high-volume sites. This is a tool adapted for use at the link desk and community level through a comprehensive approach to care that incorporates screening opportunistic infections, NCD and mental health.

Activity 5.2 Strengthen client retention in care and Improve treatment literacy (Adults, Pediatrics and Adolescents) During the quarter under review the Activity continued to support monthly airtime for defaulter tracking and coordination of inter facility referral in 110 ART/PMTCT supported sites. To improve retention and adherence, the project continued to support establishment of special clinics for children, adolescents and men during favorable days and hours with a focus to having weekend clinics to cater

46 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report for school and college going children and adolescents. Seventy-seven(77) adolescents and pediatric, and 37 male clinics were supported in all counties except Samburu where this will be rolled out in coming quarters. To strengthen complete documentation and clients follow up, the project continued to support the use of ART registers, appointment diaries, referral directories, linkage registers and defaulter tracking.

HSDSA facilitated 270 support groups reaching 6,081 adults on ART, 2,599 PMTCT clients, 1,789 adolescents clients, 1,705 pediatrics and 37 male clinics in seven counties to improve on treatment literacy. The clients discussed issues of adherence, prevention with positives, viral load monitoring, alcohol and drug abuse, index client testing and disclosure with the support of case managers in 76 facilities. During the sessions, the adolescents were provided with PHDP messages, sensitized on drug and substance use, adolescent sexual and reproductive health. The project continued to mentor HCWs and facilitate CMEs in seven counties. They discussed formation of suspected treatment failure (viremia) clinics, test and start implementation, differentiated care models, psychosocial support and adherence strategies. The figure below illustrates support group outcomes among adolescents in select supported sites. The suppression rate among adolescents in supports is better at 80% compared 70% for the overall project in the same period.

HSDSA Cluster 2 Q3 Adolescent support group Outcomes 120% 100% 100% 93.40% 93.20% 80% 80%

60%

40%

20%

0% Adolescents in support Retained at one year VL done VL suppressed groups 1902 1776 1656 1320

Figure 23: Adolescent support group Outcomes

During the quarter, 73 counselors and 202 expert clients facilitated case management and adherence counselling/peer support to improve retention and viral suppression. The team used the adherence calendar for tracking of patients. Below is a table showing the adherence calendar outcomes from 37 supported sites. In addition, these lay workers facilitated group and individual counselling group sessions.

Table 7: Adherence outcomes in HSDSA supported sites Row Labels New positive 3 Defaulters traced back Total 3 months Months 3 months A. Enrolled into cohort 518 1447 1965 B. Transfers In (T.I) 17 27 44 C. Transfers Out (T.O) 77 126 203 D. Net Cohort(A+B-C) 512 1434 1946

47 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

E. Defaulters 114 65 179 F. Lost to follow up (LTFU) 0 0 0 G. Reported Dead 20 43 63 H. Stopped 1 0 1 I. Alive and Active on Treatment 453 1310 1763 J. % Retained 88% 91% 91%

The overall 12-month retention rate at one year for the mature cohort in the quarter under review was 85% with children under 14 years having higher retention rate of 80%. Four scale up counties (Kajiado, Nakuru, Narok, Laikipia) had a retention rate of 84 % while Baringo county retention rate was 79%. Children in scale up counties had a retention rate of 82% while those in sustained counties had a rate of 79%. An analysis of time retention showed that the greatest drop in retention was at three months with an average drop of 17% overall (all clients) and 19% in children. The main challenge in retention of children is the follow up of school going children and the changing of children caregivers. The project will continue strengthening use of the adherence calendar among the newly enrolled and defaulters traced back, in addition to scaling up uptake od differentiated care so as to improve on retention rates.

Activity 5.3 Expand the differentiated care model During the quarter under review, the project continued to sensitize stable clients on differentiated care models in high volume facilities. The total number of facilities implementing differentiated care model were 141 with a total of 19,768 clients compared to 14,540 in the previous reporting period. The fast track and Community ART Groups (CAGs) are the two main models implemented by the project. The project continued to scale up differentiated care by mentoring site-level staff to sensitize clients in the facilities. Twenty-two (22) facilities were offering the CAG model of differentiated care during the reporting period with 141 facilities offering the fast track model. Differentiated care has made HIV service delivery more efficient through release time for HCWs to concentrate on new and sick clients who need their attention more while reducing the number of visits for stable clients and reducing the strain on the health care system. The number of newly enrolled clients in these facilities during the quarter was 2,539 of whom 2,166 were categorized as well while 373 had advanced disease. Among the 59,769 clients who were current on ART during the reporting period, 28,810(48%) were stable. A total of 141 facilities had operationalized facility fast track model with 18,966 clients compared to 11,871 last quarter while 364 clients were on community ART and 408 on other models. Among the 6,884 clients enrolled into fast track model 6 months prior to reporting month, 6,587(96%) were retained at six months, while 92% (656) of the 710 in the CAGs model were retained at six months.

Thirty-seven (37) facilities offered male friendly clinics/services, 77 had adolescent clinics and pediatric clinics, 109 STFs (viremia) clinics while 36 offered family clinics across the project. This is exclusive of Turkana and Samburu where the Activity has just enrolled and/or in process of established the clinics. The services offered in these clinics included HIV testing, case management, PNS where appropriate, adherence counselling, peer support through the psychosocial support groups, among others.

A total of 122 facilities, through 190 mobile phone lines, were provided airtime support by the project. The airtime was used to call clients for appointment reminders and in defaulter tracing. The project adopted a proactive approach to reducing the number of defaulters through proactive Short Message Service (SMS) reminders to clients about scheduled appointment. CHVs /peer educators were also engaged to physically trace clients if they fail to attend appointments and are not reachable on phone. A case management approach has also been adopted with a case manager appointed for each newly

48 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report enrolled client for intensive follow up of newly enrolled clients using the adherence calendar in 109 facilities. Facilities were supported with transport refund provision to clients unable to access services due to inadequate resources. This was done on a case by case basis after careful evaluation of the socio-economic circumstances affecting the individual clients.

Activity 5.4 Increase the proportion of ART patients achieving VL suppression within 6 months and one year During the quarter, a total of 16,751 Viral Load (VL) tests were done. Of these 15,634 were routine VL tests with valid outcomes; 13,628 of the valid tests were suppressed giving a suppression rate of 87.1% for the quarter as shown in figure 24 below. During the same period, there were 121 baseline VLs, 996 confirmatory repeat tests and 53 rejected samples.

Figure 24: Viral load suppression rates Apr-Jun 2018

In the quarter under review, the females accounted for 70% of the total routine VLs done with a suppression rate of 88%, while the males suppression rate was 84% as shown in the figure below.

Q3 Viral suppression Rate for Gender, HSDSA Cluster 2 12000 10,931 9,667 10000 8000 6000 4,705 3,963 4000 2000 0 F M 88% 84%

VLs done Suppresed

Figure 25: Viral suppression Rate by Gender

The cumulative total of VLs done in the year was 45,401; of these 40,692 were routine tests with valid

49 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report outcomes, of which 35,476 were suppressed giving an overall suppression rate of 87.2%. In addition, 422 baseline VLs, 4,287 confirmatory repeat tests have been done within the year, while 180 samples have been rejected. Of the total routine VLs done in the year, 28,460 (70%) were for female patients. Cumulative suppression for this group was 88.2%, whereas males had a suppression rate of 84.7%.

A further analysis of VL suppression by age group for quarter 3 is illustrated below. HSDSA FY 18 Cumulative VL suppression by Gender

89% 85% 90% 71% 70% 80% 70% 60% 50% 40% 30% 20% 10% 0% 10-14 15-19 20-24 25+ 3044 1137 1743 34768

Figure 26: Quarterly viral suppression per age group

As demonstrated the age groups of concern are the children, and adolescents. The project is supporting 72 dedicated adolescent and pediatric clinics in addition to reach this group. The adolescent support groups will be strengthened further, and technical assistance and mentorship offered to those steering them by project staff.

The coverage for VL testing against the eligible clients was at 78% as at end of the quarter under review. The project will continue to prioritize the line-listing of all due viral loads and ensure all suspected treatment failures are managed appropriately with those who will qualify for 2nd line being transitioned promptly. The suppression rates in Turkana and Samburu are especially low. The project will treat these regions as VL high priority areas and provide technical support, facilitate VL sample transport and airtime support as well as strengthen the defaulter tracing mechanisms to ensure the current gaps are bridged.

A total of 109 sites operated viremia clinics to deal with cases of suspected treatment failure while 94 high volume facilities held regular Switch meetings by multidisciplinary teams to review patients with repeat VL above 1000 cells/ml. These meetings improved switch of clients, retention, improved VL re suppression among affected clients. 94 facilities with regular STF clinics conducted targeted health talks and established buddy system to help with psychosocial support. The figure below shows the STF outcomes from 67 supported high-volume sites.

50 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

HSDSA Cluster 2 Q3 STF Cascade 4,738 5000 4,074 4000 3000 2,118 2000 1,232 1000 446 0 Total Number of Clients Number with repeat VL Number with VL Number VL switched to Number resuppressed in STF done suppressed 2nd line at 6 months post switch 100% 86% 52% 63% 87%

Figure 27: STF Cascade from select sites – Q3

As part of enhancing VL uptake, the project continued to support color coding of patient files to flag clients with VLs that are due. 122 facilities through 190 mobile lines received mobile phone airtime support to remind clients who are due for VL repeat. Transport facilitation was done for select needy cases needing to come in for a VL. To expedite the collection of repeat VLs in suspected treatment failure cases, 109 viremia clinics were operational during the quarter. 769 providers were mentored on TB, 802 on ART care and treatment, 203 CME sessions with 1,385 health worker encounters were facilitated during the reporting period. Other areas of mentorship included: quality monitoring of clients, intensive adherence counselling, synchronizing clients’ appointments with VL schedules, color coding system to flag clients due for routine and repeat viral load, proactive follow up of clients through calls and patient education on clinical monitoring. Cohort viral load testing, use of Performance Monitoring Charts (PMC), VL commodity management, use of VL samples and results monitoring log book were other areas covered. To improve the management of suspected treatment failure cases, HCWs were reached through CME sessions on treatment failure targeting service providers in all 83-high volume supported facilities and all low volume supported facilities recording a suppression rate of less than 80%. All the newly enrolled clients and all suspected treatment failure clients identified in 109 sites were assigned to a case manager for intensive adherence support and follow up using the adherence calendar. To facilitate faster relay of lab results 122 facilities were provided with airtime support. To facilitate quicker turnaround time when collecting VL samples 46 HVF continued to offer phlebotomy services for VL within the CCC. This reduced VL missed opportunities occasioned by referrals and the work load of laboratory technologists.

The project continued to facilitate all supported ART and PMTCT sites to download VL results from the National AIDS and STI Control Program (NASCOP) website in addition to using the SMS results option for quick access to results and using the NASCOP EID/VL website dashboards in CQI at facility, sub County and County levels. This resulted in clients accessing these results faster with an average turnaround time of 1 to 2 weeks from dispatch to when a facility can access the results. In addition, the Activity rolled out the SMS system for relay of results to the clients. As at end of the Q3, 57 clients had received results through the SMS system with two weeks of roll out. Across the supported counties VL uptake and suppression rates were incorporated in the facility performance monitoring charts for continuous quality improvement.

51 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

OBJECTIVE 6: STRENGTHENED SUPPORT FOR FACILITY AND COUNTY MANAGEMENT OF HIV RESPONSE

6.1 Human Resources for Health 6.1.1 Identify HRH gaps and conduct joint recruitment and deployment

The project has developed a letter of Agreement (MoU) for use with counties on all HRH management efforts including; joint advertisement, interviewing, joint recruitment, deployment and transition of the staffs to the county public service and has forwarded this to USAID in June for approval. It is expected that this shall be rolled out in all counties once the approval has been received. Meanly, the project is using a fixed price contract mechanism to manage facility staff transitioned from APHIAplus to HSDSA Cluster 2 pending the implementation of the LOA.

6.2 County Planning and Budgeting

6.2.1 Provide Technical Assistance to Improve Annual Work Plans, county budgeting and health financing Project continued to provide TA support to Baringo, Kajiado, Nakuru and started TA support for Samburu and Narok Counties for the development of costed County Health Strategic and Investment Plan (CHSIP) 2018-22 and the AWP 2018/2019 at the County level. The TA included review of the County CIDPs, 2017 APRs where available, draft CHSIPs and draft AWPs and providing feedback for improving these planning documents to ensue adhere to the Program Based Planning and budgeting Principles, linkages to the CIDP and to each other. Through the CHSIP and AWP development activities, the project provided TA on the MTEF cycle, adoption of program-based planning and budgeting and inclusion of clear HIV/AIDS and TB subprograms in the AWPs, better trend analysis and projection of health financing and effective resource mobilization strategies and operationalization of the county health stakeholders forums. This TA support is expected to continue in the next quarter until the CHSIPs and AWPs are completed. The Project liaised with all counties, sub-counties and supported facilities to develop joint work plans (JWP) with budgets for April to September 2018. The JWPs are the instruments that define the specific USAID/HSDSA HIV/AIDS and health systems strengthening financing support to the service delivery points as prioritized by the facility, sub county and county management teams. This is expected to refocus joint teamwork efforts for improved facility, sub-county and county level service and health management services delivery and avoid unrealistic frequent financial support requests to the project. The JWPs define the resource envelope available from HSDSA for all supported facility and health management activities. Examples of activities supported through the JWP include: AWP development, facility HRH, QI review meetings, samples shipments, airtime for defaulter tracking; SMS reminders, transport refund for support groups, snacks for Mentorship sessions/CMEs among others while the CHMT/SCHMT activities include routine facility supportive supervision, data review meetings and different TWGs meetings.

Though PBB training is scheduled to commence in year two, all counties have generally adopted Program Based Planning and Budgeting since this is the required format of the CIDPs 2018-2022 per the CIDP development guidelines 2018. They are however struggling to understand the PBB approach. All county CHMTs are working closely with their County Assembly Committees for Health but the challenge has been inadequate financial capacity to cater for the CACH meetings allowances. The Project provided TA for establishment of effective health stakeholders forums and resource mobilization strategies for Nakuru, Kajiado and Baringo Counties.

52 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

HSDSA C2 continued with the process of engaging the proposed Program Based Planning and Budgeting (PBB) and Governance, Leadership Management Sustainability (LMS) activities sub- contractor with the aim of scaling up rollout of LMS activities in the next quarter and subsequent period of the Project. This is expected to be finalized in the July-September quarter and have the sub- contractor on board in Year two.

6.3 Health Management Information Systems

6.3.1 Strengthen complete, accurate and timely data collection and reporting at sub county facility and community levels

Implementation of Electronic Medical Records (EMR): During the quarter, the Activity continued monitoring EMR implementation in 66 health facilities (excluding six stalled sites). As shown in the table below, a total of 20 health facilities had their EMR system fully functional (i.e. six months retrospective data fully updated in the EMR system) and the sites were able to generate accurate MOH 731 reports from the system. The number of health facilities utilizing the EMR as point of care were ten with an addition of two sites from Baringo (Eldama Ravine and Mercy Hospital).

% Baringo Kajiado Laikipia Nakuru Narok Samburu Turkana Total Achieved # of facilities with EMR 11 14 11 16 9 3 8 72 installed # of functional EMR 5 4 7 0 2 1 1 20 28% EMR Mode of Use Point of Care (POC) 5 0 4 0 1 0 0 10 14% Retrospective data entry 0 11 6 0 0 1 4 22 31% (RDE) Hybrid 6 2 0 15 8 1 2 34 47% Stalled 0 1 1 1 0 1 2 6 8% # of health facilities 2 11 0 3 4 0 0 20 36% EMR DQA conducted # of health facilities generating accurate and 5 4 7 0 2 1 1 20 28% complete MOH 731

During the quarter, the Activity conducted an EMR assessment in 58 (88%) of ART health facilities to check on the EMR implementation status focusing on the functionality of EMR, resources required, security and security measures in place, infrastructure, reliable power source, if EMR meets the required user needs, network availability and reliability, availability of external backup and any technical experiences while using EMR amongst others. Various EMR reports (CQI, HIV Cohort, DATIM, Ad hoc reports etc.) were generated for concordance with hard copy reports. Analysis of the findings will inform the Activity in EMR programming in the next quarter.

The Activity assessed the data on current on ART for the month of May 2018 reported in MOH 731 summary report and the EMR for 58 health facilities. The average consistency rate was 69% across the counties with facilities using Kenya EMR scoring an average of 99% in 13 facilities and IQCare concordance at 79% in 45 facilities. This is attributed to power outages in some of the facilities (Baringo, Laikipia and Turkana) and the recommendations was that the affected counties explore possibilities of sourcing for power back-ups. By the end of the quarter, two facilities from Baringo county were in the process of procuring a generator.

53 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

In Nakuru county, the low consistency was due to wrong use of the EMR system (using both green card and blue card) versions of the EMR. A newer version of IQCare (1.0.0.7) will be deployed in the next quarter to address the gap.

County EMR in use No of health Current Current on % report facilities on ART ART MOH concordance EMR 731 for _Current on ART Turkana KenyaEMR 3 1125 1129 100% Baringo KenyaEMR 10 3236 3289 98% Kajiado IQCare 12 7396 7987 93% Narok IQCare 9 2725 3092 88% Laikipia IQCare 9 3351 3885 86% Nakuru IQCare 15 11576 23201 50% Grand Total 58 29409 42583 69%

The Activity conducted EMR data quality assessments in 18 health facilities during the quarter as follows; Baringo (2), Kajiado (11), Nakuru (3) and Narok (4). In Baringo county, EMR DQA was conducted in two health facilities where five indicators were assessed with an average score of 100% for accuracy and average score of 77% in completeness. Incomplete indicators included first WHO stage, recent WHO stage, TB screening outcome and IPT dispensed date amongst others.

In Nakuru County, EMR DQA was conducted in three sites (Naivasha, St. May’s and Gilgil) with an average score of 89%, 98%, and 97% respectively. St. Mary’s and Gilgil registered as significant improvement in the overall RDQA score compared to Oct-Dec 2017 scores which were 89% and 87% respectively. There are however, still two major gaps for Gilgil hospital that needs to be improved on i.e. IPT dispensed date with a score of 49% and last encounter date not updated at 56%.

In Narok county, EMR DQA was conducted in four facilities (Narok CRH, Sogoo HC, Ololulunga SCH and Ntulele) with overall DQA scores of 86%, 90%, 95% and 96% respectively.

The Activity incorporated routine tracking of reporting rates in national data warehouse (NDW) in the performance improvement plan during this reporting period. The NDW is a repository for EMR data where different analytics are performed to inform the government and stakeholders on key HIV outcomes and for better HIV programming. By end of June 2018, 24 (36%) EMR sites had submitted their data to national data warehouse. Routine monitoring and addressing the challenges in reporting is expected to improve this rate. During this reporting period, a total of 88 health care workers (Baringo [27], Kajiado [24], Laikipia [8], Nakuru [17], Narok [12] were mentored on use of EMR. This was necessary after the EMR upgrades to version 1.0.0.5 in Kajiado, Laikipia and Nakuru and the latest version 1.0.0.6 in Narok.

Baringo County: In an effort to ensure complete and accurate reports within the quarter, the Activity continued to conduct joint monthly MOH reports review with the Sub County Health Records Information Officers (SCHRIO) and Sub county AIDS STI Coordinators (SCASCO) in five sub- counties. This process helped in identifying and immediate addressing of data quality gaps from facilities as well as informed targeted mentorship.

54 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Also, at the facility level, the Activity multi-disciplinary team (MDT) supported ten facilities in aggregating monthly reports (Ministry of Health (MOH) 711, MOH 731, HIV Exposed Infants Analysis (HCA), partner notification services (PNS), index clients, Maternal Cohort Analysis (MCA), cohort analysis (CA) from the source documents. During the process, 25 HCWs were mentored on how to address notable data reporting errors identified. Some of the gaps identified included: improper reporting of the new MOH 731 especially code 1.3 section (“HIV positive three months ago linked to care”) where most facilities were reporting linkage of HIV positive clients identified within the reporting month rather than HIV positive clients identified the last three months. From the efforts mentioned above, the reporting rates of 11 dataset reports i.e. MOH 711, MOH 710, MOH 731-1, MOH 731-2, MOH 731-3, MOH 717, MOH 713, MOH 733B, HCA, Mentorship by Activity staff to Marigat SCH staff to populate Monthly MOH 515 and facility commodity dispensing Report. reporting rate (FCDRR) improved from an average of 90% in Jan-Mar 2018 to 94% in Apr-Jun 2018 with the highest improvement recorded in ART reporting and FCDRR as shown in Figure ** below.

Within the reporting quarter, the Activity team together with the county health records information officer (CHRIO), identified 29 HCWs from 10 facilities across five supported sub-counties for

DHIS2 Reporting Rates - Baringo County

100% 100% 96%97% 97%95% 95% 96%98% 94%96% 95% 98% 93% 93% 90%91% 92% 84% 79%

72%75% % RR %

MOH 711 MOH 710 HTC PMTCT ART MOH 717 MOH 713 MOH 733B HCA MOH 515 FCCRR

Jan-Mar 18 Apr-Jun 18

Figure 28; DHIS2 Reporting Rates - Baringo County enrollment into the cohort II NASCOP e-learning course for the new revised HIV tools. Out of the enrolled HCWs, 11 (38%) did not access the eLearning platform. Of those that are active in the system, the group average score 63% across all data recording tools. The progress on completion of the course will be reported in the next quarter.

55 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

The Activity team assessed 27 sites for availability of standard tools, correct use, tools completeness using the M&E tools assessment checklist. The results show improvement in all aspects assessed in PMTCT and ART tools. The completeness across all the interventions was mainly because CHW did not do page summaries daily as required. In PMCT, the ANC register was the most affected. Health care workers were not familiar on how to report the current HIV status of a client tested for HIV in that visit and those tested before and reporting for an initial and a re-test in HIV. In the ART register, the ART cohort summaries were not populated and INH column not filled. A total of 61 health care workers were mentored on the correct recording in the registers and a total of 939 assorted data recording and reporting tools were disseminated where tools were missing.

Q2 and Q3 tools assessment - Baringo County (n=27)

100100 100 100 100 100 100 94 95 98 96 81 85 74 76 67 64 68 52 50 50 50

40 44 % Score %

Available In use Complete Correct Available In use Complete Correct Available In use Complete Correct HTC PMTCT ART Jan-Mar 2018 Apr-Jun 2018 Figure 29: Q2 and Q3 tools assessment - Baringo County (n=27)

Kajiado County: In the reporting period under review, the Activity continued to support strengthening of complete, accurate and timely data and reporting through offering targeted mentorship, providing data capturing and reporting tools on time, providing technical assistance to HCWs on updating of PMCs as well as working hand in hand with the SCHMT to offer support supervision to health facilities and conduct data review meetings. The Activity distributed a total 3,223 assorted standard data recording and reporting tools to facilities. Fifty-six (56) HWC were mentored on both data capturing and reporting tools to address the various gaps identified in monthly reports during report collection and DQAs conducted.

An improvement in the reporting rates for eight out of nine routine reports all achieving the 95% target reporting rates apart from FCDRR. This was due to intensified monthly monitoring of reporting rates as well as working closely with SCHRIOs to follow up and collect missing reports. However, facility contraceptive reporting was at 90% due to change of two Sub-county pharmacist who were not conversant with keying in data into the DHIS 2. Due to this major change at the sub county level and county level, the M&E team has worked hand in hand with the pharmacy technical officer to support a commodity management training with reporting in DHIS2 forming part of the training in the coming quarter.

56 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

DHIS2 Reporting Rates - Kajiado County

98% 95%97% 94%95% 95%97% 95% 96% 95%97% 96% 95% 93% 92% 90%

81% 80% % RR %

MOH 711 MOH 710 HTC PMTCT ART MOH 717 MOH 713 HCA FCCRR

Jan-Mar 18 Apr-Jun 18

Figure 30: DHIS2 Reporting Rates - Kajiado County

Laikipia County: The Activity visited 23 health facilities to monitor the availability and correct use of tools. Some of the issues observed during the visits included; inadequate or lack of supply of the NASCOP new tool such as daily activity register (DAR), ART cohort register, ANC, pre-ART registers, green cards etc. To mitigate this, the Activity distributed 10 DAR for CCC, 12 ART Cohort registers, two ANC registers, three pre-ART registers, 300 green cards to supported sites to fill in the gaps.

As pat of capacity building, a total of 23 health care workers were mentored on data recording and reporting. Specifically, health care workers from three facilities (i.e. Segera, Muramati and Doldol) were mentored on accurate reporting for HEI tested positive in the care and treatment section of MOH 731, and staff from one site (Sipili HC) were mentored on accurate reporting for HAART given to known positives (KP) at first contact in ANC.

DHIS2 Reporting Rates - Laikipia County

99%99% 98%98% 97%97% 97%99% 96%100% 95%95% 93%91% 92%91%

67%70%

% RR % 42% 35%

MOH 711 MOH 710 HTC PMTCT ART MOH 717 MOH 713 MOH 733B HCA FCCRR

Jan-Mar 18 Apr-Jun 18

Figure 31: DHIS2 Reporting Rates - Laikipia County

57 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Monitoring of reports through DHIS2 for 10 key data sets continued. During the period, the average reporting rates for the dataset was above 90% for eight data set reports with MOH 733B and HCA datasets at 70% & 35% respectively in Apr-Jun 2018.

Nakuru County: The Activity in collaboration with the sub county health management team (SCHMTs) continued supporting the transitioning process to the use of revised NASCOP tools through mentorship and on the job training. Working with the SCHMTs, the Activity in administered the monitoring and evaluation (M&E) checklist to routinely verify availability, consistency, correct and complete use of standard tools in 32 facilities. In the PMTCT program, availability and use of tools scored 99% while completeness & correct use was at 92% and 94% respectively. In ART, availability, use, completeness & correct use were scored 95%, 94%, 92% and 93% respectively. The HIV testing services (HTS) scored 96% in all domains of the assessment while tuberculosis (TB) had 100% availability of tools and 98% use, completeness & correct use as shown in the figure below. Gaps identified in the process include missing post exposure prophylaxis (PEP) register, presumptive TB register not in use and missing departmental MOH 731 for HTC in some facilities.

Tools Assessment Status (Apr-Jun 18) - Nakuru County

100% 99% 99% 98% 98% 98% 96% 96% 96% 96% 94% 95% 94%

92% 92% 93%

% score %

Use Use Use Use

Complete Complete Complete Complete

Availability Availability Availability Availability

Correctly used Correctly Correctly used Correctly used Correctly used Correctly HTS PMTCT C&T TB

Figure 32: Tools Assessment Status (Apr-Jun 18) - Nakuru County

In collaboration with NASCOP and the University of Nairobi, 65 health care workers were enrolled to the e-Learning platform on use of the NACSOP data collection and reporting tools. By the end of the quarter, 33 (51%) had never accessed the eLearning portal despite being enrolled. The overall average score for the active health care workers was 63.4%.

The Activity supported photocopying of MOH tools as a stop gap measure to cover for the deficit in tools distributed by NASCOP with the aim of avoiding stock outs. During the quarter, a total of 22,523 assorted tools were photocopied and distributed to the facilities based on need. The tools included; appointment cards, ART registers, MOH 257, intensified case finding (ICF) cards, MOH 366, HEI cards, revised MOH 731, HTS registers, appointment diary, EID tracking form and viral load sample tracking. Further, 84 HCWs were mentored on complete and correct documentation and reporting of HTS, PMTCT and care and treatment indicators.

58 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

During the quarter, the Activity continued monitoring reporting rates in the DHIS2 for 10 key data sets. The reporting rates for all ten dataset reports increased by an average of 9% compared to the previous quarter. Significant improvements in reporting rates were realized in MOH 733B from 78% to 93%, and MOH 713 from 41% to 49%. Significant drops were observed in the reporting rates for MOH 710 and HCA which dropped from 98 to 95% and 78 to 74% respectively as shown here under. The improvement in the reporting rates across the datasets is largely attributed to the routine monthly monitoring of reporting rates by the project and close collaboration with the SCHRIOs on joint reviews of MOH reports and mopping up of late and retained reports on time. However, SCHRIOs have not fully owned the reporting on HCA which has been the contributing factor to fluctuating reporting rate for this indicator

Nakuru County Reporting Rates (Jan-Mar vs Apr-June 2018)

98 98 99 100 98 95 98 97 96 96 94 95 93 93 94

78 78 74

49

41 %score

MOH 710 MOH 711 MOH 717 MOH 731-1 MOH 731-2 MOH 731-3 MOH 713 MOH 733B FCCRR HCA

Jan- Mar 8 Apr-Jun 18

Figure 33: Nakuru County Reporting Rates (Jan-Mar vs Apr-June 2018) Narok County: In this quarter under review, the Activity disseminated and distributed a total 1,243 assorted new and revised NASCOP data collection and reporting tools across the four sub-counties. In addition, a total of 52 health care workers from 28 health facilities were mentored on data recording and reporting tools. Nine health facilities underwent a monthly data assessment. The findings of the assessment maintained at 100% results in HTS, PMTCT, ART and TB in terms of availability, completeness, and correct use. This has been maintained over the last four quarters. The Activity routinely monitored the accuracy, completeness, and timely reporting rates across the four sub-counties (Narok North, Narok South, Narok East and Narok West). The overall reporting rates for nine data set reports improved from 86% in Jan-Mar 2018 to 93% in Apr-Jun 2018. This was due to monthly monitoring for reporting rates by the SCHRIO and the Activity staff as well as supporting high volume sites aggregate and report on time. Technical support was provided to health care providers in aggregating MOH711/731, HEI reports, maternal cohort analysis and ART cohort analysis reports. Further, harmonization of DHIS2 and IMIS systems data was done in collaboration with four SCHRIOs to improve the quality of data submitted to DATIM. Whenever there was any discrepancy in the MOH 731/711 report correction was done according to the prescribed standard operating procedures for reporting.

59 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

DHIS2 Reporting Rates - Narok County

99%99% 95% 95% 97%97% 96% 94% 93%94% 94% 94% 91%93% 84% 81%

63%

% RR % 46%

MOH 711 MOH 710 HTC PMTCT ART MOH 717 MOH 733B HCA FCCRR

Jan-Mar 18 Apr-Jun 18

Figure 34: DHIS2 Reporting Rates - Narok County

The Activity staff supported eight high volume sites to prepare monthly reports (MOH711/731) in an effort to ensure submission of accurate and timely reports. The project also continued to mentor on the appointment diaries and defaulter tracing registers, aimed at supporting facilities to assist in tracking defaulters back to care. The effort resulted in reduced cases of defaulters with more children being brought to the clinic in comparison to previous periods.

In collaboration with NASCOP and University of Nairobi, 28 health care workers were enrolled to the eLearning platform for them to go through the NACSOP M&E tools. By the end of the quarter, 10 (36%) had not accessed the eLearning portal despite being enrolled. The overall average score for the active health care workers was 63%.

Samburu County: The project supported training of 85 health care workers from 22 health facilities on the new NASCOP M&E tools. During the training, it was noted that knowledge on M&E tools was grossly inadequate and therefore the training was timely. The mentorship teams will concentrate in mentoring the HCWs on proper documentation for the tools as well as on correct reporting in the summary tools in the coming quarter. Most of the health facilities in the county lacked the new NASCOP M&E tools which greatly hindered complete reporting, however, the Activity provided 186 assorted photocopies of tools (ART cohort registers, DAR for CCC, ANC, Maternity, Postnatal and MOH 731 reporting tools) to the the supported sites. Reporting rates in the DHIS2 for ten data elements is illustrated. There was improvement in family planning, immunization, and nutrition MOH 713, however apart from FCDRR all the other reports are below the target of 95%. The Activity will focus on addressing the causes of the low reporting rates in the subsequent quarter.

60 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

DHIS2 Reporting Rates - Samburu County

93% 96% 90%92% 89% 89%89% 86%86% 83%83% 83%86%

% RR % 44% 31%

0% 0% 0%

MOH 711 MOH 710 HTC PMTCT ART MOH 717 MOH 733B HCA FCCRR

Jan-Mar 18 Apr-Jun 18

Figure 35: DHIS2 Reporting Rates - Samburu County

Turkana County: During the quarter, the project supported 13 health facilities in ensuring availability of current versions of standard tools for data collection and mentorship on complete and correct documentation. A total 1,372 assorted data recording and reporting tools were distributed to the health facilities based on need and 30 health facility staff from the health facilities were mentored on correct recording and reporting.

During sites visits for support supervision and mentorship, the following were the major technical gaps identified; incomplete documentation in the ART register, DAR for CCC, ANC register, HEI register, non-documentation of correction made in data, reporting of HTS under static and outreach, concordant and discordant HIV results, testing for HIV in PMTCT compared to the new ANC visits, reporting of maternal and infant prophylaxis issued, report for HEI cohort where facilities reported workload instead of cohort data and reporting of current on ART.

The project continued to monitor the reporting rates of different data set where a significant drop was recorded for majority of the reports assessed. The drops were mainly attributed to updating of reports in DHIS2 after the deadline and confusion in the use of the new and old MOH 731.

61 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Turkana County Reporting Rates Jan-March VS Apr-Jun '18 95% 95% 90% 90% 91% 89% 89% 90% 87% 86% 81% 81% 82% 69% 66% 58% 57% 57% 49%

%score 36%

MOH 710 MOH 711 MOH 717 MOH 731-1 MOH 731-2 MOH 731-3 MOH 713 MoH 733B FCCRR HCA

Jan-Mar 18 Apr-Jun 18

Figure 36: Turkana County Reporting Rates Jan-March VS Apr-Jun '18

During the quarter the project continued to support the facilities with different assorted data recording and reporting tools which were photocopied to cab the shortage experienced. A total of 1,372 assorted tools were distributed during the quarter.

6.3.2 Strengthen data analysis, dissemination and use of data at all levels of service delivery Baringo County: The project continued to support data review activities in five facilities through the joint workplan. The main gaps noted from Eldama Ravine hospital was missed opportunities for testing of ANC mothers due to the Linda Mama initiative where mothers are required to have a national identification (ID) before enrolment in to the program. The meeting agreed that CHVs would emphasize to pregnant women the need to carry IDs during their first ANC visit. This intervention saw the HIV testing rates in ANC increase from 85% to 100% during the reporting period. Similarly, the use of data led to mentorship of 23 facility staff on defaulter tracing leading to an increase in defaulter tracing from 66% to 89%. Twenty facilities across the county received technical guidance to update and interpret the performance monitoring charts (PMC). Indicators selected for monitoring indicators included HTS uptake, linkage and defaulter tracing. Because of close monitoring, tremendous improvement was noted for instance in Emining health facility, the HTS testing coverage improved from 11% in previous quarter to 22% in Apr-Jun 2018 while the 100% linkage rate of newly HIV positive clients remained at 100 for two consecutive quarters

Kajiado County: Monthly data review meetings were held in five high volume sites and quarterly meetings in three sub counties with the support of the project. Double counting of HIV testing and positives in PMTCT were among the key issues identified in two facilities (Ngong SCH and Isinya HC) during the data review meetings. This was attributed to HTS counsellors testing PMTCT mothers and reporting the positives both under HTS and PMTCT in the month of April. The meeting led by the CASCO tasked the PMTCT nurses to test PMTCT mothers to avoid double reporting. This has since been corrected through mentorship and a data verification showed improvement of a variance of 2% in previous quarter to 0%. Laikipia County: The county and sub counties continued to monitor performance against targets. During the quarter, data reviews meetings were held at five health facilities where VL uptake and

62 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report suppression rates, achievement of currently on ART against target and defaulter rates were reviewed. The review showed that HIV testing against testing reduced from 95% to 87% due to contractual related issues affecting HTS counsellors. The linkage rate remained at 98% while viral suppression rate improved from 80% to 88% in this quarter as a results of monitoring

The project continued to strength use of PMC in 16 facilities to measure progress and trends of indicators over time. A total of 23 HCWs were mentored on data analysis and interpretation. During the quarter, the county received PMC from Nakuru and these were distributed to health facilities. The chart shows trend of VL uptake against target and VL suppression rate because of data review and monthly monitoring of performance at Ndindika health centre.

The project continued to support health facilities to ship of samples to central hub and to track the TAT of viral load, EID and GeneXpert from the NASCOP databases. The quarterly analysis showed that the TAT for EID samples between collection and dispatch was within the expected time and an improvement from 10 days in previous quarter to nine days to current quarter as shown the Chart **.

Laikipia County EID TAT in Days Jan-March/April-June 2018

9 9 10 9 7 5 3 2

Collection to Receipt Receipt to Processing Processing to Dispatch Collection to Dispatch Jan-March April-June

Figure 37: Laikipia County EID TAT in Days Jan-March/April-June 2018

Nakuru County: The project supported data review meetings in 13 facilities and one sub-county. During these review meetings, the performance against targets for various indicators including HTS uptake and positivity yield among PNS clients, linkage rate of newly diagnosed HIV positive clients were monitored. The chart shows an increase in contact testing rates uptake and a decline in HIV positivity yield at Naivasha hospital.

The project further continued to support use of PMC in 43 facilities to monitor progress on different indicators within the quarter. A total of 60 HCWs were mentored on data analysis and visualization using the PMC as a way of monitoring quality improvement.

63 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

In addition, the project monitored the TAT for EID/VL samples from 69 facilities with an aim of reducing the TAT to below 14 days. An assessment of the TAT for EID/VL was done at four different levels, i.e. collection to receipt, receipt to processing, processing to dispatch and collection to dispatch. From the VL sample analysis, there was slight improvement in TAT for collection to receipt and collection to dispatch as shown below. However, compared to previous quarter, there was slight delay in TAT for EID at all stages except for processing to dispatch in this quarter as shown in figure below. The delay in TAT from collection to receipt for EID was attributed to the technical challenges experienced at the testing lab in Kericho.

Nakuru County VL TAT Jan-March Vs Apr June 2018 Nakuru County EID TAT In Jan-Mar Vs Apr-June 2018)

17 17 16 14

8 8 6 7 7 6 6 Days in TAT TAT in TATin Days 4 3 3 3 3

COLLECTION TO RECEIPT TO PROCESSING TO COLLECTION TO COLLECTION TO RECEIPT TO PROCESSING TO COLLECTION TO RECEIPT PROCESSING DISPATCH DISPATCH RECEIPT PROCESSING DISPATCH DISPATCH

JAN-MARCH APR-JUNE JAN-MARCH APRIL-JUNE

Figure 38: Nakuru County VL and EID TAT Jan-March Vs Apr June 2018

Narok County: Four sub counties were supported to conduct quarterly data review and 17 facilities to hold monthly data review meeting. The indicators reviewed during the meetings included VL uptake, EID uptake, defaulter rates, IPT uptake, linkage rates, ANC HIV testing versus first ante natal visit, TB HIV testing and PMTCT maternal prophylaxis uptake. By the end of the quarter, as a result of implementing recommendations from the data review meetings and closely monitoring progress, Olmekenyu HC noted remarkable improvement in VL uptake from 79% in quarter two to 96% in the current period. Ololunga also experienced improvement in IPT uptake from 40% in previous quarter to 66% in the reporting period.

Turkana County: The project continued to monitor the turnaround time for EID and VL sample tests. As illustrated, the county achieved an EID TAT which far below the recommended 14 days. This is largely due to availability of point of care EID in most facilities. The VL TAT has however, remained high above the recommended 14 days. This is mainly due to transport challenges both from facilities to G4S offices and G4S offices to the lab. The EID TAT dropped by one day while that for VLs increased by a day.

64 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Figure 39: Turkana County VL and EID TAT Jan-March Vs Apr June 2018

6.3.3 Institutionalize DQA systems and practices at all point of service delivery

Baringo County: The Activity conducted DQA using the M&E checklist in 32 facilities resulting in mentorship of 61 HCWs based on identified gaps. As a result, HCA reporting rate for Mogotio sub- county improved from 67% in Jan-Mar 2018 quarter to 100% in reporting quarter. Within the reporting period, two gap analysis meetings were held where identified data Baringo Q2 and Q3 2018 Gap analysis gaps (n=28) quality gaps were addressed. By the end of the quarter, the number of gaps for 28 supported 242 health facilities reduced from 242 to 149 between last quarter and the reporting quarter as 149 shown in the graph on the right. There was also 93 notable improvement in Kenya Mentor Mother 48 4849 5042 45 No. of of gaps No. 9 Program (KMMP) reports that did not have any 6 1 gap by the end of the quarter. The improvement C&T HEI HTS KMMP PMTCT Overall was attributed to the review meeting at the Jan-Mar 2018 Apr-Jun 2018 county level and facility level and follow-up of documented action points by the MDT team. Figure 40: Baringo Q2 and Q3 2018 Gap analysis gaps (n=28) Kajiado County: The Activity conducted data quality assessments using the M&E checklist in 12 Data variation trends for selected Indicators Jan`18 - facilities and mentored a total of 23 HCWs on June`2018 correct documentation and reporting of clients newly diagnosed with HIV at PMTCT and other HTS service delivery points. The variance between the reported and recorded data remained at 0% JAN-18 FEB-18 MAR-18 APR-18 MAY-18 JUN-18 within the quarter under review. (%) Variance

The Activity further supported two gap analysis meetings at county level to identify data quality Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 PMTCT positive ANC 0% 0% 0% 0% 0% 0% issues from the data submitted monthly, action HTC Positives 0% 0% 0% 2% 0% 0% points derived to address the gaps that would improve the quality of care offered to clients. Three Figure 41: Data variation trends for selected Indicators Jan`18 - June`2018 MDT reviews were done to review data quality on

65 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report reported indicators in DHIS2 and DATIM. The identified errors were mainly due to transcription error in the DHIS2, the SCHRIO’s were given feedback and corrections were addressed accordingly.

Laikipia County: All the three sub counties in Laikipia County adopted the use of the M&E DQA checklist and project supported the SCHRIOs to conduct DQA in 24 (83%) of supported facilities using the checklist. The gaps identified during the site visits were addressed with a total of 23 HCWs mentored on correct documentation for PMTCT indicators and reporting using MOH 731. Nakuru County: The Activity supported data quality audits (DQA) by administering 31 M&E checklists to verify reported data against data recorded in source document and in the process mentored 40 HCWs to address the identified gaps. By end of the quarter, the data verification factor for total positive in HTS and total starting ART across the period was at 0 for the 31 facilities except for April 2018 where the % DQVF for total starting ART was 4% due to underreporting of the indicator. In addition, the Activity continued to support implementation of the performance reimbursement plan (PRP) as a measure of improving data consistency and the reporting rates in the DHIS2. The PRP scores continued to demonstrate high data consistency levels at 100 % from 50 Nakuru County Consistency scored and PRP selected data elements in MOH 731 and [N=33 Sites] 100% 99.7% 100% 100% 100% 100% DHIS2 as shown on this illustration. There was a 3 % decrease in the overall PRP 94% 95% scores this quarter compared to last quarter 91% 92% 91% 92%

due to a decrease in reporting rates for HEI % Score cohort analysis, PMTCT, HTS and MOH 710 by 4%, 4%, 3% and 3% respectively. There was also a significant drop in the overall PRP score for Rongai sub-County Jan-Mar 17 Apr-Jun 17 Jul-Sept 17 Oct-Dec 17 Jan-Mar 18 Apr-Jun 18 from 90% in Jan-March’18 to 74% in April- Consistency Score Overall PRP Score June ’18 which came because of a lapse in Figure 42: Nakuru County Consistency scored and delegation of DHIS data entry duty by the PRP [N=33 Sites SCHRIO.

The Activity further held two gap analysis Nakuru County trends of facilities with data qualilty meeting to address identified gaps. Because gaps Jan-June '18 135 133 of these meetings, the number of facilities 131 131 identified with gaps reduced by two 130 compared to the previous quarter as shown in 127 127 125 the to the right. The number of facilities with 125 gaps has however been comparatively high in

Jan-June period compared to Oct-Dec which 120 is mainly attributed to the transitioning Jan Feb Mar Apr May Jun process to the new tools which started in Jan Number of Facilities with gaps 2018. Figure 43: Nakuru County trends of facilities with Narok County: The Activity supported two data quality gaps Jan-June '18 gap analysis meetings and further supported SCHRIO to address identified data quality gaps. In addition, 14 facilities received technical and logistical support to conduct data quality assessment (DQA) to improve data quality during which 14 HCWs were mentored based on identified gaps. By the end of the quarter, the DVF for nine facilities was at 0%, showing no discrepancy between reported and data recorded in source documents for seven data elements namely antenatal HIV testing,

66 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Antenatal HIV positive, KP at entry, maternal prophylaxis, infants issued prophylaxis at ANC, total HEI tested at 12 months and total HEI confirmed HIV positive.

The significant achievement was attributed to focused mentorship, joint supportive supervision with MOH, facility monthly data review, gap analysis and quarterly M&E TWG meetings.

6.4 Quality improvement (QI) To improve quality of care, HCSDSA Cluster 2 continued to support quality improvement activities in the high-volume facilities. In the reporting quarter, a total of 65 HVS facilities (10 Baringo, 10 Kajiado, 8 Laikipia, 26 Nakuru, 8 Narok) held monthly QI meetings and were assigned improvement topics based on their gaps and weaknesses (facility optimization, linkage to care, ART coverage, retention, viral load, waste management, IPC practices, etc.). 12 sub county QITs met once in the quarter. 45 HVs (4 Baringo, 8 Laikipia, 25 Nakuru, 8 Narok,) have established quality improvement monitoring systems that track their performance. Two (2) HVF sites, both in Narok were assessed using the SIMS checklist. A total of 45 facilities (4 Baringo, 8 Laikipia, 25 Nakuru, 8 Narok) held QI review meetings supported by the project. Key service quality issues identified included: Infection Prevention, differentiated care, Treatment failure among adolescents, Uptake of PMTCT services (1st ANC), documentation, poor retention rate, defaulter tracking, viral Load suppressions, facility optimization, linkage to care, ART coverage, retention, viral load uptake and suppression, waste management and IPC practices among others. These were addressed through mentorship, CMEs and support supervision. On compliance with the national guidelines for VMMC in Nakuru and Turkana, the project, in collaboration with Nakuru MoH supported supply of specially coded VMMC reporting tools and monitored their use. The project supported the development and production of SOPs and job aids and procured certain VMMC consumables and the emergency kits used at the health facilities in Nakuru and Turkana. The Activity continued supporting QI activities through chart abstraction, review and color coding of files of clients eligible/due for a specific service. The facilities have also utilized the suspected treatment failure registers to track patients who are due for switching to second line after their second viral loads. The Activity also mentored 199 HCWs on chart reviews, case discussions, treatment failure, differentiated care model and defaulter identification. Technical working groups meetings were supported; their discussions focused on commodity security, review of progress against targets, roll out of best practices, and challenges in care and treatment/TB HIV.

III. ACTIVITY PROGRESS (Quantitative Impact) This section presents a quantitative description of the key achievements of the April to June 2018 reporting period. The tables present the basic data of key indicators in the PPMP required to assess progress toward achievement of the targets in the project. The tables for this section have been submitted separately.

IV. CONSTRAINTS AND OPPORTUNITIES During the quarter, several constraints affected implementation of planned activities. The fact that some PEPFAR reporting requirements do not match with the current national reporting tools is a constraint towards continued strengthening of the national system. To meet this requirement, the project develops separate templates to collect the required data from supported sites. The Activity supports PMTCT services at 234 facilities out of the 800 offering this service in the region of coverage. This has affected the performance of PMTCT indicators as HSDSA support is limited to the few sites. To mitigate this, HSDSA will institute outreach services to additional PMTCT sites on the priority of client caseload in these sites.

67 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

There exists missed opportunity to offer comprehensive services, including Pre-Exposure Prophylaxis (PrEP) to Key Population (KP) clients seeking services at public facility Comprehensive Care Clinic (CCC); they do not self-identify to avoid stigmatization. To address this, HSDSA trained FHI 360 LINKAGES project staff to foster service integration in the KP drop in centres , provide information and link clients, upon request, to the link facility.

The Activity continues to make significant strides towards strengthening Electronic Medical Records (EMR) system. The Activity will continue collaborating with Palladium Group to institutionalize EMR system implementation at 83 high volume sites to improve the data quality and use of the system for patient management. The formation of USAID implementing partners forum is an opportunity to leverage on support from other partners for synergies and avoid duplication of activities.

In the next quarter, the Activity will work closely with the HTS counselors in all HVFs to scale up identification through PNS in order to maximize the yield. Rollout of dual testing in ANC and maternity provides an opportunity for early identification and cost reduction for STI screening that will increase access to care for pregnant women. Collaboration with USAID funded Afya Timiza and Afya Uzazi is also an opportunity for the Activity towards achievement of the PMTCT targets and reaching the population in need with comprehensive package of PMTCT services.

V. PERFORMANCE MONITORING During the reporting period, the Activity conducted routine performance monitoring activities including tracking of reporting rates in DHIS2, tracking availability and use of standard recording and reporting tools, monthly data quality assessments, utilization of performance monitoring charts and implementing performance reimbursement plan for SCHRIOs across the seven supported counties. A baseline assessment was also conducted in 46 health facilities across the seven counties to establish baseline values for reportable indicators.

During the quarter, the Activity monitored the DHIS2 reporting rates for 11 data set reports (MOH 710, MOH 711, MOH 731 (ART, PMTCT and HTC), FCDRR, MOH 515, MOH 717, MOH 713, MOH 733B, HEI cohort analysis reports) from supported counties. The overall project PMTCT reporting rate increased from 91% in the previous quarter to 92% in the current. This was due to significant increases in reporting rates in Baringo (+2%), Kajiado (+3%) and Laikipia (+3%). All the counties apart from Narok, Samburu and Turkana had a reporting below the target of 95%. All the counties apart from Narok, Samburu and Turkana had a reporting below the target of 95%. This is attributed to the partial transition to the new MOH 731 in the affected counties.

68 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

DHIS2 MOH 731-2 PMTCT Reporting Rates (Oct 17' to Apr-Jun 18') 120 120

100 100

80 80

60 60 % RR % 40 40

20 20

0 0 Oct-Dec 17 Jan-Mar 18 Apr-Jun 18 Baringo 81 96 98 Kajiado 54 93 96 Laikipia 92 94 97 Nakuru 94 98 96 Narok 94 88 88 Samburu 57 84 83 Turkana 94 84 85 Overall 81 91 92 Target 100 100 100

Figure 44: DHIS2 MOH 731-2 PMTCT Reporting Rates (Oct 17' to Apr-Jun 18')

The Activity also monitored the reporting rates for the revised NASCOP M&E tools. During the quarter, the overall PMTCT reporting rate was 26% in supported seven counties as follows; Baringo [3%], Kajiado [22%], Laikipia [4%], Nakuru [34%], Narok [74%], Samburu [18%] and Turkana [27%]. The plan is to increase these rates to at least 95% in order to transition fully to reporting using the revised MOH731 by September 2018. As a way to improve this performance, the Activity has printed tools to ensure all tools have the required standard tools, conducted trainings for HCW in all counties including enrolling them into the eLearning platform and monitoring of reporting rates. Mentorship will be intensified in the next quarter.

During the quarter, routine data quality assessments were conducted in 92 health facilities during which 24 routinely monitored data elements reported in MOH 731 were compared with data from source documents. Analysis from 52 facilities for the three data elements namely ART, HTS HIV+, tested at ANC showed a -1% DVF which falls within acceptable the margin of error of + 5% as shown in below. The under reporting for the indicators was caused by arithmetic errors.

69 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Variance between recounted vs reported data Apr 17 to Mar 18 10 9 7 8 7 6 5 4 2 2 3 1 1 2 0 0 % % variation 1 -1 -1 Target< -/+ 5% 0 -1 -2 -3 -4 -5 -6 Quarter Apr-Jun 17' Jul-Sep 17' Oct-Dec 17" Jan- Mar 18 Apr- June 18 and n value 61 60 28 59 52 Current on ART 1 2 0 7 -1 HTC HIV+ 1 0 -1 1 -1 Tested at ANC 1 0 0 2 -1

Figure 45: Variance between recounted vs reported data Apr 17 to Mar 18

To promote data analysis, utilization and documentation, the M&E team continued to support 143 facilities across all the counties (except Samburu and Turkana) to use performance monitoring charts and data use hand books to enhance visualization and review of indicator performance monthly. Compared to previous quarter, the percentage of facilities with completed PMC increased across all counties with an overall increase of 33% as shown in table below. Use of handbooks however, dropped across the counties due to late dissemination of the books while the percentage of facilities with evidence improved performance increase from 38% in previous quarter to 45% in this quarter.

Utilization level of Performance Monitoring Charts per county Grand Quarter Baringo Kajiado Laikipia Nakuru Narok Indicators Total Target 20 29 17 61 20 147 # of facilities Jan- Mar 2018 38% 86% 47% 20% 100% 50% with completed PMC Apr- Jun 18 100% 90% 94% 70% 85% 83% # of facilities Jan- Mar 2018 17% 28% 25% 0% 100% 22% using data use hand books Apr- Jun 18 10% 34% 0% 0% 85% 20% # facilities with Jan- Mar 2018 38% 86% 29% 8% 70% 38% evidence of improved Apr- Jun 18 100% 86% 18% 30% 0% 45% performance

The Activity continued to implement the SCHRIO PRP with an aim to improve reporting rates and timely reporting using selected 12 data sets. Data verification was further conducted using 50 data 50 data elements to cross check consistency of data between DHIS2 and MOH 731 summary report for the 84 facilities. The respective SCHRIOs were provided with monthly feedback on their performance and follow up made on identified gaps. There is steady improvement in data consistency between hard copy and DHIS2 has maintained a score of 100% for last two quarters. The overall PRP score has equally improved over time and was at 94% at by the end of the quarter. The current plans have achieved its purpose therefore in the next quarter, the Activity plans to review this plan to respond to new reporting requirements and expectations in strengthening data collection, reporting and quality.

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Overal PRP performance Vs consistency scores Apr 13' to Jun 18'

105

100

95

90

Percentages [%] Percentages 85

80

75 Apr- Jan- Jul- Oct- Apr- Jan- Jul- Oct- Apr- Jan- Jul- Oct- Apr- Jan- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jun Mar Sep Dec Jun Mar Sep Dec Jun Mar Sep Dec Jun Mar Sep Dec Mar Jun Sep Dec Mar 18 Jun 18 2013 2014 2015 2016 2017 2018 Overall PRP scores 79 80 90 81 87 88 90 84 91 87 92 84 87 87 91 91 92 88 80 90 94 94 Consistency scores 90 82 94 94 92 95 94 92 94 93 96 96 98 96 97 99 99 100 99 100 100 100 Targets 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

Quarters, Years, %s

Overall PRP scores Consistency scores Targets

Figure 46: Overall PRP performance Vs consistency scores Apr 13' to Jun 18'

VI. PROGRESS ON GENDER STRATEGY During the reporting period, the project completed the gender analysis assessment across all the seven counties. Through the process of conducting the Gender, Youth, and Social Inclusion analysis, the Activity identified key gender and social issues affecting the use of combination prevention services for priority populations in supported counties. These issues include; lower condom usage among males; high rates of Sexual and gender-based violence (SGBV); high rates of pregnancy among adolescent girls and young women (AGYW); sexual networking patterns among fisherfolk, and Low voluntary medical male circumcision (VMMC) rates in Turkana; lack of access to a complete array of modern family planning methods; increasing access to Post exposure Prophylaxis (PEP) for discordant couples and priority populations and insufficient connection between vulnerable groups with social protection services. These findings and proposed solutions will inform the work of the HSDSA project in Cluster 2 to ensure that activities and services implemented help overcome existing social and cultural barriers to testing, treatment, and care, and that they do not reinforce or compound existing social inequalities.

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING In the reporting quarter, 256 HCWs were sensitized on infection prevention control (IPC) measures and medical waste management. The activity supported supply of 25 job aids and 53 waste bins (waste bins and liners, veronica taps etc.) within facilities in Narok county.41 facilities were facilitated to revive IPC committees and were supported to develop IPC plans and display them within facilities. TB risk assessments were conducted in 52 facilities (Narok 13, Laikipia 11, Nakuru 7, and Kajiado 21) through the established IPC committees. Some of the actions from the assessment included establishment of coughers corners within the facilities and ensuring integration of TB/HIV services, workplans for monitoring IPC activities, Hand washing techniques i.e. Lack of running water in some clinical rooms hinder adequate handwashing procedure. It was also observed that HCWs did not observe expected infection procedures during sample collection. i.e. poor phlebotomy procedures.

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS HSDSA Cluster 2 project continued to collaborate with other USG/USAID programs in the seven counties for quality expanded service delivery as follows; • AFYA Uzazi: Collaborated in reaching out to pregnant and breastfeeding women and children under 5 years in Kuresoi North and South sub counties of Nakuru and sub counties of Baringo

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except East Pokot and Baringo Central. The project also partnered with Uzazi to initiate Nakuru’s HRH SP 2018-2022 development process. • AMPATH plus: The Activity collaborated with AMPATH care laboratory in rolling out of SMS to clients for VL and EID results. • FHI 360 CDC Laboratory systems strengthening program: supported in infection prevention sensitizations and CMEs in nine facilities and Hemovigilance supervisions. • NHP plus: NH plus provided food supplements to health facilities within Baringo County comprised of central, satellite and standalone sites. • Palladium Group: The project in collaboration with Palladium supported Kenya EMR/IQ care training for project staff focusing on building capacity to install the national data- warehouse module and upgrade IQCare. • PS Kenya: The project collaborated with PS Kenya in ensuring the effective functionality of computers and printers installed for EID/Viral load remote login in five laboratory hubs. PS Kenya continued supporting the facilities with data bundles. • Walter Reed: The project continued to work closely with Walter Reed Project to facilitate EID and VL samples analysis. • HRH Kenya: The project collaborated with HRH Kenya in uploading project contracted staff into iHRIS and continued discussions around development of the county’s HRH strategic plan 2018-2022.

IX. PROGRESS ON LINKS WITH GOK AGENCIES The project continued to work closely with key government line ministries as follows: • Ministry of Health: The project collaborated with the ministry of health in ensuring quality services are provided to both public and private health facilities. This is done through the Joint Work Plans, mentorship, orientations, support supervisions, capacity building and strengthening referrals through the link desks to enhance referrals from CHVs from community to facility, facility to community and facility to facility. In addition, joint data reviews were conducted with MOH in all supported counties to assess progress towards achievement of the 90-90-90 targets. The project also conducted entry meetings and staff orientation on HSDSA implementation with focus to scale up collaborative quarterly data review, feedback and work planning at subcounty levels. • KEMRI Reference Laboratory: The project continued to work closely with KEMRI Reference Laboratory for viral load sample analysis. • KEMSA: The project collaborated with KEMSA in ensuring that the commodities were supplied to different facilities in the county.

X. PROGRESS ON USAID FORWARD There were no activities implemented during the quarter under review.

XI. SUSTAINABILITY AND EXIT STRATEGY To ensure sustained strengthening of the health system and continued provision of quality health services by MOH staff, the project invested in mentorship and CMEs in various facilities to build capacity of local service delivery/primary health care cadres of MOH staff. The CME topics included; differentiated care, defaulter tracing, use of GeneXpert in TB diagnosis, suspected treatment failure follows up among others. In total 4,698 health care worker were reached through CME and mentorship sessions during the reporting period. This was also coupled with technical assistance support by project staff. All this is done to ensure that MOH workforce is equipped with necessary knowledge and skills to provide quality services. A total of 433 HCWs were given main training/updates on; NASCOP

72 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

reporting tools, Quality Improvement-IQcare, PNS, New HTS guidelines/new data tools, Revised WHO pediatric and adolescent HIV care and treatment guidelines, Community Management of Acute Malnutrition (CMAM) and New ART reporting tools.

XII. SUBSQUENT QUARTER’S (July – Sept 2018) WORK PLAN Planned actions for Actual status Explanations for Planned actions for April – June 2018 this quarter Deviations July - September 2018 Program Management Submit Gender analysis and Baseline reports as Done USAID SIMS in Nakuru, Narok and Kajiado per contract expectations Submit quarterly DATIM report/ Done Draft and submit year 2 (preliminary) Conduct performance review meeting workplan Conduct HSDSA introduction to MOH Done Submit quarterly DATIM report/ county executives, CHMT and SCHMT Conduct performance review meeting Submission of revised grants under contract Done Continued support on implementation of manual activities through JWPs Develop Joint Work Plans (JWP), support on Done Submit requests to sub contract to USAID implementation of activities through JWPs for CRS, Avencion and WI-HER Complete startup out actions Done Procure 9 project vehicles Clinical Services Continue to focus on the DATIM Ongoing Continue to focus on the DATIM indicators and achievement of 90-90-90 indicators and achievement of 90-90-90 targets. Mentorship and supervision to targets. Mentorship and supervision to continue this quarter. Continue the quality continue this quarter. Continue the quality focus of SIMs assessments in the high- focus of SIMs assessments in the high- volume sites. Also continue the efforts of volume sites. Also continue the efforts of index client testing, sexual network testing index client testing, sexual network testing and Partner notification service. and Partner notification service. Accelerate the scale up on PNS to all counties Ongoing Accelerate the scale up on PNS to all counties by training the HTS counselors by training the HTS counselors to carry out the service effectively and to carry out the service effectively and link clients to ART. link clients to ART. Fast track the carrying out of the FGDs Ongoing Planning process Fast track the carrying out of the FGDs with men to understand the needs of men taken off with with men to understand the needs of men 24-35 and AYP 15-24. development of the 24-35 and AYP 15-24. protocol Focus on the scale up of differentiated Ongoing Focus on the scale up of differentiated care using the huduma chap chap card at care using the facility. Increase the number of clients that are huduma chap Continuein various support differentiated facility care QA/QI models. Ongoing Continuechap card support at facility QA/QI meetingsDeliberate and on activitiesthe PREP through monitoring joint inwork various meetingsfacility. Increaseand activities through joint work planscounties and mentorship targeting 83 ART high plansthe numberand mentorship of targeting 83 ART high volume sites. volumeclients that sites. are in various Continue to match needs of testing target Ongoing Continue to match needs of testing target areas with the HTS workforce. areasdifferentiated with the HTS workforce. care models. Support the last batch of the meetings for Done DeliberateContinue to on support the commodity security, TB, Pharmacovigilance/commodity security, PREPRTKs allocation, HIV care and treatment and FollowHIV care through and treatment, on quality PMTCT service TWG Ongoing FollowmonitoringPMTCT throughTWG meetings. in on quality Support service quarterly provisionmeetings. andFurther documentation support the offormation nutrition of the provisionvarioussouth rift counties TWGand meeting. documentation of servicessouth rift in TWG. the 85 Sites high yield sites. Focus nutrition services in the 85 Sites high yield will be on quality of sites. Focus will be on quality of data on NACs and reporting in DHIS data on NACs and reporting in DHIS Continued support for SGBV and post rape Done for this quarter and Continued support for SGBV and post rape care interventions within health facilities and ongoing for Q4 care interventions within health facilities and community community

73 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Planned actions for Actual status Explanations for Planned actions for April – June 2018 this quarter Deviations July - September 2018 Sustain the QIT activities of the Done Sustain the QIT activities of the documentation of best practices at facility documentation of best practices at facility level level Continue the scale up the differentiated Done Continue the scale up the differentiated model with focus on community ART groups model with focus on community ART groups formation of 20 more groups in the five formation of 20 more groups in the five Strengthencounties measuring the use of the STF immediate system ofoutcomes for at Ongoing Strengthencounties measuring the use of the STF immediate system ofoutcomes for monitoringfacility level and follow up of any patients monitoringat facility level and follow up of any patients failing treatment and changing them to failing treatment and changing them to 2nd line. 2nd line.

Conduct “turning the tide” RRI • Account for every client enrolled on ART • Fast track achievement of ART enrollment target Scale up prevention activities with fisher folk communities in Turkana Conduct VMMC RRI in Turkana during August school holidays Provide TA support for the development of Ongoing for Samburu, Provide TA support for the completion of the County Health Strategic and investment Baringo and Narok development of County Health Strategic and plans(CHSIPs) for 3 counties investment plans(CHSIPs) for 5 counties: Provide TA support for the development of ProvideSamburu, TA Baringo, support Narok, for the Turkana completion and of the County Health Annual Work Plans(AWPs) for developmentLaikipia of County Health Annual Work Identify3 counties critical HRH gaps and joint identify, Extended temporary EngagementPlans(AWPs) of for a HRH5 counties: services Samburu, management interview, hire and maintain contracted facility HRH contracts for 1070 subBaringo,-contractor Narok, to Turkana lead facility and Laikipiastaff staff for supported counties facility based staff recruitment, payroll management, staff pending rationalization returns and replacement of transitioned upon sub-contracting of facility staff. a HRH services management sub- contractor Sign 7 Letters of Agreement (LoAs) on HRH support and transition to County Public Service with the supported Counties

Monitoring and Evaluation (M&E)/Strategic Information

Monthly monitoring of the EID/VL TAT to Done Monitor on a monthly basis the EID/VL TAT improve timely QOC to improve timely QOC Train 680 service providers in NASCOP M&E 85 service providers Logistical issues Train 30 service providers in NASCOP M&E tools from Baringo, Kajiado, Narok, Samburu trained hindered training for tools from Turkana County and Turkana Turkana county Enroll at least 100 health care workers from Partially done Enroll at least 100 health care workers from each county to the NASCOP eLearning portal (Registration is done by each county to the NASCOP eLearning portal Develop, print and disseminate reporting job cohort) aids for the revised MOH 731 reporting tools Not done. Engagement Develop, print and disseminate reporting job with SCHMTs ongoing aids for the revised MOH 731 reporting tools

Limited resources to train all targeted staff Conduct M&E assessments in 83 HVF Done except in Samburu M&E assessments not Conduct M&E assessments in 83 HVF & Turkana conducted in Samburu including Turkana and Samburu and Turkana due to the Conduct baseline assessment for project planned training NA indicators in 46 HVF and data quality Baseline assessment assessment using FHI360 data quality checklist done Provide TA in the utilization of data use Done in 29 facilities Partially done due to Provide TA in the utilization of data use handbooks to document issues and decisions delays in providing data handbooks to document issues and decisions made at 83 HVFs use handbooks to sites made at 83 HVFs

74 | HSDSA Cluster 2 Q3 (Apr-Jun 2018) Progress Report

Planned actions for Actual status Explanations for Planned actions for April – June 2018 this quarter Deviations July - September 2018 Institutionalize quarterly data review meetings Done Strengthen institutionalization process for at 36 sub counties quarterly data and performance review meetings at 36 sub counties Conduct monthly gap analysis to detect outliersDone Conduct monthly gap analysis to detect and inconsistent data in order to inform TA outliers and inconsistent data in order to provision inform TA provision Print and disseminate performance monitoring Done Monitor outcomes of the performance charts monitoring charts Institutionalize cascade analytics through use Done except in Samburu & Turkana Train Samburu & Turkana facility staff to use of run charts in 83 HVS Samburu& Turkana facility staff lacked run charts technical capacity use develop run charts Institutionalize cascade analytics through use of run charts in 83 HVS Provide TA to 72 EMR sites in seven counties Done in 66 sites. Six sites not provided Engage the SCHMT to address the underlying with TA because use of factors the EMR system stalled Provide TA to 72 EMR sites in seven counties

Hold quarterly EMR strategic planning Not Done Competing activities Hold quarterly EMR strategic planning meeting with Palladium Group meeting with Palladium Group Create 5 centres of excellence for EMR Not done EMR assessment Create five centres of excellence for EMR products conducted within the products quarter to inform choice of health facilities. Analysis of findings had not been concluded by end of the quarter

Conduct EMR DQA in 65 active EMR sites Done in 20 sites The ongoing EMR Conduct EMR DQA in 65 active EMR sites system upgrades affected activity Conduct monthly checks on reported indicators Done Conduct monthly checks on reported in DHIS2 and DATIM and address gaps indicators in DHIS2 and DATIM and address gaps Disseminate the DQA protocol, performance Not done Due to competing Disseminate the DQA protocol, performance review and reporting guidelines activities review and reporting guidelines

Visit five counties to provide technical support Done in 2 counties Partially done due to Visit seven counties to provide technical to M&E officers and HRIOs competing activities support to M&E officers and HRIOs

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XIII. FINANCIAL INFORMATION

Figure 47: HSDSA budget obligations vs. current and projected expenditures Obligation Vs Current and Projected Exp.

$14,000,000

$2,584,751 $12,000,000

FY19 Q2 Projection $10,000,000 $3,025,616 FY19 Q1 Projection

$8,000,000 FY18 Q4 Projection

$6,000,000 $10,964,554 FY18 Q3,Actuals $5,364,428 todate Obligated todate $4,000,000

$2,000,000 $2,434,990

$0 Obligation to date Quartely

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HSDSA Cluster 2 Budget Details T.E.C: $ 84,610,261 Cum Obligation: $10,964,554 Cum Expenditure: $ 2,434,990

Dec.17-Jun.18 July-Sept.18 Oct-Dec.18 Jan-Mar.19 FY 2018 Q3 FY 2018 Q4 FY 2018 Q1 FY 2019 Q2 Obligation Actual Projected Projected Projected CLINs Expenditures Expenditures Expenditures Expenditures $ 10,964,554 2,434,990 5,364,428 3,025,616 2,584,751

CLIN 001 Direct Costs 1,115,105 2,613,431 946,615 946,615

CLIN 002 Subcontracts 909,860 1,344,764 996,242 996,242

CLIN 002a Small Business Subcontracts 45,220 0 50,000 50,000

CLIN 002b Other Sub Contracts 864,640 1,344,764 946,242 946,242

CLIN 003 Grants Under Contracts (GUC) 0 100,000 594,500 150,000

CLIN 004 Indirect Costs 410,024 998,522 389,430 377,873

CLIN 005 Total Fixed fee 0 307,711 98,829 114,021

Total 2,434,990 5,364,428 3,025,616 2,584,751

Budget Notes (Listed below are assumptions, major changes, estimations, or issues intended to provide a better understanding of the numbers)

Salaries for the coming quarter will increase due to additional staff Salary and Wages joining the HSDSA Project. Fringe Benefits Fringe benefit rate will be applied to salaries as per approved award. Travel expenses will increase due to increased trips to project areas as Travel, Transport, implementation is accelerated. Travel especially to and within the two Per Diem counties of Turkana and Samburu will increase. Equipment and Procurement of Project vehicles is to be finalized in next the quarter. Supplies Subcontracts Facility health staff sub contract shall be reporting in the next quarter Accelerated project activities including trainings and meetings will be Other Direct Costs expected in the coming quarter. Grants Under At least 2 GUC’s to onboard subject to approval of GUC Manual Contract Overhead G&A Calculated as per Award conditions. Material Overhead

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XIV. ACTIVITY ADMINISTRATION

Personnel: The HSDSA Cluster 2 completed the onboarding of staffs in the quarter under review. The staff were given an orientation and reported to their respective duty stations.

Contract Modifications and Amendments: None was done in the reporting period.

XV. SUCCESS STORIES

RUMURUTI SCH PRISONERS SUPPORT GROUP BEST PRACTICE Background Rumuruti SCH started HIV prisoners support group services on 15/06/2007 with a client volume of 21 clients. The support group was run by MOH and APHIA PLUS supported staff till 2017October when HSDSA joined in to technically support the facility. Currently the facility has an active volume of 409 active patients all on ARVs with Current pediatrics being 16, With seven active support groups namely, Prisoners, Pediatrics, Adolescents, Adults, STF, Male and PMTCT One prisoner confirmed with treatment failure (VL 31947) but still on first line due to TB treatment hence pill burden if switched to second line.

Location and environment where practice takes place Rumuruti is situated in Laikipia county, Laikipia West sub county, Rumuruti township ward, about 40 minutes(30km) drive from Nyahururu town. This hospital serves a catchment population of about 34320, of which under one-year-old population of 1544 in total. As the prisoners grew in number and routine viral load monitoring was rolled out, more prison clients were being diagnosed for STF. There was need to offer specialized care to prison STF clients since some of the clients were missing drugs. The specialized care and messages required that group and individual enhanced counselling was key.

Ever enrolled pediatrics Adults Current on care 16 393 On first line ART 14 383 On second line ART 2 20 Prisoners 0 21 STF Prisoners 0 21 STF Prisoners on 0 21 adherence

Goal of the practice To offer specialized care to Prisoners clients To address enhanced adherence to ARVs To ensure rationalization in switching to second line ART

How the practice was developed and implemented (key steps/unique aspects) All prisoners given same appointment date

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Prisoners support group was formed STF prisoners were identified Clinical chart review was done to scrutinize the existing package of care lead by APHIA technical mentorship teams. An MDT was formed and critical roles for each MDT member was assigned. A clinic day was suggested and identified. Nutrition department was involved to support in Assessment Prisoners were re -booked and the warder was informed through phone call An STF register was developed and rolled out for tracking and following up the clients. CQI was done targeting STF care and follow up. Adherence counselling tools were rolled out and mentorship done on their use. Measurable out comes were set and agreed upon.

Names and functions of key persons implementing the practice Catherine Mwai- RCO Rose Nyambeki- Adherence counsellor Patrick Maina- HRIO Daniel Kabiru/James – Prison Warden Emmanuel Kutto- Pharmacist Peter Manwari- Technical Officer care and treatment- APHIA plus Belden Maranga – Technical officer- Monitoring and evaluation.

Measurable Successes A clinic day was set and therefore a minimum package of care in terms of counselling and treatment literacy was offered. V.L re-suppression rates among STF improved from 21% to 95.2% with a 95.2% Adherence to clinic appointment Rationalized switch to second line was observed both documentation and in practice (timing, testing and regimen). Improved and focused MDT was realized towards switch to second line (switch meetings).

How this success was measured Appointment tracking among STF prisoners’ cases Use and reviews of STF registers. Adherence log book Monthly Viral load uptake and suppression program monitoring charting Support group minutes Minutes for switch meetings done.

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Data that illustrate the practice’s success Adults pediatrics Total % Currents on ART 393 16 409 100% Number of STF 21 0 21 100% prisoners Number Eligible for 21 0 21 100% confirmatory VL Confirmatory VL 21 0 21 100% done Re- suppressed on 20 0 21 95% initial regimen Eligible for 1 0 1 100% switching to 2nd line Switched to second 0 0 1 0% line Repressed on second 0 0 0 100% line Total Re-suppressed 20 0 21 95% STF active on 1 0 1 100% treatment dead 0 0 0 N/A defaulter 0 0 0 N/A

Challenges and how they were overcome No warden was responsible for their DOTs thus one warden was identified to supervise the DOTs Medication time was not adhered to by the wardens thus a meeting was held between the warden, prisoners and CCC staffs to discuss on strict time for medication. Prisoners could not air their medication concerns and food ratios thus a support group was formed to address this. Poor adherence on medication due to time of meals and drugs not coinciding thus all the prisoners were enrolled to adherence counselling, drug champion identified, ARVs dispensing room identified and all medication was dispensed during meal time. Prisoners didn’t have a specific clinic date thus the CCC staff and the warden identified one day when only prisoners could be seen at the CCC.

Next Steps/Future plans (including replication) Explore means of integrating the prisoners to the community CCC or other Prisons during transfers Initiating a fully-fledged STF support group with a celebrated exit plan for clients who achieve viral suppression. Training of wardens on policy in stigma and Discrimination in HIV Provide treatment literacy IEC materials targeting STFs for continued treatment literacy and adherence to medication hence forth.

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XVI. ANNEXES AND ATTACHMENTS

Annex I: Schedule of Future Events

Date Location Activity

Annex II: Lists of Deliverable Products None

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