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USAID KENYA AND EAST AFRICA
AFYA KAMILISHA
COP 18 Q3 Progress Report (April 2018 – June 2019 )
SUBMISSION DATE: 30 July 2019 ACTIVITY TITLE: Afya Kamilisha AWARD NUMBER: 72061518C00001 EFFECTIVE PROJECT DATES: 14, December 2017 – 13, December 2022 REPORTING PERIOD: April 2018 – June 2019 CONSORTIUM PARTNERS: Jhpiego, LVCT-Health, Amethyst and the Cloudburst Group i
Prepared for: Dr Maurice Maina Contracting Officer Representative United States Agency for International Development Kenya and East Africa C/O American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya
Prepared by: Jhpiego – Johns Hopkins University Affiliate 2nd Floor, Arlington Block, 14 Riverside, off Riverside Drive, P.O. Box 66119-00800., Nairobi Office Tel: (+254-20) 3751882/4, (+254) 733 622 501/722 204 988 www.Jhpiego.org www.Facebook.com/Jhpiego
ii | P a g e TABLE OF CONTENTS List of Tables ...... iv List of Figures...... iv ACRONYMS AND ABBREVIATIONS ...... v EXECUTIVE SUMMARY ...... 6 KEY ACHIEVEMENTS ...... 7 OBJECTIVE 1: INCREASED AVAILABILITY AND USE OF COMBINATION PREVENTION SERVICES FOR PRIORITY POPULATIONS ...... 7 1.0 PROVISION OF DREAMS CORE PACKAGE OF INTERVENTIONS ...... 7 1.1 INTERVENTIONS THAT EMPOWER GIRLS AND YOUNG WOMEN (EG & YW) ...... 7 1.2 STRENGTHENING FAMILIES INTERVENTIONS (SF) ...... 8 1.3 MOBILIZE COMMUNITIES FOR NORMS CHANGE (MO COM.) ...... 9 1.4 INTERVENTIONS TO REDUCE RISK OF SEX PARTNERS ...... 9 1.5 ENROLLMENT AND TRAINING OF FACILITATORS ...... 9 1.6 COLLABORATION AND LINKAGES...... 10 1.7 LIPS’ ASSESSESSMENT FOR GRANTS UNDER CONTRACT ...... 10 1.8 ENROLMENT OF AGYW TO THE PROGRAM AND PROVISION OF SERVICES ...... 10 1.9 PRE-EXPOSURE PROPHYLAXIS ...... 11 OBJECTIVE 2: INCREASED UPTAKE OF TARGETED HIV TESTING SERVICES ...... 13 2.1 OVERALL PERFORMANCE BY COUNTY ...... 13 2.2 OVERALL PERFORMANCE, HTS_TST (PROVIDER INITIATED COUNSELLING AND TESTING)...... 15 2.3 ASSISTED PARTNER NOTIFICATION SERVICES ...... 16 2.4. HIV SELF TESTING...... 18 2.5 COLLABORATION WITH MOH ...... 18 2.6 INTERVENTIONS THAT ADDRESS GENDER BASED VIOLENCE (GBV) ...... 19 2.7 IMPLEMENTATION STRATEGY FOR QUARTER 4 ...... 20 OBJECTIVE 3: IMPROVED LINKAGE TO TREATMENT FOR INDIVIDUALS NEWLY TESTING POSITIVE FOR HIV ...... 24 3.1 EFFECTIVE REFERRAL AND LINKAGE TO HIV CARE AND TREATMENT ...... 24 3.2 TB / HIV SERVICES ...... 24
OBJECTIVE 4: INCREASED UPTAKE OF AND ADHERENCE TO QUALITY HIV TREATMENT SERVICES ...... 27 4.0 HIV CARE AND TREATMENT SERVICES ...... 27 4.1 ANTI-RETROVIRAL TREATMENT (ART) ...... 27 4.2 ART OPTIMIZATION ...... 28 4.3 ADHERENCE AND PSYCHOSOCIAL SUPPORT ...... 29 4.4 MALE FRIENDLY SERVICES ...... 29 OBJECTIVE 5: LONG-TERM FOLLOW-UP OF CLIENTS RECEIVING CARE AND TREATMENT ...... 30
OBJECTIVE 6: STRENGTHENED INSTITUTIONAL CAPACITY AND ACCOUNTABILITY FOR THE MANAGEMENT OF COMMUNITY, FACILITY AND COUNTY HIV RESPONSE...... 38 IV. PERFORMANCE MONITORING...... 42 V. PROGRESS ON GENDER STRATEGY ...... 46 VII. PROGRESS ON LINKS WITH GOK AGENCIES ...... 48 IIX. SUSTAINABILITY AND EXIT STRATEGY | JOURNEY TO SELF-RELIANCE (J2SR) ...... 48 IX. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 48 X. WORK PLAN STATUS MATRIX ...... 49 XI. CONSTRAINTS AND RECOMMENDATIONS ...... 53 iii | P a g e XIII. PLANNED ACTIVITIES ...... 54 XIV. FINANCIAL INFORMATION ...... 56 XIV. PROJECT ADMINISTRATION ...... 57 XV. SUCCESS STORIES ...... 59 XVI. ANNEXES ...... 60 ANNEX I: LIST OF DELIVERABLE PRODUCTS ...... 60 ANNEX II: REFERRAL AND LINKAGE BY COUNTY, SEX AND AGE ...... 61 ANNEX III: ACTIVITY PROGRESS – QUANTITATIVE IMPACT TABLES ...... 68
List of Tables
TABLE 1: PEOPLE REACHED THROUGH SASA! ...... 9 TABLE 2: NUMBER OF FACILITATORS TRAINED ...... 10 TABLE 3: DREAMS OVC SERVICE LAYERING; N=478 ...... 10 TABLE 4: SERVICE LAYERING BY AGE COHORT (N=7,963)...... 11 TABLE 5: OVC_SERV PERFORMANCE ...... 11 TABLE 6: PROGRESS ON PREP PERFORMANCE ...... 12 TABLE 7: COUNTY PREP PERFORMANCE BY GENDER ...... 13 TABLE 8: OVERALL PERFORMANCE BY COUNTY BETWEEN OCTOBER 18 AND JUNE 19 ...... 14 TABLE 9: HTS PERFORMANCE BY TESTING APPROACH: OCT 18 - JUNE 2019 ...... 14 TABLE 10: PROGRESS ON HTS_TST AT PITC BETWEEN OCTOBER 2018 TO JUNE 2019 BY COUNTY ...... 15 TABLE 11: PNS PERFORMANCE AGAINST TARGET BY COUNTY OCT 18- JUNE 2019...... 17 TABLE 12: HIV SELF-TEST KITS DISTRIBUTION BY AGE AND SEX OCT 18 – MAR 2019...... 18 TABLE 13: SERVICES PROVIDED TO SEXUAL VIOLENCE SURVIVORS (OCT 2018 TO JUNE 2019) ...... 19 TABLE 14: SERVICES PROVIDED TO SURVIVORS OF OTHER FORMS OF VIOLENCE (OCT 2018- JUNE 2019) ...... 19 TABLE 15: EID OUTCOMES PER COUNTY AT Q3 ...... 22 TABLE 16: UPTAKE OF HIV TESTING AND ART AMONG THE TB/HIV CO-INFECTED CLIENTS: ...... 25 TABLE 17: TB STAT AND TB ART SAPR PERFORMANCE AGAINST TARGETS ...... 26 TABLE 19:ART OPTIMIZATION ...... 29 TABLE 20: MALE FRIENDLY CLINICS/BENEFICIARIES BY COUNTY ...... 30 TABLE 21: VIRAL SUPPRESSION SUMMARY BY AGE BAND ...... 31 TABLE 22: VIRAL LOAD SUPPRESSION RATE BY COUNTY AND AGE BAND ...... 31 TABLE 23: VIREMIA CLINICS BY COUNTY/ BENEFICIARIES ...... 33 TABLE 24: FACILITIES IMPLEMENTING DCM BY COUNTY ...... 33 TABLE 25: UPTAKE OF REMOTE LOG-IN FOCUSING FOR AFYA KAMILISHA SITES ...... 36 TABLE 26: EMR STATUS AS AT JUNE 19 ...... 43 TABLE 27: DATA REVIEW AND DQAS CONDUCTED PER COUNTY ...... 44 TABLE 28: LINKS TO OTHER USAID PROGRAMS ...... 48 TABLE 29: OCT 2018 – JUNE 2019 WORK PLAN STATUS ...... 49 TABLE 30: CONSTRAINTS AND OPPORTUNITIES IN AFYA KAMILISHA PROJECT ...... 53 TABLE 31: PLANNED ACTIVITIES FOR NEXT QUARTER (JUL-SEP 2019) ...... 54 TABLE 33: LIST OF SATELLITE SITES ...... 60
List of Figures
FIGURE 1: PREP CONTINUATION RATE ANALYSIS ...... 12 FIGURE 2: PITC TESTING VOLUME DECREASED BETWEEN OCTOBER 2018 AND JUNE 2019 ...... 15 FIGURE 4: PNS CASCADE AMONG SEXUAL CONTACTS OF INDEX CLIENTS’ DISAGGREGATED BY GENDER ...... 16 FIGURE 5: PNS CASCADE FOR CHILDREN BY GENDER ...... 16 FIGURE 6: PNS CONTRIBUTION TO HIV POSITIVES IDENTIFIED BY MONTH. (OCT 18-JUNE 19) ...... 18 FIGURE 7: PMTCT CASCADE BY JUNE 2019 ...... 20 FIGURE 8: RTKS REPORTING RATES: FCDDR 643 (APR – JUN 2019) THROUGH HCMP ...... 37 FIGURE 9: MOH 730A CENTRAL SITES AND SUB COUNTY STORES (CDRR) THROUGH KHIS: APR – JUN 2019 ...... 38 FIGURE 10: AK ORGANOGRAM AND PDF ATTACHMENT SHOWS TEAM STRUCTURES AT COUNTY LEVEL ...... 58
iv | P a g e ACRONYMS AND ABBREVIATIONS AGYW Adolescent Girls and Young Women Presidential Emergency Plan For AIDS PEPFAR ANC Ante-Natal Care Relief AFYA Health PITC Provider Initiated Testing & Counseling ART Anti-Retroviral Therapy PLHIV People Living with HIV ARV Anti-Retroviral Prevention of Mother to Child PMTCT AWP Annual Work Plan Transmission of HIV Corrective action /preventive action PNS Partner Notification Services CAPA (CAPA) PRC Post Rape Care CCC Comprehensive Care Clinic QI Quality Improvement County Coordinators of Children QIP Quarterly Implementation Plan CCCS Services QM Quality Management CME Continuing Medical Education QMT Quality Management Team COP Country Operational Plans RDQA Routine Data Quality Assurance CQI Continuous Quality Improvement RRI Rapid Result Initiative CT Counseling & Testing RTK Rapid Testing Kits CTX Cotrimoxazole SAB Social Assets Building DBS Dry Blood Spot SCHMT Sub County Health Management Team DHIS District Health Information Software Sub County Health Records and SCHRIO DMC Differentiated Model of Care Information Officer DQA Data Quality Audit / Assessment Sub County Medical Laboratory SCMLTS DSD Differentiated Service Delivery Technicians EBIs Evidence Based Interventions SCMS Supply Chain Management System EID Early Infant Diagnosis POC Point of Care Elimination of Mother to Child SIMS Site Improvement Monitoring System eMTCT Transmission EMR Electronic Medical Records FBO Faith-Based Organization GBV Gender Based Violence HCPs Health Care Providers HCW Health Care Worker HEI HIV Exposed Infant HC Health Centre HRH Human Resource for Health HSS Health Systems Strengthening HTC HIV Testing & Counseling KEMRI Kenya Medical Research Institute KEMSA Kenya Medical Supplies Agency KMMP Kenya Mentor Mothers Program LVCT Liverpool VCT, Care & Treatment M&E Monitoring & Evaluation MDT Multi-Disciplinary Team MEC Medical Eligibility Criteria MNCH Maternal, Neonatal and Child Health MoH Ministry of Health MTMSGS Mother to Mother Support Groups NACC National AIDS Control Council NASCOP National AIDS and STI Coordinator NHRL National HIV Reference Laboratory OJT On-the-Job Training OTZ Operation Triple Zero PCR Polymerase Chain Reaction
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EXECUTIVE SUMMARY
The US Agency for International Development - USAID Kenya | EA awarded a performance-based completion-type Cost-Plus-Fixed-Fee (CPFF) contract number 72061518C00001, to a Jhpiego led consortium with partners LVCT Health, Cloudburst Group and Amethyst, to provide services that fall within the Performance Work Statement (PWS) for the HIV Service Delivery Support Activity (HSDSA) Cluster 3 (Afya Kamilisha) in October 2017. The project aims to increase access and coverage for HIV prevention, care and treatment services towards achieving the 95-95-95 PEPFAR targets. Afya Kamilisha is implementing HIV service delivery activities in 9 counties in Central and Eastern Regions of Kenya namely: Kiambu, Kirinyaga, Murang’a, Nyandarua, Nyeri, Embu, Kitui, Meru, and Tharaka-Nithi. During the quarter under review, the project continued working towards scaling up efficient identification modalities and reducing over testing, adoption of DSD, including multi-month scripting (MMS), focused on finding men and young people, enhanced viremic control across all age groups, optimized layering for the DREAMS and strengthening HSS, SI and Lab system investment for sustainability. This report highlights Afya Kamilisha achievements for COP 18 Q3 (April – June 2019).
This quarterly progress report details the achievement of the project during the reporting period. It is due to the donor 30 days after the end of the quarter, being reported on, as stated in the contract number 72061518C00001. A final report is due 60 days, after receipt of USAID comments on the draft. The data presented in this draft report covers period between October 2018 to June 2019; any data presented beyond this period, is based on estimated performance.
While the main drive is achieving the targets despite limited funding, targeted strategies to improve on HIV positive case identification, linkage to care, initiation on ART, and retention in care will be scaled up in high priority facilities utilizing the ‘Surge” strategy. Resources to support the prioritized facilities will be scaled up with weekly performance monitoring that will inform decisions on maintaining or changing implementation approaches.
The health systems and processes leading to self-reliance is a journey that Afya Kamilisha is starting to take with the counties. The project envisions County Governments that are able to make decisions that effectively and efficiently utilize their own (and mobilized) resources to plan and deliver coordinated high quality, acceptable and responsive HIV care and treatment services. The overarching vision is for the counties to achieve strategic outcomes that together improve financial protection and access to high-quality HIV services that reach the underserved, marginalized, and high-priority groups.
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KEY ACHIEVEMENTS OBJECTIVE 1: INCREASED AVAILABILITY AND USE OF COMBINATION PREVENTION SERVICES FOR PRIORITY POPULATIONS In the period April to June, the program enrolled 190 AGYW including 51 OVC referred by CASE OVC project. This has increased the unique individuals to 7,963 (93%). They were then linked to a mentor and a safe space. Trainings were also conducted for Shuga, MHMC, HCBF, financial capability and entrepreneurship facilitators. The trained facilitators then mobilised and provided age appropriate group based sessions to the AGYW. This in essence has increased the number of active AGYW from 4,168 at SAPR to 6,771 (85%). As such, 2,767 have completed financial capability training, 3,093 have completed an EBI and 3,086 received educational subsidy. Their parents were also mobilized to participate in the family matters program with 232 and 304 parents/ caregivers completing group sessions for FMP 1 and FMP 11 respectively. Other prevention services reached 1485 with contraception method mix, 74 with oral PrEP and 1,557 with condom education and demonstration. Community mobilisation for norms change using the SASA! approach reached 12,567 (12,099 through local activism, 436 with IEC materials and 32 through training). Six hot spot outreaches targeting MSP were conducted. 50 AGYW have been linked to employment opportunities in the current period.
1.0 PROVISION OF DREAMS CORE PACKAGE OF INTERVENTIONS
1.1 INTERVENTIONS THAT EMPOWER GIRLS AND YOUNG WOMEN (EG & YW) Guided by the Adolescent Girls Initiative in Kenya (AGI-K) curriculum, Afya Kamilisha supported weekly Social Assets Building (SAB) sessions reaching 6,771 AGYW. The project adopted the safe space model to provide other services like HTS, contraceptive method mix, EBIs and PrEP. This way, 429 AGYW accessed HTS, 1485 were reached with contraception method mix and 74 young women received PrEP pills for the first time. In addition, 2767 AGYW participated in financial capability training . They were imparted with skills to guide future money management decisions including earning, saving and prioritisation. HIV and violence prevention services were provided through the EBIs of MHMC, HCBF and Shuga reaching 3019 AGYW leading to 68 % achievement on the PP_ PREV annual traget as shown in graph below;
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COP18 Q3 PP_PREV Performance 81%
68% 68% HCBF MHMC Shuga PP_Prev 60%
41% 40% 42% 33% 34% 27% 19% 21% 14% 6% 0% 0%
Q1 Q2 Q3 Total
1.2 STRENGTHENING FAMILIES INTERVENTIONS (SF)
The project supported provision of SF interventions through FMP, Cash transfer and education subsidy as explained below;
The Families Matter! Program (FMP) The ultimate goal of FMP is to reduce sexual risk behaviors among adolescents. FMP supports parents to overcome communication barriers. More effective parent-child communication can help delay their children’s sexual behavior and lead to increased protective behaviors as their children get older. In the reporting period, 232 parents completed FMP 1 sessions while 304 parents completed FMP 2 sessions. Cash Transfer (CT) service The project initiated another 19 AGYW on unconditional cash transfer bringing total beneficaries to 46 (77%). A total of 33 AGYW had completed the process of ranking, home visit only to be droped at the single registry verification process. This has allowed the program to reach other needy AGYW. Education subsidy Even with highly subsidized basic education by the GOK, families often struggle to come up with the funds required for other levies e.g. food, uniforms and exam fees leading to dropping out of school. Providing educational subsidies is an effective intervention for keeping girls in school. In the reporting period, 2,060 AGYW were supported. School fees was provided to another 280 AGYW bringing school fees beneficiaries to 442 while uniform and education materials were provided to 1,780 AGYW.
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1.3 MOBILIZE COMMUNITIES FOR NORMS CHANGE (MO COM.) Community mobilization provides the HIV prevention framework for engaging the broader community. The project implemented SASA! (Start, Awareness, Support, Action), a behavioural intervention that communicates and addresses power imbalances in the community that drives the HIV epidemic. Implementation was in the second phase of AWARENESS. A total of 32 facilitators were trained on the second phase and commissioned to do advocacy on ‘’Power Over”. Cumulatively, 28679 (12055 males, 16624 female) community members were reached with HIV and violence prevention messages.
Table 1: People reached through SASA! Strategy Q1 Q2 Q3 Total Training 322 0 32 354 Local activism 3326 12070 12099 27495 IEC 62 332 436 830 Total 3,710 12,402 12,567 28,679
1.4 INTERVENTIONS TO REDUCE RISK OF SEX PARTNERS Many AGYW in the program are already sexually active at age 15. Characterization of their Male Sexual Partners (MSP) would inform provision of HIV prevention services suitable to these males and help them accept treatment if needed. MSP characterization is continuously happening at the safe spaces. Four (4) outreaches were conducted at the male joints. Services available included HTS, PrEP educational and provision, STI screening and treatment, condom education and distribution, plus linkage to VMMC. The males reached so far were in favor of HTS and condom uptake. By SAPR, 50 MSP had accessed HTS. In quarter 3, another 30 were tested. They tested negative and were supplied with prevention information including PrEP. So far they have only embraced condom use. The MSP champions are also supported to replenish condoms in the community-based dispenser.
1.5 ENROLLMENT AND TRAINING OF FACILITATORS Enrollment of AGYW is a continuous exercise that seeks to reach the desired unique individuals. It is also necessitated by filling the attrition gap due to migration or disinterest. To ensure immediate linkage of the enrolled AGYW to a mentor and a safe space, the exercise is initiated at the household but completed at a safe space. In the reporting period, 190 AGYW mainly in the age cohort 15-17 were enrolled and provided with STI screening, TB screening, HTC, PrEP education, IEC materials on PrEP and Contraception IEC services. This was a joint effort between Kamilisha and CASE OVC program with 51 OVC attaining the co-enrolment status. They will be followed up for optimal service layering. A pool of facilitators is necessary to effectively reach the AGYW with appropriate messages. During the reporting period, 117 facilitators were trained as shown in the table below: They have been engaged to conduct the age appropriate sessions reaching 1770 AGYW with various services.
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Table 2: Number of facilitators trained Intervention Biashara Ngoliba Total Shuga series 1 & 2 21 11 32 Financial Capability (FC) 20 8 28 Entrepreneurship skills 17 8 25 MHMC/HCBF 20 12 32 Total 78 39 117 1.6 COLLABORATION AND LINKAGES Regular stakeholder engagement is a prerequisite in implementation of DREAMS. The purpose of these forums is to give feedback on strides made in DREAMS rollout, implementation gaps identified and seeking for solutions. The DREAMS Advisory Committee (DAC) met twice in the quarter to review the process of providing cash transfer and education support, two services with high community interest. Consultations were also active between Kamilisha and CASE OVC program. This has improved OVC service layering as per the layering table below.
Table 3: DREAMS OVC service layering; n=478 Cohort/Services 1 2_3 4 5_6 7_10 Total 10_14 89 112 26 12 0 239 15_17 61 68 24 29 26 208 18_19 12 8 4 5 2 28 Total 162 188 54 46 28 478
Specifically, 3 OVC have received cash transfer, 100 accessed education subsidy (24 for School fees and 76 accessing dignity kit), 715 have participated in SAB activities, 39 completed the FC training and 103 have completed the HIV violence prevention sessions through HCBF and MHMC EBIs. The project worked with PHRD in mobilizing 90 AGYW for the Cervical Cancer single dose vaccine research. Following the assessment, twenty-two (22) of these are active study subjects.
1.7 LIPS’ ASSESSESSMENT FOR GRANTS UNDER CONTRACT The initial evaluation of the LIPs saw two partners emerge as the most technically sound to implement DREAMS in Kiambu county. This was followed by a pre-award assessment to further ascertain the feasibility of engaging either of the partners in DREAMS implementation. Notably, the exercise was graced by the Kiambu County Deputy director of promotive and preventive health. The findings will be shared with USAID for clearance.
1.8 ENROLMENT OF AGYW TO THE PROGRAM AND PROVISION OF SERVICES The number active - defined as an AGYW who has received a service within the previous 6-month increased from 6374 to 6771 in the current quarter. The project now has 1530 AGYW in the range of 7-14 services up from 347 in the last quarter. The project monitored service layering of the AGYW aided by the Jasper reports. 64 % of the AGYW have received 4 or more services.
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Defaulter tracing exercises reached 330 AGYW reducing the number with Zero services from 806 to 476. The table 3, has more details.
Table 4: Service Layering by Age Cohort (n=7,963) Cohort/Services 0 1 2_3 4 5_6 7_14 Total 10_14 141 201 931 476 333 4 2,086 15_19 175 165 427 239 526 891 2,423 20_24 160 91 582 804 1182 635 3,454 Total 476 457 1,940 1,431 2,041 1,530 7,963
The table 4, depicts the performance on the AGYW including OVC girls. Plans are underway to accelerate provision of school fees and dignity kit to meet the education subsidy target.
Table 5: OVC_SERV Performance Service Q1 Q2 Q3 Achieved (Total) Annual Target % achieved FMP 1 207 279 232 718 1,028 70% FMP 11 113 22 304 439 312 141% CT 0 26 45 45 60 75% Education Subsidy 359 667 2060 3086 3,685 84% PrEP 30 36 74 140 120 117% HTS 242 326 305 893 - - Post Violence Care 29 0 6 35 - - Financial Capability 0 1629 0 1629 - -
For the next period, the Jasper reports will be used to steer service provision targeting the primary services. The project will also enhance defaulter tracing activities for the inactive. Weekly safe space outreach will be conducted for PrEP, HTS and GBV response.
1.9 PRE-EXPOSURE PROPHYLAXIS
During Q3 COP 18, pre-exposure prophylaxis (PrEP) was implemented at 174 ART sites. As part of the surge implementation that was launched during this reporting quarter, identification of PrEP eligible clients was integrated into aPNS targeting elicited sexual partners who test HIV negative. Additional supported included site level mentorship and supportive supervision, PrEP commodity management, and quality PrEP data capture and use. By end of June 2019, the project had initiated 1,644 PrEP new clients, with 743 clients started during this reporting period. Out of the 1,644 PrEP new clients, (47%)770 clients are continuing on PrEP. The project took part in the NASCOP lead QI meeting to address data needs for PrEP.
Activity 2.1 Demand generation Assisted partner notification services (aPNS) was the main entry point for PrEP implementation. The negative discordant partners identified through HTS were screened for eligibility for PrEP and provided PrEP services appropriately. Discordant couples who wished to conceive were counseled for PrEP and were started on prophylaxis. HCP were trained on the use of risk assessment tool (RAST) tool on clients accessing the STI clinic, frequent PEP users and in the OPD. The clients
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were assessed for eligibility and referred to HTS for further screening. As a result of the projects effort, 1,664 new clients including 743 enrolled in Q3 were started on PrEP.
Activity 2.2 PREP adherence and continuation rates Initiation and monitoring PrEP was provided alongside the ART services. To ensure adhere to PrEP, the project provided continuous technical mentorship to HCPs to provide adherence counseling to clients on every clinic appointment. The project distributed PrEP data capture tools to all sites orienting HCPs on use and completeness. PrEP data review was integrated in the weekly site level data review meetings and planning decision making. The project assisted the facilities in the re-distribution of PrEP commodities, data capture and reporting tools. For clients defaulting on PrEP, peer educators were facilitated to trace them using similar mechanisms used to track HIV defaulters in the CCC. 770 (47%) are still continuing on PrEP as per Figure 1 below.
Figure 1: PreP Continuation Rate Analysis
1,800 1,644 1,600 1,400 1,200 1,000 770 800 509 600 340 400 200 21 4 0 Number started Number continuing Number defaulted No longer at risk Seroconverted Stopped due to PrEP on PrEP on PrEP while on PrEP medical contraindications eg.Increased creatinine clearance (CrCl)
PrEP performance vs Targets Kamilisha’s performance on PrEP NEW improved from 45% by the end of Q2 to 82 % by the end of Q3. This performance is attributed by adoption of high yield strategies for demand creation.
Table 6: Progress on PrEP Performance County Targets SAPR Q3 Grand % Achievement achievement total achievement Embu 172 86 108 194 113% Kiambu 638 203 148 351 55% Kirinyaga 37 45 36 81 219% Kitui 9 6 2 8 89% Meru 409 225 83 308 75% Murang’a 474 198 156 354 75% Nyandarua 73 58 83 141 193% Nyeri 15 24 22 46 307% Tharaka Nithi 182 56 105 161 88% Grand Total 2009 901 743 1,644 82%
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Table 7: County PrEP performance by gender County Male Female Total Embu 101 93 194 Kiambu 145 206 351 Kirinyaga 37 44 81 Kitui 5 3 8 Meru 170 138 308 Muranga 174 180 354 Nyandarua 67 74 141 Nyeri 22 24 46 Tharaka Nithi 87 74 161 Grand Total 784 860 1,644
From the data above, there were more women accepting PrEP compared to men except in Kiambu, Kirinyaga, Muranga, Nyandarua and Nyeri. In Kiambu the high number of females accessing PrEP is contributed by the initiation of PrEP among eligible AGYW in the dreams project.
Activity 2.3 PrEP commodity management The project supported county and facility level PrEP commodity management by ensuring reporting, forecasting, quantification and allocation of PrEP commodities to ensure adequate and consistent PrEP commodity supply. In addition, Kamilisha has been supporting counties with monthly ART allocation meetings. Unlike in the previous quarter, there were no reported PrEP commodity stock outs.
Collaboration and networking Kamilisha held quarterly site supportive supervision with the county MoH team to offer TA and address implementation gaps. The project has also collaborated with the CAC’s office in demand generation for PrEP the community. In addition, Jilinde Program, a PrEP project implemented by Jhpiego offered support to Kamilisha by distributing PrEP IEC materials such as; posters, wristbands and T-shirts, clinical coats and PrEP data capture tools.
OBJECTIVE 2: INCREASED UPTAKE OF TARGETED HIV TESTING SERVICES To optimize HIV testing services, the project engaged 175 HTS counsellors strategically deployed in 283 health facilities across 9 counties. Targeted provider initiated testing and counselling (PITC) and assisted partner notification services (aPNS) were the key testing strategies implemented. In Q3, 114,929 clients were tested for HIV leading to a cumulative total of 466,662 clients. 2,194 HIV positive clients were identified leading for a cumulative total of 6,600 new HIV-positive cases (45% achievement of APR target. The overall yield improved from 1% in Q1 to 2 % in Q3.
2.1 OVERALL PERFORMANCE BY COUNTY Kiambu and Meru counties accounted for 54% of all HIV positive clients identified, over the last two quarters: 1,632 (25%) and 1,890 (29%) respectively, with Embu county accounting for 13% (823) of the positives. Table 1 illustrates cumulative achievement by Q3 COP18 and positivity trends across the nine counties.
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Table 8: Overall Performance by County between October 18 and June 19 County HTS_POS Achieved Achieved Positivity Annual % Achievement (Tested) (Positive) rate Target Embu 43,882 1,113 823 74% 2% Kiambu 91,391 3,498 1,632 47% 2% Kirinyaga 22,540 306 242 79% 1% Kitui 3,136 58 38 66% 1% Meru 110,329 3,429 1,890 55% 2% Murang’a 89,351 4,226 697 16% 1% Nyandarua 42,129 395 547 138% 1% Nyeri 17,780 145 144 99% 1% Tharaka Nithi 46,124 1,622 587 36% 1% Total 466,662 14,792 6,600 45% 1.4%
Nyandarua County identified 547 new HIV positive individuals, surpassing its annual target of 395 by 38% while Embu, Kirinyaga, and Nyeri were on track towards achieving their targets. Tharaka Nithi, Meru, Kiambu, and Murang’a continued to lag behind in their progress towards targets. Additional providers and more time on mentorship of providers by program team were put in counties that had potential and were not on track.
2.2.1 Positive Yield by Testing Approach At the end of Q3, targeted PITC at OPD and aPNS accounted for the highest numbers of HIV positive individuals identified at 3,201 (49%) and 1,759 (27%) respectively. PNS among sexual contacts had the highest HIV positivity at 35 % followed by PNS for children of index clients and PITC at TB clinics at 8.3% and 8.1% respectively. Table 2, illustrates the HIV testing and positivity across testing modalities /approaches over the reporting period.
Table 9: HTS Performance by testing Approach: Oct 18 - June 2019 Testing Modality Total Tested Tested HIV- HIV-positive HIV-positive yield positive Contribution% of modality % PNS –sexual contacts 4,754 1,642 25% 35% PNS - Children of female sexual contacts 1,405 117 2% 8.3% PITC TB clinic 5,342 435 7% 8.1% PITC In-patient department 18,382 182 3% 0.9% PITC Out-patient department (OPD) 321,585 3,201 49% 0.9% Voluntary Counselling & Testing (VCT) 27,618 283 4% 1% PITC Ante Natal Clinic (ANC) 54,801 588 9% 1% PITC Post ANC 1 32,713 151 2% 0.4% PITC Child Wellness Clinic 52 0 0% 0% PITC STI clinic 10 1 0.2% 10% All 466,662 6,600 100% 1.4%
In Q4, Kamilisha will prioritize, consistent use of eligibility screening tool at OPD aimed at increasing testing efficiency by reducing the numbers of individuals tested and increasing yield. The screening tool will be used at service delivery points by clinicians and at the testing points by the
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HTS providers. In Q4 testing will focus almost exclusively on aPNS based on contacts of index clients from PNS registers, and from eligible clients on ART (TX_CURR). Elicitation of contacts will also be done on secondary index cases identified from the initial indexes. HTS providers will be re-aligned to focus in high volume facilities that are yielding more positives and at the same time ensure that providers are spending most of their time following up contacts for testing especially in counties that are lagging behind in achieving their targets. It is apparent that PITC testing volume is decreasing, as demonstrated by monthly testing trend over the last 9 months, through use of screening tool. The decline however is not as fast as anticipated to halt over-testing. Figure 3 shows the testing trend.
Figure 2: PITC testing volume decreased between October 2018 and June 2019
80000 75005 2.5% PITC testing volume Positivity 70000 63093 2.0% 60000 53507 49382 50000 43066 44427 1.5% 38417 40000 33696 32292 30000 1.0% 20000 0.5% 10000 0 0.0% October 2018November 2018December 2018January 2019February 2019March 2019 April 2019 May 2019 June 2019
2.2 OVERALL PERFORMANCE, HTS_TST (PROVIDER INITIATED COUNSELLING AND TESTING) Provider Initiated Testing and Counselling (PITC) services were provided at outpatient clinics, TB clinics, CWC clinics, ANC and In-patient wards. OPD department despite low positivity, contributed the highest number of new HIV positive cases and served as an entry point for index testing and aPNS. In Q3, facilities started using the eligibility screening tool to improve efficiency of testing. HTS providers and the clinicians at the OPD were sensitized on the eligibility screening tool. Table 10, shows the PITC testing and positivity in the last three quarters.
Table 10: Progress on HTS_TST at PITC between October 2018 to June 2019 by County County Tested Target Tested % Achievement Positivity rate (PITC) Positive Positive Embu 43,038 903 606 67% 1% Kiambu 89,748 2,957 1,187 40% 1% Kirinyaga 22,427 234 200 85% 1% Kitui 3,059 58 31 53% 1% Meru 109,226 2,770 1,475 53% 1% Murang’a 88,381 2,974 409 14% 0% Nyandarua 41,509 352 404 115% 1% Nyeri 17,634 132 121 92% 1% Tharaka Nithi 45,481 1,220 408 33% 1% Total 460,503 11,600 4,841 42% 1%
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2.3 ASSISTED PARTNER NOTIFICATION SERVICES Supportive supervision and mentorship was conducted to aPNS providers. Direct logistical support (transport, phones and airtime) was provided to facilitate client follow-up in the community. Newly identified positives and clients on ART were line listed and sexual contacts elicited. Contacts acceptability for testing improved from 66% in Q1 to 69% in Q3. In the reporting period, 5,925 index clients were offered PNS services and 5,658 (95%) accepted the services. A total 7,818 sexual contacts were elicited (ratio1:1.4) as contacts. Of the 7,163 sexual contacts eligible for testing, 4,754 (67%) were tested yielding 1,642 new HIV positive clients representing a yield of 35%.
Figure 3: PNS Cascade among Sexual Contacts of Index Clients’ disaggregated by Gender
4,047 3703 3771 3460
2438 2316
942 898 700 652 344 311
Male Female Sexual contacts identified 4,047 3771 Prior Known HIV positive status 344 311 Sexual Contacts Eligible for Testing 3703 3460 Tested 2438 2316 Positive 700 942 Linked 652 898
1957 children were listed for follow up. Out of these 1,924 were eligible for testing. 1,405 (73%) were tested yielding 117 positive clients (8%). Figure 2 illustrates the PNS cascade among children of index clients’ disaggregated by gender.
Figure 4: PNS Cascade for children by Gender 1024 1200 1004 933 920 1000 747 800 658 600 400 200 20 61 57 13 56 48 0 Male Female Sexual contacts identified 1024 933 Prior Known HIV positive status 20 13 Sexual Contacts Eligible for Testing 1004 920 Tested 747 658 Positive 61 56 Linked 57 48
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Table 11: PNS performance against target by county Oct 18- June 2019 County Annual % Target Tested % Positivity Testing Achieved Achievement Positive Positive Achievement rate Target Embu 1,173 844 72 210 217 103 26% Kiambu 2,089 1,643 79 541 445 82 27% Kirinyaga 881 113 13 72 42 58 37% Kitui - 77 - - 7 - 9% Meru 3,965 1,103 28 659 415 63 38% Murang’a 6,171 970 16 1252 288 23 30% Nyandarua 1,015 620 61 43 143 333 23% Nyeri 30 146 487 13 23 177 16% Tharaka Nithi 623 643 103 402 179 45 28%
Total 15,947 6,159 39 3,192 1,759 55 29%
Challenges experienced in PNS optimization included: Clients listed as contacts taking too long to turn up for services. Sexual contacts who stay far away from the catchment areas are difficult to follow-up, and counsellors refer them to nearest facility for testing Index clients receive HIV self-test kits for their contacts. Some clients decline the kits related to perceived or experience stigma. Despite the challenges, the following has been working: o Providing other services to contacts listed to encourage them to visit a health facility as a first attempt. o Partner Notification Services is high yielding but time consuming, especially getting the index clients to list their sexual contacts plus Capacity building sessions through one on one mentorship has continued to improve individual providers’ performance. Daily and weekly reporting by the providers has helped the project in focusing the providers through discussing their performance on a daily basis. Despite the challenges in aPNS, a significant increase in identification through this strategy has been realized as shown in figure 5.
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Figure 5: PNS contribution to HIV positives identified by month. (Oct 18-June 19)
45% 1000 870 40% 781 801 41% 900 758 38% 743 700 736 800 35% 650 34% 700 30% 560 28% 600 25% 24% 500 20% 18% 18% 19% 332 301 400 15% 17% 269 173 184 300 10% 137 142 128 93 200 5% 100 0% 0 October November December January February March April May June Total Positive HTS 781 700 560 758 736 870 650 801 743 PNS Pos 137 128 93 142 173 332 184 269 301 PNS Contribution % 18% 18% 17% 19% 24% 38% 28% 34% 41%
Total Positive HTS PNS Pos PNS Contribution %
2.4. HIV SELF TESTING TOTs were trained on HIV self-testing (HIVST) and received the commodities. HIVST training was conducted to providers. The counties that have trained providers are using and reporting the self-test kits. A total of 4,211 HIVST kits were distributed as shown in table 7 below. As much as HIVST is championed as an approach for reaching out to men, there was no significant difference between men and women seeking HIVST. 56% of individuals seeking HIVST were aged between 25 and 39 years.
Table 12: HIV self-test kits distribution by age and sex Oct 18 – Mar 2019 Age Band (Years) Male Female Total 15-19 202 154 356 20-24 296 409 705 25-29 369 514 883 30-34 344 405 749 35-39 283 451 734 40-44 168 225 393 45-49 113 194 307 50+ 39 45 84 Grand Total 1,814 (43%) 2,397 (57%) 4,211
2.5 COLLABORATION WITH MOH Team work and collaboration between the project, County and Sub-County Health Management Teams to mentor and conduct supportive supervision to health workers contributed to the achievements. This was done during support supervision visits to the facilities, monthly counsellor’s meetings and during county specific technical meetings to ensure quality testing was done following the national guidelines. The MOH supervision was very instrumental during the project surge period, there was an increase in identification across the counties during the period and this was attributed partly to support and buy-in from MOH. County / Subcounty HMT meetings were held to discuss implementation of PNS and rolling out of the self-testing services. Medical Laboratory Technologists offer HTS in facilities where HTS counsellors were not available and supervise them for adherence to Standard Operating Procedures. Annual HTS and GBV
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refresher trainings were carried out in the period with emphasis on the project’s strategic direction regarding identification and linking to care and treatment. Participants were drawn from HTS, PMTCT and Laboratory departments.
2.6 INTERVENTIONS THAT ADDRESS GENDER BASED VIOLENCE (GBV) Post GBV interventions were integrated into services at out-patient department. Survivors of sexual violence presenting at the facility were provided with comprehensive services. In the reporting period, 24 health facilities in eight counties provided comprehensive Post Rape Care (PRC) services to survivors of sexual violence, reaching 659 survivors and 1,108 survivors of physical and emotional violence. Afya Kamilisha ensured GBV integration across all service delivery points at the same time striving towards having 100% quality SGBV data reporting in DHIS through one on one mentorship with providers and facility based Continuous Medical Education (CME).
One of the gaps identified in the GBV program was lack of community information and sensitization leading to survivors reporting late to the facilities after experiencing sexual violence. The program held meetings with CHMT across counties, to discuss how all players in the field especially the public health department can support / conduct community sensitizations. Clinical officers, who are the first point of contact when survivors reach the facilities, work on rotational basis consequently documentation of services provided is not adequately done in all the registers. Continuous mentorship on documentation of post GBV services will continue in the GBV facilities. The HTS providers will also conduct GBV screening for aPNS clients to increase on number of clients reporting GBV.
Table 13: Services provided to sexual violence survivors (Oct 2018 to June 2019) PRC Service Male Female Total % of clients provided clients with service Number of survivors seen 70 589 659 n/a No presenting within 72 hrs 51 458 509 509/659 (77)% No. of survivors initiated on PEP 51 397 448 448/509 (88%) Number tested for HIV 42 438 480 480/659 (73%) Number tested HIV positive at initial visit 5 13 18 18/480 (4%) Number provided STI treatment 42 402 444 444/659 (67%) Number Eligible for Emergency n/a 381 381 381/589 (65%) Contraception Pill (ECP) Number provided ECP n/a 243 243 243/381 (64%) Number of survivors with disability 5 15 20 20/659 (3%)
Table 14: Services provided to survivors of other forms of violence (Oct 2018- June 2019) PRC Service Male Female Total clients Physical violence 564 494 1058 Verbal violence 3 6 9 Harassment 9 22 31 Total 576 522 1098
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2.7 IMPLEMENTATION STRATEGY FOR QUARTER 4 One on one mentorship for HTS counsellors on contact elicitation and follow up. Optimized PITC testing coverage in OPD and other key departments using screening tools Increase PNS approach to all index cases at the CCC
ELIMINATION OF MOTHER TO CHILD TRANSMISSION (eMTCT)
KEY ACHIEVEMENTS
The project implemented activities focused on averting mother to child HIV transmission within the supported 223 sites across the 9 counties. Emphasis was on MCHs and Maternity units as the main program entry points for mothers to EMTCT program. The key objective was to test all the pregnant women at first ANC, and subsequently testing of breastfeeding women at delivery and post-natal periods. As at quarter 3,1415(92%) of the HIV infected mothers were initiated on ART for their own optimal health outcome and for prevention of vertical transmission. HIV positive pregnant and breastfeeding women continued to receive ART adherence counseling and psychosocial support. The psychosocial support groups are structured to address psychosocial needs of the HIV positive pregnant and breastfeeding mother that aims to translate into optimal clinic attendance and treatment adherence, retention on ART and ultimately viral suppression. ART monitoring through Viral Load testing for the mothers on ART was scaled up to all the 223 health facilities through the existing project sample networking transport system. To enhance early identification and follow up of HIV exposed infants (HEI), the project supported HIV testing for breastfeeding women at 6weeks and initiating ART for any breastfeeding woman and baby identified to be HIV positive. Within the quarter, of the 18,353 pregnant women who attended ANC1 visit, 18,073(98%) of them were tested for HIV and received results, 456 were identified HIV positive and 449(98%) of those newly identified HIV infected were put on ART for their own health and for prevention of vertical transmission. The 7 women who declined prophylaxis are on follow-up by the HCPs and Mentor mothers. Of the 588 infants tested for HIV using DNA-PCR within 12 months, uptake before 2 months was 499(85%) 23 infants were identified HIV positive and 19(83%) were initiated on ART.
Figure 6: PMTCT Cascade by June 2019
67467 83% 82% 55736 55644
76% 65% 68% 1431 1415 1656
PMTCT Target Ist ANC Known Status positive ART EID
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INCREASING ANC ATTENDANCE AND HIV TESTING AND COUNSELLING FOR THE MOTHER-BABY PAIR
Kamilisha continued to link and work with the county existing community structures to mobilize for early ANC1. At MCH, most pregnant women are tested using dual test kits and issued with HIVST for their partners. The HIV positive pregnant women whose partners were not tested were targets for PNS. Newly tested HIV positive clients were linked to Mentor Mothers for one on one counselling, follow-up and enrollment to psychosocial support group. Kamilisha supported clinical mentorship and continuous medical education (CME) targeted sessions in 223 sites. These sessions covered areas requiring improvement such as quality HIV testing, ART initiation and VL suppression. Sensitization of HCPs at MCH on HIV self-testing(HIVST) to accelerate testing for the male partners at MCH continued during this reporting quarter. To complement the HIVST, HCPs were also mentored onsite to carry out couple testing. Within the quarter, a total of 18,336 pregnant women had known their HIV status at ANCI and hence 55,644(82%) achievement of APR target as at quarter 3. Screening of all breastfeeding mothers attending the family planning and Child Welfare Clinic(CWC) at 6 weeks was emphasized in all the sites. Those identified HIV positive received ART preparation educations and counseling and initiated on ART upon consent. They were linked to mentor mothers for peer counselling and enrolled in PSSG. At 6 weeks, 619 breastfeeding women were counselled and tested, 7 women identified positive and linked to treatment while DBS was collected from infants for PCR testing.
UPTAKE OF ANC SERVICES AMONG THE PREGNANT ADOLESCENT (10-19) There was an increased number of pregnant adolescent girls seeking ANC care especially in Meru county –Igembe North and South. This called for a customized ANC package to be able to address adolescent issues, more so for the HIV positive adolescent teens. Kamilisha supported HCPs to offer adolescent friendly services which allowed the adolescents to have a say on quality, environment and privacy of services at MCH. In addition, HIV positive adolescent champions were placed in Nyambene DH to support the adolescents who test HIV positive at MCH. Information on family planning, preconception care and drug adherence was provided during the HIV positive pregnant adolescent PSSG and ANC1. Within the quarter, of the 18,352 ANC1 attendance, 2,612(14%) were pregnant adolescents aged 10-19years, 2,592(99%) of the pregnant adolescents were tested, 35 were identified positive and 33(94%) initiated on ART at MCH.
ART FOR THE HIV POSITIVE PREGNANT AND LACTATING MOTHERS Kamilisha worked with the health care providers to ensure that all identified HIV positive pregnant and breastfeeding and their partners were initiated on treatment. Emphasizes was put on integrating ART services at MCH and maternity, testing of sexual partners of HIV positive pregnant and breastfeeding women and linking them for ART. A total of 1,338 HCPs received clinical mentorship, technical assistance and CMEs to ensuring required EMTCT knowledge and skills are retained. CMEs were conducted in sites where changeovers had taken place in MCH and maternity. Technical assistance within the 223 sites focused specifically on; -counselling and testing for the ANC1, PNS, preconception care, Maternal cohort analysis, HEI cohort analysis, Psychosocial support group for the pregnant and breastfeeding, updating of the EID website, defaulter tracing for the mother baby pair and implementation of ART for pregnant and breastfeeding mothers.
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The project was keen to ensure trained HCPs provided technical assistance to mentor mother lead psychosocial support group meetings. Efforts towards provision of adolescent friendly services to the pregnant and breastfeeding adolescent girls and young women(AGYW) was a priority ensuring individualized and respectful services at MCH and maternity.
The project identified 456 HIV positive pregnant women, out of which 265(58%) were Known positive(KPs) while 191(42%) were newly identified positive, 449 women were initiated on HAART (98% EMTCT site mentorship and data validation Kiambere uptake). Similarly, 449(98%) of the health center women were issued with Nevirapine (NVP) and Zidovudine (AZT) prophylaxis for their infants at ANC. This is attributed to clinical mentorship, integration of ART in MCH, provision of quality clinical care at MCHs and Maternities, ARV commodity management psychosocial and peer support by mentor mothers.
A total of 265 ( 58%) mothers identified as HIV positive at ANC1,were known positives. . Going forward, emphasizes will be on prong 2 and preconception care at MCH, postnatal clinics and CCC among the HIV positive women on ART. All HIV positive pregnant and breastfeeding mothers were monitored 6 monthly to ensure optimal adherence to ART and viral suppression. Within the quarter 1,862 women had a viral load done and 1598(86%) were suppressed. The non-suppressed pregnant and breastfeeding women were enrolled in viremia clinic for close monitoring and intensive adherence counselling. Pregnant HIV positive mothers were encouraged to form PSSG where information on safe delivery, family planning, breastfeeding, ART, EID and infant care was provided.
EARLY INFANT DIAGNOSIS (EID) AND HEI OUTCOMES
Table 15: EID Outcomes per County at Q3 County Total Total % <2 <2 2-12 <2 2-12 Months <2months 2-12 Months Months Months Months Initiated on months Positive Positive Initiated ART on ART Embu 95 15 86% 2 0 2 0 Kiambu 106 18 85% 1 7 1 6 Kirinyaga 16 0 100% 1 0 0 0 Kitui 3 1 75% 0 0 0 0 Meru 161 30 84% 4 5 4 5 Murang'a 45 10 82% 0 1 0 1 Nyandarua 27 3 90% 0 0 0 0 Nyeri 13 3 81% 0 0 0 0 Tharaka-Nithi 33 9 79% 1 1 0 0
Grand Total 499 89 85% 9 14 7 12
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Data source; EID facility Log Kamilisha supported sites to validate all the PCR samples done within the quarter and ensured all sites are using EID log promptly. A total 588 babies were done DBS before 12 months leading to 23(3.9%) positivity rate. Majority (499(85%)) of the exposed infants were tested before 8 weeks with a positivity of 9(1.8%). The 4 HIV positive infants who were not initiated on treatment are on follow up. The project facilitated sample referral network for the sites to transport DBS samples to KEMRI laboratory in Nairobi where they were analyzed and the results transmitted back to the health facilities through the EID website. Counties with low uptake of EID done before 8 weeks include; - Tharaka Nithi (79%), Nyeri (81%) and Murang’a (82%). The project supported mentorship, OJT and CME to HCPs at MCH on EID to ensure smooth synchronization of EID with immunization at 6weeks especially in counties with low uptake of EID at 6weeks. In addition, mentor mothers were supporting triage at the MCH to ensure all women were tested at 6 weeks and if HIV infected, EID done and the mother baby pair linked to psychosocial support group. Across the counties HEI cohort analysis continued within the quarter with 700 infants followed up with an MTCT rate of 4%(26) outcomes at 12 months and 615 infants followed up at 24 months with an MTCT rate of 5%(33).
MENTOR MOTHERS AND PSYCHOSOCIAL SUPPORT The 98 psychosocial support groups(PSSGs) meetings across the 9 counties were facilitated by 63 mentor mothers and Nurses at MCH. The groups served approximately 2,300 HIV positive pregnant and breastfeeding mothers their 20 male partners and infants during the quarter. The mentor mothers played a great role in one on one peer support to the newly identified HIV infected women. The participants in the psychosocial support group meetings, were provided with tea and snacks. During the meeting the HIV positive mother-baby pair get ARV refills, EID, viral load testing, HIVST for their partners and clinical assessment at MCH.
The Activity supported roving mentor mothers with lunch and transport to be able to support HIV infected women in medium and small sites. The focus was to achieve peer support and defaulter tracing across all the Afya Kamilisha supported sites. Mentor mothers were facilitated with airtime, lunch and transport to track defaulters either by calling or physical defaulter tracing especially in counties like Tharaka Nithi and Meru with high numbers of infants defaulting clinic.
CAPACITY BUILDING AND QUALITY IMPROVEMENT Kamilisha program staff conducted clinical mentorship on PMTCT and EID in 223 sites across the 9 counties. Gaps identified during site mentorship included viral load and EID filling of the forms and documentation, filling of green cards, some indicators in the ANC registers and HEI register. Site specific plans were developed and were being tracked for implementation progress to address the gaps. The Activity carried out CMEs in self-testing and Dual test kits, MCA, HCA and EID at site level.
COLLABORATION WITH MOH Within the quarter, the Project jointly with MOH conducted supportive supervision to selected PMTCT sites across the 9 counties. Joint CHMT meeting were conducted in Tharaka Nithi county to discuss on the high MTCT rates. The CHMT and sub county teams were supported to carry out EMTCT mentorship and CMEs at MCH and maternity. The Activity supported joint TWG with the county teams and other partners to discuss the difficult cases at facility level. The project staff attended county meetings to discuss EMTCT Agenda.
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OBJECTIVE 3: IMPROVED LINKAGE TO TREATMENT FOR INDIVIDUALS NEWLY TESTING POSITIVE FOR HIV In the reporting quarter, Kamilisha provided technical and logistical support to 174 care and treatment sites in the 9 counties with key focus on identification, immediate linkage and ART initiation to the positive clients, defaulter prevention, ART optimization to the eligible population and eventually maximal viral suppressions. To achieve this Kamilisha strengthened the following approaches, deployment of linkage officers to coordinate linkages, providing airtime, transport and lunch allowances to MOH staff and peer educators (P.E) to track defaulters and also link clients from non-ART sites, provided targeted mentorship to the lay workers and health care providers to be able to provide quality services and also ensuring the facilities are able to utilize their data in decision making. In the reporting quarter, an additional 2,215 new HIV positive clients were identified in Kamilisha supported facilities with 1,767 (80%) clients starting ART. This led to an increase in the number of clients new on treatment to 4,991 from 3215 at SAPR translating to 36% of the annual target for new on treatment. The number of new clients on treatment coupled with 1,037 net new led to an increase of patients current on treatment to 46323 (86%) against an annual target of 53,781. To monitor the treatment outcome, 37,158 were subjected to a viral load test with 32349(87%) suppressing the virus. To minimize the daily caseloads at the facilities and also reduce on frequency of clients visits, Kamilisha had scaled up differentiated service delivery models to 125 care and treatment sites in the 9 Counties and enrolled 44% (20318/46,323) clients in DSD.
3.1 EFFECTIVE REFERRAL AND LINKAGE TO HIV CARE AND TREATMENT As of quarter 3 COP 18, 6600 new HIV positive clients were identified in 284 HTS sites through various testing modalities with 4991 (76%) starting ART in Kamilisha supported sites while 924(14%) were enrolled into other sites and their enrolment status confirmed. The overall linkage for the quarter was 90% with 561 (8.5%) patients on follow up to ensure they get enrolled and started on ART, 95 (1%) patients were lost to follow up and 29 died before enrollment. There was improvement on linkage into Kamilisha supported sites and overall linkage compared to SAPR where the linkage was 73% into Kamilisha sites and an overall linkage of 89%. This was attributed to surge strategy where there is accountability at every level from testing to linkage and also consumption of the linkage data at the site level. Moreover, 8 of Kamilisha high volume facilities started initiating ART to stable patients in the ward as well as having a standby clinician over weekends to ensure all clients identified are started on ART.
The linkage table above demonstrates that the linkage characteristics across the 9 counties was similar with children aged 1-9 years and the clients above 45 years having the highest linkage rates. However, adolescents aged 10-14 years recorded the lowest linkage rates in both males and females across the 9 counties except Tharaka Nithi and Murang’a County. This called for more targeted interventions to improve the linkage rates. Some of the interventions that the project will use in quarter 4 include;
Mentorships to the HTS providers on post-test counselling and treatment preparation Reinforcing accountability at all levels from identification, linkage and ART initiation. Tasking the HTS providers with linkage of the positives that they have identified Ensuring the clients ideas are incorporated in their treatment Plans-Client centered approach Fast tracking the newly identified clients.
3.2 TB / HIV SERVICES April to June 2019, the project continued to support health facilities to implement TBHIV activities in accordance to the WHO 5 I’s namely; Intensive case finding, Isoniazid preventive therapy, immediate initiation of ART, integration and infection prevention control in 174 care and treatment sites. This was enabled through technical mentorship, CMEs, commodity management and data capture and review
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meetings. Of the 37,374 PLHIV screened for TB using the ICF tool card, 1,116 were positive and were subjected to a GeneXpert diagnostic test as well as other laboratory diagnostic tests. A total of 388 were confirmed to have contracted TB and started on potent TB treatment according to the Kenya TBHIV guidelines. During this quarter, 1,382 out of 1419 ART clients completed 6-month standard course of IPT. At the TB clinic 6,065 were diagnosed with TB through active and passive case finding. Through the projects effort 6,201 accessed a HIV testing service, 730 were known positive, 437 were newly identified HIV positive and 423 of the new positives were started Anti-retroviral treatment. Achievements in TBSTAT stood at 124% (6,065/4,912) against the annual target while achievement in TBART was 122%(1,144/940). Facility level prevention cascade performance was 43,951/53,779 (82%) while IPT was 23%(1,545/6,598). 1. Intensive Case Finding (ICF): Kamilisha supported the CCC’s in giving onsite mentorship and coaching on quality TB screening among PLHIV clients. This resulted in 43,951 clients screened out of 46,333 clients already on ART by the end of June. As a result, 1,166 TB presumptive patients were identified and were subjected to further diagnostic evaluation using Gene Xpert test. Sputum samples were transported to GeneXpert hub through an elaborate laboratory sample networking that the project supports. Those confirmed to have contracted TB were 388 and all were started on potent TB treatment in line with the national TB treatment guidelines. The project supported maintenance of 11 GeneXpert machines (1 in Kiambu, 1 in Murang’a, 3 in Embu, 1 in Tharaka Nithi, 1 in Nyandarua and 4 in Meru) to enable their functionality. Integration of TBHIV services and immediate initiation to ART: Support for full integration of TB and ART is in 131 ART sites was strengthened through technical mentorship and aligning client flow. The project supported identification of 1,153 TBHIV co-infected patients through active screening using the ICF screening tool card, 721 patients were known HIV positive and 426 were newly identified TBHIV patients. All known positive PLHIV are on ART while 423/426 are new TB HIV co-infected and have been started on ART. The 721 co-infected known HIV positive clients, underwent assessment of possible treatment failure by focusing on their viral load levels. Close assessment is on course in line with treatment failure management guidelines. The 3 patients not initiated on ART underwent adherence counselling sessions and will shall be initiated on ART within 14 days of start of TB treatment. Table 16: Uptake of HIV Testing and ART among the TB/HIV Co-Infected Clients:
County TB Tested for % Tested TBHIV co- Co-infected % uptake Notified HIV for HIV infected ART uptake cases Embu 1118 1056 94% 178 177 99% Kiambu 767 762 99% 195 195 100% Kirinyaga 215 215 100% 34 34 100% Meru 2548 2538 100% 415 415 100% Muranga 542 542 100% 125 122 98% Nyandarua 259 251 97% 69 68 99% Nyeri 73 73 100% 23 22 96% Tharaka Nithi 646 605 94% 94 94 100% Kitui 33 23 70% 20 20 100% Total 6201 6065 98% 1153 1144 99%
By the end of Q3 HTS uptake among TB patients was 98%(6,075/6,201) with 5 counties of Kirinyaga, Meru Murang’a and Kitui performing 100% and equall6 good ART initiation of averagely 99%. The project will
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ensure that the remaining 126 TB patients have been tested for HIV during the next quarter. Below is a county level summary of HTS and ART uptake. 2. IPT Kamilisha is focused on reducing the incidence rate for TBHIV coinfection among clients already on ART by promoting TB prevention services at the CCC. The project continued to support the sites in offering technical assistance on utilizing biomedical methods of TB prevention. The project supported the sites to conduct IPT CMEs to maintain its uptake. During this implementing period, 1,382 patients completed 6- month standard course of IPT. Cumulatively, 36,767/45,286 (81%) patients’ currently on ART have completed IPT. This is 1 % higher than the national average whose coverage stands at 80%. 3. IPC To promote and maintain IPC activities, the project supported the sites with onsite mentorship on IPC activities and supported sites developing IPC plans for its utilization. Through Activity support 129 out of 174 sites had active IPC plans suitable for infection control needs. Table 17: TB STAT and TB ART SAPR performance against targets County TB_STAT SAPR Q3 TB_STAT % TB_ART SAPR Q3 ART % target achievement Achievement target achievement Achievement Embu 863 729 327 1056 122% 124 132 45 177 143% Kiambu 723 530 232 762 105% 217 147 48 195 90% Kirinyaga 196 156 59 215 110% 23 14 7 21 91% Meru 1647 1617 921 2538 154% 252 255 160 415 165% Murang’a 516 353 189 542 105% 105 76 46 122 116% Nyandarua 280 172 79 251 90% 94 53 15 68 72% Nyeri 147 40 33 73 50% 30 9 13 22 73% Tharaka Nithi 499 418 187 605 121% 83 66 28 94 113% Kitui 41 12 11 23 56% 12 27 3 30 250% Total 4912 4037 2,119 6065 124% 940 779 368 1144 122%
During this implementation period, Kamilisha assigned an HTS counselor in TB clinic to test all the TB clients. In addition, the project made sure that there were enough commodities to test all TB patients with an unknown status The project assisted the counties to print and distribute guidelines and job aids for TB screening and ART initiation among the co infected patients to ensure the correct protocols are observed. This enabled the project to surpass COP 18 APR targets for all the key TBHIV indicators in five counties. Other counties are on the right trajectory towards achieving APR targets except for Nyeri where ACF activities has not yielded more TB cases. 3.2.3 Collaboration with MoH and other partners Every quarter the CTLCs and SCTLCs were supported in giving TA and supportive supervision activities to supported sites. During this visits the facilities received mentorships through CMEs and departmental visits. The project collaborated by leveraging support for implementation of TBHIV activities with other key HIV and TB implementing partners such as CHS Tegemeza plus project in Murang’a, Nyandarua and Nyeri, CRISSP Plus project in Kiambu and Kirinyaga and TB ARC in supporting DR TB clinical surveillance meeting. We collaborated with AMREF and KCCMB CBO’s supporting TB defaulter tracing. Kamilisha supported sites to evaluate quality of care and address gaps identified during the visits. The facilities were assisted in developing quality improvement teams that were tasked in creating improvement plans to assist in improving indicators that well not doing well.
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3.2.4 Data Review meeting The project supported 8 counties in holding data review meetings that focused on addressing TBHIV challenges, how to improve on the TB/HIV indicators and how to use data for decision making. The program has also participated and supported in onside mentorship and county performance review meeting that has helped in tracking progress. The project also supported the counties in holding county based TBHIV quarterly review meeting in preparation for the cluster meetings. Some of the challenges that were derived from the meetings include high TBHIV mortality rates and data reporting in the DHIS. As an effort to reduce the TBHIV mortality rates, the project included mortality audits as part of the agenda in MDT meeting for care and treatment. 3.2.5 TB ECHO KAMILI supported counties in procuring internet bundles for the activation of TB ECHO e learning platform. Every Tuesday 12 ECHO hubs access virtual CME’s that are held nationally. Giving TA to facilities that host the hubs on different TBHIV related topics.
OBJECTIVE 4: INCREASED UPTAKE OF AND ADHERENCE TO QUALITY HIV TREATMENT SERVICES
4.0 HIV CARE AND TREATMENT SERVICES
In the reporting quarter, the project focused on systems strengthening to ensure all the patients testing HIV positive are linked, started on ART at the recommended period, provided with adherence and support services, and also access timely viral load testing and suppress the virus. Morever, the project supported age and gender specific interventions targeting children, adolescents and young people(AYP)and men.
4.1 ANTI-RETROVIRAL TREATMENT (ART)
4.1.1 Pediatric Treatment Services Kamilisha supported pediatric specific intervention across the 9 counties which included, psychosocial support, mentorships on pediatric package of care and also adherence counselling and disclosure. As at the end of quarter 3, 30 health care providers had been mentored on the package of care as well as ART optimization for children. To improve on retention and viral suppression, 47 PSSG meetings were supported where a total of 536 children and their guardians were in attendance. In this meetings, children above 5 years were taken through partial disclosure and the guardians taken through adherence and drugs administration to their children (Measuring the correct dosage and also storage of drugs at home). Additionally, the project collaborated with CASE OVC who are providing adherence support to HIV positive OVC, defaulter tracing and also linking OVC with unknown status to Kamilisha sites for testing and linkage. To monitor the treatment outcomes for the children, 1350 children accessed viral load testing with 936(69%) suppressing the virus. There has been a notable challenge in viral suppression amongst the children and to address this, Kamilisha is working with the supported facilities to ensure children get the recommended regimen and dosage and also ensure those who are failing are actively transitioned to 2nd line.
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4.1.2 Adolescent and Young people (AYP) treatment services
Managing adolescents and young people remains a challenges and require a collective effort between all stakeholders while involving them in decision making in order to retain them into ART and achieve viral suppression. As of quarter 3 COP 18, Kamilisha continued to support the facilities to recruit more adolescents and young people into operation triple zero clubs with 2700 beneficiaries enrolled in 83 supported facilities as demonstrated in the table below. The project provided technical support mentorships and OJT to the health care providers on adolescent package of care reaching a total 60 healthcare providers. To monitor treatment outcomes, 2877 samples from adolescents aged 10-19 years and 1262 samples from young people age 20-25 years were analyzed with 68% (1969/2877) adolescents and 80%(1012/1262) young people returning viral suppression. These results compare favorably with Q2 (67% and 78%) and Q1 (65% and 75%) respectively. The improvement in viral suppression can be attributed to utilization of viral load results in the management of adolescents suspected to be failing, enrollment of more adolescents into OTZ from 2700 in SAPR TO 2858 quarter 3 COP 18 and also equipping health care providers with the right skills.
Table 4.1: OTZ Implementation by County COUNTY No. supported ART No. Facilities No. Adolescents/ Facilities implementing OTZ Children enrolled Embu 31 16 943 Kiambu 18 17 382 Kirinyaga 19 5 55 Kitui 2 1 23 Meru 47 5 314 Murang’a 7 7 483 Nyandarua 23 13 245 Nyeri 9 6 119 Tharaka Nithi 18 13 293 Total 174 83 2858
In quarter 4, the project will scale up OTZ into 100 sites and ensure more AYP enroll with special focus in Meru, Nyandarua and Embu Counties.
4.1.3 Adults’ treatment services As of quarter 3 COP 18, Kamilisha provided technical support to health care providers with special focus to ART optimization, adherence and retention support, scale up of viral load testing, utilization of viral load results in decision making and patient categorization for DSDM. Moreover, the project focused on defaulter prevention and tracing all the lost clients leading to a retention rates of 87% amongst adult clients. With implementation of the above, 31,669 clients aged above 25 years accessed viral load testing with 28,432(90%) suppressing the virus which is an improvement compared to SAPR where the suppression rate was 88%.
4.2 ART OPTIMIZATION Kamilisha provided support to the facilities on ART optimization through mentorships, supportive supervisions, and charts abstraction to identify eligible clients and also stock redistribution. Moreover, peer educators and health care providers continued creating demand through health talks at the waiting bay and one on one counselling to all the clients. As of quarter 3 COP 18, a total of 35,444 clients had been transitioned to either TLE400 or TLD based on eligibility criteria against 43,054 clients above 15 years currently on ART translating to 82% as demonstrated in the table below. The project intensified efforts to
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ensure women of reproductive age get more information on TLD and allow them make an informed choice irrespective of their contraception status. Regular chart reviews to flag out clients eligible for transition and call them back for transition as they bleed those without a current viral load result.
Table 18:ART Optimization County TX_CURR >15 TLD Transition # of Women on % Optimized Years EFV 400 Embu 7,305 2,650 3,333 82% Kiambu 7,634 2,323 3,969 82% Kirinyaga 1,523 505 650 76% Kitui 577 191 221 71% Meru 12,534 4,183 5,988 81% Murang'a 5,580 2,579 2,862 98% Nyandarua 2,872 968 1,117 73% Nyeri 2,055 713 1,148 91% Tharaka Nithi 2,974 917 1,145 69% Kamilisha 43,054 15,029 20,415 82%
In quarter 4, the project will scale up ART optimization to achieve 100% for the eligible clients. This will be achieved through, actively calling the eligible patients who are not optimized and switching them to the recommended regimen, continuous health talks to create demand and ensuring non suppressed patients receive enhanced adherence counselling and timely repeat viral loads.
4.3 ADHERENCE AND PSYCHOSOCIAL SUPPORT Adherence to ART is vital in ensuring all patients on ART achieve viral suppression. However, it’s more critical amongst patients who are new on ART, children, adolescents and young people aged 20-25 years. To ensure adherence is optimized among the clients on ART, the project invested in age and gender appropriate PSSG targeting children and their guardians, adolescents and young people, men, newly enrolled patients and also suspected treatment failures. As of quarter 3 the project supported over 150 support group meetings with 8734 beneficiaries across different age groups. The project emphasized on adherence assessment for all the clients at every contact as well as re-evaluation of adherence barriers and addressing them. Through this intervention, the project has been able to retain over 86% of patients on ART.
4.4 MALE FRIENDLY SERVICES The project continued to address male health seeking behavior through men specific intervention like men only appointment dates and PSSG and also having flexi time to accommodate their busy schedule. Additionally, the CCC in charges and peer educators have identified male champions amongst the group members who coordinate them and act as the link between the group and the facility. With this intervention, there was an improvement in viral suppression amongst the clients enrolled into male only clinics where the viral suppression was 89% compared to 86% in males in general population and a retention rate of 90%. The number of males enrolled in male friendly services went up from 2013 at end of Q2 to 2,192 at the end of Q3.
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Table 19: Male friendly clinics/Beneficiaries by County COUNTY No. supported ART No. Facilities with male No. clients enrolled Facilities friendly services Embu 31 7 435 Kiambu 18 17 416 Kirinyaga 19 5 44 Kitui 2 0 0 Meru 47 6 414 Murang’a 7 4 439 Nyandarua 23 0 0 Nyeri 9 4 65 Tharaka Nithi 18 14 290 174 57 2,192 in quarter 4W, the project will scale up the interventions into 80 sites and special focus will be put in Embu, Meru and Nyandarua Counties to ensure more men get enrolled and also more sites get on board.
4.5 QUALITY IMPROVEMENT INTERVENTIONS
In Q3, the project implemented the surge initiative in all the 9 counties for poorly performing indicators like HIV case identification (HTS_POS), linkage, and initiation on ART (TX_NEW). With surge implementation, 108 MDTs were revitalized and conducted weekly surge review meetings to address performance issues. linkage within Kamilisha supported sites improved from 73% in SAPR to 80% in quarter 3, viral suppression improved from 85% in SAPR to 87% in quarter 3.
OBJECTIVE 5: LONG-TERM FOLLOW-UP OF CLIENTS RECEIVING CARE AND TREATMENT Patients receiving ART require long-term follow up for the purposes of attaining viral suppression, improved quality of life, and reduce transmission of the virus. Personal dedication and also provision of supportive services like adherence and psychosocial support are key to ensuring adherence and retention. To achieve these, Afya Kamilisha worked with the facilities to minimize missed appointment as well as lost to follow ups through the following strategies; Deployment of 131 peer educators who provide peer counselling, defaulter tracing and maintaining appointment and defaulter tracing registers Provision of appointment diaries and defaulter tracing registers in all the facilities for appointment and defaulter tracking Provision of mobile phone airtime and transport to peer educators and CHV appointment reminders and defaulter tracing Supporting age appropriate PSSG and also special support groups for clients with adherence challenges Utilizing EMRs to flag off patients who miss appointments for real time defaulter tracing Updating of patient demographic from time to time to assist in physical tracking Characterization of the clients who miss appointment, defaulters and lost to follow up to ensure the facilities customize their interventions based on patient needs. Through the implementation the project has been able to retain over 86% of patients on ART.
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5.1 VIRAL LOAD MONITORING AND INTEGRATION
The overall goal for ART is to ensure patients are virally suppressed in order to reduce community transmission and also improve on quality of their lives. As of quarter 3, 37,158 clients had been subjected to viral load testing which was a significant improvement compared to SAPR where a total of 23,780 clients had accessed Viral load testing. This improvement in the uptake can be attributed to line listing of the eligible clients at the facility both manually and using EMR, sharing site level targets, client’s knowledge on frequency of viral load testing, increasing the frequency of sample transport as well as most clients becoming eligible towards the third and fourth quarters of the COP year due to previous RRIs.
Table 20: Viral suppression summary by Age Band Age bands (Years) Viral load done Virally Percentage suppressed suppressed 1-9 1350 936 69% 10-14 1430 990 69% 15-19 1447 979 68% 20-24 1262 1012 80% 25-49 21749 19276 89% 50+ 9920 9156 92% Kamilisha 37158 32349 87%
Table 21: Viral Load Suppression rate by County and Age band County Age Viral load done V.L Suppressed %V.L Suppression Embu 1 to 9 199 123 62% 10 to 14 235 142 60% 15 to 19 257 160 62% 20 to 24 224 177 79% 25 to 49 3,715 3,246 87% 50+ 1,843 1,698 92% Total 6,473 5,546 86% Kiambu 1 to 9 234 161 69% 10 to 14 216 159 74% 15 to 19 200 146 73% 20 to 24 250 203 81% 25 to 49 4,181 3,755 90% 50+ 1,536 1428 93% Total 6,617 5,852 88% Kirinyaga 1 to 9 39 29 74% 10 to 14 39 32 82% 15 to 19 32 22 69% 20 to 24 47 33 70% 25 to 49 848 757 89% 50+ 362 334 92% Total 1367 1207 88% Kitui 1 to 9 21 12 57% 10 to 14 33 17 52% 15 to 19 22 16 73% 20 to 24 13 7 54% 25 to 49 225 191 85% 50+ 158 146 92% Total 472 389 82% Meru 1 to 9 390 252 65% 10 to 14 409 268 66% 15 to 19 416 272 65% 20 to 24 360 277 77%
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25 to 49 5,519 4,818 87% 50+ 2,402 2,165 90% Total 9,496 8,052 85% Murang'a 1 to 9 189 156 83% 10 to 14 182 151 83% 15 to 19 204 158 77% 20 to 24 142 121 85% 25 to 49 3,078 2,893 94% 50+ 1,763 1,712 97% Total 5,558 5,191 93% Nyandarua 1 to 9 132 92 70% 10 to 14 133 97 73% 15 to 19 122 76 62% 20 to 24 85 75 88% 25 to 49 1,599 1380 86% 50+ 699 626 90% Total 2,770 2,346 85% Nyeri 1 to 9 34 25 74% 10 to 14 64 54 84% 15 to 19 96 77 80% 20 to 24 46 41 89% 25 to 49 1021 923 90% 50+ 601 561 93% Total 1,862 1,681 90% Tharaka Nithi 1 to 9 112 86 77% 10 to 14 119 70 59% 15 to 19 98 52 53% 20 to 24 97 78 80% 25 to 49 1,563 1313 84% 50+ 556 486 87% Total 2,545 2,085 82%
There was an improvement in overall suppression where Kamilisha attained 87% compared to SAPR where overall performance was 85% and an improvement of between 1 and 2% amongst different age bands. However, it’s evident that most counties continued experiencing challenges with viral suppression amongst children and adolescents except for Nyeri and Murang’a that have suppression rates above 80% just like SAPR. This was attributed to adherence challenges amongst the affected population as well as guardians picking drugs on behalf of their children especially those at school. To mitigate this, Kamilisha in collaboration with the supported facilities conducted charts abstraction and line listed all the non- suppressed cases so that they can be invited in August during school holidays for adherence counselling, ART optimization for the eligible ones and regimen change for the confirmed treatment failures. Morever, the project is supporting the facilities to summarize the cases for children failing on PI based regimen for discussion at the technical working groups at the County and regionally.
5.2 VIREMIA CLINICS Kamilisha is striving to ensure that all the patients who are on ART achieve viral suppression and those with detectable viral load, line listed and enrolled in viremia clinics for enhanced adherence and further management. As of quarter 3, Kamilisha supported 101 health facilities to have viremia clinics with 3356 non suppressed clients benefitting and amongst them 1088 patients were subjected to a repeat viral load after completion of 3 sessions of enhanced adherence and 435(40%) re-suppressed. To reduce these cases of non-suppressed, the project provided mentorship to the adherence counsellors and clinicians to be able to detect cases of non- adherence early, identify the barriers and act on them. Additionally, clinicians are also mentored on management of treatment failures to avoid delays in switching clients into a superior regimen.
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Table 22: Viremia clinics by County/ beneficiaries COUNTY No. supported ART No. Facilities with Viremia No. Patients Facilities Clinics enrolled Embu 31 30 991 Kiambu 18 18 884 Kirinyaga 19 6 71 Kitui 2 1 35 Meru 47 6 349 Murang’a 7 7 253 Nyandarua 23 12 192 Nyeri 9 6 99 Tharaka 18 15 410 Nithi Total 174 101 3,356
In quarter 4, the project will scale up viremia clinics into additional 25 sites and also ensure all non- suppressed are enrolled. Special attention will be accorded to Meru, Kirinyaga and Nyandarua counties where we have less sites with structured viremia clinics.
5.3 DIFFERENTIATED CARE SERVICE DELIVERY MODEL (DSDM) In order to reduce the daily case load in the facilities, reduce on the frequency of the appointments for the clients, as well as schedule around the patient’s convenience, Afya Kamilisha supported patient categorization with stable ones enrolled into DSDM while providing intense monitoring to the unstable clients. As of quarter 3, COP 18, Kamilisha had scaled up differentiated service delivery models into 125 care and treatment sites in the 9 counties and enrolled 44%(20318/46323) clients into facility express model of DSD. However, the process has been slowed by ART optimization process where the previously stable clients are getting short period appointment for the first three months of the optimized regimen and switched back to multiple month dispensing after having undetectable viral load on the 3rd month. It’s worth noting the overall retention rates for patients on DSDM was 94% compared to 86% retention rates for the entire project. The project aims at increasing the proportion of patients on DSD in the coming quarters of the year by supporting county and sub county pharmacists in forecasting, quantifying and timely ordering to ensure more patients get multiple month dispensing. Morever, the project will support retention and adherence structures in the facilities to ensure more clients adhere and also ensure they are on efficacious regimen. In addition, Kamilisha has continued to support community PSSG for the previously established CAGs as they wait for the 3rd month viral load testing for them to resume receiving ARVs at the community.
Table 23: Facilities implementing DCM by County COUNTY No. supported ART No. Facilities TX_CURR (Q3) No. Patients Proportion of Facilities implementing enrolled Patients enrolled DCM in DSD Embu 31 22 7882 3,511 45% Kiambu 18 18 8140 3,736 46% Kirinyaga 19 7 1628 602 37% Kitui 2 1 620 270 44% Meru 47 36 13565 5,746 42% Murang’a 7 7 5878 2,982 51% Nyandarua 23 16 3193 1,162 36% Nyeri 9 8 2162 1,024 47% Tharaka Nithi 18 10 3265 1,285 39% Kamilisha 174 125 46333 20,318 44%
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In the table above, its evident County are almost at the same level in enrolling the patients into DSD apart from Tharaka Nithi and Nyandarua where extra efforts need to be put in to ensure they push over 70% of patients on ART to DSDM and also increase the number of facilities offering the service. In Quarter 4, the project strives to scale up DSDM into additional 30 sites to make a total of 155 sites and enroll at least 60% of patients current on ART.
5.4 COLLABORATION WITH MOH AND OTHER STAKEHOLDERS The project collaborated with County and sub County teams to conduct sensitization on surge strategy, provide clinical mentorships, and monitor surge activities and progress towards achieving the set targets. Additionally, the project is collaborating with CASE OVC who are providing case management to OVCs living with HIV and KRC through catholic diocese of Murang’a who are supporting in defaulter tracing and routine home visit to adolescent and women living with HIV in Murang’a County.
5.5 LABORATORY SUPPORT
Laboratory plays a key role in supporting other program areas to achieve the set targets. This is by ensuring the availability of necessary commodities to conduct EID and Viral load testing, adequate test kits for HTS and the necessary consumable for TB diagnosis and CD4 testing. Ensuring samples are transported to either central or National laboratories for analysis following the already established sample integrated networking system and results management back to the respective facilities for clinical intervention(s) During the quarter, the following are the key achievements a) Trained 207 lab officers on Annual Biosafety/Biosecurity refresher trainings. b) Supported certification of nine Biosafety cabinets and Hoods in Murang’a, Tharaka Nithi, Meru, Kiambu and Nyandarua Counties in collaboration with National Biosafety Office. c) Facilitated eight Counties to update EQA PT list ahead of round 20. d) Increased the number of sites conducting remote log-in for viral load and EID samples from 76 to 91 in Quarter 2 and Quarter 3 respectively.
5.5.1 Biosafety and biosecurity refresher training and Continuous Medical education In the reporting period, a total of 367 Medical Laboratory officers were eligible for the annual biosafety and biosecurity refresher training. In collaboration with the county Health Management Teams the project supported 207 (56%) laboratory officers comprising of 113 males and 94 females to go through annual biosafety and biosecurity refresher training. In the same setting the team carried out continuous medical education focusing on viral load and EID sample and result management including determination of eligible clients for testing, sample collection and documentation, tracking of referred samples, fast tracking of delayed results, accessing of results and documentation. All the refreshers were done at hospital conference halls to reduce costs and to encourage county ownership, self-reliance and sustainability. The facilitators were from within the counties. The officers were issued with individually signed documentation record as proof of training for filling in their respective personnel files. The staff were guided to develop site level improvement plans on biosafety which the team will be following up on during facility mentorship visits.
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5.5.2 Biosafety cabinets and hoods annual certification To ensure staff safety in processing of TB samples, the project supported nine biosafety cabinets and hoods (Magutuni, Sabasaba, Nyambene, Kigumo, Bamboo, Mary Help of the Sick Mission, St Mathew and Sarah, Immaculate Heart of Mary, and Kahembe Health Center) due for annual certification were certified in collaboration with the National biosafety office. All passed the test of usability apart from Nyambene hospital which has a new biosafety cabinet which is in the process of installation to replace the old faulty one. 5.5.3 Facility site improvement monitoring through systems, assessment (SIMS) The team conducted facility level mentorship using the site improvement monitoring through systems tool to identify areas of improvement and help them set improvement plans. The mentorship focused on Essential Laboratory Quality Management System including; organization, process management, customer focus, document and records, facilities and safety, information management, personnel, nonconforming event management, purchasing and inventory, assessments, equipment and continual improvement. Mentorship on VL and EID sample remote login was done so as to improve on VL and EID facility data in the National website as well as reduce turnaround time for the results. The feedback on the site visits were shared with facility staff for action and the team is following up with the respective sites to ensure compliance. 5.5.4 Preparation of HIV PT round 20 EQA processing Afya Kamilisha supported the County and Sub County Laboratory coordinators to ensure the updating on the HIV PT online platform in readiness for round 20 panel distribution led by the National HIV Reference Laboratory. The activity involved registration of all new HTS providers and updating of the personnel details as well as deactivation of personnel who have exited. A total of 2,932 HTS providers were enrolled to participate in round 20 as compared to 3,374 enrolled in round 19 which is a drop in numbers occasioned by the cleaning of the system to remove double entries and some nurses declining to test at selected hospitals following the recent court ruling on HIV testing. The project will support the sub-county laboratory coordinators in ensuring a coordinated distribution of the panels, 100% uploading of the reports in the online system and 100% response rate, 100% submission of the hardcopies across the counties in July 2019. 5.5.5 Facility TAT flagging and monitoring To address VL and EID test TAT, the project focused on sites with extended facility delay by monitoring site level data monthly, flagging sites with extended facility delay, sharing the data with the County and sub-County Coordinators and liaising with the sites for corrective action/preventive action. A job Aid on “action for delayed VL/EID results” was developed and shared with all sites to give guidance and facilitate prompt action. Additionally, Afya Kamilisha continued to collaborate with PS Kenya that enabled establishment of Laboratory HUBs through placement of computers and printers. The hubs continued to support the facilities with sample login, tracking of the testing progress at the reference lab, results access and delivery of soft copies, print out for viral load and EID hard copy results and coordination delivery to the sites and fast tracking of results with extended delay. Through the support, the number of sites conducting remote log-in increased drastically from 56, 76 and 91 sites in Q1, Q2 and Q3 respectively. This has subsequently reduced transcription errors emanating from wrong client biodata entered into the system.
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Table 24: Uptake of Remote log-in focusing for Afya Kamilisha Sites Oct-Dec 2018 Jan-March 2019 April-June 2019 Number of sites doing Number of sites doing Number of sites doing County remote login (n=167) remote login (n=167) remote login (n=167) Kiambu 6 6 8 Murang’a 6 6 6 Nyeri 9 9 10 Kirinyaga 13 17 17 Nyandarua 7 16 15 Embu 1 8 13 Tharaka Nithi 10 12 17 Meru 4 2 5 Total 56 76 91 Viral Load Suppression To help improve the suppression rate, the project focused on correcting the VL test justification- “reason for testing”. This was following the observation that a significant proportion of client data had been captured/indicated wrongly (marked as “routine” whilst the correct reason was either baseline, confirmation of treatment failure or single drug substitution). The project initiated a process of validating Viral load test justification from facility level using the patient files. A database of all viral Load tests performed from October 2018 to June 2018 was shared with the MER team in Embu as a pilot to start the process. This process is ongoing, and the corrected data will be shared with the managers of the EID/VL NASCOP website data for corrections. The strategy will be rolled out to the other counties a process that is expected to be complete by 15th July 2019. A standard operating procedure has been shared with all CCC clinicians and Laboratory officers to ensure correct data is captured moving forward. To ensure minimum service interruption, machine functionality was continuously checked and ascertained to be fully operational. Close monitoring is ongoing to ensure real time report on any downtime to the maintenance company. The team is working closely with the facility staff to ensure daily routine maintenance is done and the logs updated appropriately.
5.6 COMMODITY MANAGEMENT Commodity management plays a key role in supporting various program achieve the required targets. This guides the actual requirements to reduce on overstocking or understocking of a certain commodity. These commodities include ARVs/TB drugs, RTKs, GeneXpert cartridges, CD4 reagents/cartridges, Viral load/EID commodities among others. During Quarter 3, Afya Kamilisha continued to collaborate with various counties to strengthen commodity management and security. This was achieved through the well-established commodity management technical working groups which oversee commodity quantification, projections and sharing county needs with National allocation teams for support on regular basis. The groups have clear terms of reference (TORs) which are well outlined to guide the groups on their mandate. Establishment of commodity management hubs for viral load and EID commodities at sub county Hospitals was achieved as strategy to ensure continued supply of required commodities to lower level facilities. Hubs allocation (s) was based on set targets and number of peripheral sites per Sub County.
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During the quarter, Afya Kamilisha continued to collaborate with counties to improve on efficiency, quantification and accountability of health commodities. Key achievements include the following; a) Supported 8 counties to conduct ARV and RTKs redistribution to reduce on understocking and overstocking b) Supported 8 counties on RTKs and ARVs projection and quantification following bottom – up approach c) Supported integrated commodity TWGs in 8 counties in collaboration with other implementing partners d) Achieved >90% reporting rates for tracer commodities (ARVs, RTKs, Cartridges for GeneXpert for VL/EID/CD4 testing)
5.6.1 Commodity Data Acquisition, Reporting and Use Counties adopted the use of DHIS/HCMP platforms which are the national recommended reporting platforms for HIV related commodities. During the quarter, commodity reporting rates for HIV related commodities improved drastically in comparison with the previous quarter (see below). This include reporting rates for ARVs/TB drugs, RTKs, GeneXpert and CD4 cartridges. On monthly basis, Afya Kamilisha supported Sub county MLTs and pharmacists with data bundles to ensure commodity reports are uploaded on monthly basis. On commodity security, Afya Kamilisha supported 8 counties to conduct quarterly allocation for HIV test kits and monthly for ARVs drugs using a bottom-up approach and the projections were shared with National allocation teams guided by pre-determined drawing rights. Kiambu and Embu counties have started piloting the new bottom-up approach for ARVs quantification in line with the new circular. To reduce on understocking and overstocking of commodities, Afya Kamilisha supported 8 counties to conduct ARVs and RTKs redistribution within the counties. This was guided by the needs and the reports that were submitted by sites during the period. Commodity reporting rates for tracer commodities during the quarter (Apr – Jun 2019) are as indicated below. Afya Kamilisha will work closely and support counties to achieve 100% reporting rates for tracer commodities.
RTK Reporting Rates FCDDR (Apr - Jun 2019) 100 99 97 97 98 95 96 92
Kiambu Muranga Kirinyaga Nyeri Nyandarua Embu Tharaka Nithi Meru
Figure 7: RTKs Reporting Rates: FCDDR 643 (Apr – Jun 2019) through HCMP
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MOH 730A CDRR Reporting Rates (Apr - Jun 2019) 100 100 100 100 97 96 94 93
Kiambu Muranga Kirinyaga Nyeri Nyandarua Embu Tharaka Nithi Meru
Figure 8: MOH 730A Central Sites and Sub County Stores (CDRR) through KHIS: Apr – Jun 2019 NB: Afya Kamilisha will work closely with the counties to migrate fully to KHIS especially on RTKs reporting 5.6.2 Strengthen Commodity Oversight for Supply Chain Afya Kamilisha has continued to build county capacity by strengthening the existing Commodity Technical working groups in line with sustainability strategy that will assist the counties to management health commodities beyond partners’ support. During the quarter, in collaboration with other implementing partners (IPs), 8 counties were supported to hold quarterly TWG meetings to re-evaluate key areas touching on HIV/TB activities. This include quarterly reviews of commodity management data to identify the gaps and reporting, commodity redistribution for HIV related commodities among others.
OBJECTIVE 6: STRENGTHENED INSTITUTIONAL CAPACITY AND ACCOUNTABILITY FOR THE MANAGEMENT OF COMMUNITY, FACILITY AND COUNTY HIV RESPONSE.
6.1 LEADERSHIP, GOVERNANCE & STRATEGIC PLANNING The key achievements in the quarter under review were; County coordination for HIV surge strategy implementation, eMTCT brainstorming meeting in Tharaka Nithi, CHMT site support supervision and mentorship (SIMS) quarterly county and regional HIV TWG review meetings, drafting of the Kiambu 2019/20 AWP and County 2019/23 HSSP and Nyandarua county Health stakeholder’s forum. a) Annual Work Planning Support (2019/20) & County Health Sector Strategic Plan Three counties; Kiambu, Nyeri and Nyandarua, were assisted to conduct Annual Performance Review (APR) of the 2018/19 AWP. The APR reports were then used to inform the drafting of the County Budget Review Outlook Paper (CBROP) which provided the departmental budget recommendations. The CBROP informed the drafting of the 2019 County Fiscal Strategy Paper (CFSP), which provided the departmental budget ceilings and informed the drafting of the 2019/20
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AWP. Afya Kamilisha collaborated with CMLAP II to provide technical and financial support for the drafting of the 2019/2023 Kiambu County Health Sector Strategic (CHSP) from the first draft to the completion stage. The Strategic plan will provide a framework for evaluating progress of service delivery and guide the day to day decisions in the health department. b) Strengthening HIV Service Integration In Kiambu county, Afya Kamilisha supported the county to sensitize 60 clinicians from all the 12 sub counties on strengthening integration of HIV services in all OPD and IPD service delivery areas. Also discussed was the shift from routine out-patient HIV testing to targeted full scale Partner Notification Services (PNS) at facility and community levels, targeted PITC using the MOH screening tool, HIV self-testing, focus on key population and other high yielding strategies. The meeting was informed that the purpose of efficient targeted testing was to reduce OPD testing and increase index testing which ultimately yields higher number of positives and reduces irrational use of test kits. c) Coordination of SURGE strategy implementation county buy-in The project coordinated county teams to get the buy-in for the Surge strategy, which is programmatic intensification of priority activities as a way of working towards the achievement of the last mile of 95- 95 -95 targets for HIV epidemic control. In collaboration with the CHMTs, the project was able to quickly and efficiently disseminate the Surge strategy to the counties, sub counties and targeted facilities. After dissemination, the county HIV program leadership embraced the surge strategy and moved on with it alongside the Afya Kamilisha teams. d) CHMT & SCHMT Support Supervision Afya Kamilisha supports 168 care and treatment sites, 224 PMTCT and 285 HTS sites across the 9 counties. Afya Kamilisha supported 7 out of 9 CHMTs to conduct site supportive supervision (SIMS) in supported sites. Site support supervision assists healthcare service providers to continuously improve their service delivery performance. It also provides an opportunity to mentor and update the service providers on new relevant skills in addition to assessing and addressing their personal and facility needs. e) Quarterly HIV TWG review meetings Afya Kamilisha supported 8 out of 9 counties to conduct quarterly HIV TWG meetings. The TWG meetings track HIV program progress across the HIV cascade. In addition, the meetings were used to share experiences and best practices in patient clinical management. Participants exchange new ideas and information needed to address emerging HIV program gaps. The TWGs were attended by technical staff from CCCs, CASCO, SCASCOs CTLC, HIV lead mentors and county HIV implementing partners. Cases of patients with suspected treatment failure or whose treatment options had been exhausted were discussed. In the same forums, CMEs were carried out on HIV topical issues. f) County Health Stakeholders’ Forums Nyandarua county held a one-day county health stakeholders’ forum in June 2019. The meeting was attended by 30 participants who included the CHMT, sub-county heads and division heads and other development partners. The meeting discussed sub-county performance across program areas. The SURGE strategy briefing was done by Afya Kamilisha and the county leadership buy-in was achieved by the county Director of health calling upon her senior staff to support the process.
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Health Partner collaboration was emphasized to create synergy in activity implementation. Tharaka Nithi county held a stakeholders meeting to sensitize staff, partners and the community on the county health bill. The partners gave their expert in-puts that will be incorporated in the final draft of the bill. g) Coordination of eMTCT Brainstorming Meeting in Tharaka Nithi This meeting was called by the CEC to discuss the alarming MTCT data in the county which was 20.6 by the end of 2018 data. After discussions, the meeting made the following recommendations; i. Integrate PMTCT in community health strategy ii. Introduce ART starter packs in peripheral sites iii. Aggressive sensitization at community level to address late identification at ANC iv. Improve on quality of data for decision making.
6.2 HUMAN RESOURCE FOR HEALTH (HRH) a) HRH Staffing Human resources contribute to the performance of all main functions of health systems; efforts to improve the effectiveness of the health workforce are central to improving health system performance. Current HRH staffing supported by Afya Kamilisha is as detailed in the table below:
Tharaka Cadre Kiambu Murang’a Embu Meru Nyeri Kirinyaga Nyandarua Kitui Total Nithi RCO’s 7 6 5 7 3 4 2 0 2 36 KRCHN 4 2 3 1 2 1 0 0 0 13 MLT 4 4 3 2 1 0 0 0 0 14 Pharm Tech 0 2 0 0 0 0 0 0 0 2 HRIO 0 0 1 1 1 1 0 0 0 4 Data Clerks 10 4 4 10 3 1 2 5 0 39 HTS Counsellors 37 21 22 47 24 5 4 17 2 179 Mentor Mothers 10 4 12 18 6 3 5 5 0 63 Peer Educators 20 11 24 36 8 7 7 17 2 132 Dreams Mentors 85 0 0 0 0 0 0 0 0 85 TOTAL 177 54 74 122 48 22 20 39 6 567
b) Staff Transition In the period April to June, 2019, the Activity engaged Murang’a, Embu and Kiambu counties to discuss the Letters of Agreement regarding staff transition into the county payroll as a measure to Journey to Self-Reliance (J2SR). The activity through the office of the Chief Officer of Health and the County Public Service Boards were able to facilitate the review of the HRH transition plan and developed a document that should be adopted for signing as a guide to HRH management and transition in respective counties. Staff replacement was successfully done in Murang’a County, through the office of the Director of Health services and the Public Service Board for 2 staff that transitioned to the county.
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c) HRH Staff Support Supervision Afya Kamilisha supported 7 out of 9 CHMTs to conduct site supportive supervision in HRH supported sites in collaboration with the HRH and HR Officer. In addition, the team discussed the role of HRH in surge implementation, shared the individual surge targets per staff and the annual performance appraisal. d) HRH Stakeholder Forum and TWG for Upper Eastern and Central Cluster The Activity supported two zonal HRH meetings for the Central and Upper Eastern regions to share on the project achievements and surge strategies for the project. The team deliberated on the need for partners to involve the Public Service Board in recruitment of staff and to further have a signed MOU stipulating the staff transition at the close of the project. Each partner was tasked to engage the respective authorities to support staff transition.
6.3 QUALITY ASSURANCE / QUALITY IMPROVEMENT (QA/QI) Afya Kamilisha continued carrying out continuous quality improvement (CQI) activities under the Health Systems Strengthening (HSS) component. The project oriented the program staff on the SIMS 4.0 version and supported the CHMT to conduct SIMS assessment in 60 (35%) of the supported comprehensive sites. Through the ongoing surge activities, the project has seen doubling activation of QITs to 102 from 71 in the previous quarter. These will greatly improve on the quality of data and utilize the same for decision making and enhance service delivery.
Key Achievements a) Site Improvement Management System (SIMS) In order to ensure quality of services provided in our sites, the project has cumulatively conducted Site Improvement Management System (SIMS) though the CHMT in the spirit of Journey to Self- Reliance (J2SR) in 60 (35%) of our supported sites. All program staff have also been oriented on the SIMS version 4.0 and this is cascaded to the CHMT on a need basis. This will foster ownership of the exercise and enhance implementation of remedial measures. Some of the positive aspects of the site visits findings included: . Retesting of newly identified clients, test and start is at 100% . HIV testing for all TB patients done . Elaborate facility/community linkage with documented information of the client receiving the services which he/she was referred for. . CaCX screening in some of the facilities partnered with CHAP (CBO) in Embu county . 100% ART uptake for TBHIV co-infected . There’s evidence of testers having gone through observed practice done by the SCASCO and the Lab in charge to ensure that a quality process of HTS is adhered to. . The providers have gone through safety training during the annual refresher training. . Data consistency between DATIM and facility MOH 731 summary commendable. . Improved coordination and team work, . Improved waste management and infection control practices across departments in the facilities . Proper commodity management and documentation of both drugs and RTKs leading to reduced stock out rates . HIV testing at ANC done and documentation of the ANC registers well done, however, a number of weaknesses too were identified as follows and recommendations given:
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. Some health facilities not adequately utilizing some of the registers e.g. Treatment Preparation, Defaulter Tracing and the Patient Diary. . There is a need for a Peer Educator or a Mentor Mother in some health facilities to facilitate in defaulter tracing and other services for efficient tracing back of the patients. . Some documentation not complete e.g. the Green Card, TCF tool. . Some sites missing active psychosocial groups for the PLHIV clients, hence high stigma. . Clients relocating and changing contact details without informing the clinic hence making defaulter tracing difficult. . Low partner testing and decline in PNS. Key Findings, Recommendations and Action Plan Template are then populated to enable the project teams make appropriate follow up of the action points on a timely manner. b) Continuous Quality Improvement (CQI) Training Major gaps noted during the Organizational Capacity Assessment (OCA) in the counties was the low knowledge of continuous quality improvement. The project had planned on carrying out CQI trainings, however this activity was postponed to a later time, surge implementation taking precedence. c) Quality Analysis Tracking for QIT/WIT, SIMS & DQAs Leveraging on the surge activities, there has been improvement in the number of active QITs from 71 in COP18 Q2, to 102 in the reporting quarter against 168 comprehensive sites (61% achievement). Afya Kamilisha has kept track of it quality interventions at the site level and the table below displays the status by county for the active Quality Improvement Teams (QITs), Site Improvement Monitoring System (SIMS) conducted and Data Quality Audits (DQAs) conducted for the Activity.
IV. PERFORMANCE MONITORING The Monitoring, Evaluation and Learning team is providing required support to track the project goal of increasing access and coverage for HIV prevention, care and treatment services towards achieving 90-90-90 targets. The National Information management systems, i.e. DHIS2, EID & VL website and Electronic Medical records are integral part of the efforts to eliminate HIV pandemic. Improving these systems are a priority to gain advantage in information demand and use. Key on the menu of support are data quality improvement, information use, learning, planning, reporting and performance tracking to inform project progress. In Q3 FY 19 (April-June’19), Afya Kamilisha MER team supported 283 facilities 9 Counties of eastern and Central regions, (174 offer Care and Treatment services, 283 offer HTS, 174 offer TB, 223 offer PMTCT, 88 PrEP and 14 SGBV sites) to track progress and quality of service delivery by ensuring that documentation, data collection and reporting is done as prescribed by NASCOP and PEPFAR. The department also supported DREAMS service delivery in Ngoliba and Biashara wards of Kiambu County. The MER staff in the field worked hand-in-hand with MOH staff and other stakeholders to improve data quality across all the program areas and boost data demand and information use for sound decision making. Below are the achievements of the quarter:
(I) EXPANDED USE OF ELECTRONIC MEDICAL RECORDS
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. In Q3, EMR was installed in Tigoni Health Centre in Kiambu County, increasing the total number of EMR sites 92 in the program . 27 of these facilities are now fully Point of Care (POC) whereas 53 are hybrid i.e. POC and Retrospective data entry (RDE). . DWAPI was rolled out in the quarter that has enabled the facilities to upload data to the National Data warehouse on time. . 33 Kenya EMRs were upgraded to version 17.0.1 whereas 27 IQCare were upgraded to version 2.0. The key new features in Kenya EMR include: Line list of patients on differentiated care, Family and partner testing and DQA report. Improvements in IQCare include: Line lists for Tx_ML, TB screening, HIV+ women attending ANC and HTS line lists. . The Afya Kamilisha IT team collaborates with MER to revamp EMR applications. This quarter two staff attended a system admin training organized by the Palladium group where they learnt more on installation, troubleshooting and upgrade of both IQCare and Kenya EMR. With the EMR Champions (both from MOH and Kamilisha) these staff have been quite instrumental in the upgrading and troubleshooting of system threats as well as mentorship of health care workers on the use of the EMRs at health facilities.
Table 25: EMR status as at June 19 County Number of No. of sites No. of sites with No. of POC sites facilities with EMR Functional EMR Embu 31 14 14 6 Kiambu 18 15 12 2 Kirinyaga 19 5 5 5 Kitui 2 1 1 0 Meru 47 26 21 5 Murang'a 7 7 4 2 Nyandarua 23 8 8 5 Nyeri 9 6 6 4 Tharaka-Nithi 18 10 9 1 Total 174 92 80 30
(II) DATA REVIEW MEETINGS AND DQAS
Data review meetings were conducted in 62 facilities across 20 sub-counties (based in 6 Counties). 50 DQAs were also conducted within the reporting period. All the data reviews were aimed at strengthening data demand and information use by all the stakeholders and to also address data quality issues across all the reporting levels. DQA findings were documented and a copy of the reported filed at the facility, follow up of action points is ongoing. Validation of EID data was done at facility level. Data was extracted from the EID network and compared with what is in the EID tracking logs and HEI registers. The validated data is shared with CHAI team for updating in the network. This has greatly improved the program’s data quality in the network. Below is the county breakdown:
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Table 26: Data Review and DQAs conducted per County County County data Sub county data Facility data review review meetings review Facility meetings meetings DQAs Embu 3 0 8 7 Kiambu 1 4 18 16 Kirinyaga 2 7 9 6 Kitui 0 2 0 2 Meru 0 4 40 28 Murang'a 0 1 12 6 Nyandarua 2 0 0 2 Nyeri 2 12 22 6 Tharaka-Nithi 3 0 2 4 Total 13 30 111 78
(III) WEEKLY TRACKING OF PREP PERFORMANCE
In the second quarter of Q3, MER team continued to collect PrEP data weekly, this was necessitated by the slow uptake of the service hence the need for scale-up and close monitoring. The weekly tracking has seen the program achieve 84% of the PrEP_New annual target by the end of Q3.
(IV) MENTORSHIP SUPPORT SUPERVISION
During the quarter, the MER team conducted support supervisions across the Counties. The MER management team and the County MER Officers worked to ensure that all the health care workers know how to document services offered in the registers and compile weekly and monthly reports with ease. The data clerks and HRIOs were also mentored on the use of EMR and data quality assurance.
(VI) MEETINGS AND TRAININGS
o All MER team review meeting was conducted in June where a monthly performance sheet was developed and adopted, the team was also taken through the SAPR indicators and strategies on accurate and timely reporting were devised. o Program performance review meeting was conducted in this quarter: program staff jointly assessed program progress of Q3 FY 19 o HRH review meeting was conducted in Q3 where strategies on how to support surge. Data clerks, HRIOs and HTS counsellors in all the counties were sensitized on weekly reporting and surge data quality assurance.
(VI) REPORTING SURGE MER developed and distributed HTS surge reporting tools and oriented HRIOs and data clerks within the quarter. The department also collected and reported surge progress on a weekly basis in Partner Performance website. For program level feedback and strategy review, weekly calls with the County teams has been taking place where previous week’s data is discussed, working strategies embraced and failing strategies dropped. The department has incorporated surge reporting into the internal data granulation system (JHIS).
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(vii) DATIM
During the period under review, all program reports were collected, tracked and submitted for, verification and JHIS entry monthly. The data was subsequently entered into DATIM at the end of the quarter. All Counties had reporting rates of 99% for all components i.e. PMTCT, Care and treatment, HTS and TB/HIV. The team also, verified data and addressed queries.
(VIII) HIGH FREQUENCY REPORTING
From June 2019, the MER department collected and submitted weekly High Frequency Reporting data – this is data aimed at capturing better results and making timely course corrections to programs and interventions. Reportable indicators for HFR include: HTS_TST, HTS_TST_POS, TX_NEW, PrEP_New, TX_CURR and DSD
(IX) PRINTING OF AND DISTRIBUTION OF NASCOP HIV DATA CAPTURE TOOLS
In Q3, Afya Kamilisha printed and distributed revised NASCOP HIV data capture and reporting tools. The program is also working with the County Health Management Team to source more registers from NASCOP, this will ensure that all facilities have sufficient data tools and a buffer stock is kept at each sub-county.
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V. PROGRESS ON GENDER STRATEGY The underlying socio-economic and cultural dynamics of the HIV epidemic persist in the project sites. To address this, the project adapted sex and gender based analysis of data and interventions rolled out in a n effort to tailor service delivery models to the diverse needs and requirements and needs of the populations reached.
Objective 1: Increase Availability and Use of Combination Prevention Services for Priority Populations Social isolation, poverty, discriminatory cultural norms, gender-based violence and lack of education all contribute to girls’ vulnerability to HIV. Health providers in the two DREAMS link facilities that is Ngoliba Health Centre and Gachororo Health Centre have been sensitized to provide comprehensive GBV minimum package of care to survivors of sexual violence. A total of 46 AGYW s screened during safe space activities within the areas of implementation. The evaluation of the results will identify barriers that are causing AGYWS not to access services.
Objective 2: Increased Uptake of Targeted HIV Testing Services. Project data generated during the months of April to June 2019 indicate that 34,584 tests were done to men and 80136 tests done to the women. Out of the 34,584 tests done to the men 816 have a positive result getting the positivity of men to 2.3%. Out of the 80,136 tests done 1404 provided a positive result bringing the positivity 1.7%. The analysis indicates a higher positivity in men than women. More men continue to engage in sexual risk taking behavior. This is evident through the outcomes of PNS indicating that men are providing more sexual contacts than women. A total number of 1502 male index client provided 1337 number of female sexual contacts who were screened and tested compared to 902 women index clients who provided 1257 number of male sexual partners who were screened and tested. In an effort to address barriers to access HTS services, the project trained HTS providers from all facilities in the 9 counties on HIVST and approaches to reaching the most as risk through the index clients. Consequently, a total number of 1185 HIVST given to the male gender and 1,764 given to the female gender have been provided from April 2019 to June 2019. Afya Kamilisha through Jhpiego developed a Gender Transformation toolkit and disseminated the tool in the month of April in Mozambique to the Gender Program staff. The tools objective capacity of health workers to address provider attitudes, believes and stereotypes that affect uptake of HIV services and understand how stereotyping, societal/cultural norms and beliefs are creating facility barriers to treatment. Training of the health care workers on addressing disclosure, couple counselling and male engagement has improved the attitude and provided the providers with skills to convince the clients to involve their sexual partners in taking up HIV services.
Afya Kamilisha managed to provide a means of measuring the quality of post-GBV care in clinical settings using the WHO/CDC/Jhpiego GBV QA tool. The objective of the assessments was to identify key gaps and challenges in Post GBV service provision and create action plans to improve identified gaps and challenges in service provision A total of 6 sites have administered the tool mainly Kihara DH, Ithanga health center, Maragua district hospital, Embu PGH, Runyenjes L-4 and Kiritiri District hospital and the results provided to the facility for their action. In the Afya Kamilisha regions of implementation women’s decision-making about pregnancy and health are deeply influenced by their sexual partners and community. Barriers to male participation involve reproductive health services as women’s problem, PMTCT sites as women’s spaces, fear of
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stigmatization by other men when they are seen attending the PMTCT clinics and addressing the fact that women should not be telling men what to do, even if it comes from clinicians since this is seen as a sign of weakness or lack of masculinity and power. Afya Kamilisha has increased male engagement, through encouraging pregnant women to attend the first ANC with their partners. The health workers have been sensitized on ways to make the health care facility more male friendly, in terms of IEC materials and posters communicating available services, engaging more male providers in the ANC/PMTCT and early and late provision of services to fit their availability.
Objective 3: Improved Linkage to Treatment for clients Newly Tested HIV-Positive
Project data generated indicates gender disproportion in linkage between male and female genders, with men less likely to be linked for HIV than women, across the 9 counties. Out of the 816 number of men identified as positive 597 (73%)number was linked for ART compared to 1404 number of women identified as positive 1157(82%) linked for ART. The gap of linkage in men is mainly contributed to masculine norms in the central and eastern region that require men to be and act in control, to be strong, resilient, disease free, and ensure they are sexually and economically productive. Afya Kamilisha is providing a continuous capacity building of the linkage officers to understand how masculinity is affecting health seeking behavior and with this understanding they are able to handle the men differently when they conducting post-test counselling. Overall findings from the data analysis show that 1390 males were diagnosed with TB in a HIV integrated set up compared to 648 females. In the period of April to June 2019 a total number of female diagnosed with TB/HIV co-infection was 213 male compared to 156 female diagnosed with TB/HIV. HIV remains the strongest risk factor for TB. Yet despite higher HIV prevalence among women than men in, TB incidence is still higher in men. Intense screening of the men during initiating of ART and putting more men on IPT is a strategy that is being used to reduce the incidence.
Objective 4: Increased Uptake of and Adherence to Quality HIV Treatment Services. Afya Kamilisha put up strategies to ensure that all the clients identified and linked are initiated on treatment the same day or within two weeks for those who are not ready to start. Data analysis indicates that more men had lower rates of adherence to ART than their female counterparts Afya Kamilisha scaled up male specific clinics reaching to 140 care and treatment sites. the project engaged male peer educators with well-defined roles, scaling up of male only support groups and have introduced flexi hours to accommodate men’s schedule. The DSD program played a big role in ensuring that more men were put on differentiated care so that programs reduce the frequency of the men coming to the facility and allow them to attend to their work.
OBJECTIVE 6: Strengthened Institutional Capacity and Accountability for the Management of Community, Facility and County HIV Response. Jhpiego Gender Service Delivery Standards tool asses the quality of facility’s provision of gender- sensitive, respectful care. The Gender standards provide an opportunity for facilities to apply components of respectful, gender-sensitive care, and identify performance gaps that need to be reduced or eliminated in service delivery, and create action plans for quality improvement. A total number of 7 sites have had the gender service delivery standards administered and the facility come up with an action plan. The facilities are Kibugua health center, Muthambi Health Center, Runyenjes L-4, Kiritiri L-4, Ithanga H/C, Kihara DH and Maragua Sub-County hospital.
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Scores for each standard have been shared with the facilities, action plans developed and follow up of the action plans to be done in the next quarter.
VII. PROGRESS ON LINKS WITH GOK AGENCIES Afya Kamilisha collaborated effectively with the nine county government departments of health to enhance and promote efficiency and effectiveness in the use of resources.
IIX. SUSTAINABILITY AND EXIT STRATEGY | JOURNEY TO SELF-RELIANCE (J2SR) The vision of program sustainability for Afya Kamilisha is infused into the implementation approaches designed to help counties and facilities to operationalize existing Government of Kenya policies and programs. At the sub county level AWP development stage, Afya Kamilisha activities were included and therefore a significant number of the project approaches can therefore be funded using local budgets since they are embedded in the County AWPs. These are key initial steps in strengthening the systems and placing the counties in the driver’s seat in the journey to self-reliance. The project initiated discussions with CHMTs to sensitize them on surge and COP 19 guidance. J2SR, envisions County Governments that are able to make decisions that effectively and efficiently utilize their own (and mobilized) resources to plan and deliver coordinated high quality, acceptable and responsive HIV care and treatment services. The overarching vision is for the counties to achieve strategic outcomes that together improve financial protection and access to high-quality HIV services that reach the underserved, marginalized, and high-priority groups. Afya Kamilisha prioritized existing and new partnerships with a broad range of implementing partners and other development organizations. Kamilisha is capitalizing on partner-led synergies, while working side-by-side with government counterparts at the county: building the capacity of sub-county and county health management teams (S/CHMTs) to engage in county planning and budgeting, strengthening leadership and governance, identifying champions and mentors to support fellow providers in HIV clinical care. The project is enabling local actors to sustain project results into the future. Leveraging all resources available from implementing partners, donors and private companies working within their communities will further empower counties to effectively stand on their own. Afya Kamilisha is working with the Counties to implement letters of agreement (LOA) and related documents that chart out the path from recruitment to transition of HRH during the life of the project.
IX. PROGRESS ON LINKS TO OTHER USAID PROGRAMS The table below describes the joint activities carried out by Afya Kamilisha in collaboration with other USAID funded Activities: Table 27: Links to other USAID programs Funded Activity Areas of linkage and collaboration TB ARC Afya Kamilisha carried out joint technical assistance/supervision visits to TB/HIV sites in Meru county, assessed TB case finding and TB management and provided mentorship. In addition, collaborated on HIV/TB drug resistance, co-shared supportive supervision in the county and quarterly review meeting for TB/HIV
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. Afya Kamilisha collaborated with Afya Halisi in Kitui to provide RMNCH services to HIV+ clients Afya Halisi . The services include Cervical and breast cancer screening and Family planning /HIV integration CASE-OVC Collaborate to ensure 10-17 year old AGYW in OVC and 18 years graduating from OVC receive appropriate DREAMS interventions. . Supports Afya Kamilisha in establishment of Laboratory result management hubs PS Kenya . Afya Kamilisha supported clients benefit from PSK supported FP/HIV integration . Provided 7 modems and additional 11 cartridges for the 11 Established Hubs Afya Kamilisha collaborated with CMLAP II in Leadership and Governance and in Palladium Group Monitoring and Evaluation activities. (CMLAP II project) . In Kiambu county, we collaborated with Palladium to support development of AWPs Palladium, Kenya Afya Kamilisha worked with Palladium in EMR implementation at ART sites. Palladium HMIS Project continues to ably provide the much needed technical support and direct training for our staff. Kamilisha provides direct capacity to MOH staff, implements EMR in 92 sites, engages data management assistants, conducts routine data quality assessment. Kamilisha uploads data on a monthly basis to the national data warehouse Intra-Health HRH . Collaborated in supporting the central and Eastern HRH cluster meetings Kenya University of . Collaborated in Continuous Quality Improvement (CQI) and laboratory Maryland accreditation in 16 and 4 supported sites University of . EQA PT distribution and Corrective Action Preventive Action (CAPA) focusing in Maryland, CHS HTS service providers with unsatisfactory performance and CRISPPs
X. WORK PLAN STATUS MATRIX Table 28: Oct 2018 – June 2019 Work Plan Status Planned Activities (Reporting Period) Actual Status Explanations for Action plan Deviations HIV TESTING AND COUNSELLING, GBV & PRC Support facilities and mentorship providers to scale up Partner Notification Done Services Facility CME sensitization on PRC tools on Done improve reporting in the DHIS Support supervision and mentorship Done Annual refresher training planning Done PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV (PMTCT) Refresher HTS training Nurses at MCH Ongoing
Viral load monitoring and follow up for -62 mentor mothers non-suppressed pregnant and breastfeeding supported to carry out women
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adherence counselling and defaulter tracing. Tool to audit and follow non-suppressed women developed HAART for the HIV positive pregnant and All PMTCT sites are able breastfeeding mothers to offer ART for pregnant and breastfeeding mothers Clinical systems mentorship on 223 sites mentored Mentorship to continue synchronization of EID with immunization in the next quarter in MCH 3.3 HIV CARE AND TREATMENT Scale up on TLD transition On going Orientation of more HCP on OTZ On going Scaling up of Viremia clinics On going Scaling up of male friendly interventions On going SIMs tool administration On going 3.4 PERFORMANCE MONITORING EMR training Done DQA in high volume sites Done Project Learning Meeting Ongoing Rolling out interoperability layer in 12 more Ongoing sites DREAMS training and implementation of Done DQA recommendations Printing and distribution of revised Ongoing NASCOP tools Facility data review meetings Ongoing
CQA/CQI Limited funds and Training Upper Eastern counties HCPs and competing priorities to Not Done S/CHMT on Quality Improvement conduct one next quarter Formation and reviving QIT and WITs Ongoing SIMS Assessment for the region Ongoing Support QI/QA mentorship circuits in high Ongoing volume facilities Develop county and sub-county QI plans Ongoing Automate the SIMS tool for ease of Software identified and a monitoring and tracking findings and action demo conducted points LABORATORY SUPPORT
Trained lab officers on Biosafety/Biosecurity Done Support distribution of EQA PT panels to Done supported sites
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Support service contract for 9 GeneXpert Ongoing platforms Support Biosafety cabinets /TB Hood Done certification LEADERSHIP, GOVERNANCE & STRATEGIC PLANNING Most counties have Conduct annual Health Stakeholders’ planned to hold the 2/6 conducted Forums in 6 counties CHSFs in the next 3 quarters Conduct OCA feedback meetings for Done Kiambu, Murang’a, Meru Other counties were Launch of 2019/20 AWP planning cycle by 6 5/6 counties assisted supported by other counties partners Train 30 AWP development team members Trainings planned for n Program Based Budgeting (PBB) from 30 trained early May 2019. The Murang’a, Kiambu and Kitui counties 9 counties conduct quarterly HIV TWG Kitui county held MDT 8/9 supported meetings instead of TWG. Hold world health focus day namely; Done World TB day in 6 counties 3.8 STRENGTHEN SUPPLY CHAIN MANAGEMENT CAPACITY AND COMMODITY LOGISTICS Train County/sub county pharmacists on new ARVs allocation by use of KHIS system Done following bottom-up approach Support 8 integrated County commodity Ongoing management TWGs Quarterly RTKs and ARVs allocation for 8 Ongoing counties Support 8 counties to conduct ARV and RTKs redistribution to reduce on Ongoing understocking and overstocking Train County/sub county pharmacists on To focus on Nyandarua Ongoing online Web ADT & Nyeri counties Train lab officers on commodity management in Embu, Kiambu and Tharaka Done Nithi counties Human Resource for Health (HRH ) Renewal of HRH Clinical staff contracts for Completed the period 1st January 2019 – 31st December, 2019 Renewal of the lay-workers contracts for Competed the period 1st January, 2019 to 31st Dec, 2019. Conduct meetings with respective County On going PSB’s and Health Department to review
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and eventually adapt the Letter of Agreement.
County induction for all our teams in Completed Murang’a County HRH Zonal (Central, Upper Eastern & Completed Kitui) review meeting Conduct suitability test for the HTS staff in On going Murang’a and Kiambu Conduct supportive supervision for all On going HRH staff Recruit and deploy 13 HRH staff for Meru, On going Nyandarua and Kitui Counties Update of the HRH data base On going DREAMS Focus on service layering to ensure that Ongoing This is the core business AGYW in the program remain active and until all are fully layered have a least the primary services
Mobilize communities (Mo Com) for norms Ongoing Completed the First Continue change (START) Phase community mobilization in the awareness phase Strengthen Collaboration with CASE OVC Done Joint quarterly review and develop TOR meetings scheduled Engage an LIP to carry on DREAMS ongoing There were delays in implementation USAID approval of Manual
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XI. CONSTRAINTS AND RECOMMENDATIONS
Table 29: Constraints and Opportunities in Afya Kamilisha project Service Area Constraint Recommendation AGYW A total of 356 AGYW aged 10-17, who There is need for USAID guidance on how have been in the OVC programs for a to handle the affected AGYW longer period turned out to be from outside the DREAMS ward of Biashara and Ngoliba. They have no quick access to safe spaces. They may never achieve full layering for the primary services offered at the safe spaces. PrEP Inadequate IEC materials for PrEP Print PrEP IEC materials demand creation Low continuation rates for PrEP Improve the quality eligibility screening; Mentor HCPs on PrEP adherence counselling and provide PrEP adherence counselling to clients on every clinic visit. eMTCT Boycott of HIV testing at MCH by Engaging the county and national teams to nurses in selected sites across the have a clear guidance on HIV testing. counties Frequent NVP/AZT syrup stock-outs in Working with the counties to redistribute most of the sites NVP/AZT syrup on-going. Care & Linkage for HIV positive clients Facilitate the counsellor and the client with Treatment especially in HTS only sites transport to Kamilisha supported site Engage the roving clinician to initiate the clients on treatment at the testing site Stock out of some commodities like Support the counties in forecasting and LPV/r tablets and pellets ordering the correct quantity. National commodity TWG to work with County TWG while quantifying and ordering
TB/HIV Support the county in the redistribution of Stock outs of Paediatric anti TB s in Pediatric anti TBs Embu and Meru due to a national wide . shortage Project supported counties to revert to GeneXpert Cartridge stock out in Smear microscopy to ensure early diagnosis Tharaka Nithi and TB treatment until the redistribution of cartridges was done HSS Surge strategy taking precedence / Refocus on trainings after completion of competing tasks surge implementation Limited capacity for selected CHMTs / SCHMTs on the AWP development Training the CHMTs / SCHMTs on PBB process HRH phased transition Share best practices of counties that have already begun the transition Nurses declining to offer HTS services The project is working closely with the HTS has affected testing at MCH and OPD lay counselors and Laboratory officers to ensure no missed opportunities in testing
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departments especially in Tharaka Nithi and Meru Counties
XIII. PLANNED ACTIVITIES
Table 30: Planned Activities for Next Quarter (Jul-Sep 2019) Program Area and Planned Activities AGYW a. Mobilization of Community and AGYW for PrEP uptake b. Home visits for Cash Transfer c. Issuance of Education Subsidy d. Issuance of Business start-up kits/ Vocational trainings support e. Enrolment of eligible AGYW and service provision f. Outreaches to AGYW/MSP/Community g. Talent development/Nurturing/Empowerment of Girls h. Providing services that empowered AGYW- Shuga, MHMC, Entrepreneurship, FC, MHMC, HCBF sessions HIV Testing and Services, GBV and PRC i. One on one mentorship for HTS counsellors on contact elicitation. j. Optimized PITC testing coverage in OPD and other key departments using screening tools k. Increase PNS approach to all index cases at the CCC EMTCT l. Advocacy on support of pregnant adolescent continuity of ANC care, especially in Meru county m. Mobilization on ANC1 using the community structures to increase ANC1 coverage n. Clinical system Mentorship on eMTCT intervention o. Intensify monitoring of HIV positive mother baby pair using viral load. p. Age specific psychosocial support group at MCH HIV Care and Treatment q. Surge strategies implementation to achieve TX_NEW, Retention and Viral Suppression targets in all the Counties r. RRI on TLD transition for all eligible clients s. Scale up of PEPFAR recommended strategies (OTZ, Male Only Clinics, Viremia Clinics and DSD) in all the supported sites TB/HIV t. Line Listing for clients not on IPT u. Cluster TBHIV Quarterly review meeting for 8 counties v. TA visits to facilities and site supportive supervision on TBHIV collaborative activities w. County level TIBU data cleaning and review meetings Laboratory Services x. Support 5 counties to distribute HIV PT panels for round 20 and conduct Corrective action preventive action (CAPA)for unsatisfactory performance cases in collaboration with other implementing partners y. Scale up on Remote log in for EID/Viral load samples from 96 sites to 120 sites z. Conduct Annual Biosafety/Biosecurity training targeting laboratory officers from supported facilities aa. Reduce further Turnaround time (TAT) for samples referred to either central or National reference laboratories for analysis by improve on sample transport efficiency.
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Program Area and Planned Activities bb. Support facility level meetings for laboratories undergoing either accreditation or Continuous Quality Improvement (CQI) process Commodity Management cc. Quarterly RTKs/Monthly allocation for ARVs targeting 8 counties dd. Achieve 100% reporting rates for tracer commodities in KHIS/HCMP platforms ee. Support Commodity distribution/redistribution to reduce on understocking or overstocking in collaboration with county teams ff. Support Quarterly Commodity management Technical working groups (TWGs) focusing on 8 counties in collaboration with other partners gg. Upgrading of Online web ADT to a newer version (3.4) targeting sites with the system across all supported sites Leadership, Governance & Strategic Planning hh. Coordinate sensitization of 5 counties on the journey to self-reliance ii. Hold meetings with Kitui, Nyeri, Kiambu and Kirinyaga counties to inform them about Afya Kamilisha’s impending departure by 30th September 2019 jj. Continue Supporting quarterly county and regional TWG forums kk. Coordinate and participate in Afya Kamilisha Surge activities in Embu and Tharaka Nithi Human Resource for Health (HRH) ll. Conduct meetings with respective County PSB’s and Health Department to review and eventually adapt the Letter of Agreement. mm. HRH Zonal (Central, Upper Eastern ) review meeting nn. Conduct supportive supervision for all HRH staff oo. Discuss with Kiambu, Nyeri and Kirinyaga the project departure and HRH transition pp. Update of the HRH data base Quality Assurance / Quality Improvement (QA/QI) qq. Train Meru, Embu and Tharaka Nithi counties HCPs and S/CHMT on CQI rr. Support Quarterly Site Support Supervision (SIMS) through CHMTs ss. Formation / reviving QITs and WITs tt. Support development county and sub-county QI plans uu. Automate the SIMS tool for ease of monitoring and tracking findings and action points vv. Development and Tracking of Quality Indicators Progress on Gender Strategy ww. Capacity build peer educators on gender and social cultural barriers that hinder access to care and treatment in 6 counties xx. Administer the gender service delivery standards through MOH in Embu, Nyandarua, Meru, Tharaka Nithi, Murang’a and Kiambu counties yy. Administer the GBV QA standards in 16 post GBV sites and provide analysis of the data Performance Monitoring zz. Rolling out of IL in 10 more sites aaa. Weekly surge reporting bbb. Installing DWAPI and P-Smart in 8 more sites ccc. Transitioning from IQCare to Kenya EMR in Eastern Region. ddd. Analyze existing data for some learning questions and do at least 2 abstracts eee. Conduct data verification in all the surge sites fff. Conduct DQAs in at least 30 high volume sites ggg. Replace old computers in high volume sites hhh. Support characterization of defaulters, STF and non-linked clients iii. Development/Revision of MER SOPs
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XIV. FINANCIAL INFORMATION Cash Flow Report and Financial Projections (Pipeline Burn- Rate)
Chart 1: Obligations vs. Current and Projected Expenditures - $Millions
Obligation Qtr 1 -6 Actuals Qtr 7 Actuals & Accruals Qtr 8 Projection
14
12 2.104
10 2.368
8 13.931
6 8.135
4 USD USD Millions
2
0 Obligation Expenditure
Table 2: Budget Details T.E.C: $38,695,839.61 Cum Obligation: $13,930,809 Cum Expenditure: $10,158,688
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Funding Source MTCT HVOP HVCT HTXS PDTX TOTAL A. Obligated Funds to date: $1,418,905 $980,755 $2,192,169 $8,629,708 $709,273 $13,930,809
B. Actual reported expenditures $1,034,700 $715,191 $1,598,583 $6,292,995 $517,219 $10,158,688 01-Jan-18 to 30 June-19
C. Unreported expenses (Accruals + Projections) $35,042 $24,222 $54,140 $213,126 $17,517 $344,047 June -19
D. Total Expenditures + Accruals + Projections (B+C) $1,069,742 $739,412 $1,652,723 $6,506,121 $534,736 $10,502,734 From inception to June -19
E. Remaining Balance (Pipeline) (A-D) $349,162 $241,343 $539,446 $2,123,587 $174,537 $3,428,075
F. Estimated Expenditures for quarter Ending $214,281 $148,113 $331,059 $1,303,249 $107,114 $2,103,815 ending 30-September 2019
G. Estimated Monthly Burn rate for next quarter $71,427.13 $49,370.84 $110,352.98 $434,416.33 $35,704.53 $701,272 ending 30-September 2019
H. Estimated remaining Length of Pipeline (LOP) $134,881 $93,230 $208,387 $820,338 $67,423 $1,324,259
XIV. PROJECT ADMINISTRATION Afya Kamilisha administration is at various level: The executive committee: Comprises the Chief of Party Afya Kamilisha, Country Director Jhpiego, CEO LVCT Health, CEO Amethyst Technologies, CEO Cloudburst Group The senior management team: Comprises the Key personnel – COP, DCOP, Director Finance and Administration, HSS TA, MER Specialist Team Leads: Program area team Leads – Manager/ SPO level County Teams: Mainly PO and PA level
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Figure 9: AK organogram and pdf attachment shows team structures at County level
ORGANOGRAM Kamilisha_Staffing Plan_Counties_UPDATED FEB.pdf
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XV. SUCCESS STORIES
HTS Best Practices.
In Embu L5 the previous quarter performance indicated that quite a number of clients were being tested yet the yield was low. The program team together with the facility management team after a data review meting resolved to intensify the use of the HTS eligibility screening tools at all services delivery points. All HTS providers were again sensitized on the tool and were expected to screen all clients and document the findings in a file. There was great improvement on the yield in quarter 2 as shown in table below. A few clients were tested but the number of positives identified was high. This practice has since been cascaded to all other high volume sites.
Period HTS_TST HTS_POS Positivity Rate Pre intensive screening phase October 2018 874 13 1% November 2018 698 19 3% December 2018 399 18 5% Post intensive screening phase January 2019 233 29 12% February 2019 281 26 9% March 2109 405 28 7%
In Makongeni Dispensary in Kiambu County, the Program team realized that the providers were not able to achieve their identification targets through offering PNS to the newly identified clients. They therefore resolved to have PNS sensitization meeting with the clients who attended the Viremia clinics. After the sensitization, the clients were very willing to list their sexual contacts and gave consent for them to be contacted by the providers for testing. The testing was conducted and results shown in table below were achieved. This practice has since been cascaded to all other facilities.
Index clients Contacts Contacts Newly Positivity linked screened(Viremia identified Tested tested clients) positive 34 74 52 27 52 26(96%)
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XVI. ANNEXES
Annex I: List of Deliverable Products Twelve satellite sites, linked to high volume facilities in Afya Kamilisha region, were included in the list of supported facilities to improve on services. These sites are listed below.
Table 31: List of Satellite Sites County Sub-county Satellite Site Main Facility to Report Through
PMTCT Satellite Sites the Sites
Kiambu Limuru Limuru Cottage Tigoni Sub County Hospital Kiambu Kiambaa Ndenderu Dispensary Kihara Sub County Hospital Kiambu Kiambaa Human Cargo Care Medical Center Kihara Sub County Hospital Embu Manyatta OLL Mwea Dispensary Dallas Dispensary Kirinyaga Kirinyaga East Gathungura Dispensary Kabare Health Center Kirinyaga Kirinyaga East SDA Gathumbi Dispensary Kabare Health Center Meru Tigania West-DREAM Aina Onlus Cottolengo Mission Hospital Meru Igembe North Mutuati Catholic Hospital Mutuati Sub District Hospital Meru Igembe south Kalemene Dispensary Akachiu Health Center Murang'a Maragua Gikomora Dispensary Maragua District Hospital Murang'a Gatanga Gituamba Health Center Ithanga Dispensary Tharaka-Nithi Maara Kariakomo Dispensary Baragu Health Center
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Annex II: Referral and Linkage by County, sex and age
County SEX Age (Years) Positives TX _New %Linkage <1 0 4 >100% 1-4 10 1 10% 5-9 5 10 200% 10-14 7 3 43% 15-19 23 28 122% 20-24 65 69 106% Female 25-29 99 71 72% 30-34 94 89 95% 35-39 67 54 81% 40-44 44 38 86% 45-49 33 34 103% 50+ 41 42 102% Embu <1 0 1 >100% 1-4 9 1 11% 5-9 9 13 144% 10-14 5 2 40% 15-19 7 6 86% 20-24 15 11 73% Male 25-29 31 22 71% 30-34 60 37 62% 35-39 76 37 49% 40-44 38 32 84% 45-49 46 23 50% 50+ 39 31 79% <1 1 6 600% 1-4 5 3 60% 5-9 7 13 186% 10-14 5 3 60% Kiambu Female 15-19 42 31 74% 20-24 176 130 74% 25-29 212 155 73% 30-34 227 148 65% 35-39 164 120 73%
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40-44 110 97 88% 45-49 54 52 96% 50+ 69 59 86% <1 0 4 >100% 1-4 9 1 11% 5-9 9 12 133% 10-14 2 1 50% 15-19 7 5 71% 20-24 23 22 96% Male 25-29 80 53 66% 30-34 118 76 64% 35-39 93 59 63% 40-44 90 65 72% 45-49 70 43 61% 50+ 75 59 79% <1 0 0 N/A 1-4 3 0 0% 5-9 3 3 100% 10-14 3 1 33% 15-19 8 3 38% 20-24 25 15 60% Female 25-29 21 16 76% 30-34 26 26 100% 35-39 27 20 74% 40-44 18 11 61% Kirinyaga 45-49 7 7 100% 50+ 12 8 67% <1 0 1 >100% 1-4 1 0% 5-9 0 3 >100% 10-14 2 1 50% Male 15-19 1 0 0% 20-24 3 5 167% 25-29 11 7 64% 30-34 18 15 83%
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35-39 13 18 138% 40-44 11 12 109% 45-49 10 5 50% 50+ 19 12 63% <1 0 0 N/A 1-4 0 0 N/A 5-9 0 0 N/A 10-14 0 0 N/A 15-19 0 0 N/A 20-24 3 3 100% Female 25-29 3 3 100% 30-34 4 7 175% 35-39 3 2 67% 40-44 3 0 0% 45-49 3 0 0% 50+ 4 2 50% Kitui <1 0 0 N/A 1-4 0 0 N/A 5-9 0 0 N/A 10-14 0 0 N/A 15-19 0 0 N/A 20-24 0 0 N/A Male 25-29 1 1 100% 30-34 0 2 >100% 35-39 5 3 60% 40-44 3 0 0% 45-49 1 1 100% 50+ 5 2 40% <1 2 2 100% 1-4 18 3 17% 5-9 14 27 193% Meru Female 10-14 14 8 57% 15-19 54 50 93% 20-24 145 113 78% 25-29 240 161 67%
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30-34 264 208 79% 35-39 155 137 88% 40-44 107 96 90% 45-49 77 82 106% 50+ 112 100 89% <1 0 8 >100% 1-4 14 4 29% 5-9 15 37 247% 10-14 17 7 41% 15-19 12 11 92% 20-24 34 29 85% Male 25-29 55 37 67% 30-34 110 73 66% 35-39 149 76 51% 40-44 112 72 64% 45-49 68 56 82% 50+ 102 75 74% <1 1 0 0% 1-4 9 0 0% 5-9 4 9 225% 10-14 6 3 50% 15-19 18 14 78% 20-24 55 29 53% Female 25-29 66 32 48% 30-34 85 52 61% 35-39 74 47 64% Murang'a 40-44 53 42 79% 45-49 30 21 70% 50+ 47 42 89% <1 0 0 N/A 1-4 4 0 0% 5-9 7 11 157% Male 10-14 3 5 167% 15-19 4 3 75% 20-24 7 7 100%
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25-29 16 8 50% 30-34 36 23 64% 35-39 46 23 50% 40-44 51 26 51% 45-49 49 32 65% 50+ 26 28 108% <1 2 3 150% 1-4 5 0 0% 5-9 4 6 150% 10-14 2 2 100% 15-19 14 12 86% 20-24 45 35 78% Female 25-29 68 48 71% 30-34 45 44 98% 35-39 51 36 71% 40-44 38 24 63% 45-49 35 29 83% 50+ 38 29 76% Nyandarua <1 0 2 >100% 1-4 6 0% 5-9 6 8 133% 10-14 3 1 33% 15-19 3 1 33% 20-24 6 2 33% Male 25-29 18 11 61% 30-34 29 26 90% 35-39 41 28 68% 40-44 26 19 73% 45-49 26 24 92% 50+ 35 32 91% <1 0 0 N/A 1-4 0 0 N/A Nyeri Female 5-9 1 2 200% 10-14 0 1 >100% 15-19 1 3 300%
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20-24 10 8 80% 25-29 19 12 63% 30-34 18 13 72% 35-39 12 6 50% 40-44 11 11 100% 45-49 13 9 69% 50+ 16 12 75% <1 0 0 N/A 1-4 1 0 0% 5-9 0 1 >100% 10-14 1 0 0% 15-19 0 0 N/A 20-24 1 0 0% Male 25-29 4 5 125% 30-34 7 4 57% 35-39 7 7 100% 40-44 12 9 75% 45-49 5 6 120% 50+ 10 6 60% <1 0 4 >100% 1-4 5 1 20% 5-9 5 7 140% 10-14 9 10 111% 15-19 13 8 62% 20-24 49 34 69% Female 25-29 65 52 80% 30-34 65 41 63% TharakaNthi 35-39 51 36 71% 40-44 33 28 85% 45-49 21 24 114% 50+ 45 30 67% <1 0 2 >100% 1-4 11 0 0% Male 5-9 2 8 400% 10-14 2 2 100%
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15-19 4 2 50% 20-24 15 7 47% 25-29 28 21 75% 30-34 27 21 78% 35-39 38 27 71% 40-44 42 29 69% 45-49 29 15 52% 50+ 28 24 86%
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Annex III: ACTIVITY PROGRESS – Quantitative Impact Tables
INDICATOR TITLE: Number of Individuals who Received HIV Testing Services (HTS), and Received their Test Results INDICATOR #: UNIT: DISAGGREGATE BY: Location, Event, Date and Gender Geographic Location Activity Title Activity Dates Female Male Sub-Total
Support for sessional counsellors Number of Facility CME and feedback meetings clients tested Nyeri, Nyandarua, Muranga, Mentorship on HTC documentation for HIV Kiambu,Kitui,Kirinyaga, Embu, Tharaka & Apr – Jun 2019 80,484 34,560 114,929 Meru Counties Supervision visit for CHMTs
Partner Notification Services Results:
Additional Criteria FY 2018 FY Oct – Mar(SAPR) 2019 April-June 2019
Tracking by Gender Target Target Target Achieved Target Achieved Disaggregation Kiambu 77,176 87,642 87,642 63,692 87,642 27,699
Kirinyaga 22,780 12,558 12,558 17,597 12,558 4,943
Murang'a 184,644 171,165 171,165 75,104 171,165 14,247
Nyandarua 50,616 27,380 27,380 31,306 27,380 10,823
Nyeri 19,360 5,025 5,025 13,497 5,025 4,283
Embu 51,036 31,269 31,269 30,703 31,269 13,179
Kitui 4,211 6,115 6,115 2,179 6,115 957 Meru 118,876 105,002 105,002 84,703 105,002 25,626 Tharaka-Nithi 47,778 52,643 52,643 32,952 52,643 13,172
Grand Total 566,536 498,799 498,799 351,733 498,799 114,929
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Number of Individuals who Received HIV Testing Services (HTS) , and Received Positive Test Results INDICATOR #: UNIT: DISAGGREGATE BY: Location, Event, Date and Gender Geographic Location Activity Title Activity Dates Female Male Sub-Total Support for sessional counsellors Number of Facility CME and feedback meetings clients tested Nyeri, Nyandarua, Muranga, Kiambu, Kitui, Mentorship on HTC documentation Apr – Jun 2019 799 1398 2,197 for HIV Kirinyaga, Embu, Tharaka & Meru Counties Supervision visit for CHMTs Partner Notification Services Results: Additional FY 2018 FY Oct – Mar(SAPR) 2019 April-June 2019 Criteria Tracking by Gender Target Achieved Target Achieved Target Achieved Disaggregation Kiambu 2,196 1,757 3,498 1,146 3,498 487
Kirinyaga 248 287 306 174 306 68 Murang'a 3,408 797 4,226 505 4,226 192 Nyandarua 784 616 395 360 395 187 Nyeri 476 323 145 102 145 42 Embu 1,308 1,479 1113 525 1113 298 Kitui 100 38 58 26 58 12 Meru 3,132 2,227 3,429 1,200 3,429 690 Tharaka-Nithi 796 660 1,622 368 1,622 218
Grand Total 12,348 8,184 14,792 4,406 14,792 2,194
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INDICATOR TITLE: Number of adults and children Co – infected with TB/HIV on ART INDICATOR #: UNIT: DISAGGREGATE BY: Location, Event date and Gender Period: Oct 2018-March 2019 Geographic Location Activity Title Female Male Sub-Total (Counties) Kiambu, Kirinyaga, Mentorship on 5is and enforcing it – Muranga, Nyandarua, IPC, Immediate enrolment into e.g. Number of Nyeri, Embu, Kitui, Meru ART,IPT, Integration of ART into TB, 511 603 1,114 Individuals & Tharaka Nithi Intensive case finding, Re-sensitization on GeneXpert & Re-orientation of HCPs on active case finding
Results: Additional Criteria: FY 2017 Oct-March 19 April to June 2019 Tracking by Gender Baseline FY 2018 Disaggregation (Age category) Target Achieved Target Achieved Achieved % achieved (oct18 (oct18- to June 2019) June2019 Kiambu 200 252 240 214 147 195 90% Kirinyaga 27 31 59 24 27 21 91% Murang’a 118 163 182 104 76 122 116% Nyandarua 91 55 116 93 53 68 72% Nyeri 47 48 32 29 9 22 73% Embu 109 263 232 108 132 177 143% Kitui 6 18 12 14 30 250% Meru 241 395 491 261 255 415 165% Tharaka-Nithi 79 147 157 82 66 94 113% TOTAL 918 1354 1527 927 779 1114 122%
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INDICATOR TITLE: % pregnant women with known status (includes women tested for HIV and received their results) INDICATOR #: UNIT: DISAGGREGATE BY: Location, Event, Date and Gender Geographic Location Activity Title Activity Dates Female Male Sub-total Community mobilization on first ANC, Outreached targeting Nyeri, Nyandarua, Muranga, Number of children ANC1 Kiambu, Kirinyaga, Embu, Tharaka, April – June 2019 18,337 18,337 Support site CME on Kitui & Meru Counties Early ANC attendance Facility support supervision using SIMs Results: Additional Criteria Tracking by Gender FY2017 FY2018 Oct ’18-Mar’19 April – June 2019 Disaggregation
Target Achieved Target Achieved Target Achieved Target Achieved Target Achieved Kiambu 11,225 12,036 18,821 15,878 14645 8244 14645 4,133 Kirinyaga 16,079 2,087 2,073 2,704 2,434 1545 2,434 577
Murang'a 2,951 4,418 5,288 6,239 3,810 3176 3,810 1,560
Nyandarua 1,754 3,987 6,868 6,754 7,513 3495 7,513 1,699
Nyeri 37 1,430 1,589 1,553 1,926 914 1,926 445
Embu 349 6,325 9,927 10,736 9,615 5406 9,615 2,619
Kitui 28,061 667 1,944 855 877 268 877 130
Meru 2,143 14,866 25,873 20,944 21,088 10994 21,088 5,657
Tharaka-Nithi 6,601 3,180 5,960 5,634 5,588 3265 5,588 1,547
Grand Total 82,173 48,996 76,399 71,297 67,467 37,307 67,467 18,337
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INDICATOR TITLE: Number of adults and children started on ART INDICATOR #: UNIT: DISAGGREGATE BY: Location and event date Geographic Location Activity Title Activity Dates Female Male Sub-Total Kiambu, Kirinyaga, Muranga, Monthly chart review to establish the eligible clients. e.g. Number of individuals Nyandarua, Nyeri, Embu, Fast tracking adherence to patients who are not on ART Apr-June 2019 1167 601 1768 Kitui, Meru & Tharaka Nithi Adoption and dissemination of test and treat guidelines Counties Strengthening linkages and "bringing back the positives" Results:
FY 2018 FY 19 ( Oct 2018-March 2019) April-June 2019 Achievement (Oct 18-Jun 19 FY 2017
Baseline
Achieved Target Achievement Percentage Achieved Achievement Percentage Target
Kiambu 1202 1331 1259 3,067 793 3,067 425 1218 40%
Kirinyaga 184 181 230 296 139 296 50 189 64%
Murang’a 2896 656 3761 304 3761 153 457 12% 627
Nyandarua 494 532 593 271 593 151 422 71% 349
Nyeri 326 211 116 79 116 36 115 99% 218
Embu 1071 1011 1,388 416 1388 243 659 47% 745
Kitui 42 71 17 71 9 26 37% 37
Meru 1426 2768 1622 3,201 935 3201 537 1472 46%
Tharaka-Nithi 379 514 470 1,453 269 1453 164 433 30%
Total 5167 9581 6033 13,946 3223 13946 1768 4991 36%
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INDICATOR TITLE: Number of adults and children with advanced HIV infection receiving ART – CURRENT INDICATOR #: C2.2.D UNIT: DISAGGREGATE BY: Location and event date Geographic Location Activity Title Dates Female Male Sub-Total Treatment literacy classes for those newly started on ART Enhanced adherence counselling for clients with adherence challenges e.g. Number of Kiambu, Kirinyaga, Muranga, Nyandarua, Facility level data consumption for patient management April- June, individuals Nyeri, Embu, Kitui,Meru & Tharaka Robust defaulter tracing mechanism 31,572 14,761 46,333 2019 Nithi Counties Enrolment of the clients into support groups to promote adherence Differentiated care for stable and those presenting with advanced disease Results: FY 2018 FY 2019 (SAPR) April- June, 2019 FY 2017 SAPR APR Target Achieved Achieved (Oct18 Baseline Target Achieved APR Target Achievement to June 2019) Kiambu 9221 7784 11,108 7,811 11,108 8140 73% 7253 Kirinyaga 1328 1542 1,453 1,614 1,453 1628 112% 1190 Murang'a 7758 5834 8,635 5,828 8,635 5878 68% 5337 Nyandarua 3214 2856 3,237 3,019 3,237 3193 99% 2720 Nyeri 2359 2208 2,091 2,151 2,091 2162 103% 1982 Embu 8585 7254 8334 7,729 8334 7882 95% 6640 Kitui 608 702 621 702 620 88% 580 Meru 15294 12916 14,760 13,325 14,760 13565 92% 11426 Tharaka Nithi 3207 3042 3,489 3,188 3,489 3265 94% 2549 Grand Total 39677 50966 44314 53,809 45,286 53,809 46333 86%
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