Afya Ziwani

FY19 - QUARTER 1 PROGRESS REPORT

OCTOBER 1 – DECEMBER 31, 2018

AWARD/CONTRACT No: AID-615-C-17-00002

USAID KENYA HSDSA CLUSTER Prepared for Dr. Stanley Bii US Agency for International Development Kenya 1 c/o American Embassy United Nations Avenue, Gigiri QUARTERLYPO Box 629, Village MarketPROGRESS REPORT Nairobi 00621 Kenya

Prepared by PATH’s Country Office in Kenya ACS Plaza, 4th Floor Lenana and Galana Road PO Box 76634 Nairobi 00100 Kenya

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

JANUARY 2019 This publication was produced for review by the US Agency for International Development (USAID). It was prepared under the leadership of the staff of the PATH-led USAID Afya Ziwani project.

Contents Abbreviations ...... iii List of tables ...... vi List of figures ...... vii Executive summary ...... viii A. Key achievements (qualitative impact) ...... 1 1. Priority Population Intervention (Adolescent Girls and Young Women) ...... 1 2. Priority population intervention (fisherfolk) ...... 6 3. Voluntary medical male circumcision (VMMC) ...... 6 4. HIV testing services (HTS) ...... 8 5. HIV care and treatment ...... 14 6. Laboratory support ...... 24 7. TB–HIV coinfection services ...... 27 8. Elimination of mother-to-child transmission of HIV ...... 31 9. Commodity security ...... 39 10. HRH ...... 42 11. Strategic M&E ...... 50 B. Activity progress (quantitative impact)...... 53 C. Constraints and opportunities ...... 53 D. Performance monitoring ...... 54 E. Progress on gender strategy ...... 55 1. AGYW/ABYM ...... 55 2. Provision of gender-based violence (GBV) activities ...... 55 3. Male-focused activities ...... 56 F. Progress on environmental mitigation and monitoring ...... 56 G. Progress on links to Other USAID programs ...... 58 H. Progress on links with Government of Kenya agencies...... 58 I. Global development alliance (if applicable) ...... 59 J. Subsequent quarter’s work plan ...... 59 K. Financial information ...... 60 Budget details ...... 60 Budget notes ...... 61 L. Activity administration ...... 61 Personnel ...... 61 Contract amendments ...... 61 Sub-contractors ...... 61 Other significant approval(s) from USAID ...... 61 M. GPS information ...... 61 N. Success story ...... 62 Awendo Sub-county Hospital successfully implements assisted Partner Notification Services (aPNS) 62 O. Appendices ...... 1 Appendix 1. Facilities MPR-CQI assessments done ...... 1 Appendix 2. ECHO CME sessions ...... 2 Appendix 3. Cumulative trainings in FY18 ...... 4

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Abbreviations

ADT ART dispensing tool AGYW adolescent girls and young women AIDS acquired immune deficiency syndrome AMPATH Academic Model Providing Access to Healthcare ANC antenatal care APR annual program review ART antiretroviral therapy ARV antiretroviral CARG community ARV refill group CASCO County AIDS STI Coordinator CCC comprehensive care center CD4 cluster of differentiation 4 CDC Centers for Disease Control and Prevention CHMT county health management team CHV community health volunteer CME continuing medical education CMM Community Mentor Mother COP country operational plan CPSB County Public Service Board CQI continuous quality improvement CRH county referral hospital DAR Daily Activity Register DATIM Design and Analysis Toolkit for Inventory and Monitoring DHIS District Health Information Software DOT Directly Observed Treatment DQA data quality assessment DR drug-resistant DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored and Safe DSD direct service delivery DTG dolutegravir EBI evidence-based intervention ECHO Extension for Community Healthcare Outcomes EID early infant diagnosis EMR electronic medical record EMTCT elimination of mother-to-child transmission FMP Families Matter! Program FP family planning FTE full-time equivalent HCA HEI Cohort Analysis

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HCBF Healthy Choices for a Better Future HCW health care worker HCWM health care waste management HEI HIV-exposed infant HIV human immunodeficiency virus HIVST HIV self-testing HMIS health management information systems HR human resources HRH human resources for health HRIO health records and information officer HRPI HR performance improvement HSDSA HIV Service Delivery Support Activity HTS HIV testing services iHRIS integrated Human Resources Information System IPC infection prevention and control IPT isoniazid preventive therapy IQR interquartile range KEMRI Kenya Medical Research Institute KEMSA Kenya Medical Supplies Authority KHQIF Kenya HIV Quality Improvement Framework LIP local implementing partner LOA Letter of Agreement LTFU lost to follow-up LVCT Liverpool Voluntary Counselling and Testing M&E monitoring and evaluation MCH maternal and child health MDR multidrug-resistant MER monitoring, evaluation, and reporting MFLR Master Facility Linkage Register MHMC My Health My Choice MLT medical lab technologist MM Mentor Mother MOH ministry of health MPR monthly progress review MSP male sex partner MTCT mother-to-child transmission NASCOP National AIDS & STIs Control Programme NHRL National HIV Reference Laboratory OCA Organizational Capacity Assessment ODK Open Data Kit OJT on-the-job training

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OTZ Operation Triple Zero OVC orphans and vulnerable children PBB performance-based budgeting PCR polymerase chain reaction PE peer educator PEPFAR President’s Emergency Plan for AIDS Relief PHDP Positive Health, Dignity, and Prevention PLHIV people living with HIV PMTCT prevention of mother-to-child transmission PNS partner notification services POC point of care PrEP pre-exposure prophylaxis PRISM Program Reporting Information System Management PSSG psychosocial support group PT proficiency testing Q quarter QA quality assurance QI quality improvement QIT quality improvement team RLSN Rider Led Sample Network RRI rapid results initiative RTK rapid test kit SCASCO Subcounty AIDS STI Coordinator SCH subcounty hospital SCHRIO Subcounty Health Records Information Officer SCHMT subcounty health management team S/CHMT subcounty/county health management teams SDP service delivery point SMS short message service SOP standard operating procedure STF suspected treatment failure STI sexually transmitted infection TAT turnaround time TB tuberculosis TWG technical working group USAID United States Agency for International Development VL viral load VMMC voluntary medical male circumcision WIT work improvement team

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List of tables

Table 1. Number of AGYW reached by target and county...... 1 Table 2. Key behavioral evidence-based interventions (EBIs)...... 2 Table 3. AGYW receiving behavioral interventions by county (FY19 Q1)...... 2 Table 4. Number of AGYW who know thier HIV status by age and county...... 3 Table 5. Number of AGYW receiving Financial Capability Training...... 3 Table 6. AGYW with complete primary layering...... 4 Table 7. AGYW PrEP uptake...... 4 Table 8. VMMC performance by county (FY19 Q1)...... 7 Table 9. HTS results by county (FY19 Q1)...... 8 Table 10. Pediatric HTS results by county (FY19 Q1)...... 9 Table 11. HTS_TST_POS results by county (FY19 Q1)...... 9 Table 12. PNS cascade of services (FY19 Q1)...... 10 Table 13. HTS results from weekend testing (FY19 Q1)...... 13 Table 14. HTS results from extended-hours testing (FY19 Q1)...... 13 Table 15. HTS results from male targeted HTS outreaches (FY19 Q1)...... 13 Table 16: Linkage of HIV-positive clients to care, by county (FY19 Q1)...... 14 Table 17. New clients on ART, by county (FY19 Q1)...... 15 Table 18. Current ART results by county (FY19 Q1)...... 16 Table 19. Accounting of net losses (FY19 Q1)...... 17 Table 20. Current ART net gain by county (FY19 Q1)...... 17 Table 21. 12-month cohort retention (FY19 Q1)...... 18 Table 22. Operation Triple Zero (OTZ) outcome (FY19 Q1)...... 19 Table 23. PLHIV Enrollment in PSSGs (FY19 Q1)...... 19 Table 24. Viral load uptake performance per county...... 25 Table 25. CD4 uptake performance per county...... 25 Table 26. Key TB–HIV performance indicators for COP18...... 27 Table 27. FY19Q1 TB cascade...... 28 Table 28. IPT for TB...... 30 Table 29. County TB screening...... 30 Table 30. PMTCT uptake by county (FY19 Q1)...... 31 Table 31. PMTCT_POS summary achievements against COP18 targets (FY19 Q1)...... 32 Table 32. Average VL suppression among PMTCT clients (FY19 Q1)...... 33 Table 33. PMTCT cohort analysis (FY19 Q1)...... 33 Table 34. Overall EID tests between 0-12 months old (FY19 Q1)...... 35 Table 35. EID test performance for 0-2 months old (FY19 Q1)...... 35 Table 36. Early infant diagnosis (EID) cascade – initial tests only (FY19 Q1)...... 36 Table 37. Linkage status of all HIV-positive infants - 0-12 months and >12 months (FY19 Q1)...... 37

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Table 38. Outcome of HEI positivity audits (FY19 Q1)...... 37 Table 39. Validation testing results for PCR-positive infants 0–12 months old...... 38 Table 40. HEI analysis of 12-month cohort (FY19 Q1)...... 38 Table 41. HEI analysis of 18 month-cohort at 24 months (FY19 Q1)...... 39 Table 42. Facilities where MPR-CQI was performed...... 43 Table 43. Training data...... 43 Table 44. Health facility staff participation in the ECHO CME sessions...... 44 Table 45. Refresher training # by county...... 45 Table 46. Health care professionals contracted (FY19 Q1)...... 47 Table 47. Health care lay workers contracted (FY19 Q1)...... 47 Table 48. Non-health care lay workers contracted (FY19 Q1)...... 47 Table 49. Other ministries and departments with which the project collaborated...... 58 Table 50. Work plan activities, statuses, and explanations...... 59 Table 51. Actual expenditure details...... 60 Table 52. Budget notes...... 61 Table 53. Facilities where MPR-CQI was conducted (FY19 Q1)...... A-1 Table 54. Training institution capacity to offer HIV in-service training. A-Error! Bookmark not defined. Table 55. Health facility staff participation in the ECHO CME sessions (FY19 Q1)...... A-2 Table 56. Cumulative training held (FY19 Q1)...... A-4

List of figures

Figure 1. Differentiated care cascade (FY19 Q1)...... 21 Figure 2. Overall suppression by age (FY19 Q1)...... 22 Figure 3. Suppression by county (FY19 Q1)...... 23 Figure 4. PMTCT AGYW viral suppression by age group (FY19 Q1)...... 23 Figure 5. TAT, from collection to the time results are received at the facility...... 26 Figure 6. AGYW PMTCT Cascade (FY19 Q1)...... 32 Figure 7. Central and satellite ART commodity sites’ reporting rates into DHIS2 (FY19 Q1)...... 40 Figure 8. County reporting rates of RTK in the health commodity management platform (FY19 Q1). .... 41 Figure 9. VL suppression for the collaborative sites n=32 ...... 49 Figure 10. Viral load uptake dashboard...... 51 Figure 11: Expenditure status and financial projections (pipeline) in USD ...... 60

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Executive summary

Afya Ziwani is a PEPFAR-funded USAID project that is implemented by a PATH-led consortium of US small business partners and Kenyan NGOs. The project aligns its activities with PEPFAR’s county prioritization based on HIV burden and continuum-of-care HIV goals of 95-95-95—along with strengthening Ministry of Health (MOH) institutional capacity and accountability for the management of community, facility, and county HIV responses. Scheduled to run five years, from 1 October 2017 to 30 September 2022, the project supports five counties of western Kenya. Three are designated as scale-up to saturation counties (Homa Bay, Kisumu, and Migori), with the other two (Kisii and Nyamira) designated as aggressive scale-up to saturation counties. In FY19 (PY2), the project is supporting a total of 270 PEPFAR-targeted health facilities (HFs) in these five counties. Of these, 213 have ART/TB targets, with the remaining having targets only for HIV testing services (HTS) or voluntary medical male circumcision (VMMC). For prevention services, a key area for project support is provision of services to the priority population of adolescent girls and young women (AGYW). Through five local implementing partners (LIPs), the program, working in 51 wards of 17 sub-counties in the three counties of Homa Bay, Kisumu, and Migori, provided services to 38,662 AGYW, reaching 49% of the annual target of 78,524 vulnerable AGYW with assorted interventions under the comprehensive package of services for primary HIV prevention. Another key prevention area supported by the project is the provision of services to fisherfolk (FF) located at Lake Victoria landing sites of Kisumu County. Working through one LIP, 5,467 FF received project-supported services in Q1, reaching 20% of the annual target of 27,979. A third key prevention area is VMMC. In Q1, 19,374 clients accessed VMMC services, 6 of whom were infants 0-60 days old, reaching 49% against a COP 2018 target of 39,584. Of these, 7,834 were ≥ 15 years old, reaching 39% of the PEPFAR target of 60% for this age group. For HIV testing services (HTS), 181, 543 clients counseled and tested for HIV, in Q1, reaching 40% of the annual target of 450, 673. Of these, 2,075 (1.1%) tested HIV positive, reaching 22% of the annual target of 9, 613. Partner Notification Services (PNS) testing contributed 889 (43%) of the total positives. PNS’ high contribution resulted from an HIV positive yield of 11%, in contrast to the around 1.1% from other HF- based testing. In addition, in Q1, the 45 supported HFs targeted to provide self-testing kits distributed 2,013 kits, reaching 80% of the annual target of 2,013.

For the initiation of HIV positives on antiretroviral therapy (ART), 1,708 clients were initiated, reaching 20% of the annual target of 8,643. At the end of Q1, 50,369 clients were active on treatment, reaching 93% of the annual target of 54,108. The project recorded a crude retention of 93% with a net loss of 2,830 clients in the quarter. Of these, 1,212 have been accounted for either transfer-outs, deaths, or defaulters. For viral load (VL) testing, in Q1, 52,780 ART clients had a recent VL test (routine and targeted), reaching 97% of the annual target of 54,226. Of these, 44,967 (85%) presented VL suppression of <1,000 copies/ml.

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To support retention on ART, the project, in Q1, continued to support differentiated care service delivery, with 135 HFs supported to provide the service, which reflected 63% of the total targeted 213 ART/TB sites, an increase from 55% in the last quarter. Overall, 15,527 ART clients were enrolled, reflecting 75% of the total 20,781 eligible stable ART clients. Of these, 87% were enrolled in HF-based fast track services. For adolescent focused Operation Triple Zero (OTZ), 1,939 adolescents are enrolled by end of Q1, reflecting 42% of the total of 4,568 adolescents on treatment. Of those enrolled, 89% were virally suppressed. For HIV/TB coinfection, in Q1, 500 (95%) of 521 total TB cases were tested for HIV and received their result, reaching 32% of the annual target. Of these, 225 (45%) were found co-infected with HIV, with 217 (96%) started on ART, reaching 35% of the annual target. As well, 46,717 (92%) comprehensive care center (CCC) clients were screened for TB at their last visit, and 1337 (96%) of eligible CCC clients completed IPT. For elimination of mother to child transmission (eMTCT) of HIV, in Q1, of the 9,246 women visiting ANC, 9,067 (98%) knew their HIV status, which reached 24% of the annual target of 38,176. Of these, 780 (8.6%) were found HIV positive. A total of 750 (96%) of the positive pregnant women were initiated on ART, reaching 20% of the annual target of 3,681. As well, 725 infants (93%) received prophylaxis. For Early Infant Diagnosis (EID) testing, 899 initial virologic tests were done for infants between 0-12 months old, of which 65% (585) were tested at 2 months, against the revised target of 90% to 95%.

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A. Key achievements (qualitative impact)

1. Priority Population Intervention (Adolescent Girls and Young Women)

1.1 Primary individual interventions The adolescent girls and young women (AGYW) implementation seeks to reduce new HIV infections amongst vulnerable AGYW 9 to 24 years old. The strategy used envisions provision of primary individual interventions to all enrolled AGYW as per their age cohort and secondary individual interventions based on each unique individual’s circumstances. Under the primary individual interventions are such interventions as EBIs, Education on PrEP, Condom and Contraception, HTS, and Social Asset Building and Financial Capability training.

Social Asset Building (SAB) The project tracks the number of AGYW who come to the safe spaces and receive interventions under the SAB indicator. This number refers to the active AGYW within a reporting period, in this case the October to December quarter. In financial year 2 (FY2), the project seeks to reach 78,524 vulnerable AGYW with assorted interventions under the comprehensive package of services for primary HIV prevention. In the reporting quarter, the project engaged with 38,662 AGYW in the safe spaces, which figure is reported under social asset building indicator. These active AGYW were broken down as follows per county (table 1). Table 1. Number of AGYW reached by target and county. County Kisumu Homa Bay Migori Project Overall target 37,711 32,097 8,716 78,524 SAB Qtr. 1 reach 12,249 (32%) 21,879 (68%) 4,534 (52%) 38,662 (49%)

Due to various end-year festivities, AGYW may travel away from the implementation areas.

PP_PREV Under this indicator is the number of priority populations (AGYW in this case) reached with a standardized, evidence-based interventions required that are designed to promote the adoption of HIV prevention behaviors and service uptake. Various age-based EBIs, as shown below, help in reporting this indicator. As defined in the AGYW layering table, the key behavioral evidence-based interventions (EBIs) are shown in table 2. Table 2. Key behavioral evidence-based interventions (EBIs). Healthy Choices for a Better Future (HCBF) ages 10–14years

Behavioral (EBI) My Health My Choice (MHMC) ages 15–17years

SHUGA2 (ages 18–24)

The project uses certified facilitators to provide these EBIs to the AGYW. The project takes advantage of the availability of AGYW during school holidays and weekends to conduct daily sessions for each group, rather than conducting them on a once-weekly basis. Provision of biomedical services and education on PrEP, condoms and contraception are mainstreamed in the EBI sessions for the older cohorts as appropriate.

Key results In Q1, the results are presented in table 3. Table 3. AGYW receiving behavioral interventions by county (FY19 Q1). County AGYW Q1 Achievement Kisumu 19,301 3,058 16% Homa Bay 15,699 6,859 44% Migori 6,699 2,839 42% Afya Ziwani Total 41,699 12,756 31%

Discussion For FY 2, the project will seek to prioritize uptake of EBIs by all enrolled AGYW. As of the end of FY 18, 53,183 out of 94,557 AGYW had completed an EBI. In this reporting period, the project took advantage of the long holidays to provide behavioral EBIs to the AGYW, reaching 12,756 of the eligible 41,699 AGYW. The project invested in the training of new facilitators to mitigate previous attrition. As a strategy for long-term availability of EBI facilitators, the project incorporated mentors in the training. Majority of mentors are permanent, married residents of the wards with very AGYW being tested at a safe space Photo: PATH slim chances of moving away.

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The project also made the decision to actively mainstream education on PrEP, condoms and contraceptives in the EBIs. This not only cuts costs and helps accelerate the achievement of optimal primary layering, but also provides a good linkage of the EBI lessons with an understanding of HIV prevention commodities. To this end, 5,218 AGYW aged 18-24 received PrEP education, 12,945 aged 15-24 received contraceptive method mix education and 13,276 of similar cohort received condom education.

HIV testing services (HTS)

Key results The project provided HTS services to AGYW as an entry to HIV prevention. As of the close of FY1, the project had provided HTS to 65,176 AGYW. The project does not provide continued repeat testing to AGYW but provides that AGYW may be tested once a year, in line with the national re-testing guidelines. In the reporting period, the project tested as shown in table 4. Table 4. Number of AGYW who know their HIV status by age and county. County/Age cohort 9-14 15-19 20-24 Total Kisumu 49 869 629 1,547 Homa Bay 312 1,793 1,220 3,325 Migori 18 321 287 626 Afya Ziwani total 379 2,983 2,136 5,498

Discussion HTS was provided to AGYW, some for the first time while others to those who hadn’t tested in the past year. In the quarter, one newly-enrolled AGYW in Awendo Subcounty who didn’t know her status returned an HIV+ result and was linked to treatment. The rest of the AGYW (4,376) returned HIV- results.

Financial Capability Training (FCT) The project has so far managed to achieve a little over a quarter of the FCT targets. All AGYW need to receive FCT as a primary intervention to build their money skills. Lack of facilitators due to attrition has affected uptake of this service. The project is working on training new facilitators and procuring materials. This will also include appropriate scheduling of the 12-14 sessions required to complete the curriculum. The project will undertake an accelerated FCT session concept where a couple of sessions will be conducted on the same day. In the reporting quarter, the project reached 7,080 with FCT as table 5 below shows. This increases the number of AGYW ever receiving FCT to 25,531. Table 5. Number of AGYW receiving Financial Capability Training. County/Age cohort 9-14 15-19 20-24 Total Kisumu 1,172 1,955 1,325 4,452 Homa Bay 435 61,001 613 2,049 Migori 204 240 135 579 Afya Ziwani totals 1,811 3,196 11,949 25,531

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AGYW with complete primary layering (AGYW_PREV) As of the end of the reporting period, the project achieved a total of 8,569 AGYW who have received all their primary individual interventions. Going forward, the project will work to push this number to 20,000 to enable graduation. Particularly, the project will enhance FCT for AGYW as this is the single intervention not yet received by a majority to achieve primary layering. Table 6 below shows the county distribution of the number of AGYW with complete primary layering. Table 6. AGYW with complete primary layering. County 9-14 15-19 20-24 Total

Kisumu 1,018 611 1,359 2,988

Homa Bay 1,733 1,450 2,222 5,405

Migori 77 57 42 176

Afya Ziwani total 2,828 2,118 3,623 8,569

1.2 Secondary individual interventions The AGYW secondary services are availed to the recipient based on their circumstances and risks. In this category are such interventions as PrEP uptake, Post violence care, education support, cash transfer and combination socio-economic approaches.

PrEP uptake The project had minimal reach on new enrolments to PrEP, majorly because of commodities stock-out and attrition of service providers. In Migori’s Kuria Subcounty, lack of PrEP personnel in the facilities hampered PrEP uptake. In Awendo, the sub-county health management team recommended PrEP provision only after sensitization of health care workers. In total, the project enrolled 115 new on PrEP, increasing those on PrEP to 646 as table 7 below shows. Table 7. AGYW PrEP uptake.

Indicator Age Total

18-19 20-24 Number newly eligible for PrEP 222 391 613 Number newly enrolled for PrEP 18 97 115 Number current on PrEP (New +Previous on PrEP) 182 464 646 Number stopped PrEP* 2 5 7 Number restart on PrEP* 1 8 9 Number treated for STIs 0 0 0

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Education support The project continued to support AGYW to remain in school, paying school fees and providing sanitary commodities to AGYW. The payment of school fees facilitates AGYW to stay longer in school, even beyond the financial year. Currently, the project has supported 5,315 AGYW to attend school. The project supported 13,848 AGYW with sanitary commodities and paid school fees for 717 AGYW in the quarter. The project is currently processing further fees to take care of AGYW once the duration of their fees is over.

Cash Transfer (CT) In the reporting quarter, the project approved CTs to 4,034 new, in addition to the 7,501 in the previous quarter. A special consideration this quarter was conducting post-disbursement household visits to follow- up on AGYW and the impact of CT to their lives. Majority of the AGYW, especially those that are mothers, increasingly use CT as seed money for micro-enterprises, generally on sale of fast-moving foodstuff.

1.3 Contextual interventions

Reducing risk in male sex partners (MSP) The project appreciates the role of men in reducing the chances of AGYW HIV incidence. As such, the project conducts outreaches to target the typical male sex partners of the AGYW. Using the male characterization tool, the project works with AGYW aged 15 to 24 years old to characterize MSP, ranking them per geographical area on the most common partners. Thereafter, the project, working with link health facilities, conducts planned outreaches at the MSP’s meeting points to facilitate male uptake of highly effective HIV prevention services: HTS with enrolment to treatment, VMMC, and condoms.

Key results In Q1, the project conducted 143 outreaches across the 51 wards, reaching 3,135 men. Most of the outreaches reached boda-boda men, sand and cane harvesters and bus conductors. The project had 35 men taking up VMMC and 1,880 tested for HIV. Of these, 19 returned an HIV+ result and were all linked to treatment. As well, 29,500 condoms were distributed to the men.

Discussion As a special strategy, the project is increasingly planning and sharing the outreach dates with AGYW and encouraging the married AGYW to have their partners attend the outreaches. This has played a huge part in facilitating AGYW safe space utilization while also improving partners HIV prevention efforts. During the quarter, the project worked in Kisumu to introduce the concept of HIV self-testing (HIVST) to the men. Training and commodity distribution through the LIPs will be done in the coming quarter.

SASA! for violence prevention SASA! is an evidence-based intervention that seeks to help recipients understand power and how to utilize the various types of power to prevent gender-based violence (GBV). The project conducts SASA! to reach both the AGYW and community members.

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In the reporting quarter, the project reached a total of 36,082 community members, including AGYW with SASA! Of major import was reaching MSP during their outreaches with SASA!, taking the opportunity of the gathered men to discuss power and its application.

2. Priority population intervention (fisherfolk)

The project works in collaboration with respective Beach Management Units (BMUs) to reach both male and female fisherfolk with a comprehensive beach package of prevention services. Behavioral interventions implemented include Splash Inside Out and SHUGA 2; the biomedical interventions of HTS, VMMC and condom promotion; and SASA! as a structural intervention. The project works in 12 beaches, namely, Dunga, Kichinjio, Nyandiwa, Paga, Usare, Rota, Ngege, Usoma, Mawembe, Ogal, Nyamware, and Nduru.

Key achievements A total of 5,467 (2,150 males; 3,317 females) fisherfolk completed SIO and SHUGA 2 sessions, Moonlight outreach at Dunga Beach. Photo: PATH while 1,557 tested for HIV, with 6 returning HIV+ result and all linked for treatment. The project conducted both moonlight and daylight HTS activities to cater for the availability of the fisherfolk. As well, 121 male fisherfolk were circumcised during the period, this being part of the 1,612 that received VMMC education.

Discussions The hyacinth problem affected fisherfolk interventions as the fishermen and women either migrated to other areas away from the project area or took up other businesses like boda-boda, hawking, etc. to mitigate the poor access to the lake.

3. Voluntary medical male circumcision (VMMC)

In FY19, Afya Ziwani is targeting 39,584 circumcisions by providing direct service delivery (DSD) support to 62 voluntary medical male circumcision (VMMC), providing HFs. Of these, 36 have PEPFAR specified targets; the remaining 26 are satellite HFs of the targeted sites. All the VMMC sites are in the scale-up to saturation counties of Homa Bay, Kisumu, and Migori. Support includes provision of consumables, equipment, reporting tools, support supervision, and mentorship on VMMC service provision. In the quarter, the project employed use of the recommended dorsal slit technique, while those eligible were circumcised using the Shang ring male circumcision device and Mogen clamp (for EI-MC) device. The quarter had 11 weeks of Rapid Response Interventions (RRI), coinciding with the long school holidays.

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Results In FY19 Q1, the following results were achieved:

• 58 sites reported having conducted VMMC in the quarter. • 19,374 clients accessed VMMC services, 6 of whom were infants aged 0-60 days, reaching 49% against a COP 2018 target of 39,584. • 7,834 (39%) of the 19,374 were aged ≥ 15 years old, reaching 33% (7,834 of 23,750) of the PEPFAR target of 60% of 39,584. • 15,839 (82%) of the 19,374 clients returned for follow-up within 14 days of circumcision. • 2 (0.01%) adverse events reported, all assessed as moderate. • 8,845 (45%) of the 19,374 circumcised were tested for HIV, with 29 (0.3%) testing positive, all of whom were linked into care and treatment at the respective HF. The quarter’s performance by county is presented in the table 8. Table 8. VMMC performance by county (FY19 Q1). Achieved (Q1) County COP 2018 # Percent Homa Bay 26,163 13,219 51% Kisumu 3,306 783 24% Migori 10,115 5,372 53% Total 39,584 19,374 49%

Discussion In this quarter and following the roll out of early infant male circumcisions (EI-MC) guidelines in FY18, the project rolled out EI-MC services in select facilities, starting with facilities like Homa Bay County Teaching and Referral Hospital and Rachuonyo Subcounty Hospital, with already established capacity following the pilot of EI-MC services in these 2 facilities. In quarter 2, the project plans to build the capacity of 3 other facilities by training 12 service providers and 30 Community Health Volunteers (CHVs) derived from 2 (Homa Bay and Migori) counties. A directive from the National AIDS & STIs Control Programme (NASCOP) that de-emphasizes testing for clients aged 10-14 years affects HTS rates in VMMC clients. This coupled with the fact that 61% of the clients circumcised in Q1 were aged ≤14 years, resulted in the low HTS rates of 45%. Out of the 29 clients who turned HIV positive, 16 (55%) were aged between 25 and 39 years, a pointer that the older men, though difficult to reach with VMMC as a prevention service, are still the drivers of the epidemic and still need to be the age of focus for HIV identification. The proportion of clients coming back for follow-up within 14 days of circumcision was at 82%, up from 73% in the previous quarter. The project continues to put measures in place to ensure more than 80 percent of circumcised clients come back for postoperative follow-up within 14 days of circumcision. These measures include giving clients appointment cards that states the dates of post-op follow-up appointment, updating the minor theatre register whenever clients return for post-op review and calling clients who miss their appointment and updating the outcome of these calls in the missed appointment log.

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Even though the two sugar companies within which the two core facilities in Kisumu County are situated has since been re-opened (Chemelil sugar company re-opened in August 2018 while Muhoroni sugar company re-opened in October 2018), Kisumu County’s performance has been greatly affected by a possible migration of male workers and their families in search of livelihood following the closure of the two sugar companies in the earlier quarters. This migration also affected the number of trained VMMC mobilizers and service providers in this region, leaving these facilities with inadequate numbers of trained mobilizers as well as service providers. In quarter 2, the project will focus on building the necessary capacity for service provision in some of the facilities, including Miwani Dispensary, one of the project’s supported sites with capacity needs. One of the best practices the project has so far put in place is the missed appointment management mechanism in HFs. This mechanism makes it possible to account for efforts made to track clients who miss their appointment 14 days post-operatively. Some of the challenges in implementation include a limited number of program officers, which has made it difficult to provide oversight to mobilization activities by CHVs, thus making it difficult to track clients referred for services by demand creation strategies. The project is strengthening the use of referral forms across all sites for documenting referrals, from both the community and the different service delivery points within the facility. This is through capacity building of the CHVs from select facilities in quarter 2.

4. HIV testing services (HTS)

4.1 Health facility-based HTS In FY19, Afya Ziwani targets to test 450,673 individuals for HIV, with 9,613 (2.1 %) expected to be HIV positive. To achieve this, the project provides DSD support to 224 health facilities (HFs) with PEPFAR targets for HTS, through deployment of HTS providers, capacity-building, provision of data collection tools, mentorship, and supportive supervision.

Key results In Q1, the following key results were achieved:

• 224 HFs were provided with direct service delivery (DSD) support, including deployment of 166 non- clinical HTS providers at 134 sites, a 60% coverage • 181, 543 clients counseled and tested for HIV, reaching 40% of the annual target of 450,673. Project supported HTS results for the quarter, by county, are presented in the table 9. Table 9. HTS results by county (FY19 Q1). County Target Q1 achieved % Achieved Homa Bay 88,598 41,536 47 Kisii 16,485 8,782 53 Kisumu 82,770 24,215 29 Migori 126,299 35,163 28 Nyamira 136,521 71,847 53 Total 450,673 181,543 40

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Pediatric clients (<15 years of age) A total of 25,361 pediatric clients under 15 years old were counseled and tested, representing 14% of the total tested, which is consistent with FY18’s ratio. For pediatric clients, project-supported HTS results for the quarter are shown in table 10. Table 10. Pediatric HTS results by county (FY19 Q1). County Target Q1 achieved % Achieved Homa Bay 2,989 8,072 270 Kisii 957 1,185 124 Kisumu 2,419 2,500 103 Migori 3,763 2,592 69 Nyamira 5,211 11,012 211 Total 15,339 25,361 165

For total yield, the following HIV positive yield (HTS_TST_POS) was achieved in Q1: 2,075 (1.1%) of clients tested were identified as HIV positive, reaching 22.0% of the annual target of 9,613. Table 11 presents Q1 performance for positive yield against the annual targets by county. Table 11. HTS_TST_POS results by county (FY19 Q1). County Target Q1 % Achieved Homa Bay 1,850 373 20 Kisii 355 81 23 Kisumu 1,938 431 22 Migori 2,415 529 22 Nyamira 3,055 661 22 Total 9,613 2,075 22

Discussion For overall HTS, the trend indicates that the project is on track, in all the supported counties, to meet its overall COP 2018 target for number of people tested. Even though Nyamira and Homa Bay counties tested more, 71,847 and 41,536 respectively compared to the other 3 counties, the two counties each had a yield of 0.9% (661 of 71,669 tested in Nyamira and 373 of 41,536 tested in Homa Bay). Kisumu, Migori and Kisii counties had a yield of 1.8% (431 of 24,215), 1.5% (529 of 35,163), and 0.9% (81 of 8,782) respectively. This yield is below the expected 2.1%. For pediatric HTS, the project is at 14% of total tested are <15 years old. For the counties, the pediatric trend indicates that the project is on track with the number tested for all the counties with Migori being the lowest at 69% which is indicative that this indicator will be surpassed in performance by the end of the year. For HIV positive yield, the Q1 achievement of 22% indicates that the project is not on track to meet its overall COP 2018 target for number of HIV positives identified. This lower than expected performance

9 was largely contributed by the drop-in identification in the month of December (579) compared to the average 748 that had been achieved in October and November 2018. The HIV positive yield of 1.1% (2,075 0f 181, 543 tested) is well below the COP 2018 target of 2.1% (9, 613 of 450, 673 tested annually). However, Q1 yield is consistent with the project’s FY18 yield of 1.3%. By counties, the performance indicates that the project is not on track in any of the counties with their respective performances being Kisii (23%), while for Migori, Kisumu and Nyamira at 22% each and Homa Bay at 20%. To address the lower than expected percentage yield, the project has found that only two interventions present high yield i.e. the testing of TB patients for HIV (14% in Q1), and PNS (11% in Q1). The project will continue to prioritize these interventions, with the PNS strategy described below. As well, the project will continue to implement male focused strategies (self-testing, after hours and weekend services, male clinics, male targeted outreaches), although the yield has been low.

4.2 Partner Notification Services (PNS) To increase the uptake of PNS services, the project expands the range of providers capable of providing PNS by supporting sensitization training of HCWs, including nurses, clinicians, adherence-support counselors (ASCs), non-clinical and volunteer HTS providers, lab officers, and supervisors. The project also works with HF based and roving PNS champions to mentor these providers on PNS.

Results In Q1, the project achieved the following:

• Contribution of PNS: 43% of total newly identified positives (889 of 2,075). • Yield overall: 11% (889 of 8,073 tested). • Yield by gender: 38% (321) adult male; 62% (514) adult female. • Yield for pediatric 1.7% (62/3,565). • Linked/initiated on HIV care and treatment: 96% (852 of 889), with 94% (299 of 317) for adult males; 95% (492 of 510) for adult females. The cascade of services achieved in Q1 is presented in the table 12. Table 12. PNS cascade of services (FY19 Q1). Cascade H/ Bay Kisii Kisumu Migori Nyamira Totals Index clients screened 1,339 344 394 649 1,568 4,294 Contacts identified 4,661 629 1,177 1,659 3,323 11,449 Known positives (KP) 745 56 124 283 339 1,547 Eligible 3,914 581 1,042 1,375 2,990 9,902 Tested 3,249 511 719 1,290 2,304 8,073 Positive 131 33 93 325 307 889 Linked 119 33 85 308 307 852 Uptake of testing (%) 83% 88% 69% 94% 77% 82% Positivity rate (%) 4% 6% 13% 25% 13% 11% Linkage to care (%) 91% 100% 91% 95% 100% 96% KP in contacts reached (%) 16% 9% 11% 17% 10% 14%

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Discussion The above results indicate that PNS is the most effective intervention for achieving significant numbers of HIV positives. On average, there were 2.7 contacts elicited per index client. Of the 11,449 contacts elicited, 14% (1,547 known positives) were ineligible for testing. Of the 9,902 eligible for testing, 8,073 were tested, translating to a testing uptake of 86% and a yield of 11% (889 of 8,073). The overall yield of 11% is significantly higher than the quarter’s overall 1.1% (2,075 of 181, 543) yield, which was primarily achieved by HF based testing. As well, PNS contributed 43% of total newly identified positives in Q1 (889 of 2,075). While the testing of TB patients provides a higher percentage of HIV positives, at 14%, the actual number of identified positives (43 positives out of 318 tested) is much lower than from those identified by PNS. This lends PNS as both high proportionate and absolute positive yielding strategy. Despite the successful scale up of PNS, the project experiences challenges around HRH, time and cost incurred in follow-up of contacts elicited when assisted partner notification/passive approach is used. Several home visits are required to reach out to particular sexual partners, some of which are not finally determined. A national referral directory, which is not currently available, would allow the tracking and accounting of outcomes of these individuals. Inadequate counseling skills of some HTS providers for contact elicitation can be a challenge. Capacity building through engagement of the MOH clinical and project technical teams and on-the-job training (OJT) and mentorship, and promotion by PNS champions will help address this. Another challenge has been reporting of elicited contacts reached months later, which is not accounted? for in the PNS reporting tools. The project is scaling up an Open Data Kit (ODK) application will enable the HTS providers to capture and track clients tested after the reporting period and account for tracking and testing outcomes of these individuals.

4.3 HIV self-testing (HIVST) In FY19, the project undertook a scale-up of the HIV self-testing modality from the 5 pilot sites in FY18 to 45 targeted HFs located in all the 5 supported counties, with a targeted distribution of 2,511 HIVST kits. A key focus of self-testing is to improve uptake among men by reducing missed opportunities, especially among partners of PMTCT mothers attending ANC services at the facilities, and partners of HIV-positive clients who are unwilling to participate in PNS by having the option of self-testing at the HF or at home. The project adopted a more focused male targeted outreach approach of HIVST distribution during the hypertension screening activities in the two counties of Homa Bay and Kisumu, which led to distribution of 611 HIVST kits as part of the total 2,013 HIVST kits distributed. In these integrated outreaches, information was given during mobilization for and distribution of the self-testing kits to the clients in the following ways:

• During demand creation ahead of integrated male outreaches, clients can walk in and request HIVST kits and walk away without having to pass through an HTS provider, allowing them to test at their own convenience. • Clients who are offered HTS but opt out are given the alternative of HIVST at the site or at home. • Clients tested (and/or who picked HIVST) at the outreach can opt to have their partners tested at home.

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• The female clients testing positive who also were assessed for intimate partner violence and found to be at low risk can pick secondary distribution to their sexual partners. • Follow-up calls are made by the health care provider to all clients who consented during HIVST distribution to enable feedback within 24 hours. • All positive results are offered additional testing using the national testing algorithm and linked to the facility of choice.

Results In Q1, the project achieved the following:

• 2,013 HIVST kits distributed, 80% of the 2,511-annual target. • Improved (98%) testing uptake among clients who turned up for hypertension screening • 39% (240/611) of the clients were tested with HIVST at the site, which provided instant feedback and additional tests for the 3 HIV positive clients. • 50% (305/611) of the clients picked HIVST for partner testing at home. • 88% of the clients who picked HIVST outside the facility gave feedback of the test result

Discussion During this reporting quarter, the project distributed a total of 2,013 HIVST kits, an achievement of (80%) against the COP 2018 target. Homa Bay achieved 803 (155%), Kisii 300 (429%), Kisumu 896 (145%) and Nyamira 14 (2%). The low achievement in Nyamira was due to incomplete sensitization workshops, occasioned by healthcare workers (HCWs) strike, but which were later accomplished in the quarter. For the 2,013 HIVST kits distributed, 51% of users were tested through the unassisted approach, with 49% of the tests done through the directly assisted approach. Migori County (0% achieved) was in phase II of the HIVST roll out and has not started distributing HIVST. The challenges experienced with HIVST include lack of standardized documentation tools for the distributed HIVST, insufficient follow-up mechanisms to verify use of HIVST distributed for use away from the HF, delays in additional tests and subsequent possible linkage for those reporting HIVST positive results. To address this, the project improvised tools to capture data from the site level and facilitate site monthly summary for compilation. For the targeted outreaches, the project developed an ODK app that captures this information alongside telephone contacts and the link facility for subsequent follow-up of any positives.

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4.4 Other HTS approaches (weekend, extended hours, and male-targeted HTS outreaches Weekend and extended hour testing are conducted in 23 high-volume facilities across the 5 counties. Male-targeted outreaches are carried in the mapped outreach/hot-spot sites of the three priority counties of Migori, Homa Bay and Kisumu.

Key results For weekend testing, in Q1, 4,722 clients were tested, as summarized by county in table 13. Table 13. HTS results from weekend testing (FY19 Q1). Linked to Care and Counseled and HIV Positive County Treatment Tested No. Percent No. Percent Homa Bay 1,101 5 0.5 4 80 Kisii 555 3 0.5 3 100 Kisumu 321 3 0.9 2 67 Migori 398 7 1.8 7 100 Nyamira 2,347 7 0.3 7 100 Total 4,722 25 0.53 23 92

For extended hours, in Q1, 1,833 clients were tested, as summarized by county in table 14. Table 14. HTS results from extended-hours testing (FY19 Q1). Linked to care and Counseled and HIV Positive County treatment Tested No. Percent No. Percent Homa Bay 605 5 0.8 5 100 Kisii 110 0 0.0 0 0 Kisumu 283 1 0.4 1 100 Migori N/A Nyamira 835 2 0.2 2 100 Total 1,833 8 0.4 8 100

For male targeted HTS outreaches, in Q1:

• 146 outreaches conducted by 27 HFs. • 4,509 clients were tested, as summarized by county in the tables 15 and 16 below. Table 15. HTS results from male targeted HTS outreaches (FY19 Q1). Linked to Care and Counseled and HIV Positive County Treatment Tested No. Percent No. Percent Homa Bay 2,044 9 0.40 9 100 Kisumu 530 10 1.90 10 100 Migori 1935 41 2.10 32 78 Total 4,509 60 1.33 51 85

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Discussion The project has prioritized high-volume HFs to provide HTS through extended hours, weekend testing and male targeted outreaches. However, even this targeted approach has not led to a viable HIV positive yield. The HIV positive yield of 0.5% during weekend testing and 0.4% during extended hours is way below the quarter’s overall yield of 1.1%, while 1.3 % for male targeted outreaches compares with the quarter’s overall yield. All the strategies are significantly lower than the 11 % achieved during PNS. This calls into question the efficacy of these approaches. Despite the low yield realized and the strain on the HRH from these optimization strategies, it has significantly minimized missed opportunities in testing, especially among male clients during weekends and those that are reached during community testing activities

5. HIV care and treatment

5.1 New on treatment Afya Ziwani, in FY19, is supporting 213 HFs with PEPFAR targets to provide ART and HIV/TB services. The target for newly initiated on ART is 8,643, which reflects 90% of the HTS target of 9,613 for newly tested HIV positives. The project employed both proxy linkage as well as actual (use of the Master Facility Linkage Register (MFLR) in reporting linkages in all supported counties.

Key results In Q1, the following was achieved:

• 1,708 clients newly initiated on ART, reaching about 20% of the annual target of 8,643. • Of total new positives identified 2,075, 82% were newly initiated on treatment. • 113 pediatric clients were newly initiated on treatment, reaching 41% of the annual target of 270. Table 16 presents Q1’s linkage and treatment initiation rates by county: Table 16: Linkage of HIV-positive clients to care, by county (FY19 Q1). County HTS Positive New on ART % Linkage Homa Bay 373 285 76 Kisii 81 81 100 Kisumu 431 327 76 Migori 529 449 85 Nyamira 661 566 86 Total 2,075 1,708 82

Source: Ministry of Health (MOH) 731 Report.

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Table 17 presents the total number of new clients initiated on ART as well as the pediatric (<15 years old) against annual target, by county. Table 17. New clients on ART, by county (FY19 Q1).

Total New clients on ART Pediatric New on ART County Target COP % Target COP Q1 Q1 % Achieved 2018 Achieved 2018 Homa Bay 1,999 285 14 74 19 26 Kisii 429 81 18 13 2 15 Kisumu 984 327 33 20 16 80 Migori 2,285 449 20 68 30 44 Nyamira 2,946 566 19 95 46 48 Total 8,643 1,708 20 270 116 43

Discussion A total of 1,708 clients were initiated on treatment within the entire project in October to December 2018, which translates to a 20% achievement against a COP 2018 target of 8,643. This is slightly below the expected quarterly target of 25%, although this is an improvement from last quarter’s performance of 16%. Performance among the counties was varied, with only Kisumu ( at 33%) exceeding the expected 25%. Homa Bay was the only county way off the target (14%), and this is being addressed by intensifying identification of HIV positive clients through targeted testing and optimizing linkage of those identified. Two counties, Homa Bay and Kisumu reported less than expected proxy linkage, each at 76%. The lower than normal linkage in these counties is ascribed to increased numbers of transient clients seen during the festive season who preferred being enrolled in their primary residence. Linkage was affected in low volume sites during the festive season due to staff shortage courtesy of accrued leave taken. This is evidenced by the significant reduction in linkage rates in December, of 75%, compared to 85% for October and November. The urban nature of the two counties with a transient nature of the clients also contributed the overall lower proxy linkage in the two counties, with more transfers out reported than the other counties. The two most affected facilities are the largest in the counties and are situated in urban areas i.e. Migosi and Rachuonyo subcounty hospitals. The project will continue to track linkage using the MFLR to identify true missed opportunities across the facilities. The project has put in place mitigating measures, including daily monitoring of facility-level linkage and immediate follow-up of missed opportunities. This will be reviewed on a weekly basis at the program level. ART enrollment strategies that included facility performance tracking were used to assess the gaps and opportunities that existed in the facilities; contracted staff were hired through the counties’ department of health, while also engaging more clinical short-term locum staff in some counties, especially Nyamira, which led to improved performance during the quarter

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The project’s good performance on pediatric identification and enrollment is founded on strong PMTCT interventions. The project ensured a high percentage of eligible children were tested through index client testing and testing optimization in pediatric SDPs.

5.2 Currently on treatment The Afya Ziwani target for currently on ART in COP 2018 is 54,108. Of these, the pediatric target for <15 years old is 4,330 (8% of total).

Key results In Q1, the total number of HIV clients currently on ART was 50,369, with a 93% performance against the annual target of 54,108. Of the total currently on ART, 3,993 (8%) were children <15 years old, which reaches 92% of this age group’s annual target. The quarter’s performance by county and target is presented in table 18. Table 18. Current ART results by county (FY19 Q1).

Total Current ART Achievement Pediatric Current on ART County Target COP % Target COP Q1 Q1 % Achieved 2018 Achieved 2018 Homa Bay 16,000 14,157 88 1,313 1,185 90 Kisii 2,298 2,142 93 178 158 89 Kisumu 4,056 8,130 200 260 536 206 Migori 15,442 13,162 85 1,172 1,108 95 Nyamira 16,312 12,880 79 1,407 1,006 71 Total 54,108 50,369 93 4,330 3,993 92

Discussion In the reporting period (October – December 2018), the project achieved a current ART of 50,369 against a COP 2018 target of 54,108 giving an overall achievement of 93%. Starting from a baseline of 50,501 (current ART in September 2018) and the reported 1,728 new ART enrollments giving an expected current ART of 52,229. Against this, a current ART of 50,369 was realized in December 2018 indicating a net loss of 1,860 in the Q1 reporting period. This represents a 96% crude retention for the 3-month reporting period. The drop can be attributed to challenges experienced with poor documentation due to the holiday season, as well as increased number of defaulters during the holiday season, especially in urban facilities. This is evidenced by the drop-in current on ART numbers seen in December vis a vis November. In November, current on ART was at 51,795 being a net gain of 626 over and above the enrollments in November from an initial October current on ART of 50,543. All the unaccounted-for clients are being accounted for through facility reconciliation with pharmacy numbers Strategies to improve retention include increased effort to improve ART preparedness of clients newly starting ART with frequent messaging around enhanced adherence through group and individual

16 counseling. The project identified new clients as being at the highest risk of loss to follow-up and other adverse outcomes. To address this, the project has sensitized staff on the case management model and printed registers to follow up high-risk clients, including new clients. Progress on this will be reported in the coming quarter. Active physical tracking of newly enrolled clients uses community peer educators (PEs) to ensure the clients meet their appointments regularly, as well as through reminders via SMS or calls two days prior to appointment. Strengthening implementation of differentiated care model to reduce workload in high-volume sites and offering flexible ART refill models for clients who would otherwise miss appointments and provide ample time for clinicians to see unstable clients will lead to improved retention of clients on ART. Managing appointments within three weeks of the month, with active defaulter tracing in the last week to ensure clients who missed appointments, all help ensure clients make their appointments within the reporting month. As well, Nyamira performance against pediatric targets was the lowest, at 71%. These results can be attributed to the low yield in HIV positives in Nyamira County and the HCW industrial action experienced in October.

5.3 Retention

Key results In Q1, beginning with a baseline of 50,433 in September 2018, plus a total of 1,708 new ART clients in the quarter, and 131 who transferred in for the period, the expected current ART is 52,749. The actual current ART reported is 50,369, presenting an overall net loss of 2,380.

Table 19 details the losses. Table 19. Accounting of net losses (FY19 Q1). Transferred Total Accounted-for Pending Net Losses Death Defaulters Out Losses accounting No. 200 64 948 1,212 1,168 Percent to 17% 5% 78% Total

To further detail the above net losses, the net loss for current ART in Q1, by county, is shown in table 20. Table 20. Current ART net gain by county (FY19 Q1). Expected Actual FY17Q4 Total Transfer- Expected Current on Current on Loss County Current New Ins Gain ART ART (Dec- (Dec-18) On ART ART (Dec-18) 18) Homa Bay 14,224 285 38 389 14,613 14,055 -558 Kisii 2,121 81 2 91 2,212 2,142 -70 Kisumu 7,847 327 19 427 8,274 8130 -144 Migori 13,232 449 34 603 13,835 13,162 -673 Nyamira 13,019 566 38 796 13,815 12,880 -935 Total 50,443 1,708 131 2,306 52,749 50,369 -2380

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For the 12-month cohort of newly enrolled ART patients, the project reported an 80% retention in Q1, with 6,296 of the total cohort of 7,170 still active at 12 months. Specifics by county are shown in table 21. Table 21. 12-month cohort retention (FY19 Q1). Oct-Dec 2018 net Oct-Dec 2018 On ART % County cohort 12 months retention Homa Bay 368 273 74 Kisii 65 54 83 Kisumu 387 292 75 Migori 468 393 84 Nyamira 259 225 87 Project total 1547 1237 80 Source: Ministry of Health (MOH) 731 HF report.

Discussion Of the 1,212 accounted for losses, transfers out contributed 17%. The project in the near future intends to use EMR to provide further details on whether these clients transfer into or out of project supported sites. Deaths contributed 5.3% of the accounted for losses which is in keeping with what has been seen in the previous years. Mortality audits have continued to be conducted at facility level to provide near-definite diagnoses of the causes of death. Defaulters form the biggest bulk of the accounted for losses (78%). Three counties, Nyamira, Migori and Homa Bay jointly contribute 91% of the 2,380 net loss experienced in the quarter. The month of November contributed the highest loss (891) compared to the other months. Further analysis showed that high-volume sites in the three most affected counties were the biggest contributors to client loss. With a 12-month retention of 80%, the project is awakened to look further into novel retention strategies to curb the client losses. Longitudinal follow-up of clients in chronic care, such as those with HIV, in urban settings, is challenging. This is due to the frequent movement of clients from one area to another in search of employment and the multiplicity of HIV clinics, all within proximity to clients, making it easy for them to transfer to other clinics without informing their current provider/facility. This is compounded by the lack of a national unique identifier system to allow identification of self-transferred patients. Poorly defined community structures and support systems in urban areas also make it harder to effect follow-up. In some instances, inaccurate locator information provided by the newly enrolled clients makes it difficult to conduct physical tracing. Together with the MOH, the project is working toward a retention strategy specific to facilities in the urban setting to mitigate some of the urban specific challenges.

5.4 Additional retention interventions

Care for HIV-infected children and adolescents The project supported dedicated pediatric and adolescent clinic days, as well as psychosocial support groups (PSSGs) for children, adolescents, and their caregivers. As well, support and scale-up was provided to the Operation Triple Zero (OTZ) intervention, which focuses on adolescents and youth between 10-25 years old, and emphasizes commitment to zero missed appointments, zero missed drugs, and zero (undetectable) viral load (VL). The project further supports pediatric and adolescent adherence

18 support through a peer-to-peer buddy support system, adolescent literacy session on HIV self- management, a case management approach for clients with adherence issues, including directly witnessed ingestion (DWIs), and appointment management harmonization to accommodate school calendars to minimize missed appointments. The following key results were achieved:

• 1,409 children enrolled in PSSGs for children and their caregivers at 213 HFs. • 4,568 adolescents enrolled in OTZ (67% of total adolescents and young people current on ART). • 100 HFs are implementing OTZ. Table 22. Operation Triple Zero (OTZ) outcome (FY19 Q1). 10–14 Years 15–19 Years 20–24 Years Outcomes Total Male Female Male Female Male Female Adolescents Currently on 839 848 450 676 362 1393 ART 4568 Enrolled in OTZ 444 494 243 404 98 256 1939 Number Viral Load Done 155 215 82 133 36 134 755 Number Suppressed 126 190 74 113 36 134 673 Suppression (%) 81% 88% 90% 84% 100% 100% 89%

As the table 22 above presents, the cascade of outcomes for adolescents participating in OTZ present an overall VL suppression of 89%.

Positive Health Dignity and Prevention (PHDP) interventions

Results The enrollment of PLHIV in the PSSGs in Q1 is shown in the table below. The overall enrollment into PSSGs is at 12,581, which is 25% of current on ART of 50,451. Table 23 summarizes the effectiveness of enrollment in PSSGs on VL suppression for PLHIV. Table 23. PLHIV Enrollment in PSSGs (FY19 Q1). Attending Enrolled in Eligible for # % Support Groups literacy classes PSSGs VL Suppressed Suppression Total General PSSGs 2,143 3,826 3,826 3,821 100 Total PMTCT PSSGs 1,344 2,485 2,485 2,344 94 Total STF PSSGs 1,273 1,766 1,766 388 22 Total Pediatrics PSSGs 863 1,409 1,409 1,200 85 Total Adolescents PSSGs 1,162 1,942 1,942 1,591 82 Total Men-Only PSSGs 558 722 722 722 100 Total Discordant-Couples 372 431 431 413 96 PSSGs Total 7,715 12,581 12,581 10,479 83 Source: Facility records, including peer educators’ logs.

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Discussion As table 23 above presents, the PSSGs have been effective in increasing VL suppression, indicating that they improve adherence. Considering that the focus of the HF support groups is on clients considered to be at high risk, the above VL suppression rates are good. Overall, the PSSGs have been found effective in increasing retention and defaulter tracing and have eased the formation and running of community ART Groups (CARGs). They have been effective in adherence and disclosure counseling. Children and adolescents in PSSGs report significantly better suppression compared to overall suppression in that age groups. There are many situations and events that push PLHIV into vulnerable circumstances in the first place (like parental illness and death, lack of substitute parental care, abuse, etc.),which may have a lasting impact on their wellbeing. These groups help people living with HIV (PLHIV) to express themselves freely, and share experiences and challenges. The success of Afya Ziwani support groups has been attributed to these groups being run by peers in collaboration with HCWs. The peer educators identify clients’ needs per group and develop various educational topics for discussion during every support group meeting. The major challenge the support groups face is the transition to community support groups. The project is working in collaboration with AMREF to strengthen this. The project is identifying HFs with particularly low suppression rates to provide more support to, and is scaling up viremia clinics to address low VL amongst STF. The project is undertaking facility-level VL QI collaborative activities that are looking at the processes in management of STF to improve management of treatment-failure clients and standardize best practices across the program.

Differentiated models of care In differentiated models of care, clients are given longer intervals between clinic appointments, either through facility fast track or community ART delivery. These are interventions intended to better meet client needs, while decongesting overburdened ART sites, ensuring that care meets the diversity of patient needs and program expansion. The project supports HFs to implement differentiated care for eligible clients on ART, involving both facility fast track and CARGs.

Results In Q1, the following was achieved:

• 135 project supported HFs implemented differentiated care, reaching 63 % of the total 213 HFs supported. • 15,257 clients are supported through differentiated care, reaching 86% of the total 38,526 eligible clients currently receiving ART. • 13,474 are enrolled in facility fast track and 1,783 in CARGs.

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The reduction of the number of clients on DCM in this quarter in comparison to last quarter could be attributed to the characterization of clients with low viremia as STF clients, which has resulted in several DCM clients moving from the category of stable to unstable, hence being removed from DCM. Figure 1. Differentiated care cascade (FY19 Q1). Summary of DCM status Y1Q3 45,000 40,000 38,526 35,000 30,000

25,000 20,781 15,257 20,000 (86%) 15,000 12,262 13,474 10,000 5,108 5,000 384 1,753 Number of clients current on ART on current clients of Number 0 Well Advanced Current Stable Unstable Number of Number of Total DCM ART clients on clients on fast track CARGS At Enrolment < 12 months After 12 Months on treatment

Discussion As seen in the above Figure, a large percentage of eligible ART patients are accessing HF based fast tracking system where stable patients have a clinic appointment at least once every 6 months for clinical review, to ensure the standard package of care is delivered and to review if the patient still meets the stable criteria. Different HFs have different processes for facility based fast track ART refills that work best for their staffing levels, patient load, and infrastructure. The utilization of CARGs is most efficient when one member of the group visits the HF to pick up drugs for the other members. In Afya Ziwani, most facilities have adopted the peer-led CARGs and the family model CARGs for differentiated care. The project is working to increase the number of clients in the community ART groups through creating more awareness on the community model of differentiated care and encouraging client-led formation of CARGs. Evidence shows that patient formed and led groups have better outcomes than those driven by HCWs.

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5.5 Treatment of PLVLS Strategies to improve suppression include use of adherence support counselors (ASCs) to follow up on high VL clients and those with low level viremia, specific clinic days for unsuppressed clients, psychosocial support groups for high VL clients, and facility and regional MDTs to discuss clients with high VLs.

Results In Q1, project results include:

• 52,780 patients have a valid VL test (done within 12 months) as at the end of the reporting period. • 85% overall suppression, routine 88% and targeted. VL suppression by age cohorts is summarized in figure 2 below. Figure 2. Overall suppression by age (FY19 Q1).

60,000

50,000

40,000

30,000

20,000

10,000

0 < 9 10 to 14 15 to 19 20 to 24 25+ Total Unsuppressed 812 757 453 466 5,325 7,813 Suppressed 1,753 1,516 1,095 2,854 37,749 44,967

Suppressed Unsuppressed

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VL suppression by county is summarized in figure 3. Figure 3. Suppression by county (FY19 Q1).

88% 84% 88% 84% 82% 85% 100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Homa Bay Kisii Kisumu Migori Nyamira Total Suppressed Unsuppressed

VL suppression for the PMTCT AGYW subgroup, by age cohort, is shown in figure 4. Figure 4. PMTCT AGYW viral suppression by age group (FY19 Q1).

100% 90% 80% 70% 60% 50% 40% 80% 85% 88% 87% 30% 20% 10% 0% 10 to 14 15 to 19 20 to 24 Total

Suppressed Not Suppressed

Discussion During the reporting period, a total 52,780 clients had a VL done against the expected target of 54,226 for the period, giving a coverage of 97%. Of the total who received a VL test, an overall suppression rate of 85% was realized. This comprises 46,303 clients who received a routine VL with a suppression rate of 88%, and 6,464 who received a targeted viral load test with a suppression rate of 65%. Only 9, comprising 0.004%, had no data identifying whether they were routine or targeted tests and were 100%

23 suppressed during the reporting period. Across gender, 86% female and 83% male achieved viral suppression. Data were extracted from the national viral load website and re-duplicated using Excel before analysis. Q1’s routine VL test suppression rate of 88% is an improvement from the suppression rate of 85% achieved in FY18 and is approaching the PEPFAR target of 95%. Adults were better suppressed than were the adolescent and pediatric age groups across counties. But, as presented earlier, members of support groups from these groups presented much higher VL suppression. Children < 10 in support groups presented an 84% VL suppression rate, versus an overall rate of 66%. Adolescents between 10-19 years old presented an 88% VL suppression rate, versus an overall rate of 70%. This is a clear indicator that the project’s support for the above described PHDP interventions are having a positive effect on VL suppression for pediatric and adolescent cohorts. Suppression among the pregnant and breastfeeding PMTCT AGYW, at 87%, was also better than the overall suppression among the AGYW, at 79%. This could be due to the closer follow-up of pregnant and breastfeeding women. The project will leverage on the DREAMS interventions, such as Sister to Sister, as well as scaling up OTZ clubs to improve outcomes in this age group. The project will also continue to optimize ART for improved VL suppression, especially in pediatric clients and adolescents, in line with the new guidelines and through regular chart reviews. Rollout of dolutegravir (DTG) for improved VL suppression, as per the new guidelines, will be continued. The project will more closely follow up on suppressed clients with low level viremia (who account for approximately 8% of suppressed clients), by managing them like STF clients. This is because they have been shown to be at a higher risk of progression to treatment failure compared to fully suppressed clients. Registers are being procured to follow up these clients. The project is further identifying the HFs with particularly low suppression rates to provide more focused support. The project is undertaking HF-level QI collaborative activities that are looking at VL suppression and the processes in management of STF.

6. Laboratory support

In line with the directive provided by NASCOP requiring the VL monitoring of clients on ART using plasma, during this reporting quarter, the project supported biosafety training for Nyamira County lab staff, sensitization meeting on transitioning from DBS to plasma for the riders and HCWs from our five supported counties, and the Homa Bay Laboratory Commodity TWG.

6.1 Results

Laboratory monitoring In FY19, the project is supporting 213 HFs with ART and HIV/TB targets, with an annual target of 58,549 currently receiving ART (and who require access to VL and other testing, as per the national guidelines). The national system requires that samples be done for remote login at a subhub lab before being sent to a testing lab. The sub-hub lab HF then sends the samples to their identified central testing lab, which includes KEMRI Alupe-(Busia), KEMRI/ CDC (Kisian), and the Walter Reed Program (WRP) (Kericho). The project supports 14 sub-hubs for our 15 subcounties.

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During this reporting quarter, a total of 52,780 VL samples for the period of January to December 2018 were analyzed against 51,515 TX_CURR as of Dec 2018 (see table 24), translating to 102%. Females were 36,507 (69%), males 16260 (31%), and 13 had no data (0.02%). Of the 52,780 samples, 48,38 were pediatrics (9%), 4,868 adolescents (9%) and 43,074 adults (82%). Table 24. Viral load uptake performance per county. County VL Performance County No. VL done TX _CURR (Dec 2018) % Uptake Homabay 14,340 14,027 102 Kisii 2,036 2,080 98 Kisumu 8,742 7,853 111 Migori 13,731 13,888 99 Nyamira 13,931 13,667 102 Total 52,780 51,515 102

The project is supporting 13 CD4 sites, and during the period under review, a total of 1,214 baseline CD4 tests were done against 1,750 newly enrolled on treatment, translating to 69% uptake (see table 25). This is an improvement against 53% reported in the previous quarter and is due to increased availability of reagents. An average of 5% of the samples had CD4 less than or equal to 100. Table 25. CD4 uptake performance per county.

TX New- CD4 Done % County CD4 < 100 CD4 > 100 Oct-Dec 18 Oct-Dec 18 Coverage

Homa Bay 285 255 89 13 242 Kisii 174 80 46 5 75 Kisumu 313 218 70 11 207 Migori 442 131 30 10 121 Nyamira 536 530 99 20 520 Project Total 1,750 1,214 69 59 1155

Capacity building Capacity-building achievements during the quarter include:

• 26 laboratory staff from Nyamira County supported HFs received 5-day biosafety training toward infection prevention and control (IPC). • 40 sample riders from ten high-volume HFs, identified to transition from DBS to plasma transport, were sensitized on IPC, together with 11 sub-county medical lab coordinators (SCMLCs) from the respective facilities. The SCMLCs and riders also remapped facilities taking into consideration the timelines needed to handle plasma samples. • 31 HCWs from the ten high-volume facilities identified to transition from DBS to plasma were sensitized on safe phlebotomy, sample collection and packaging. The sessions were conducted by the testing lab staff from AMPATH, KEMRI Alupe, and KEMRI Kisian, who took the participants

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through the different testing protocols and sample management. Becton Dickson (BD) focal person also took the participants through safe phlebotomy.

Quality improvement Quality improvement achievements during the quarter include:

• During the reporting period under review, the project supported the Laboratory Commodity TWG for Homa Bay County, which led to 100% reporting rates for our two supported county subcounties (Kabondo and Kasipul), hence there was no RTK stockout. • Supported 7 testing sites that use POC EID machines that serve 158 EID satellite sites, in collaboration with the Elizabeth Glaser Pediatric AIDS Foundation. This has led to an average TAT of 1 day for the spoke facilities, and 1 hour for the hubs. • Continued to support 14 sub-hub labs serving 209 facilities, thus reaching 98% coverage of supported HFs with remote login. There has led to a tremendous increase in samples being processed in the respective sub-hubs, from 7,705 in January-December 2017 to 40,727 in January- December 2018. The average TAT for viral load is 11 days, while for EID is 5 days when we include sites without POCs (figure 5). Figure 5. TAT, from collection to the time results are received at the facility.

6.2 Discussion During the quarter under review, the project identified 10 high-volume facilities to pilot plasma transition. The identified sites are: Borabu SCH, Manga SCH, Keroka SCH, Ekerenyo SCH, Nyamira CRH, Gesusu SCH, Awendo SCH, Isebania HC, Rachuonyo SCH and Kabondo SCH. These are, in addition to four sites already processing plasma VL samples, that are located in Kisumu. Sensitization for the HCWs and the riders was done to enable smooth transition with minimum sample rejections. Sample collection commodities were sourced from the testing labs, with enough acquired to start off the process in the first week of January 2019. All the Nyamira samples will be taken to Walter Reed testing lab, a shift from KEMRI Alupe.

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Some of anticipated challenges and mitigations are as follows:

• Where there are frequent power outages, especially in Migori, secondary networking to private facilities with power back up will be an alternative to help meet the timeline of sample separation. • Due to poor road networks, like in Nyamira, remapping of hard to reach facilities was done to allow riders to collect samples and transport to the sub-hubs within the stipulated timelines. • USAID allocated slots for five centrifuges and the project shared a list of five facilities with need. • Plasma collection requires technical skills and the project will support safe phlebotomy training of the clinicians, nurses and lab staff, which will allow task shifting where there are no lab staff. The project expects to transition to plasma samples in 80% of the ART sites by the end of the next quarter. This is in consideration of the smaller facilities with inadequate HRH. There was a national stockout of Serum Crag reagent; the project has allocated some funds to procure buffer stock

7. TB–HIV coinfection services

7.1 Coinfection services results The implementation of TB–HIV services in all the 214 supported sites were conducted through continued provision of DSD with a focus on various capacity-building initiatives, which included sensitization of HCWs, mentorship, facility CME, joint supportive supervision, and performance-review meetings to improve on the testing of TB cases for HIV. Key TB–HIV performance indicators for COP 2018 are shown in table 26 below. Table 26. Key TB–HIV performance indicators for COP18. COP 2018 %age TB–HIV performance indicators Targets Y2Q1 achieved Number of TB cases registered 521 Number of TB patients who were counseled, were tested 1,558 500 32% for HIV, and received results Proportion counseled and tested for HIV and received 100% 96% results against COP17 targets Number of HIV-infected TB patients 225 Proportion of TB–HIV coinfection 45% Number of HIV-infected TB patients on cotrimoxazole 225 Number of HIV-infected TB patients on ARVs 622 217 35% Proportion of HIV-infected TB patients on ARVs 100% 96% Number of HIV-positive clients screened for TB 50,369 46,717 Proportion of PLHIV clients screened for TB against 100% 93% currently on ART TB_PREV 1,337 Source: PRISM. Note: ARV, antiretroviral; COP, country operational plan; PLHIV, people living with HIV.

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7.2 Coinfection services discussion The project is on track in reaching TB performance indicators for the FY 2 period. The project achieved 90 percent newly registered TB cases, 96 percent coinfected clients on ARVs, 93% percent HIV-positive individuals screened for TB, and 95% percent of CCC clients who completed IPT.

7.3 TB cascade

Results For the Y2 Q1 period, there were 521 new TB cases were identified, of whom 500 were counseled and tested for HIV, a 96 percent counseling-and-testing uptake among the TB-infected clients. When compared with the Y2 target of 1,558, this is a 32 percent achievement well above the expected 25% for the quarter. Table 24 summarizes the performance at county level. Table 27 shows the TB cascade for the reporting period. Table 27. FY19Q1 TB cascade. All TB County registered TB Known TB–HIV TB–HIV on TB–HIV on Cases Status Coinfection CPT ART Homa Bay 61 59 (97%) 30 (51%) 30 (100%) 26 (87%) Kisii 15 14 (93%) 7 (50%) 7 (100%) 7 (100%) Kisumu 66 65 (98%) 34 (52%) 34 (100%) 30 (88%) Migori 98 90 (92%) 37 (41%) 37 (100%) 37 (100%) Nyamira 281 272 (97%) 117 (43%) 117 (100%) 117 (100%) Afya Ziwani 521 500 (96%) 225 (45%) 225 (100%) 217 (96%) Note: ART, antiretroviral therapy; CPT, cotrimoxazole preventive therapy.

Discussion Twenty-one TB clients were reported as not tested for HIV who upon follow-up were found to have received the test, but improper documentation had taken place at the facility. The project is working with the SCTLCs to correct this and strengthen reporting in non-ART sites. To improve reporting, the project will continue involving the TB coordinators in the monthly data review meetings to improve their understanding of the TB–HIV data. Of the 500 TB clients that received a HIV test, 318 (64%) were newly tested cases while the rest were know positives co-infected with TB. Of the 318 newly tested, 43 (14%) were new positive which when combined with the known positive gives an overall positivity rate of 45% (225/500). The TB data were collected by the project team from the facility TB4 registers using an age- disaggregating tool and uploaded into the projects data management system, PRISM. Compared to the APR target of 1,558, the project is well on course to achieve with a performance of 32% (500) against the expected 25% for the quarter. Homa Bay and Kisii were below the expected target at 20% and at 13%. Respectively. The lower than expected performance was as a result of the low TB detection rates in the supported facilities which is being addressed by improving active case finding in those facilities. In the coming quarter the project is going to conduct sensitizations on active case finding in all the supported facilities to improve on this. The project will continue working through the cough

28 monitors to strengthen facility level active case findings and referral for TB diagnosis and treatment. The project is also experiencing stockouts of the TB ICF cards in some facilities and redistribution is ongoing as the project awaits printing and distribution from the national mechanisms on printing of MoH tools.

7.4 TB ART

Results During the reporting period of October to December 2018, 217 clients of the 225 identified as TB–HIV coinfected (96 percent) were put on ART. Five (5) of the patients were in the requisite pre-initiation stages of TB treatment by the end of the reporting period while three (3) were ascertained to be poor documentation since they were already known positives on ART. The county-specific ART uptake showed that Nyamira, Migori and Kisii at 100%, Kisumu 88% and Homa Bay 87%. This is an improvement from similar period Q1 FY 2018 when ART uptake in Migori was 100%, Nyamira 98%, Homa Bay 97%, Kisumu 91% and Kisii 50%. The greatest improvement has been in Kisii County.

Discussion Towards the end of quarter one, the TIBU system had challenges with synchronizing of data from cloud which interfered with some of the TB–HIV indicators data completeness. This has since been addressed through TIBU phase 3B training. To improve ART uptake, management of TB–HIV co-infected clients and integration of TB–HIV services, the project, in the coming quarter, will organize a HIV training specifically targeting county and sub county TB coordinators. The project is also strengthening the HIV TWGs to have a standing HIV/TB agenda in all supported counties in addition to the TB specific TWGs such as the GeneXpert TWG.

7.5 Provision of Isoniazid Preventive Therapy (IPT) for TB

Key strategies/interventions The project supports isoniazid preventive therapy (IPT) initiatives in all project-supported counties, with a focus on asymptomatic clients initiated on IPT along with clear analysis of the IPT outcomes of those initiated on IPT six months earlier. To ensure sustainability and improvement on IPT documentation and completion, the project provides capacity-building initiatives and mentoring of HCWs and pharmacists on accurate documentation in IPT registers, as well as timely ordering of IPT tablets and other commodities. The project conducts file reviews to establish the IPT status among the CCC clients.

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Results During the reporting period, 1337 of the 1380 clients started IPT six months prior completed TB prophylaxis treatment. 1% each discontinued, transferred out and were lost to follow-up as highlighted in table 28 below. A total of 7 clients developed TB after completing TB preventive therapy treatment and were investigated and started on anti TB treatment. Table 28. IPT for TB. Indicator Number Percentage Total Clients who Started IPT 6 months ago 1380 Total Treatment completed (TC) 1337 97 Total Transferred out (TO) 20 1 Total Discontinuation (TNC) 13 1 Total Lost to follow-up (LTFU) 10 1

7.6 TB screening

Results During the reporting quarter, 46,717 of the 50,369 were screened for TB representing a 93% screening rate as highlighted in table 29 below. Table 29. County TB screening. County TX_CURR TB Screening Percentage

Homa Bay County 14,055 13,712 98

Kisii County 2,142 2,113 99

Kisumu County 8,130 7,047 87

Migori County 13,162 11,744 89

Nyamira County 12,880 12,101 94

Total 50369 46717 93

Source: DHIS.

Discussion Migori and Kisumu performed below expected at 89% and 87% respectively. This is due to poor reporting of the indicator during data collection in some facility something which is being addressed. All TB data will be reviewed during the data review meetings before submission for uploading to DHIS2. The project work with 23 cough monitors supporting all high-volume sites in active case finding in OPD and other service delivery points. In Q1, 13,777 suspected TB cased were identified through active case finding. 12,392 were tested for TB using GeneXpert of whom 200 were diagnosed with TB and put on treatment.

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8. Elimination of mother-to-child transmission of HIV

8.1 PMTCT The project provides DSD support to 163 HFs with PEPFAR targets. In the quarter, a significant additional deployment of 63 mentor mothers (MMs) was made to make a total of 120 MM’s covering 87 supported PMTCT sites. In addition, the project is supporting a total of 20 community MM’s (10 in Homa Bay, 5 Nyamira and 5 Migori). Support was also provided through ASCs, whose services were rendered to the high VL clients. Integration of FP services within the CCCs with the strengthening of the pregnancy intention assessment screening also continued in the quarter.

Results Key results of the intervention are as follows:

• 120 MMs deployed at 87 HFs providing PMTCT services • 288 HCWs received sensitization on dual HIV/syphilis testing in all the counties to improve uptake of syphilis testing at antenatal care (ANC) facilities. In Q1, as presented in the following table, of the 9,246 women attending first ANC visit, 9,067 (98%) knew their HIV status, which reached 24% of the annual target of 39,248. With 98% of women knowing their status, this reached 98% of the 100% percent target. Table 30 presents total results for PMTCT_STAT by county. Table 30. PMTCT uptake by county (FY19 Q1). 1st ANC (with 100% with known PMTCT STAT status) Testing Total Known New County Percent Missed Positives Positive Positive Target Actual Against Actual Percent Opportunities Target Homa 6,248 1,432 23 1,417 99 231 183 48 15 Bay Kisii 2,075 554 27 552 88 8 7 1 2 Kisumu 5,154 1,447 28 1,435 97 167 119 48 12 Migori 11,231 2,838 25 2,769 97 247 185 62 69 Nyamira 13,468 2,975 21 2,894 88 127 80 47 81 Total 38,176 9,246 24 9,067 94 780 574 206 179 Source: Ministry of Health (MOH) 711/MOH 731 reports.

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The project further disaggregated PMTCT performance for AGYW, as shown in the figure 7. Figure 6. AGYW PMTCT Cascade (FY19 Q1).

Source: Project databases.

Overall, 255 (2.6%) of the pregnant women who knew their HIV status were positive, as presented in table 31. Table 31. PMTCT_POS summary achievements against COP18 targets (FY19 Q1). Numeric Against Indicator Q1 Result Target numeric target Number of pregnant women that are HIV 3,652 780 8.6% 21.0% positive Number of pregnant women known to be HIV 2,453 74.0% positive (known positives) Number of pregnant women newly positive 1,199 26.0% Number of pregnant women issued with 1,095 750 96.0% 21.0% prophylaxis Number of infants issued with prophylaxis 3,652 728 93.0% 20.0% Source: Ministry of Health (MOH) 731/ MOH 711 reports. As can be seen, the project has reached 21% of the numeric target, and 96% of the percent target for first- contact ANC clients starting maternal ART. While achievement against the percent target was at 21%, the lower performance against the numeric target is due to the lower than targeted number of first ANC contacts identified Project supported PMTCT providing HFs continued to record a high number of known positive clients at entry, with 73% percent (574 out of 780 positives identified), which is attributed to known positive clients desiring and confident to have children due to the success of the PMTCT program and improved quality of life with good viral suppression.

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PMTCT cohort analysis and VL suppression PMTCT cohort analysis was conducted in all PMTCT-supported sites to establish client retention at 3, 6, 9, and 12 months after enrollment and viral suppression. Table 32 summarizes the findings. Table 32. Average VL suppression among PMTCT clients (FY19 Q1). Pregnant Breastfeeding

<15 years 15–19 >20 years <15 years 15–19 >20 years Number of samples taken 2 8 290 3 25 766 Number suppressed 2 6 269 3 23 698 % Suppression 100 75 93 100 84 91 Source: National AIDS & STIs Control Programme (NASCOP) /early infant diagnosis (EID) website.

According to the EID website, there has been an improved national trend of PMTCT cohort suppression with an overall average suppression of 87% among pregnant and 91% among breastfeeding mothers. In reviewing the month-on-month VL suppression trend, the project demonstrated an upward trajectory with suppression at Q1 of 90%.

Maternal cohort analysis PMTCT cohort analysis was conducted in all PMTCT-supported sites to establish client retention at 3, 6, 9, and 12 months after enrollment and VL suppression. Table 33 illustrates the quarter’s performance. Table 33. PMTCT cohort analysis (FY19 Q1).

Indicator 3M Cohort 6M Cohort 12M Cohort 24M Cohort KP NP Total KP NP Total KP NP Total KP NP Total

Retention Enrolled into cohort 347 217 564 354 247 601 306 221 527 206 168 374 Transfer in (T.I) 67 2 69 62 2 64 53 1 54 38 8 46 Transfer out (T.O) 8 13 21 13 24 37 24 35 59 24 24 48 Net Cohort 406 206 612 403 225 628 335 187 522 220 152 372 Defaulters 1 7 8 4 5 9 6 4 10 0 2 2 Lost to follow-up (LTFU) 0 0 0 12 12 24 7 19 26 9 23 32 Reported Dead 0 1 1 1 0 1 0 1 1 0 2 2 Stopped 0 0 0 1 1 2 0 0 0 0 0 0 Alive and active on treatment 405 198 603 385 207 592 322 163 485 211 125 336 % Retained 99.8% 96% 99% 96% 92% 94% 96% 87% 93% 96% 82% 99% VL testing Viral load collected and results available 316 0 316 338 175 501 302 147 449 201 117 318 Virally suppressed (VL<1000) 307 0 307 327 163 490 295 143 438 197 116 313 % Virally suppressed 97% 0% 97% 97% 93% 98% 98% 97% 98% 98% 99% 98%

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Retention As the above table presents, retention at 3, 6, and 12-month cohorts was 99%, 94%, and 93% respectively. KPs have slightly better retention across the cohorts; perhaps these are clients on follow-up with good adherence. This strong performance can be attributed to monthly maternal cohort analysis at the HF level, updating of the PMTCT cohort dashboard, and gaps identified for follow-up. The same is discussed during facility data-review forums to identify retention and suppression gaps within the cohort for review. MM program has also demonstrated retention among the mothers.

VL uptake and suppression The results are similar across cohorts, with viral load uptake for the 6-month (501/592) and 12-month (449/485) cohorts at 85% and 93% respectively, with similar results for known and newly tested positives. This strong performance can be attributed to continuous mentorship and tracking of eligible mothers for VL, using the patient file and PMTCT ART cohort register. However, the low performance for the 6-month (85%) and 3-month (52% - 316/603) cohort is majorly lack of documentation. Continuous chart reviews at HF level to flag any missed opportunity were also conducted, and mothers were pre-called for sample collection.

Discussion The 7 supported HFs in Homa Bay with community MMs demonstrated high performance, showing the efficacy of the intervention. This included PMTCT_STAT (26%), EID testing <2 months (>80%), MTCT rate (<5%), and retention of mother-baby pairs >85%. There were 179 missed opportunities for testing at first ANC contact in the reporting quarter, most of them in Nyamira (81) and Migori (69) The high number in Nyamira was due to the HCW strike that extended to October. Other challenges experienced were the refusal by some MCH nurses to test mothers for HIV (which is being addressed nationally by MOH/NASCOP through the nurses’ professional body) and through frequent rotation of staff in ANC departments, especially in high-volume facilities. Overall, the project supported the HFs to follow-up with the mothers in subsequent visits and offer testing. To improve the proportion of ANC clients with known status during the reporting quarter, the project hired locum staff to cover MCH and other HIV service delivery points (SDPs) in affected facilities in Nyamira County. In addition, the project supported MOH mentors to visit medium- and low volume facilities to provide technical mentorship and provide services. There were 30 maternal ART and 52 infant ARV prophylaxis missed opportunities during the reporting quarter. The main reasons for the missed opportunities were issues of inadequate and/or incorrect documentation that was shown by data audits undertaken; mothers declining ART; the desire by some to consult their spouses (disclosure issues); and not being ready for ART at the first ANC visit. The HFs closely followed up with these mothers to ensure that they get ART prophylaxis in subsequent visits. A challenge faced during the reporting period included client charges for ANC profile testing in private and faith-based organization sites, and the limiting of universal access to PMTCT services and retention up to the fourth ANC visit. Limited access to community-level structures to enable them to assist CHVs in doing ANC mapping and referrals led to only a few mothers being referred to the facilities by CHVs.

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8.2 Early infant diagnosis (EID)

Overall key results The number of EID tests for HEI between 0–12 months old, overall and by county, is shown in table 34. Table 34. Overall EID tests between 0-12 months old (FY19 Q1). Achievement County Target Q1 Against Target Homa Bay 957 219 23%

Kisii 96 21 22%

Kisumu 718 168 23%

Migori 914 287 31%

Nyamira 967 204 21%

Total 3,652 899 25%

As can be seen, 899 children were tested in Q1, reaching 25% of the annual target of 3,652. However, PEPFAR is targeting 90% to 95% of HEIs to receive EID within 2 months old. Q1 results are shown in table 35. Table 35. EID test performance for 0-2 months old (FY19 Q1)1. Total PMTCT POS (ANC1 plus No. No. % Achievement County Total POST ANC1- 0–2 Months Old 2–12 Months Old 0–2 Months Old Preg, L&D, PN) Homa Bay 243 145 74 219 60 Kisii 25 16 5 21 65 Kisumu 200 120 48 168 60 Migori 247 202 85 287 82 Nyamira 173 102 102 204 59 Total 888 585 314 899 66

EID testing achievement in Q1 for infants under two months old was at 66%, an improvement from the overall EID testing for that age group of 60% for FY18. Overall, county performance was not optimal with Homa Bay at 60%, Kisumu and Nyamira at 60% and 59%, respectively caused by low achievements across the cascade.

1 Establishment of EID POC in Uriri, Kabondo, Keroka, Awendo and Isebania and SCHs has helped to reduce TAT of results and allow caregivers to receive results within 24 hours.

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Discussion of overall results The below-target uptake of PCR testing for infants by 2 months old can be attributed to mothers coming late for follow-up and missed opportunities for sample collection due to lack of skills by providers to draw PCR samples from the infants (which has been observed across the counties). In addition, some HCWs, mainly nurses, see this activity as not part of their duties, especially witnessed in Nyamira and Migori county project-supported HFs. Despite this low achievement, the MM program is an initiative that has led to an upward trajectory of early EID in the facilities where they are deployed. EID tests’ booking, appointment reminders, and line listing of missed opportunities at 6 weeks for follow-up before eight weeks have been some of the best practices that has led to increase in early EID, albeit at a slow pace. To address this low performance, the project is working with county and subcounty public health nurses to address this, and at the same time the project is building the capacity of these nurses through facility- based OJT on sample collection. HTS providers and the laboratory personnel are also collecting the samples where we there are serious challenges

EID cascade and linkage of positive infants

Key cascade results The project results for the EID cascade (for initial tests of infants between 0-12 months old) for the quarter are shown in table 36. Table 36. Early infant diagnosis (EID) cascade – initial tests only (FY19 Q1). Number HIV-positive women 780 Number initial PCR 0-12 months old 899 Number PCR test 0-2 months old 585 66.0% Number confirmed PCR positive 21 2.3% Number HEI PCR POS linked to treatment 20 100.0% Number PCR POS baseline VL 16 76.0%

Using the PMTCT_POS indicator as a proxy denominator for PCR testing, the project recorded a lower number of PCR at initial testing of (66%) compared to the total number of HIV-positive pregnant women at ANC, L&D and PNC for the quarter for testing within 0-12 months, with 21 PCR positives, giving a mother-to-child transmission (MTCT) rate of 2.3% for the reporting period. Of the 21 infants who turned PCR positive, 76% (16) received a baseline VL with results obtained from the EID website. This is a lower performance from 84% performance in FY18. More efforts will go towards ensuring all the infants who turned positive get a baseline VL.

HEI MTCT audits MTCT audits were conducted for all the 19 infants identified positive. A majority of these were due to missed opportunities at ANC, so were later identified during postnatal visits; unskilled deliveries, mixed feeding by the HIV-positive mothers; and mothers who remained in denial that led to poor adherence due to nondisclosure and lack of acceptance of their HIV status.

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Project results for the EID cascade for all HIV-positive findings (0-12 months and >12 months) are summarized in table 37. Table 37. Linkage status of all HIV-positive infants - 0-12 months and >12 months (FY19 Q1). Linkage to HEI treatment and other outcomes Total HEI confirmed positive 21 Number enrolled and initiated on treatment 20 Number died before enrollment 0 Number LTFU 1 Source: National AIDS & STIs Control Programme (NASCOP)/early infant diagnosis (EID) website.

Of the 21 infants confirmed HIV positive, 11 were between 0-12 months old, and 10 were >12 months old, based on data collected form the facility EID tracking log Of the 21 total positives identified, all had a documented outcome, with 20 (95%) enrolled and initiated on treatment. One mother declined having her infant enrolled and initiated on treatment but is being followed up on to ensure enrollment in subsequent visits. This is consistent with FY18’s result of all infants accounted for and 96% enrolled on treatment.

HEI positivity and HEI mortality audits HEI audits were conducted for 19 infants identified as positive at initial and repeat testing during the quarter, with an aim of understanding the possible causes of transmission and finding solutions to prevent such causes where possible. Table 38 summarizes the findings of the positivity audits. Table 38. Outcome of HEI positivity audits (FY19 Q1). Infant PCR Audit Report Maternal Details General findings General findings Total PCR positive 19 Total audited 19 Total PCR positive audited 19 Attended ANC 13 PCR positive <2/12 8 Known positives 7 PCR positive > 2–2/12 5 Newly diagnosed 12 PCR Pos> 12/12 6 Partner tested 9 Maternal prophylaxis received at HEI missed infant prophylaxis 13 8 ANC Baseline VL 14 Good adherence 4 Exclusive breastfeeding by 6 months 13 Hospital delivery 8 Outcomes Disclosure done 11 Enrolled on treatment 19 Mothers with high VL at ANC 4 Dead 0 Outcomes LTFU and unlinked 2 Alive 19 Transferred out 0 Dead 0

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The MTCT audit showed that key reasons for MTCT were lack of skilled deliveries (42%), missed infant prophylaxis (68%), missed maternal prophylaxis (58%), late PCR tests after two months (58%), and lack of attendance at ANC by the mother (79%). The high number of missed opportunities for skilled delivery can be attributed to many HFs not providing 24-hour maternity services, and mothers preferring home delivery by traditional birth attendants. This is based on a focused group discussion conducted with 10 of the mothers in Homa Bay and Migori who claimed they receive better care by the birth attendants compared to hospitals. PCR testing >2 months old was attributed to mothers with late presentation at postnatal care, maternal appointment adherence challenges, and/or defaulting on treatment at ANC. The project conducts PCR validation using the NASCOP EID website with samples for identified PCR- positive at initial test and repeats at second and third PCR tests for infants 0 to 12 months old, with results presented in table 39. Table 39. Validation testing results for PCR-positive infants 0–12 months old. EID Cascade (October to December 2018) Number HIV-positive women 780 Number initial PCR 0-12 months old 899 Number PCR test 0-2 months old 585 66% Number confirmed PCR positive 21 2.3% Number HEI PCR POS linked to treatment 20 100% Number PCR POS baseline VL 16 76%

In Q1, there were no HEI positives reported as deceased, thus no HEI mortality audit conducted in the reporting period.

HEI cohort analysis (12- and 24-month cohort review) During the reporting period, PMTCT infant outcome results were reviewed across the 12 month and 24- month cohorts. The primary goal was to establish MTCT rates and the percentage retained/active in follow-up. The HEI cohort analysis outcome data for the 12-month cohort of infants on follow-up at 12 months is presented in table 40. Table 40. HEI analysis of 12-month cohort (FY19 Q1). HEI Outcome Analysis of 12-month Cohort Absolute % (at 12 Months) Numbers outcomes Total enrolled into the cohort 613 Active in follow-up 477 78 Died between 0 and 12 months old 11 2 Missing 12 months follow-up 41 7 Identified as positive between 0 and 12 months 35 6 Transferred out between 0 and 12 months 49 8

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HEI cohort analysis outcome data for the 18-month cohort of infants reviewed at 24 months are shown in table 41. Table 41. HEI analysis of 18 month-cohort at 24 months (FY19 Q1). HEI Outcome Analysis of 18-month Cohort Absolute % (at 24 Months) Numbers outcomes Total enrolled into the cohort 542 HEI AB negative at 18 months 401 74.0 HEI Active at 18 months but no AB test done 43 8.0 HEI Identified as positive between 0 and 18 23 4.0 months HEI Transferred out between 0 and 18 months 25 5.0 HEI Lost to Follow‐Up between 0 and 18 months 42 8.0 Died between 0 and 18 months 8 1.5

Overall, the retention rate was 78% for the 12-month cohort, and 82% for the 24-month cohort. The MTCT rate was 6% for the 12-month cohort, and 4% for the 24-month cohort (with testing between 0-18 months). The retention rate for the 12-month cohort is better than 24-month cohort, though <90% percent. The project recorded only 8% of infants missing 12-month follow-up.

EID cascade discussion Overall, the above fair performance can be attributed to the project’s continued focus on promoting retention of mother-baby pairs by strengthening appointment and defaulter tracing systems; PMTCT PSSGs; quality improvement team (QIT) meetings with clinicians, MMs; and capacity-building of HCWs and PEs/MMs. These data are collected at facility level and uploaded into DHIS2. Facility staff utilize the data to make decisions like early defaulter tracing, and mortality audits to determine cause of deaths and how these can be averted to prevent future deaths. The MM program has supported and improved mother-baby pair retention through their mentoring process and ensuring the mother doesn’t miss her appointment. They also support adherence, including leading the mothers in PSSG to improve on adherence. Harmonized clinic visits with the immunization program has helped to improve retention since the mothers make one clinic visit in a month for all the services, which is a motivation to the mothers. Integration of ART and HEI follow-up at MCH has also improved retention of mother-baby pairs, as mothers get all their services as one-stop-shop, which reduce issues of stigma. Despite this good practice, there are still challenges of that hinder quality provision of services to the mothers, including some HCWs still viewing HIV as a partner affair, leading them to be hesitant to follow mother-baby pairs at MCH clinics.

9. Commodity security

To improve supply chain logistics and commodity management, the project supports 22 ART ordering sites (18 central and 4 standalone) and the over 200 HFs that they link with in commodity management. In the quarter, focus was put on supporting the national transition to the new drug regimen of TLD (tenofovir/lamivudine/dolutegravir). The project is supporting the availability of enough stock through mentorship, CME, and sensitization on TLD transition. Owing to the recent circular on potential adverse

39 effects of dolutegravir (DTG) in pregnant and breastfeeding women, the transition is now required to focus only on eligible populations (adolescents, adult men, and women over 49 years old).

9.1 Results

DTG transition The project currently has 172 facilities with clients on TLD, which is an improvement from 120 in FY18. Across all supported HFs, 7,083 clients have been transitioned to TLD, compared to 2,810 in FY18. This represents 14.1% of the total number of project-supported clients on treatment.

Treatment optimization The project has transitioned a total of 6,345 patients to TLD and TLE400, representing an achievement of 40% of the NASCOP target of 16,031 in 20 ARV ordering sites, which are also the RRI sites.

Pharmacovigilance reports A total of 15 pharmacovigilance reports were submitted to the Pharmacy and Poisons Board in the quarter. Nine (9) were related to side effects associated with Efavirenz, 4 to Cotrimoxazole, and 1 each related to Isoniazid and Atazanavir/ritonavir.

Monthly ordering sites reporting rates into DHIS2 In Q1, the 22 ordering sites achieved an overall 98% reporting rate for submission of monthly reports into the DHIS2 platform. Figure 7 shows each of the project supported counties’ reporting-rate percentages for the quarter. Figure 7. Central and satellite ART commodity sites’ reporting rates into DHIS2 (FY19 Q1).

100.00%

80.00%

60.00%

40.00%

20.00%

0.00% Homa Bay Kisii Kisumu Migori Nyamira

October November December

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Laboratory commodities Figure 8 breaks down the RTK reporting rates by county and month. Figure 8. County reporting rates of RTK in the health commodity management platform (FY19 Q1).

100

80

60

Percentage 40

20

0 Homabay Kisumu Kisii Migori Nyamira Oct 100 100 100 93 100 Nov 100 100 100 93 98 Dec 100 100 100 100 100

During the reporting period under review, Migori County added a total of 15 HTS sites that were not in the HCMP but in the DHIS, hence the drop in reporting in the month of October and November. The additional sites were able to report independently in the month of December, thus achieving 100%. Adding the sites to HCMP platform was also to allow the sites to get RTK commodities directly from KEMSA and not rely on the subcounty to redistribute to them after KEMSA distribution.

9.2 Discussion Owing to the recent circular on potential adverse effects of DTG on pregnant and breastfeeding women, progress on DTG transition in the quarter was slowed, as the only eligible population are adolescents, adult men, and women over 49 years old. Transition to TLD now requires the patient to have a low detectable viral level of HIV of <50. The project has been supporting DBS for VL testing, which is not sensitive below around <839 copies/ml. As such, the project is now transitioning to using blood plasma for assessing VL. This is a much more complicated procedure, as the blood has to be drawn at the HF and placed in a plasma preparation tube (PPT), then centrifuged, and then with the plasma placed into another PPT. The plasma needs to then be refrigerated, and once removed, transported to and received at a testing site to allow testing within 6 hours. This requires scheduled blood drawing days, and increased logistics between the HFs, sub-hub labs, and testing sites. It also requires necessary equipment and supplies e.g. PPTs, centrifuge, and refrigerator. Transitioning of the MOH identified 6,031 current patients in 20 HFs with low detectable levels (LDL) has, therefore, been slow. As of the end of the quarter, 3,813 patients have been transitioned to TLD, while another 2,532 have been transitioned to tenofovir/lamivudine/efavirenz 400 (TLE400), representing a total of 6,345 patients and 40% achievement. In addition, NASCOP also directed facilities to first consume tenofovir/lamivudine/efavirenz 600 (TLE600) before transitioning patients to TLE400 to

41 avoid expiry of the commodities. The project is redistributing excess TLE600 to hasten the transition to TLE 400. To mitigate against any stockouts of NVP due to the delayed transition to DTG, the project is closely monitoring, on a regular basis, the NVP stock status in all supported facilities and will redistribute the stocks where necessary. The project will also continue supporting pharmacovigilance reporting in all sites in view of the ART optimization

10. HRH

10.1 Providing mentorship, monitoring, and advocacy capacity-building to CHMTs and SCHMTs

Mentorship During the reporting period, the project engaged the lead mentors for Homa Bay, Kisii, Kisumu Migori and Nyamira counties in discussions on the NASCOP mentorship model to identify mentorship gaps in eleven high and medium volume facilities.2 The process involved chart reviews and register audits carried out with the facilities’ CCC teams. Gaps identified across the facilities included: inadequate documentation in MOH client encounters and primary tools, missing HIV job aids in patient files, HCWs not oriented to new ART treatment guidelines, and a lack of mentorship by S/CHMT. A mentoring action plan was developed with the lead mentors leading to the C/SCHMTs conducting 77 mentoring visits to eleven high and medium-volume sites across five counties in the quarter.

MPR/CQI During reporting period, the Afya Ziwani project engaged the SCHMTs Major gaps identified in the Monthly Progress Reviews for Homa Bay, Kisii, Kisumu, Migori / Continuous QI Reviews: and Nyamira through the Subcounty AIDS STI Coordinator (SCASCOs) 1. Data discrepancies on current number of clients (at the end of the month) between the MOH primary tools and county lead mentors to assess and the EMR and ADT tools. monthly progress review and 2. Page summary in MOH 361B (ART tegister) not continuous QI review data to identify updated at the end of the month capacity gaps and training needs for 3. Incorrect documentation in the presumptive TB HIV service delivery. The review register for Gene -Xpert results. process involved comparisons of HIV 4. Incorrect management of patient appointment diaries. 5. Challenges with documenting PNS outcomes in the service data between primary source appropriate tool. registers, the ARV dispensing tool (ADT), electronic medical records (EMR), and the MOH 731 reporting tool. Chart audits and monthly report reviews were undertaken together with the facility staff at 14 CCCs. The SCHMTs and lead mentors developed a follow-up action plan with the facility staff in the 14 high and medium-volume facilities3 in quarter one. Gaps identified were addressed through clinical mentorship, OJT, and CME.

2 Nyalenda Health Centre, Airport Health center, Uriri Sub county Hospital, Ntimaru Health Centre, Awendo Sub County Hospital, Gesusu Sub County Hospital, Masimba Sub County Hospital, Kijauri Sub county Hospital, Nyamira County Referral Hospital, Othoro Health Center, and Kabondo Sub County Hospital. 3 Ojola Health center, Airport HC , Gita SCH, Ntimaru, Kegonga SCH, Isebania SCH, Ting’a, Kokwanyo, Othoro HC, Kijauri SCH, Keroka SCH, Nyamira CRH, Gesusu SCH, Masimba SCH.

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Table 42 shows the facilities where MPR-CQI was conducted in the reporting quarter.

Table 42. Facilities where MPR-CQI was performed. County Facilities where MPR –CQI conducted Airport Health Centre Kisumu Ojola Health Centre Gita SCH

Othoro Health center Homa Bay Ting’a Health center Kokwanyo Health center

Kisii Gesusu Sub County Hospital Masimba Sub county hospital

Nyamira County Referral Hospital Nyamira Keroka Sub county Hospital Kijauri Sub County Hospital

Ntimaru Sub County Hospital Migori Kegonga Sub County Hospital Isebania Sub county Hospital

As a result, the project supported 18 hospital mentors drawn from 54 medium and high-volume facilities across the five counties. Mentorship covered the following topics: new Kenya ART Treatment Guidelines 2018, MOH reporting tools, and management of STF, reaching 112 HCWs cumulatively.

Training During the reporting period, the project worked with the NASCOP trainers and community facilitators to support the training of 562 HCWs on quality HIV service delivery, with the training data updated in iHRIS. Table 43 provides a summary of the trainings supported by the project. Table 43. Training data. Training Number Trained Training on 2018 New Kenya ART Treatment Guidelines 395 Training on Electronic Management of Records (EMR) 167 Total 562

Continuous medical education (CME) support In the reporting period, the project supported the rollout of CME sessions across project supported facilities. Specifically, the project supported CMEs on Operation Triple Zero (OTZ) in Kisumu, Nyamira, Kisii, Migori and Homa Bay counties, reaching 53 facility staff from 15 HFs with the objective of improving retention and viral suppression among adolescents. An additional CME session on STF

43 management covered seven facilities, reaching 30 HCWs. In total, during the reporting period, 83 facility staff from 22 health facilities were reached with CME activities. HCWs were oriented on the use of job aids for selected priority areas aimed at improving the quality of service provision at 14 medium and high-volume facilities. The key areas addressed included: PNS, and STF (management of patients with high viral load). The project supported subcounty hospitals in Kisumu, Homa Bay, Migori, Nyamira, and Kisii to participate in web-based CME case management sessions through the Extension for Community Health Outcomes (ECHO) platform, hosted at Jaramogi Oginga Odinga Teaching and Referral Hospital by the ICAP project. In total, 100 HCWs across five counties (table 44) were reached during the reporting quarter. Table 44. Health facility staff participation in the ECHO CME sessions. County Facility No of Staff Reached Awendo Sub County Hospital 6 Sony Medical Centre 2 Isebania Sub County Hospital 3 Migori Kuria District Hospital 2 Kegonga Sub county hospital 3 Uriri Sub County Hospital 7 Ntimaru Sub County Hospital 3

Disciples of Mercy 3 Migosi Sub County Hospital 12 Port Florence Community Hospital 4 Kisumu Nyalenda Health Centre 4 Airport Health Centre 3 Gita Sub County Hospital 3

Kisii Gesusu Sub County Hospital 8

Nyamira CRH 3 Kijauri Sub County Hospital 2 Nyamira Manga Sub County Hospital 2 Keroka Sub County Hospital 2

Rachuonyo Sub County Hospital 17 Homa Bay Matata Nursing Home 4 Kabondo Sub County Hospital 7 Total 100

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CME topics included:

• Use of family clinics to optimize viral load suppression in children. • Laboratory investigations in HIV infections. • Cervical cancer screening for women living with HIV. • 2018 ART Treatment Guidelines refresher on transitioning clients from Nevirapine and Efavirenz to Dolutegravir based regimen.

10.2 Strengthening the annual work plan and performance-based budgeting (PBB) process To achieve this goal, Afya Ziwani project engaged with the USAID projects, HP+ and Tupime Kaunti, to collaboratively implement a harmonized strategy to strengthen PBB in the 5 five counties jointly supported by the three projects. The project works with HP+ trained PBB trainers of trainers (TOTs) to design and implement capacity strengthening interventions for SCHMT and HF managers. The project also worked with HP+ to support PBB-TOTs to mentor CHMTs, and train and mentor SCHMTs and HF managers to understand the importance of the budgeting cycle, as well come up with a mechanism for monitoring the PBB process.

Key results Table 45. Refresher training # by county. During the reporting period, Afya Ziwani worked with the HP+ project to conduct a refresher training to PBB- Afya Ziwani Number TOTs from 13 counties in the western Kenya region. Supported Counties trained Among them were the 5 Afya Ziwani supported counties. Kisii county 2 In this collaboration, HP+ supported Homa Bay, Kisumu Nyamira county 3 and Migori, while Afya Ziwani supported Kisii and HP+ Supported Nyamira PBB TOTs to participate in the refresher training Counties (table 45). The participants were a mixed group, made up Kisumu 2 of county HRIOs, health economists, and accountants and Homa Bay 2 administrators from the county departments of health and Migori 2 treasuries.

Discussion During the plenary, it emerged that the health sector at the county level is yet to fully institutionalize PBB in the majority (75%) of the counties represented. However, comparatively, the health sector is still far ahead of the other departments in the utilization of the PBB templates. The departments of health should work closer with the county economic planning and treasury department, especially in adhering to the budget cycle. This will enable the departments of health to improve absorption of disbursed funds, as well as improve allocative efficiencies.

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There is minimal involvement of internal stakeholders 1) Sensitize all CHMT on importance of budgeting cycle e.g. SCHMTs, in undertaking PBB. Only the county 2) Train SCHMT on budget cycle and importance of PBB. leadership structure (CHMT), is consulted during the 3) Continuously engage the County Budget Committee, process. It also emerged that prioritization is not carried County Implementation Committee and County Health out in a structured manner and the counties need Committees to support health sector agenda and PBBs. technical support to utilize PBB, activity-based costing, 4) Lobbying the Executive to properly institute sector as well as ensure that the mid-term expenditure working groups to assist in preparing sector ceilings, framework (MTEF) process is understood by all policy county budget review, outlook papers (budget and makers. The output of the PBB TOT refresher training expenditures), quarterly expenditure reviews, and was action plans to be implemented in January – March preparation of sector reports. quarter of 2019. A summary of cross-cutting key 5) Partners to support the department to lobby/advocate at activities from all the 5 counties is highlighted in the the county with members of the county assembly text box. (MCAs), and the core leadership to support the MTEF and PBB process.

10.3 Human Resources for Health (HRH) Support

InQ1, three main interventions were undertaken to provide HRH support. First, as staff contracts were to be renewed as of January 1, 2019, the project reviewed the HRH assessment findings and worked collaboratively with county governments to prioritize staff assignments based on current staffing levels and workload-based staffing needs. Secondly, the project worked closely with county governments to conduct annual staff performance appraisals to jointly identify common issues and support needs, and to identify high performing staff and ensure that they are retained. Finally, the project’s HRH advisor worked closely with the QI/QA advisor to implement the second learning session for the Human Resources Performance Improvement (HRPI) approach that has been integrated into selected sites participating in VL collaborative to strengthen the capabilities of facility and CCC managers to improve staff management and performance, with the aim of enhancing service delivery quality and outcomes.

Key results In FY18, the project completed the drafting of the Initiatives-led HRH assessment report, which was shared with USAID. Of note, the HRH assessment data indicated that Afya Ziwani currently meets the USAID target to ensure that 95% of HFs have at least 80% of their full time equivalent (FTE) positions filled to carry out core HIV service provision. Although overall staffing is currently adequate, the assessment noted that staffing imbalances may exist, with some facilities having too many staff and others too few for the respective workload. At present, a total of 936 staff are contracted and funded by the project, including 214 professional HCWs, 651 lay HCWs, 19 data clerks, and 52 sample transport bike riders. This represents a reduction of 256 staff from PY1. Based on the review of workload-based staffing needs and context, the project also identified around 25 staff to shift from facilities where staffing exceeded workload needs to those with shortages based on projected client loads for 2019.

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Data on the numbers and types of contracted staff supported by Afya Ziwani in each of the five counties for January 2019 through September 30th 20194 are presented in tables 46 through 48 below.

Table 46. Health care professionals contracted (FY19 Q1). Professional HCW County Total RCO RN PT MLT HRIO Homa Bay 59 24 11 3 4 17 Kisii 11 3 3 1 1 3 Kisumu 44 15 10 4 2 13 Migori 55 15 15 6 4 15 Nyamira 45 12 12 5 4 12 2019 Total 214 69 51 19 15 60 Note: RCO (registered clinical officer), RN (registered nurse), PT (pharmacy technician), MLT (medical laboratory technician), HRIO (health records information officer). Table 47. Health care lay workers contracted (FY19 Q1). Lay Worker (HCW) COUNTY Total PE in HTS ASC MM CM CCC Homa Bay 136 47 13 31 39 6 Kisii 38 13 3 5 16 1 Kisumu 76 25 7 17 23 4 Migori 145 40 11 27 60 7 Nyamira 256 90 16 40 105 5 Total 651 215 50 120 243 23 Note: HTS (HIV testing provider), ASC (adherence support counselor), MM (mentor mother), PE (peer educator at CCC), CPE (community peer educator), CM (cough monitor). Table 48. Non-health care lay workers contracted (FY19 Q1). Lay Worker (other) Sample County Total Data Clerk Data Clerk Transport

(Program) (EMR) Riders Homa Bay 5 4 1 8 Kisii 1 1 4 Kisumu 3 2 1 8 Migori 5 4 1 12 Nyamira 5 5 20 Total 19 16 3 52 Note: EMR (electronic medical records).

4 Note: staff contracts have been aligned with the project budget cycle to improve budget management.

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Discussion These 936 staff represent a significant proportion of the HIV/AIDS workforce, accounting for between 60 and 90% of the FTE staff contributing to HIV/AIDS service delivery depending on the county and facility. As a result, maintaining staffing levels is essential if quality services are to be sustained and ensuring county ownership of the staff and, eventually, transition of staff to county employment. To lay the foundation for transition, the project continued to work with county governments to finalize the letters or agreement (LOAs) with USAID. The project received feedback from the county leadership on the USAID proposed LOA and is working to address issues raised by the counties so they can be finalized in Q2. Jointly with the SCHMT and HF managers, the project completed performance appraisals for all 936 contracted staff to prepare the ground for Q2 renewal of contracts and deployment in line with the HRH assessment recommendations. Afya Ziwani successfully co-sponsored the Lake Basin Inter-county HRH TWG meetings with HRH Kenya. The meeting was held 4th – 5th December in Nyamira County and was attended by over 60 county staff and representatives from 5 implementing partners. During the meeting, the project’s HRH advisor shared the updated iHRIS data for project supported staff and lobbied for absorption of staff and improvement of their working environment, specifically improvement of infrastructure to enhance client confidentiality during testing, initiation and adherence counselling. Site visits to support HRPI implementation and its second learning session showed that sites were making some important changes to staff management and coordination, including re-instating weekly staff meetings, re-aligning staff roles and responsibilities to reduce the workload of over-burdened staff, and increase responsibilities of others to better meet client’s needs for services that contribute to VL suppression. A broader discussion of the HRPI results to date is presented in the Quality Improvement section.

10.4 Quality improvement (QI) In a bid to institutionalize and sustain QI systems within the counties, subcounties and HFs, the project works together with the CHMT and SCHMTs to implement the Kenya HIV Quality Improvement Framework (KHQIF) and develop joint work plans to bridge identified gaps and reinforce their QI systems. The county QI focal persons have appointed QI coaches in project supported subcounties, comprised of HF management and SCHMT team members, to use a project adapted coaching guide to conduct coaching visits to support HF QITs/work improvement teams (WITs) in their implementation of QI activities. Project technical staff also independently conducted site coaching visits to QITs/WITs at high and mid volume sites on the KHQIF service delivery indicators, root cause analysis, and Plan-Do-Study-Act (PDSA). As the project continues to build the capabilities of the QI coaches, they will increasingly take over the coaching visits.

QI collaboratives The project, in collaboration with the counties and subcounties, identified VL suppression as a key area of focus after reviewing HIV data, and proceeded to support a QI collaborative initiative focusing on improving VL suppression. The project further identified 32 high and mid volume HFs across the five counties with low VL suppression in the last year to participate in VL collaboratives. This has been ongoing from FY18 and is expected to conclude in FY19.

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HRPI To further enhance QI results, Afya Ziwani is working with county governments to integrate a human resources performance improvement (HRPI) approach into QI activities in 10 sample sites in Kisumu and Migori Counties. HRPI focuses on clarifying staff roles and responsibilities, documenting task lists, identifying skills gaps and providing skills building, supervision support and recognition to improve staff performance and achieve better outcomes. In collaboration with the county partners, the project’s QI/QA advisor and the HRH advisor oriented the HF teams participating in the first phase of HRPI. Results for VL suppression from HFs with HRPI will be compared with HFs implementing QI without HRPI, with an eye on scaling up the process as the project builds county buy-in.

County and subcounty and facility support In the reporting period, the QI/QA advisor conducted 27 HF visits to coach QIT/WIT’s on QI methodologies (root cause analysis, developing change solutions, and PDSA) in Homabay, Kisumu and Migori counties. Thirteen of these site visits were conducted jointly with the subcounty QI coaches in Homabay and Kisumu counties, and the remaining visits were independent coaching visits conducted by the project technical staff.

Results There has been marked improvement in the VL management processes (figure 9). Initiation of enhanced adherence counselling sessions has improved from a median of 98 days to a median of 30 days. Patients whose VL are still high (treatment failure) are being switched to more efficacious regimens within a month, which is timely as opposed to the average of 3 months that was being practiced previously. Teams are more aware of management of VL as a result of the developed task lists and the coaching visits. Figure 9. VL suppression for the collaborative sites n=32

% VL Supression A. Goal =95% Conducted learning 95% session Two Improved documentation through register reconstruction and Conducted mentorship on correct documentation. learning session Baseline data One B. 89% 90% Introduced patient focused 88% 88% 88% appointment management. Short 87% 87% clinic appointment schedules. 86% Restructured patient flow at the CCC 85% C. 85% 84% Introduction of HRPI and development A B C of VL specific task lists and cross functional matrices. Formation of pediatric caregivers PSSG’s. developed orientation package for new staff on 80% VL management. Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18

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Discussions From the conducted joint coaching visits, it was evident that the QIT/WIT’s were consistently meeting to improve performance at the HFs. However, they still need more guidance on utilization of QI tools and approaches, specifically PDSA and documentation of the change solutions. It was also noted that the subcounty QI coaches, particularly those who are part of the SCHMT, had competing tasks and couldn’t carry out all the coaching visits. The county QI focal persons, in collaboration with the project QI advisor, have nominated three more facility QI coaches to support the coaching visits and report to the subcounty QI coaches, who will act as the super coaches by taking up a more supervisory role. In the reporting period, QIT’s/WIT’s have implemented some change ideas that have led to improved VL outcomes, such as:

• Appointment management that is more patient centered and focusses on both the dates and timing of the appointments. • Scheduling short clinic appointment visits for patients who have had VL test samples collected, to ensure more timely initiation of interventions for those that receive a high VL test result. • Restructuring of patient flow and integration of some services, such as pharmacy and triage desks, to increase space for the adherence counseling services. • Formation of special support groups for caregivers of pediatric patients and men, which have targeted messages on adherence and VL. • Developing orientation packages for new staff to improve skills and knowledge on management of VL.

11. Strategic M&E

Key results In Q1, the project developed a data reporting tool to capture data for all indicators and disaggregation as recommended in the Monitoring, Evaluation, and Reporting (MER) Indicator Reference Guide 2.0 (Version 2.3), September 2018. The project also revised its PRISM database to capture the MER 2.3 guidance. PRISM is a DHIS2-based system that the project instituted to consolidate all its data in one central online system

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Through working with Datablick, the project managed to design indicator dashboards that help automate reporting on all project indicators that are captured in HMIS/DHIS2. The dashboards have the ability to show the facility data available in HMIS/DHIS2 data sources and roll up to ward, sub-county and county levels. Design indicator reporting dashboards help automate reporting for Viral Load data (figure 10) on a quarterly or monthly basis using historical year cohorts. The contractor will use Alteryx and Tableau to automate and design reports. Figure 10. Viral load uptake dashboard.

Through Datablick assistance the project was able to update to the Viral Load ETL workflow and develop 3 dashboards for the EMR data. These dashboards focus on analyzing time to treatment and enrollment source, exit reason, and adherence by various patient demographics Sixty-five HCWs from Migori and Nyamira Counties were trained on the use of revised health management information systems (HMIS) tools, including registers and the summary 731 reporting tool. This was largely due to the project-supported staff transition in the county that resulted in many new staff joining the project’s sites who had minimal understanding of the registers and reporting tools. Two hundred and eighty-six health workers were reached through on-site mentorship on documentation and reporting tools: Homa Bay (39), Migori (52), Kisumu (23), Nyamira and Kisii (120). The focus was on addressing documentation challenges in DARs, the ART register, the ANC register, and the HCA, as well as on reporting challenges in the use of the new MOH 731.

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Sixty-seven HF DQAs, in liaison with HRIOs at HFs, were conducted at supported high-volume HFs across the 5 supported counties: Kisumu (6), Nyamira/Kisii (33), Migori (14), , and Homa Bay (14). A comparison of data was carried out across three data systems (registers, MOH731 summaries, and DHIS2), with the variances corrected and a QI plan developed to mitigate future variances. Fifteen monthly data review meetings were conducted (3 each by the project’s 5 county program offices). Key gaps found in HF data on HTS, HIV care and treatment, PMTCT, and VMMC were reviewed. Key gaps including missed opportunities in service provision, were discussed and strategies formulated for improved quality of data. Findings from the meetings were shared with the project’s main office for strengthening oversight. The project conducted training for key healthcare providers on EMR new features. The training incorporated SCHRIOs, SCASCOs, SCTLCs & Sub county pharmacists. A total of 80 Health care workers were trained from the 4 supported sub counties in Migori and in Kisii/Nyamira 96 health workers were trained. Five data-review meetings were held, one in each supported county, which brought together all the HF in- charges, HRIOs, clinicians, and other key facility staff who offer HIV services, to present and discuss their data, followed by corrective action plans. Forty HFs were supported to use EMR,

• 13 (33%) transitioned to paperless mode: Kisumu (2), Kisii (2), Nyamira (9). The remaining 27 HFs are in process to transition to paperless mode or reduced paper. • 35 (88%) achieved POC usage of the system • 29 (70%) achieved EMR data concordance threshold of >90%; and 6 (15%) between 80-89% • 29 (70%) achieved data quality thresholds: Nyamira (18), Migori (4), Homa Bay (2), Kisumu (3), and Kisii (2). Seventeen HFs were provided continuing support to host the ADT through software upgrade with core features to manage commodities. For AGWY, the project focused on improving data quality by conducting annual program performance review meeting for 51 wards and quarterly data review meetings for 25 wards in the 3 Counties. The internal DQA was done for 9 wards and 1 external DQA. In Kisumu County 5 wards were covered Kajulu, \Nyalenda A, Manyatta B, Kolwa Central and Kondele wards. In Homabay county 4 wards were covered Homabay Central, Kendu Bay, Kagan and Kanyamwa Kologi wards using a standard tool with a focus on data consistency between the source documents, summary tools and the database. The DQA also assessed three general data management and monitoring of project, cash Transfer and PrEP. The M & E Kenya DREAMS lead partner conducted an external DQA in Homa Bay Central ward of Homa Bay Town sub-county. The DQA looked at general AGYW implementation and specifically PrEP and Cash Transfer data. The results and the findings of the DQA are yet to be disseminated. Support supervision was done using the quality assessment tool as a pilot in 41 wards, 8 in Kisumu 29 in Homabay and 4 in Migori counties with the aim of ensuring adherence to the availability of and use of data management SOPs, quality of evidence-based interventions, proper documentation, tracking the co-enrolment of AGYW and layering of interventions. Consistency, accuracy and completeness of information documented on the DREAMS enrollment form, service uptake, referrals tool, MSP planning and monitoring tools and EBI registers. Physical verification of all the AGYW files was done as part of quality monitoring of the interventions given to AGYW. The monitoring of the project will continuous with all activities planned as action points from previous assessments

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Discussion The project experienced various challenges including; Minimal time to implement data collection and reporting tools to capture data as per Monitoring, Evaluation, and Reporting Indicator Reference Guide 2.0 (Version 2.3), September 2018. This has now been accomplished and it will greatly assist in more comprehensive and efficient data management. During this reporting period the project experienced a shortage of key HIV tools e.g. DAR, ART Cohort Reg, Treatment preparation reg, ICF cards for both Adults and Peads, Green cards, HEI cards. Quantification of the required tools has since been done and the project is planning to print and distribute all the tools that are required The project also lost 2 key staff in the M&E department and this has affected the data management and analysis when preparing for the FY19Q1 reporting. HRIOs performance has also not been optimal. In Migori 3 out of the 15 HRIOs were put on Performance Improvement Plan (PIP) based on the appraisal evaluation. The project experienced challenges in implementing EMR in selected HFs, which has hindered continuity and consistent POC use of EMR, affecting reporting concordance. Some of these challenges included frequent power outages in Migori and Homa Bay counties, inherent system gaps, the inability to generate registers, a lack of a dispensing module, poor internet connectivity at the HFs to support automatic download of VL results from the NASCOP website, and high staff turnover. Others included hardware malfunctions (e.g. N-Computing devices which have been used for more than five years and damaged by power surges and in the need for replacement).

B. Activity progress (quantitative impact)

Please refer to the performance data tables in the attachment.

C. Constraints and opportunities

In the FY19 Q1, two key constraints are highlighted:

• Transition from DBS to plasma based VL testing. In the quarter, NASCOP provided a directive that restrained the project’s transitioning of clients to the more efficacious regimen of TLD. The directive required patients to have measured low VL suppression (LDL) from plasma, not DBS. Plasma testing requires facilities to draw blood on specific days, and centrifuge and refrigerate it. Then the plasma needs to be rushed to subhub lab, and then, on specific days, rushed to a testing lab within six hours for testing. This far more logistically challenging approach has slowed the transitioning of clients at the time when facilities were also faced with a looming shortage of the legacy ART regimens. In response, the project initiated a rapid transitioning to plasma testing for its clients, piloting in 17 high-volume sites, with the HCPs and transport riders trained. The project is also contracting local transport to ensure its limited number of vehicles are not diverted from facility visits.

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• Spillover of FY18 activity expenditures. The project has been informed that it must operate within its FY19 budget of 19,711,347. No under-expenditure from FY18 nor pipeline beyond FY19 can be accessed. The problem is that the project is not a one-year stand-alone project, so expenditures of FY18 activities can spillover into FY19. This is especially the case with one-time payments. Even if 99% of the activity was conducted in FY18, if the invoice fails to be received by the end of the FY (30 September 2018), the expenditure will be booked as an FY19 expense against the FY19 budget. The project is now facing $1,037,906 of FY18 activity expenditures that spilled over into FY19 and its budget. This includes $628,151 (with overhead) for direct aid to AGYW (cash transfers and school fees). These are labor intensive activities that require processing and focused verification of thousands of AGYW. However, USAID CO approval to the project for the AGYW implementing LIPs’ sub- contracts with USAID mandated expanded activities and targets was not provided until 29 Jun-18. As such, the project was unable to be book these expenses until early FY19. Also included is $254,826 9 (with overhead) for VAT and customs for import of 7 Toyota hardtops. USAID’s agreement with GoK lapsed at end of September 2018, which led to the project not having an exemption for and having to pay these costs. When the accepted vendor, Toyota Kenya, stated that they would not provide their ‘NGO discount’ as a result of the project not having an exemption, they increased their bid cost by $318,945. This forced the project to rebid and select another vendor, which led to the vehicles not arriving at port until Nov-18. A third spillover was $154,927 (with overhead) in printing costs for government reporting tools e.g. registers, patient cards, were not booked until October 2018. Receiving USAID approval, identifying the gaps at HF level, and completing the procurement process for this late FY18 initiated activity proved too laborious and time consuming to be invoiced for until early FY19. To adjust for this spillover, the project is reducing budgeted expenditures wherever feasible, including not implementing the planned expansion of contracted lay HCWs, especially HTS provides, delaying initiation of the provision of grants under contract, reducing some LIP budgets, and providing less than the expected expenditure per AGWY for education subsidies, and possibly reducing the number of planned months of AGYW cash transfers.

D. Performance monitoring

Please refer to the performance data tables, attached separately.

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E. Progress on gender strategy

The project’s gender strategy revolves around three key intervention areas: AGYW/ABYM, GBV, and male focused support.

1. AGYW/ABYM

Within the AGYW programming, gender is a critical determinant of the HIV epidemic, with 15-24, female infection rates for adolescent girls between the ages of 15-24 significantly higher than those of their male counterparts. Also, social norms can condone violent, non-consensual, and unprotected sex, which, combined with gender barriers, increase vulnerability, especially for women and girls. Vulnerability to GBV, especially for AGYW, is highlighted in the project’s FY18 Gender, Youth, and Social Inclusion Analysis. And while the analysis did not find significant barriers to access to services, the project has found that access to such services as PrEP requires specific support to ensure access. The Afya Ziwani project implements a comprehensive package of service interventions for GYW that also includes interventions for adolescent boys and young men (ABYM), with the aim of achieving primary prevention of HIV.

2. Provision of gender-based violence (GBV) activities

2.1 Results and achievements Afya Ziwani supports 29 sites to integrate post GBV clinical services in provision of comprehensive HIV prevention, care and treatment. Between October and December 2018, 285 GBV survivors (119 sexual violence and 166 non-sexual physical violence) had received a minimum package of post GBV services as defined in the national guidelines. Female survivors were 214 representing 75% of the survivors, being the majority. All the survivors were provided with Post Exposure Prophylaxis (PEP) based on eligibility with zero sero-conversion reported. Trauma counselling was provided by lay counsellors onsite as necessary, with referrals for complex cases as per the county’s established GBV stakeholders network. Integration of GBV services into HIV prevention and treatment services remains a key focus in year 2.

2.2 Challenges Though response to GBV is available, challenges exist that need to be tackled in order to make the response comprehensive. Clinical management is currently limited to the provision of PEP, emergency contraception, and STI prophylaxis. This is however biased towards individuals that have undergone sexual and gender-based violence (SGBV), leaving out those who present to the clinic after episodes of physical violence and need wound care treatment and management. The lack of forensic evidence has translated to low rates of prosecution of perpetrators. To ensure perpetrators are prosecuted, the program is working on enhancing referral mechanisms to legal services.

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2.3 Key interventions/activities for rest of the reporting period Plans will focus around enhanced provision of the minimum package of interventions for GBV, particularly screening of clients at all entry points in facilities with subsequent provision of services.

3. Male-focused activities

The project supports HFs to conduct male focused support. To improve testing of males, the project supports male peer educators, male champions, and male CHVs to mobilize men for testing. The project is piloting 1 integrated male clinic based on the “Lesotho men’s clinic model’ and expanding testing to all men coming to the supported high-volume HFs regardless of symptoms of HIV as guided by the ‘expanded HIV testing eligibility decision-making algorithm’, which was earlier distributed. The algorithm allows testing clients who verbally report unverified negative results. The project supports HFs to conduct PNS that includes male focused outreaches to formal/informal work places. The project is integrating HTS within VMMC service provision and supports selected HFs to provide HIV self-testing that targets men. To improve male retention and suppression, the project supports HFs to have specific male psychosocial groups (PSSGs), male peer educators and champions, and pilot an integrated male clinic based on the “Lesotho men’s clinic model’. The project is promoting extended hour early morning/late evening hours at the integrated male clinic and in selected sites at mid volume sites and weekend clinics at high-volume sites. It supports the establishment of male specific community ARV groups (CARGs).

F. Progress on environmental mitigation and monitoring

The project supports an annual environmental mitigation, monitoring, and reporting plan as part of its annual work plan. The focus in FY19 includes strengthening health care waste management (HCWM) at all levels of health care service delivery in the supported counties. Major HF focused activities supported include (1) provision of HCWM commodities to support IPC, (2) capacity-building through training, technical assistance, and supportive supervision to HF staff, and (3) improvement of waste handling and disposal practices and infrastructure. HIV services, including testing services and voluntary medical male circumcision, offered at both HF and outreaches, generate hazardous health care waste, which include used sharps, body tissues such as the foreskin and other infectious waste. If not properly handled and disposed of, these pose risks to HCWs, patients and the community. Other HIV interventions such as provision of antiretroviral medications, family planning services, and condom distribution can result in health care waste into the environment. This could be due to expiry of commodities, damage or other factors rendering them unusable. Materials used in labs, such as for collecting lab samples, such as for TB diagnosis, including sputum collection containers and other supplies, generate hazardous health care waste. Collection of blood samples for VL testing generate highly infectious waste. Risk increases when specimens are transported by riders from facilities under the hub and spoke model.

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To minimize the risk of the health care worker’s exposure to hazardous wastes, the project will support the HFs with personal protective equipment (PPE) such as aprons and gloves for use by health care workers during procedures as well as during handling of wastes. In addition, the project will support HFs to segregate waste by having adequate sharps containers, color coded waste bins and bin liners. Waste generated from outreaches will be safely packaged and transported back to the facility for destruction and disposal. The project will provide job aids and SOPs on waste management and guidelines to service delivery points. The project will ensure facility staff are trained on waste management and biosafety, by providing annual biosafety training targeting 52 riders and 125 HCWs, annual biosafety refresher training targeting 125 lab personnel, and ensuring staff have adequate safety gear, including through the planned procurement and provision of 720 N95 protective masks. The project will cover maintenance contracts for lab bio-safety cabinets. The project will support counties, sub-counties and HFs to implement a program that supports proper commodity management, including sub-county mentors to monitor and ensure proper disposal of expired drugs consistent with the national guidelines. The project will support HFs to conduct 60 IPC meetings that will develop infection control plans and reviews, including of I/C reports. As part of this, it will provide mentorship and support and participate in S/CHMT supportive supervisions that provide technical assistance and oversight of HFs and HCWs on waste management and IPC practices. Mentorship will include sessions for HCWs on safe waste handling and disposal practices, and, along with support supervision, support adherence to SOPs for waste incineration and use of personal protective equipment by waste handlers. The project will support secured waste disposal pits as the minimum requirement for disposal of health care waste for non-biohazardous waste. It will support HFs to have secured waste disposal pits to diminish the risk to staff, patients, and the community from exposure to the waste and restrict access by unauthorized persons. It will support a hub and spoke system where lower-level HFs can dispose of their biohazardous infectious waste and sharps. The project will support the hub and spoke system, with hub incinerators including: Homa Bay (Rachuonyo SCH, Kabondo SCH, Matata Nursing Hospital), Migori (Awendo SCH, Uriri HC, Kuria District Hospital), and Nyamira (Nyamira CRH, Manga SCH, Getare Health Centre, Isoge HC, Kipkebe Dispensary). These incinerator sites are central sites for final disposal of hazardous infectious waste coming from the lower sites. Waste from lower-level facilities are to be secured in a safe storage box/space at the HF and periodically transported to the central sites for final disposal. The project will work with S/CHMTs to strengthen their integration of waste management, infection prevention and HIV service delivery. As noted above, this includes supporting and participating in their support supervision of HFs that include oversight of waste management. As well, the project will support quarterly sub-county review meetings that include environmental review/audit of supported HFs’ waste management.

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G. Progress on links to Other USAID programs

In the current reporting period, Afya Ziwani worked collaboratively with HRH Kenya and USAID Health Policy Plus on HRH strengthening and PBB, respectively. The project will continue to work collaboratively with these two mechanisms at the SCHMT level in the next quarter. Collaboration with the global impact firm Palladium Group continued in the project quarter in the area of EMR. The two projects worked toward improving the utilization of the EMR systems through conducting routine DQAs, support supervision, and review meetings, as well as migrating the existing EMR to the upgraded version 22. In the coming quarters, the service delivery partner is expected to support all the EMR activities apart from review meetings, which Palladium will continue to support, as well as support paperless reporting at 14 earmarked sites.

H. Progress on links with Government of Kenya agencies

During the reporting quarter, the project was able to hold stakeholder engagement meetings with all the five counties on various intervention service areas supported by the Afya Ziwani project. In the reporting quarter, the following collaboration was accomplished: • The project continued to partner with the MOH in supporting service delivery activities at health facilities and safe spaces. This included conducting capacity-building activities, such as trainings, orientations, and mentorships for mentors and paralegals, and providing biomedical services. • The project collaborated with the Ministry of Education to provide safe spaces in some selected schools, as shown in table 49. The project also supported quarterly stakeholder and gender TWG meetings in the two counties. Table 49. Other ministries and departments with which the project collaborated.

Government of Kenya Agency Component Area of Linkage Ministry of Health Biomedical services • Facilitation of trainings • Provision of biomedical outreach and referral services for AGYW Department of Youth and Gender, Social-asset building • Safe spaces for girls Children Services • Gender-based TWGs • Stakeholders’ forum Youth Enterprise Development • Cash transfers Fund • Loans for AGYW Ministry of Education, Science and Education • Safe spaces Technology • School fees

Ministry of Internal Security Security and • Post-GBV care for (Kenya Police) accountability AGYW/accountability—legal support • Security at safe spaces Provincial Administration • Bursaries County Government Note: AGYW, adolescent girls and young women; GBV, gender-based violence; TWG, technical work group.

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I. Global development alliance (if applicable)

Not applicable.

J. Subsequent quarter’s work plan

Table 50. Work plan activities, statuses, and explanations. PLANNED ACTIVITIES FROM ACTUAL STATUS THIS EXPLANATIONS FOR PREVIOUS QUARTER QUARTER DEVIATIONS

INCREASED AND EXPANDED HIGH-QUALITY HIV SERVICES

Support facility mentorship activities by the Fully accomplished in this mentoring teams for ART, PMTCT, HTC, lab, quarter and pharmacy Train HCWs on the revised ART guidelines Fully accomplished in this quarter Support facility-based CME for ART and Fully accomplished in this PMTCT on a quarterly basis quarter Support the laboratory-networking model Fully accomplished in this (CD4, EID, biochemistries, hematology, and quarter N/A viral load) Support ART PMTCT reporting to meet Fully accomplished in this N/A COP17 quarterly targets quarter Support accelerated ART enrollment and Fully accomplished in this retention activities quarter N/A Support RDQA for EMR Fully accomplished in this N/A quarter Support facility ART/PMTCT defaulter Fully accomplished in this tracing mechanisms (diaries, peer educators, quarter N/A airtime, and SMS reminders) Support facility PLHIV support group monthly Fully accomplished in this meetings (including pediatric, male, quarter N/A adolescent, PMTCT, general CCC) Support HIV counseling and testing of Fully accomplished in this pregnant mothers and mother-baby pairs at quarter N/A ANC and MCH clinics Provide HCW mentorship on EMTCT Fully accomplished in this N/A quarter Support nonclinical counselors Fully accomplished in this N/A quarter Support DR TB patients to access treatment Fully accomplished in this quarter N/A Note: ANC, antenatal care; ART, antiretroviral therapy; CCC, comprehensive care center; CME, continuing medical education; COP, country operational plan; DR, drug-resistant; EID, early infant diagnosis; EMR, electronic medical record; EMTCT, elimination of mother-to-child transmission; HCW, health care worker; HTC, HIV testing and counseling; MCH, maternal and child health; PLHIV, people living with HIV; PMCTC, prevention of mother-to-child transmission; RDQA, routine data quality assessments; SMS, short message service; TB, tuberculosis.

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K. Financial information

Figure 11: Expenditure status and financial projections (pipeline) in USD

40000000

35000000 36,447,312 Obligation 30000000 5,107,632 2019 Quarter III Projected 25000000 Expenditures 4,886,048 20000000 2019 Quarter II Projected Expenditures 15000000 16,865,214 2019 Quarter 1 Cumulative 10000000 Expenditures

5000000

0 Expenditure Pipeline Obligation

Source: Project financial records, September 2018.

Budget details

Total Expected Costs (TEC): US$77,873,573.00 Cumulative Obligation: $36,447,311.87 Cumulative expenditure: $16,865,213.80 Table 51. Actual expenditure details.

FY 2019 Q1 FY 2019 Q2 FY2019 Q3 Obligation cumulative projected projected expenditures expenditures expenditures $36,447,311.87 $16,865,213.80 $4,886,048.15 $5,107,632.00 Personnel $2,869,899.30 $756,780.15 $836,619.00 Consultants $94,034.74 $0.00 $0.00 Travel and Transportation $313,307.82 $74,897.00 $78,641.85 Other Direct Costs $10,030,343.29 $2,797,850.00 $2,683,185.75 Overhead $3,156,201.65 $895,000.00 $907,691.40 Fixed Fee $401,427.00 $361,521.00 $601,494.00 Source: Project financial records, December 2018.

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Budget notes

Table 52. Budget notes. Personnel This has now stabilized. However, the project expects 7 more staff in the next quarter ( 2 M&E officers, 2 Data officers, I health informatics Officers, 1 TB project officer and 1 communications officer) Consultants The project does not anticipate hiring any consultant in the next quarter.

Travel and transportation This has now stabilized.

Other Direct costs The project plans to pay school fees and execute cash transfers for AGYW in the next quarter. This will lead to a rise in other direct costs. Overhead Calculated as per contracts terms and conditions. Fixed Fees Earned as per contract terms and conditions.

L. Activity administration

Personnel

The project successfully hired and on boarded Dr Habel Ang’ani Alwang’a and Gerald Maina Kimondo as substantive Deputy Chief of Party and M&E specialist respectively during the reporting period.

Contract amendments

The project fully executed Modification no 3 which increased the cumulative obligated funds by $17,225,877.51 and incorporated the project’s approved Branding strategy and Marking plan.

Sub-contractors

No new sub-contractor was engaged by the project during the reporting period.

Other significant approval(s) from USAID

The project’s Grants under Contracts manual (GUC) was approved on 28th November 2018.

M. GPS information

Please see the GPS information sheet in the attachment.

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N. Success story

Awendo Subcounty Hospital successfully implements assisted Partner Notification Services (aPNS)

Awendo Subcounty Hospital is one of the Afya Ziwani project supported sites in Awendo Subcounty of Migori County of western Kenya. Afya Ziwani is a USAID project funded by PEPFAR and implemented by a PATH-led consortium of Kenyan NGOs and American small businesses. Assisted partner notification services (aPNS) is an approach that actively seeks the sexual contacts of HIV positive clients for HIV testing. Evidence has shown that these contacts contain a significant percentage of people who are unaware of their HIV positive status. As such, a key strategy in addressing the HIV epidemic is to actively seek out and test these sexual contacts and then ensure that those who are tested HIV positive are linked to a health facility for initiation into HIV care and treatment. Awendo Subcounty Hospital has embraced PNS, and has 6 trained PNS providers on its staff, including 5 HIV testing services (HTS) providers and 1 nurse. The facility implements a multilevel elicitation approach that involves community and facility level interventions. An example of their success is their elicitation of 16 HIV positive sexual contacts from a woman who tested HIV positive at the facility in 2018. The women were initially tested by one of the HTS providers who was trained as a PNS provider. This provider elicited two sexual contacts from her. From these two, the provider elicited another seven contacts. When the women were enrolled into care and treatment, the PNS trained nurse elicited another contact, from which another eight contacts were elicited. Working with community health volunteers, the PNs providers were able to trace all eighteen contacts in the HIV testing at the community level. Photo: PATH community. Of these, seventeen were found eligible for HIV testing, with all successfully tested by the providers in the community. Of these, sixteen (94%) were found HIV positive. All were successfully linked to the hospital and enrolled into HIV care and treatment. Assisted PNS remains an effective strategy in the identification of people living with HIV. Use of a multilevel approach of contact elicitations brings together a blend of skills that ensures there are no missed opportunities.

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O. Appendices

Appendix 1. Facilities MPR-CQI assessments done

Table 53. Facilities where MPR-CQI was conducted (FY19 Q1). County Facilities where MPR–CQI was conducted Port Florence Community Hospital Migosi Sub County Hospital Airport Health Centre St. Marks Health Centre Kisumu Ober Kamoth Health Centre Nyalenda Health Centre Gita Sub County Hospital Disciples of Mercy

Rachuonyo District Hospital Kabondo Sub County Hospital Homa Bay Kokwanyo Health Centre Matata Nursing Home and Hospital

Kisii Gesusu Sub County Hospital

Ting’a Health Centre Nyamusi Sub County Hospital Nyamira Nyamira County Referral Hospital Keroka Sub County Hospital

Ntimaru Sub County Hospital Kegonga Health Centre Dede Health Centre Migori Awendo Sub County Hospital Kehancha Sub county Hospital Isebania Sub County Hospital

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Appendix 2. ECHO CME sessions

Table 54. Health facility staff participation in the ECHO CME sessions (FY19 Q1). County Facility # of Staff Reached Awendo Sub County Hospital 31 Dede Dispensary 8 Rabondo Dispensary 3 Sony Medical Centre 18 Ranen SDA Dispensary 2 Isebania Sub County Hospital 7 Migori Kuria District Hospital 8 Masaba Dispensary 5 Kegonga Sub county hospital 6 Uriri Sub County Hospital 28 Tisinye Dispensary 4 Ntimaru Sub County Hospital 7 Mariwa Dispensary 6

Disciples of Mercy 7 Migosi Sub County Hospital 36 Port Florence Community Hospital 5 Chiga Health Centre 1 Nyalenda Health Centre 4 Kisumu Ojola Health Centre 1 St. Marks Health Centre 8 Airport Health Centre 8 Star Hospital 5 Gita Sub County Hospital 3

Kisii Gesusu Sub County Hospital 15

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Nyamira CRH 3 Tinga Health Centre 1 Bosiango Sub County Hospital 1 Ekerenyo Sub County Hospital 2 Nyamusi Sub County Hospital 1 Kijauri Sub County Hospital 2 Nyamira Amaterio Health Centre 1 Manga Sub County Hospital 2 Getare Health Centre 1 Ikobe Health Centre 1 Keroka Sub County Hospital 2 Magombo Health Centre 1 Gesima Sub County Hospital 1

Rachuonyo Sub County Hospital 35 Matata Nursing Home 6 Kabondo Sub County Hospital 13 Othoro Sub County Hospital 2 Homa Bay Ober Dispensary 1 Nyang’iela Health Centre 2 Ombek Dispensary 1 Got Kamondi Dispensary 1 Tala Dispensary 1

Total 307

Note: CME- continuing medical education; ECHO- Extension for Community Health Outcomes.

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Appendix 3. Cumulative trainings in FY18

Table 55. Cumulative training held (FY19 Q1). Training Number Trained HCBF facilitators trainings in new wards of Kisumu, Homa Bay, Migori 81 MHMC facilitators trainings in new wards of Kisumu, Homa Bay, Migori 96 Shuga facilitators trainings in new wards of Kisumu, Homa Bay, Migori 62 Sister to Sister and Respect K trainings for HTS counselors in 3 counties 34 FMP1 facilitators trainings in new wards of Kisumu, Homa Bay, Migori 65 Training of FC and entrepreneurship facilitators trainings 20 Training on Financial Capability for AGYW 4,405 Support Entrepreneurship training sessions for eligible AGYW 198 VMMC service providers Training on MC under LA and MC devices 40 Refresher training of VMMC service providers on dorsal slit method 29 Train pharmacy technologists on web-based ADT (NASCOP curriculum) 32 External laboratory quality assurance for laboratory technologists 38 Refresher training on biosafety for HCWs 57 Training of the CMM on KMMP in priority facilities 29 Refresher training and CME for HCWs on EID algorithm at facility level 41 Training on ART service provision including PMTCT 8 Adherence counseling training in all high-priority sites 36 OTZ and management of peer support groups training for the nurses 232 Adherence counseling training on the provision of ART literacy classes for adolescents 54 on self-management Training on HRH management and supervisory skills, including iHRIS data entry 30 system for 3 SCHMTs Training of the S/CHMTs and facility managers to improve staff management, define 75 training needs, and improve staffing in HIV clinics. Revised DHIS2 training for key health care providers 42 Support refresher trainings for key health care providers on EMR 150 EMR training for clinicians 29 KHQIF training for QIT I members to train WITs on CQI, including collaborative 47 Training on new MOH reporting tools for facility-based HRIOs 351 Organizational capacity assessment training for 5 counties 120 Staff induction training for newly hired HCW - Nyamira County 116 Total 6,517 Note: ADT, ART dispensing tool; AGYW, adolescent girls and young women; ART, antiretroviral therapy; CME, continuing medical education; CMM, Community Mentor Mothers; CQI, continuous quality improvement; DHIS, District Health Information Software; EID, early infant diagnosis; EMR, electronic medical record; FMP, Families Matter! Program; HCBF, Healthy Choices for a Better Future; HCW, health care worker; HRH, human resources for health; HRIO, health records and information officer; HTS, HIV testing services; iHRIS, integrated Human Resources Information System; KHQIF, Kenya HIV Quality Improvement Framework; KMMP, Kenya Mentor Mother Program; MC, male circumcision; MHMC, My Health My Choice; MOH, ministry of health; NASCOP, National AIDS & STIs Control Programme; OTZ, Operation Triple Zero; PMTCT; prevention of mother-to-child transmission; QIT, quality improvement team; S/CHMT, sub/county health management team; VMMC, voluntary medical male circumcision; WIT, work improvement team.

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