HIV SERVICE DELIVERY SUPPORT ACTIVITY (HSDSA) CLUSTER 3
BASELINE REPORT
11 June 2018 This document was produced for review by the United States Agency for International Development.HIV Services It Deliverywas prepared Support Activity by (HSDSA) Jhpiego – Activity, Johns Baseline Hopkins Report University affiliate.
1 HIV SERVICE DELIVERY SUPPORT ACTIVITY (HSDSA)
Contract No. 72061518C00001
Submitted to: USAID Kenya and East Africa Date: 11 June 2018 Submitted by: Jhpiego Corporation
Sub-contractors/Implementing partners: LVCT Health, Amethyst Technologies LLC, Cloudburst Group
Contracting Officer’s Representative: Dr Maurice Maina Contracting Officer: Nya Kwai S. Boayue
DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
HIV Services Delivery Support Activity (HSDSA) – Activity Baseline Report
2 TABLE OF CONTENTS
ACKNOWLEDGEMENT ...... 6
ACRONYMS ...... 8
GLOSSARY OF KEY TERMS ...... 9
EXECUTIVE SUMMARY ...... 10
1. BACKGROUND ...... 11 HSDSA Project Technical Approach ...... 11 HSDSA Project Results Framework ...... 12
PURPOSE AND OBJECTIVES OF BASELINE ASSESSMENT ...... 12
2. METHODOLOGY ...... 14 2.1 Key Project indicators and Differentials Explored ...... 14 2.2 HSDSA Cluster 3 Baseline Assessment Approach ...... 15 2.3 Data Management and Analysis ...... 16 2.4 Baseline Assessment: Stakeholder Meetings ...... 16 2.5 Ethical Consideration ...... 16 2.6 Challenges and limitations ...... 16
3. KEY FINDINGS ...... 18 3.1 Desk Review ...... 18 3.2 Organizational Capacity Assessment ...... 30 3.3 Health Facility Assessment ...... 34 3.4 APHIAPLUS KAMILI project End-line Survey ...... 38
4. ACTIVITY LEARNING AGENDA ...... 40
5. CONCLUSION AND RECOMMENDATIONS ...... 41
Annex A: Indicator Reference Sheet ...... 43 Annex B: Activity Indicator Tracking Table ...... 48 ANNEX C: Health Facility Assessment Tables ...... 51 Annex C: HSDSA Cluster 3 Supported Health Facilities ...... 54 Annex D: OCA capacity gaps and plans ...... 60
HIV Services Delivery Support Activity (HSDSA) – Activity Baseline Report
3 LIST OF TABLES Table 1: Distribution of Vulnerable AGYW by ward: in Biashara and Ngoliba wards ...... 18 Table 2: Distribution of Vulnerable AGYW by age groups: in Biashara and Ngoliba wards ...... 18 Table 3: HIV Population projections 2016, 2018 in Cluster 3 counties ...... 19 Table 4: HIV positive case identification by County against annual targets by COP17 SAPR ...... 21 Table 5: Baseline HIV Positive by County, Age bands and Gender in Cluster 3 (COP17 SAPR) ...... 21 Table 6 Number of tests and yield per testing modality (Oct’17 – Mar’18) ...... 22 Table 7 Number of Partner Notification Services (PNS) sites by County at COP 17 SAPR ...... 22 Table 8: Linkage to treatment by Gender and Age-bands...... 23 Table 9: County contribution on newly initiated clients on ART (TX_NEW) ...... 23 Table 10: County contribution on newly initiated clients on ART (TX_NEW) ...... 23 Table 11: Newly enrolled and current on ART in Cluster 3 counties ...... 24 Table 12: HIV testing among pregnant women ...... 24 Table 13: HIV testing among HIV Exposed Infants ...... 25 Table 14: Baseline Viral load suppression rates in nine Cluster 3 counties in COP16 ...... 25 Table 15: Baseline Viral load suppression rates in nine Cluster 3 counties in COP17 SAPR ...... 26 Table 16: Baseline Viral Load Suppression Rate by County and Age bands in Cluster 3 (COP16) ...... 26 Table 17: Baseline Viral Load Suppression Rate by County and Gender in Cluster 3 (COP16) ...... 27 Table 18: Baseline Viral Load Suppression Rate by County and Gender in Cluster 3 (COP 17 SAPR) ...... 28 Table 19: Differentiated service Models: Health facilties Implementing DCM in COP17 SAPR ...... 28 Table 20: Number of Facilities with Viremia clinics by county in Cluster 3 ...... 29 Table 21: Number of Facilities with Electronic Medical Records by county (COP 17 SAPR) in Cluster 3 ...... 29 Table 22: Number of Facilities with PSSGs by County in Cluster 3 ...... 30 Table 23: Planning and Budgeting, Performance (May 2018) ...... 30 Table 24: Leadership and Governance, Performance (May 2018) ...... 31 Table 25: Human Resources for Health, Performance (May 2018) ...... 31 Table 26: Health Information System (HIS), Performance (May 2018) ...... 32 Table 27: Five year Plan to improve OCA capacity scores ...... 32 Table 28: Distribution of Health facilities by County ...... 34 Table 29: Health facilities sampled by KEPH Levels ...... 34 Table 30: Availability of specific HIV Services at HFs in Cluster 3 ...... 34 Table 31: Service Delivery points offering HTS Services at ...... 35 Table 32: Baseline SIMS Scores (COP16) in selected 10 HFs in Murang’a & Tharaka-Nithi Counties ...... 36 Table 33: Household Interviews Completed ...... 38 Table 34: Among antenatal and post-natal mothers interviewed by county ...... 38 Table 35: Ever heard of HIV/AIDs and knowledge of HIV Prevention ...... 39 Table 36: Adolescents /Youth Sexuality & Reproductive Health and HTS among Adolescents/ Youth...... 39 Table 37: Proposed learning questions...... 40 Table 38: Availability of Guidelines, Algorithms, Checklists, SOPs & Job-aids in surveyed HFs in Cluster 3……...... 51 Table 39: Availability of reporting tools at health facility ...... 52
LIST OF FIGURES Figure 1: Distribution of Health Facilities in nine counties in Cluster 3 ...... 6 Figure 2: HIV Positivity Rates (COP 17 SAPR) Cluster 3 ...... 20 Figure 3: HIV testing showing PNS services yield in COP 17 SAPR ...... 22 Figure 4: Baseline Viral Load Suppression Rates in Cluster 3 Supported Counties (COP16) ...... 26 Figure 5: Viral Load Suppression Rate by Age bands in Cluster 3 (COP17 SAPR) ...... 27 HIV Services Delivery Support Activity (HSDSA) – Activity Baseline Report
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HIV Services Delivery Support Activity (HSDSA) – Activity Baseline Report
5 Figure 1: Distribution of Health Facilities in nine counties in Cluster 3
HIV Services Delivery Support Activity (HSDSA) – Activity Baseline Report
6 ACKNOWLEDGEMENTS
We acknowledge the following people for making the baseline assessments and report materialize. We thank the United States Agency for International Development (USAID) for funding the HSDSA Cluster 3 project and for providing guidance on baseline assessment. Appreciations to the County Health Management Teams (CHMT) for the nine Cluster 3 counties for providing the necessary authorizations and supporting the process of the assessment; the management and staff of the facilities that were assessed. Thanks to the senior management team (SMT) of HSDSA Cluster 3 for provided leadership and guidance through the baseline assessment process; the project team who coordinated the entry into the counties and facilities; and partners LVCT and Cloudburst for contributing to or participating in the assessments.
Most of all we acknowledge the HSDSA Cluster 3 M&E Specialist, HSS Advisor, and the teams that went out to conduct assessments, conduct interviews, collect data, and analyze the data that ultimately made this report possible.
HIV Services Delivery Support Activity (HSDSA) – Activity Baseline Report
7 ACRONYMS
AGYW Adolescent Girls and Young Women ANC Antenatal Care ART Antiretroviral Therapy AWP Annual Work Plan CASCO County AIDS & STI Coordinator CCC Comprehensive Care Clinic CHMT County Health Management Team CME Continuing Medical Education DCM Differentiated Care Model DREAMS Determined Resilient Empowered AIDs-Free Mentored Safe EID Early Infant Diagnosis EMR Electronic Medical Record GBV Gender-Based Violence HEI HIV-Exposed Infant HMIS Health Management Information System HRH Human Resources for Health HSDSA HIV Services Delivery Support Activity HSS Health Systems Strengthening HTS HIV Testing Services MCH Maternal and Child Health M&E Monitoring and Evaluation MOH Ministry of Health NACC National AIDS Control Council NASCOP National AIDS and STI Control Program OCAT Organizational Capacity Assessment Tool OTZ Operation Triple Zero PCR Polymerase Chain Reaction PE Peer Educator PEPFAR U.S. President’s Emergency Plan for AIDS Relief PITC Provider-Initiated Testing and Counseling PLHIV People Living with HIV PMTCT Prevention of Mother-to-Child Transmission PSSG Psychosocial Support Group PNS Partner Notification Services QA Quality Assurance SAB Social Asset Building SCASCO Sub-County AIDS & STI Coordinator SCHMT Sub-County Health Management Team SGBV Sexual and Gender-based Violence SOP Standard Operating Procedure SIMS Site Improvement Monitoring Systems TWG Technical Working Group UNAIDS Joint United Nations Programme on HIV/AIDS USAID United States Agency for International Development USAID/KEA Unites States Agency for International Development in Kenya and East Africa WHO World Health Organization
HIV Services Delivery Support Activity (HSDSA) – Activity Baseline Report
8 GLOSSARY OF KEY TERMS
Systems thinking: is powerful tool for guiding investments in health systems. It maps and measures health system, to identify where some of the key blockages, weaknesses or gaps and challenges lie, and to design sound, synergistic and system-ready interventions targeting those weaknesses1.
Health system: The sum total of all the organizations, institutions and resources whose primary purpose is to ensure delivery of quality services to all people, when and where they need them. The World Health Organization (WHO) identifies six core components or ‘building blocks’ of a health system: (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing and (vi) leadership/governance2.
Lots Quality Assurance sampling (LQAS): LQAS is a random sampling technique that is widely used in public health and social applications. Analysts classify sub-units of a population as acceptable or unacceptable depending on the number of failures observed in a random sample of a given lot.
Integration: The process of bringing together, in a holistic manner, different kinds of related services and HIV and AIDS interventions at the levels of legislation, policy, programming and service delivery to ensure access to comprehensive services in an efficient and effective manner.
Adolescent Girls and Young Women: Females aged 10-24 years
1 Adapted from WHO (2009), Systems thinking for Health Systems Strengthening, Alliance for Health Policy and Systems Research. 2 Adapted from WHO (2010). Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies. HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
9 EXECUTIVE SUMMARY
Baseline assessment is a key requirement for the start-up HSDSA cluster 3, whose contract was awarded on 13 December 2017. The due date for the baseline report as directed in the fully executed contract number 72061518C00001 is180 days after the award, which falls on 11 June 2018. HSDSA Cluster 3 will be implementing HIV service delivery activities that are ultimately expected to achieve the UNAIDS 90-90-90 goals and epidemic control of HIV in counties in Central and Eastern regions of Kenya namely: Embu, Kiambu, Kirinyaga, Kitui, Meru, Murang’a, Nyandarua, Nyeri, and Tharaka-Nithi. The primary purpose of the assessment was to determine the status of key program indicators, which will serve as benchmark for future implementation, and the organizational capacity at facility and County levels to handle various implementation, coordination, and management functions related to HIV service delivery. HSDSA identified four priority areas that provided a framework for baseline evaluation. These included a) assessment of key programmatic indicators; b) Organizational capacity and facility assessment; c) Implementation of key strategies recommended by PEPFAR; d) County and facility environmental assessments. The report details the methodology used to conduct the baseline assessments that included key stakeholder interviews, physical observation, and secondary data analysis. The findings of interest are presented in narrative and data of specific activities up to SAPR COP 17. Gaps in achievement of targets for specific indicators are described in the narrative as well as status of implementation of strategies relevant to achieving the targets. The report provides recommendations on the way forward from the current baseline towards achieving the objectives of COP 17 and beyond.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
10 1. BACKGROUND
The primary focus of the HSDSA project in Cluster 3 is to identify, link, treat, retain and virally suppress HIV- positive individuals across the nine focus counties in Central and upper Eastern Kenya regions (Embu, Meru, Tharaka-Nithi, and Kitui in upper Eastern and Kiambu, Kirinyaga, Murang’a, Nyeri and Nyandarua in Central Kenya). This is in line with achieving the UNAIDS targets of 90-90-90 by 2020. Jhpiego is leading an experienced team—comprised of LVCT Health, a local organization; and Amethyst Technologies and Cloudburst, U.S.- based small businesses, to effectively and efficiently achieve project objectives.
HSDSA Cluster 3 project transitioned from APHIAPLUS KAMILI project (Jan 2011 to March 2018). KAMILI was a USAID-funded technical assistance project contributing to the overall USAID framework goal of ‘Sustained improvement of health and well-being for all Kenyans’. It was implemented in Eastern and Central Kenya focusing on key result areas of USAID implementation framework, which are; increased use of quality health services, products and information and social determinants of health addressed to improve well-being of targeted communities and populations. The project Implemented activities in eleven counties located in Eastern: Embu, Machakos, Meru, Tharaka-Nithi, Makueni, Kitui and Central Kenya: Nyeri, Nyandarua, Kirinyaga, Kiambu, Murang’a.
The transition period, has ensured uneventful changeover between the two projects, with KAMILI winding up its activities in March 2018, making an end to over seven years of stellar performance and a start of Cluster 3 game changing approach to intervention in the region. There is then an inevitable overlap between the final six months of KAMILI closeout and the first year of Cluster 3. This Baseline report, therefore presents benchmark metrics upto the SAPR of COP17 (FY 2018).
HSDSA Project Technical Approach
The Government of Kenya (GOK) recently committed to achieving the UNAIDS 90-90-90 goals by 2021: 90% of HIV infected individuals will be identified, 90% of those identified as positive will be initiated on ART (81% of all PLHIV) and 90% of individuals on ART will achieve viral suppression (73% of all PLHIV). Key elements are in place to achieve this goal: a national strategy, the Kenya AIDS Strategic Framework (KASF); evidence- based prevention, care and treatment policies and guidelines; and numerous public, faith-based organizations and private health facilities that provide comprehensive HIV services; complemented by outreach and community-based services. Nonetheless, critical challenges remain. A large number of PLHIV are unaware of their HIV status, and therefore unable to take advantage of the treatment and prevention benefits of ART and continue to transmit HIV to others. Stigma and discrimination—including gender-based discrimination and masculinity norms that preclude health and wellness care—inhibit care seeking. There is inadequate retention in care, insufficient adherence and continued limited availability of viral load (VL) testing3.
Project goal: To increase access and coverage for HIV prevention, care and treatment services towards achieving the 90-90-90 targets.
HSDSA Cluster 3 vision: Achieving success through this project will not only benefit the more than seven million people living in Cluster 3 counties: five counties in Central Kenya i.e. Kiambu, Murang’a, Kirinyaga, Nyandarua and Nyeri, four counties in Eastern Kenya i.e. Meru, Embu, Kitui, and Tharaka Nithi. It will also demonstrate to the rest of Kenya and the African continent that, achieving and sustaining the 90-90-90 goal is possible, hence inspiring continued perseverance and leading to an HIV/AIDS-free generation.
Objectives: As depicted in the Project Framework, the Project objectives are as follows: Objective 1: Increased availability and use of combination prevention services for priority populations Objective 2: Increased use of targeted HIV Testing Services (HTS) Objective 3: Improved linkage to treatment for individuals newly testing positive for HIV
3 Kenya AIDS Strategic Framework (KASF) 2014/15 – 2018/19, National AIDS Control Council (NACC). HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
11 Objective 4: Increased uptake of and adherence to quality HIV treatment services Objective 5: Long-term follow-up of patients receiving care and treatment services, including laboratory and logistics support. Objective 6: Strengthened institutional capacity and accountability for the management, facility and county HIV response in the eight Cluster 3 counties.
Across Cluster 3 counties, HSDSA will support 236 facilities (Annex C) for HIV-related interventions: 236 health facilities offering HIV Testing Services 140 health facilities have HIV Comprehensive Care Clinics (CCCs) 153 health facilities with maternal and child health (MCH) clinics, which provide prevention of mother- to-child transmission (PMTCT) services. HSDSA Cluster 3 is building on the strong foundation laid by its predecessor, APHIAPLUS KAMILI project in making quality data available, whereby health facility DHIS2 reporting rates improved from 40% in 2011 to 96% in 2016. At the same time, health facility reporting by the 15th of each month (timeliness) improved from approximately 30% to 85% and data quality median variance between DHIS2 and PEPFAR reporting improved, declining from 69% to 4%4.
HSDSA Project Results Framework
The project results framework (Figure 1) visually presents HSDSA’s overall goal, project outcomes, key interventions and guiding principles. This framework maps the pathway to increase access and coverage of HIV prevention, care and treatment services and contribute to achieving the 90-90-90 targets by 2021. To realize this goal, the Kenya health system must have strong foundational elements to develop a sustainable response throughout the country. The five pillars illustrated represent these critical elements and within each pillar are the key interventions and actionable approaches that will lead to the expected project results. The Project will implement, monitor, and evaluate activities and results under each objective to ensure they contribute to overall goal of the project, and that the project complies with environmental regulations, following 22CFR216 and international and national environmental laws. Figure 1: Project Framework
At the framework’s foundation, underlying all interventions and objectives, is the Project’s sixth objective to strengthen institutional capacity and accountability for county coordinated HIV response. Finally, HSDSA has laid out a set of seven guiding principles (outlined in the green base of the framework) that will permeate all aspects of the Project and lead to meaningful partnership with the 8 County governments to achieve lasting impact on HIV/AIDS in Kenya.
PURPOSE AND OBJECTIVES OF BASELINE ASSESSMENT
The purpose of the baseline assessment is • To establish the initial status of key performance indicators to inform target setting and provide benchmarks against which the project performance will be tracked.
4 APHIAPLUS KAMILI Project Annual Progress Reports HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
12 The objectives of the assessment are to: • To determine status of key performance indicators to guide target setting and project performance tracking and management • To identify size of vulnerable AGYW and map out their location in Biashara and Ngoliba wards in Kiambu County • To establish organizational capacity of CHMTs to offer quality HIV service in HSDSA Cluster 3 supported counties. • To conduct environmental assessment on medical safety and healthcare waste management
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
13 2. METHODOLOGY
2.1 Key Project indicators and Differentials Explored
HSDSA Cluster 3 has identified a priority list of performance indicators as guided by USAID KE/EA and outlined in Activity indicator tracking sheet (ITT). This assessment identified baseline indicator estimates for the following indicators that relate to the six project objectives:
The First 90 (90% of PLHIV know their status) Objective 1: Increased availability and use of combination prevention services for priority populations. Priority Performance indicator related to this objective is: 1. >80% of vulnerable AGYW reached with a defined package of services in HIV high burden counties (in the first year of HSDSA cluster 3; this Intervention being implemented in Kiambu county in two wards (Ngoliba and Biashara wards).
Objective 2: Increased use of targeted HIV Testing Services (HTS). Priority Performance indicators related to this objective are: 2. Number of HIV Positive individuals identified (HTS_TST_POS) 3. Number/percentage of individuals identified as positive through HIV testing services linked to comprehensive Care Clinic: Target is 95% 4. Number/percentage of pregnant women with known HIV status (includes women who were tested for HIV and received their results, positive or negative) – (PMTCT_STAT) 5. Number/percentage of pregnant women tested HIV positive (PMTCT_ POS) 6. Percentage of children born to HIV infected mothers receive an HIV test by age 8 weeks (through DNA polymerase chain reaction – PCR testing): Target: 80%
The second 90 (90% of all people with diagnosed HIV Infection receive ART) Objective 3: Improved linkage to treatment for individuals’ newly testing positive for HIV. Priority Performance indicators related to this objective are: 7. Number/percentage of HIV-positive pregnant women who receive ART to reduce risk of mother-to-child- transmission during pregnancy (PMTCT_ART): Target: 95% 8. Percentage of HIV positive Individuals identified being initiated on ART within 2 weeks of identification, Target: ≥80%
Objective 4: Increased uptake of and adherence to quality HIV treatment services. Priority Performance indicators related to this objective are: 9. Number of adults and children NEWLY enrolled on antiretroviral therapy (ART) – (TX_NEW) 10. Number of adults and children CURRENTLY receiving antiretroviral therapy (ART) – (TX_CURR)
The Third 90 (90% of all people receiving ART will have viral suppression) Objective 5: Long-term follow-up of patients receiving care and treatment services, including laboratory and logistics support. Priority Performance indicators related to this objective are: 11. Number/percentage of adult and pediatric ART patients with a viral load result documented in the patient medical record within the past 12 months. Target is 95% 12. Number/percentage of ART patients with a viral load result documented in the medical record within the past 12 months with a suppressed viral load (<1000 copies/ml) (TX_PVLS), Target is 90%.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
14 2.2 HSDSA Cluster 3 Baseline Assessment Approach
This baseline assessment enables USAID/KEA and HSDSA Cluster 3 to establish baseline performance for the project and inform key stakeholders if or not the counties are achieving expected results throughout the project implementation period. The assessment established benchmarks for measurement of project performance and generated data for evidence-based decision making at project initiation in relation to tracking of project progress and outcomes; opportunities for leverage/linkages and synergies for better results. Providing opportunities for learning for improvement for better impact. Secondary analysis of existing data from DHIS, EMRs and other sources and data triangulation formed an important part of this report. The activity’s approach to baseline assessment consisted of six main outputs, as outlined below: 1. Desk Review conducted to document county specific HIV estimates 2016 in cluster 3 counties. However, expected documents from KENPHIA 2018 and latest (2017) NACC HIV estimates were not ready by the time this report was compiled. Health facility level data was extracted and analyzed from DHIS2 https://hiskenya.org), Electronic Medical Records (EMR), EID (https://eid.nascop.org ) and Viral Load (https://viralload.nascop.org) websites for Cluster 3 counties.
2. Organizational Capacity Assessment (OCA): Phase one of OCA in three counties i.e. Meru, Kiambu and Embu, which require immediate attention as they account for most the Cluster 3 numbers. The OCA gauged the capacity of the CHMT to offer quality HIV service. This facilitated development of appropriate capacity development plans. The project HSS interdisciplinary team identified key informants among the CHMT, and other relevant stakeholders who provided insights on the various management/institutional competencies, which were assessed and county specific capacity-building plans developed and implemented in partnership with the respective counties.
3. In order to plan interventions for AGYW in focus wards of Biashara and Ngoliba in Kiambu County, Cluster 3 conducted a project level estimation of Adolescent Girls and Young Women (AGYW) through a household mapping and registration, which was conducted by trained community volunteers led by local administration (the assistant chief and village elders), to ensure that all households are mapped and AGYW living in these households were entered into a girls’ roster and screened for vulnerability, using a project screening form. The girl’s roster will be updated routinely every year to reflect the changing status of the AGYW e.g. those who exit due to age, migration, or vulnerability changes once girls empowered.
4. Health facility assessment: The purpose of the Health facilities was to ascertain preparedness of health facilities and availability of essential items for service delivery e.g. reporting tools, guidelines, human resources, Standard operating procedures and guidelines, training needs and quality of HIV Services offered. Data collection was done via electronic health facility assessment questionnaire, targeting facility managers or designated staff. The questionnaire was loaded in Galaxy tablets and administered as face to face at the health facility. a. A sample of health facilities selected represented 30% (72/236) of health facilities in cluster 3 counties. The selection was designed to include health facilities in all nine counties, across the KEPH Levels (level 2-5), ownership (public, Private and Faith-based), services offered and geographical distribution. b. HIV quality of care – Health facility structures to support quality of care were assessed including presence of functional quality assurance/improvement team, supportive supervision, record of quality assurance activity in the past year. c. Site Improvement Monitoring System (SIMS): SIMS data was collected as part of project supervision and support in COP 16 (FY 2017). The Sites were rated and scored based on core essential elements (e.g., testing interruptions, results and information management, biosafety, compliance with national testing algorithms, supply chain reliability, waste management, proficiency testing of test kits and quality management systems).Data collected at baseline (in COP 16) in selected high volume facilities has helped identify key facility-level gaps. The gaps identified will help standardize site quality services through regular monitoring.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
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5. APHIAPLUS KAMILI project end line survey data: APHIAPLUS KAMILI end line household survey across the project supported counties was conducted to: 1) evaluate the change in knowledge, health seeking behavior and health outcomes in APHIAPLUS KAMILI project regions and 2) to assess the level of uptake HIV services at health facility by the end of the project period. This report captures analysis of the HIV services household interview data for PMTCT, HTS and HIV Care and Treatment, in upper Eastern and Central Region. The household survey utilized Lot Quality Assurance Sampling (LQAS) methodology to identify study locations and participants. The ‘lots’ otherwise known as ‘supervision areas’ were defined the wards and the county was the program area. Two sampled sub-counties from each county were sub divided into programmatically meaningful five (5) supervision areas (SAs), where nineteen interviews were conducted per SA, forming 95 interviews per sub-county, and therefore 190 per county, totaling to 1,710 interviews in 9 Cluster 3 counties.
2.3 Data Management and Analysis
Where data collection was required, i.e. for health facility assessment and household survey; HSDSA Cluster 3 utilized REDCapTM application via use of smart phones or tablets to collect data and uploaded this data into a remote server for management. Utilizing this technology ensured that data cleaning minimized. Inbuilt data validation measures ensured that human error was minimized. Minimal data cleaning was done throughout the data collection period and prior to analysis. Analysis of already existing data was performed using MS Excel spreadsheet and STATA or R statistical softwares where needed. Dummy tables were developed to ensure that only data needed for this report was gathered and used.
2.4 Baseline Assessment: Stakeholder Meetings
The baseline report will be validated by key stakeholders at county, sub-county, facility and community level through stakeholder fora, where stakeholders will be invited at county level to validate the report for revisions and adoption. This will be conducted within the first three months after the draft report is generated and shared with USAID KE/EA. Weekly and monthly project staff meetings will be the fora to discuss emerging or observed achievements and corrective actions taken to improve situations. Data from the learning agenda and other studies will be disseminated through local and international fora as well as publication in peer-reviewed journals. HSDSA project will facilitate best practices meetings in the targeted counties to allow the county teams to share lessons learned and discuss data implications
2.5 Ethical Consideration
Data collection for APHIAPLUS KAMILI end line survey ensured that participation was solely voluntary. Respondents signed informed consent forms, which included their rights to refuse to participate or to end the interview at their discretion. The household survey team secured ethical approval from JHSPH IRB & KEMRI ERC. Project level assessments including estimation of AGYW in Ngoliba and Biashara wards, Organizational Capacity Assessment (OCA) and health facility assessment received approval from county leadership prior to data collection.
2.6 Challenges and limitations
2.6.1 Population-based HIV Impact Assessments (PHIAs) provide necessary data to monitor coverage and impact of programs and are valuable in understanding the gaps to reaching epidemic control. At the time of developing this report, KENPHIA survey data collection is ongoing; therefore, latest HIV estimates are unpublished and not official. Obtaining reliable data for baseline population estimates responding to 90-90-90 cascade is challenging in Kenya. Data that are more reliable will be available once KENPHIA Is completed. This will inform better ground for setting baseline performance benchmarks, therefore, the findings of this baseline report will be updated once the KENPHIA results are available.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
16 2.6.2 Assessments face response problems partly due to lack of appropriate respondents (most knowledgeable persons to respond to survey questions). This affected OCA and Health facility assessment. However, data was collected with the most knowledgeable representatives available. The data represents best responses possible at the time of data collection. 2.6.3 Health Facility selection is not a generable sample across the Cluster 3 counties. Results should therefore be interpreted with caution. However, the survey purpose for rapid assessment to document baseline status of health facilities pertaining to HR, training needs, infrastructure, enabling environment and services available and their utilization was achieved. This will help with identifying key gaps to address during implementation phase of the project. 2.6.4 Numerous HIV services data disaggregation-reporting requirements in PEPFAR reporting requirements require that a concurrent data collection mechanism are instituted to respond to the reporting standards. This does not align with the MOH minimum reporting practice. It is anticipated that revision of reporting tools will align the reporting systems to assure data consistency and assure reminiscent support to government Health information system in Kenya.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
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3. KEY FINDINGS
This section of the report presents a summary of baseline values for selected HSDSA cluster 3 performance indicators, followed by a detailed analysis of findings pertaining to each of the approaches as outlined in methodology section.
3.1 Desk Review
Analysis of available HIV Services statistics from Cluster 3 counties, KAMILI project progress reports and information outputs, National HIV estimates including prevalence rates, trends for new HIV infection and treatment coverage was conducted. Cluster 3 counties has overall low prevalence ranging from 2.8% in Embu to 4.2% in Murang’a according to 2018 estimates (unpublished). Incidence rate across the counties stand at about 1.8 per 1000. Four counties i.e. Meru, Murang’a, Kiambu and Embu account for 46% PLHIV and close to half of all new HIV infections in HSDSA Cluster 3 counties5. HIV Prevention and Support in AGYW Cluster 3 is focusing on the reduction of HIV incidence in adolescent girls and young women by delivering a package of evidence-based interventions. The core package layers approaches that address individual, community and structural factors that directly and indirectly increase girls’ HIV risk. Comprehensive prevention to break the cycle of transmission from young adult men to younger women need be strategically implemented. Cluster 3 project estimated the number of vulnerable AGYW in Kiambu County, through household mapping and registration in Ngoliba and Biashara wards; the focus AGYW wards in Kiambu County. The registration was done in a girl’s roster and then the team identified the most vulnerable AGYW through filling vulnerability-screening form. Tables 1 and 2, illustrates the distribution of estimated number of vulnerable AGYW in the two wards by age bands.
Table 1: Distribution of Vulnerable AGYW by ward: in Biashara and Ngoliba wards Ward 10 to 14 15 to 19 20 to 24 Total Biashara 1693 (29%) 1653 (28%) 2494 (43%) 5,840 (100%) Ngoliba 876 (43% 606 (30%) 534 (26%) 2,016 (100%) Grand Total 2,569 2,259 3,028 7,856
Table 2: Distribution of Vulnerable AGYW by age groups: in Biashara and Ngoliba wards Ward 10 to 14 15 to 19 20 to 24 Total Biashara 1693 (66%) 1653 (73%) 2494 (82%) 5840 (74%) Ngoliba 876 (34%) 606(27%) 534 (18%) 2016 (26%) Grand Total 2,569 (100%) 2,259 (100%) 3,028 (100%) 7856 (100%)
Biashara ward is in urban areas, and families rent houses and have smaller households, it is densely populated compared to Ngoliba ward, which is in a rural setting with a scattered and sparsely populated areas, but households are larger in size. Biashara ward accounts for 74% (5,840) of vulnerable AGYW in the project focus areas in Kiambu County. The age distribution differs sharply in the two wards. In Biashara ward, 29%, 28% and 43% of the vulnerable AGYW are within the 10-14, 15-19 and 20-24 age bands respectively. There are older AGYW in Biashara compared to Ngoliba where this population constitutes 26%. On the other
5 County HIV Estimates 2018 (non-published) HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
18 hand, the age distribution in Ngoliba shows that 43%, 30% and 26% are aged 10-14, 15-19 and 20-24 respectively. This suggests that age focused interventions are required for each ward e.g. PrEP for older adolescent girls who are sexually active and at higher risk of HIV infection, would be a priority in Biashara ward. Kiambu County boast of high completion rate of secondary education at 92.5%6, and the secondary school enrolment rate stands at 69.3%7 therefore, given the high cost of education support, minimum education subsidies are expected under this intervention in the county. The project will focus on community mobilization to address change at community rather than at individual level. This will include placing emphasize on preventing sexual violence and any form of coercive/forced/non-consensual sex in the community, preventing early sexual debut, supporting healthy choices, HTS services, PrEP for those eligible (especially older AGYW) and helping communities and families to support the youth with education and opportunities to contribute to the community. The project will prioritize the meaningful engagement of AGYW in planning, implementing, monitoring the activities targeting these girls/young women to ensure their needs, perspectives, and experiences are appropriately addressed. The project will employ GIS technology to map and identify safe places for AGYW within the wards to further partner with local community resource persons peer educators , teachers, tutors, facilitators, mentors, community health workers) to reach to vulnerable AGYW. Through these interventions, the project will reach at least 80% of Vulnerable AGYW with a defined package of services in Kiambu County, every year for the next five years. Cluster 3 will plan to assess efficiency of the core package being implemented. HIV incidence and prevalence in AGYW ages 10-24 will be re-explored once the KENPHIA survey is completed, later in the year. The project will review existing data to characterize the male sex partners of AGYW and ensure that HIV testing services (HTS), condom promotion and distribution, and treatment programs are targeting men with those characteristics.
Identification of HIV-positive Individuals (The first 90) The ‘First 90’ of the UNAIDS’ 90-90-90 targets to end the HIV epidemic by 2020 speaks to ‘90% of all people living with HIV know their HIV status’. Timely identification of HIV-positive individuals, optimal linkage and retention to care for persons diagnosed with HIV, increased coverage of ART and viral suppression are critical to achieve the 90-90-90 target. Identification is the first step in the cascade, and when its low, efforts to enroll HIV-positive clients into care and to initiate and sustain treatment is affected. Review of National County HIV estimates shows that prevalence and incidence rates are decreasing over the period, suggesting that HIV prevention interventions are showing progress. Table 1, show the estimated prevalence and incidence per 1000 and estimated number of PLHIV in 2016 & 2018 by county. The number of PLHIV in Cluster 3 is estimated at about 25% of PLHIV in Cluster 3, based on estimated catchment population of the supported 236 health facilities in the region. Table 3: HIV Population projections 20168, 20189 in Cluster 3 counties 2016 201810 County Prevalence Incidence Estimated Total Prevalence Incidence Estimated per 1000 No. of Population per 1000 No. of PLHIV PLHIV Kenya 5.9% 2.7 1,338,162 48,460,000 4.8% 1.8 1,493,382 Embu 3.3% 2.1 9,915 554,081 2.8% 1.1 10,721 Meru 2.9% 1.8 23,154 1,455,850 2.4% 0.9 24,005 Kitui* 4.4% 2.7 25,733 1,086,598 4.5% 1.7 28,661 Tharaka Nithi 3.9% 2.4 8,092 392,097 3.2% 1.2 8,453 Nyeri 3.4% 2.1 16,783 782,864 3.7% 1.8 21,428
6 County Government of Kiambu, education and literacy (www.kiambu.go.ke/about/education-and-literacy ) 7 County Integrated Development Plan (CIDP), Kiambu County 2013-2017 8 County HIV Estimates 2016 9 County HIV Estimates 2018 (non-published) 10 County HIV Estimates 2018 (non-published) HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
19 Nyandarua 3.0% 2.0 11,435 673,000 3.5% 1.8 16,005 Kiambu 5.6% 3.6 61,691 1,831,800 4.0% 2.2 59,016 Murang'a 4.2% 2.5 24,022 1,063,721 4.2% 2.0 30,376 Kirinyaga 3.1% 2.0 11,037 596,030 3.1% 1.6 14,481 191,862 8,436,041 213,146 Estimated Cluster 3 47,965 53,286 * Limited presence for cluster 3 in county (in two FBO facilities) Estimated PLHIV in cluster 3-supported region in 2018, 2019 and 2020, (assuming the estimated incidence in 2018 remains unchanged) stands at about 53,286, 56,107 and 58,479 respectively. It will be required that Cluster 3 identifies 90% of these i.e. 47958, 50, 496 and 52, 631 respectively. To identify 90% of estimated PLHIV and subsequently ensure 90% treatment and viral load suppression by 2020, it is estimated that the clients receiving ART must increase from steadily, from 39, 677 by end of COP’16 and by SAPR COP17 at 42,534 to 47,367 by end of COP 19. This is 20% increase or three-year cumulative 7,690 newly started on ART (or a minimum of 2,564 annual net gain). To realize this, the leaky pipe owing to Loss-to-follow-up (LTF) must be fully repaired and closed.
Figure 2: HIV Positivity Rates (COP 17 SAPR) Cluster 3 From project level data reported by APHIAPLUS KAMILI from 2015-2017, four counties (Meru, Kiambu, Embu and Murang’a) contributed 76%, 78%, and 78% (on the number of HIV Positive identified) in the three consecutive years(2015-2017), prior to Cluster 3 project startup.
Meru and Kiambu account for about 53% over the same period. This trend is expected to continue during project implementation phase and beyond. This is consistent with the GIS map showing variations in positivity in these counties.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
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Identification of HIV-positive cases, in this region is standing at 31% towards the COP 17 SAPR. Looking at historical identification data, four number of counties achieve their target by about 90% or higher i.e. Meru, Embu, Nyeri, and Kiambu. On the other hand, Murang’a has posted the lowest performance against target, over the period, followed by Kirinyaga, Nyandarua and Tharaka-Nithi. Table 4, highlights the county performance against target over the period. Table 4: HIV positive case identification by County against annual targets by COP 17 SAPR 2015 APR COP16 APR CO17 SAPR County Tested HIV Target % Tested Target % Tested Target % positive achievement HIV Achievement HIV Achievement positive positive Embu 1,175 1,025 115% 963 1,025 94% 697 1,309 53% Meru 2,606 2,016 129% 1,791 2,016 89% 1,159 3,130 37% Kitui 46 151 30% 54 151 36% 14 - - Tharaka Nithi 493 600 82% 396 600 66% 287 795 36% Nyeri 345 347 99% 333 347 96% 176 474 37% Nyandarua 669 680 98% 438 680 64% 293 783 37% Kiambu 1,799 953 189% 1,547 953 162% 741 2,197 34% Murang'a 938 1,816 52% 664 1,816 37% 368 3,408 11% Kirinyaga 255 360 71% 179 360 50% 124 249 50% Total 8,326 7,948 105% 6,365 7,948 80% 3,859 12,345 31%
This county variation in performance stresses the need to update HIV estimates in the counties to reflect actual prevalence and incidence rates. It is evident, that there is potential to under/overestimate across the cluster 3 counties. Finalization of KENPHIA is expected to provide reliable estimates to inform target re- setting. Using data for COP 17 SAPR, 66% of individuals identified HIV-positive are female. Table 5, highlights gender variations across the counties, showing a similar trend across counties, where 34% of those identified HIV- positive are male, with exception Nyeri County, 41% males having tested positive over the same period. Table 5: Baseline HIV Positive by County, Age bands and Gender in Cluster 3 (COP17 SAPR) County Tested Positive Tested positive Total F M Adults Children Embu 451 246 660 37 697 Kiambu 479 262 704 37 741 Kirinyaga 85 39 123 1 124 Kitui 12 2 14 0 14 Meru 774 385 1,100 59 1,159 Murang’a 245 123 355 13 368 Nyandarua 194 99 277 16 293 Nyeri 104 72 171 5 176 Tharaka Nithi 194 93 270 17 287 Total 2,538 1,321 3,674 185 3,859
Targeted Testing strategies: Targeted testing is the new recommendation by PEPFAR in order to optimize HIV positive yield while being efficient with resources. The recommended approaches include partner notification services, and those targeting ANC, TB Clinics, and in-patient services. The goal of targeted testing is to identify and test individuals
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
21 with high likelihood of being HIV positive due to previous exposure or high-risk circumstances. Table 6 highlights yields by different modalities in COP17 SAPR. Table 6 Number of tests and yield per testing modality (Oct’17 – Mar’18) Modalities Tested Positive % Positivity Index testing-Sexual contacts 1,104 232 21.0% Index testing-Children 759 44 5.9% TB clinic 3,058 140 2.6% OPD 148,443 2,648 1.1% VCT 13,744 222 1.0% ANC 31,793 386 0.9% IPD 14,564 186 0.7% Others (STI,CWC) 404 1 0.3% Total 213,869 3,859 1.8%
Figure 3: HIV testing showing PNS services yield in COP 17 SAPR 4500 3859 4000 97% 3500 3000 2711 78% 2381 2500 1863 2000 1508 1500 1000 15% 500 330 276 267 0 Positives from Sum of index Contacts Contacts with Sum eligible Tested Identified new Linked all modalities clients identified Known positive positive status
One of the recommended high yield strategies that is being implemented in COP 17 is partner notification services (PNS) which involve notifying and testing sexual contacts and family members of index cases. By COP 17 SAPR, 97 facilities in the nine cluster 3 counties were implementing PNS. Table 7 Number of Partner Notification Services (PNS) sites by County at COP 17 SAPR County Total HTS Sites PNS SITES
Embu 46 18 Kiambu 33 17 Kirinyaga 9 6 Kitui 2 0 Meru 61 15 Murang’a 15 8 Nyandarua 34 15 Nyeri 12 7 Tharaka 23 11 Total 235 97 (42%)
Linkage to treatment services is critical to achieve the second and third 90 goals. Linkage data from COP 17 at SAPR indicate that linkage to care has been less than optimum, with linkage across age bands and gender failing to reach the 95% required by PEPFAR. Table 9, highlights linkage proportions at baseline, according to HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
22 gender and age bands. Males demonstrate lower linkage rates 69% compared to female at 74%. Age-band 25- 49 has lowest linkage followed by 0-9 years. Table 8: Linkage to treatment by Gender and Age-bands Age-group Male Male % linkage Female Female % Total Total % positive ART positive ART Linkage Positive linked Linkage 0-9 years 65 51 78% 76 58 76% 141 109 77% 10-19 years 41 38 93% 149 119 80% 190 157 83% 20-24 years 51 41 80% 336 231 69% 387 272 70% 25-49 years 957 619 65% 1,734 1,269 73% 2691 1888 70% 50+ years 207 165 80% 243 200 82% 450 365 81% Total 1,321 914 69% 2,538 1,877 74% 3859 2791 72% *Linkage data for first 6 months of COP17 used for as baseline.
HIV Care and Treatment (The second 90) Since 2015, the project has been realizing on average 5,800 newly initiated clients on ART annually i.e. 5,581, 6,361 and 6,104, in 2015, 2016 and 2017 (see table 10). Table 9: County contribution on newly initiated clients on ART (TX_NEW) County 2015 2016 2017 **2018 (COP14) (COP 15) (COP16) (COP17) Embu 17% 16% 14% 17% Kiambu 17% 19% 24% 22% Kirinyaga 3% 3% 4% 4% Kitui 1% 1% 1% 1% Meru 31% 31% 28% 28% Murang'a 12% 11% 11% 9% Nyandarua 9% 8% 7% 8% Nyeri 3% 4% 4% 4% Tharaka Nithi 6% 7% 7% 7% Contribution of the Four counties (Meru, Kiambu, 78% 77% 77% 76% Embu and Murang’a) ** Data presented for SAPR COP17 (Oct’17-March 2018). Notably, four counties i.e. Embu, Kiambu, Murang’a and Meru account for 77% of newly started on treatment. Table 10: County contribution on newly initiated clients on ART (TX_NEW) County 2015 2016 2017 **2018 COP17 (COP14) (COP 15) (COP16) (COP17) APR Target Embu 1,081 953 745 478 1,071 Kiambu 1,089 1,169 1,243 627 1,331 Kirinyaga 173 204 184 99 181 Kitui 81 48 37 18 - Meru 1,985 1,885 1,426 768 2,768 Murang'a 759 672 586 261 2,896 Nyandarua 547 483 349 235 494 Nyeri 204 214 218 99 326 Tharaka Nithi 410 446 379 206 514 Total 6,329 6,074 5,167 2,791 9,581 Contribution of the Four counties (Meru, 4,914 4,679 4,000 2,134 Kiambu, Embu and Murang’a) (78%) (77%) (77%) (76%) ** Data presented for SAPR COP17 (Oct’17-March 2018).
Progress at COP17 SAPR is at 29%towards COP 17, with Meru, Murang’a and Nyeri, falling far behind 50% of the expected progress by SAPR, in Particular Murang’a achievement is blow 10% of target by SAPR. HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
23
Data from COP 14 through COP 17 shows that current on ART (TX_CURR) has been increasing at a rather subdued rate, taking into consideration the relatively higher number of new clients receiving ART annually. This suggests a challenge with retention on treatment at all levels of HIV services. This implies that investing on identification and linkage in these counties, as well as retention is critical to realize the bulk of cluster 3 annual performance targets in subsequent years. Table 11: Newly enrolled and current on ART in Cluster 3 counties 2015 2016 2017 **2018 COP 17 (COP14) (COP 15) (COP16) (COP17) Target Number identified HIV-positive (HTS_TST_POS) 9,518 8,371 6,365 3,859 12,345 Number newly enrolled on ART (TX_NEW)(% 5,581 (67%) 6,361 (73%) 6,104 (81%) 2,791(72%) 80% linkage) (Linkage target 80% linked within two weeks of initiation ART) Number receiving ART (TX_CURR) 34,683 39,627 39,677 42,534 50,966 Minimum number of clients expected to be *40,048 46,152 48,943 receiving ART *Based on current on ART of 29584 in 2015 and new on ART in 2015. ** Data presented for SAPR COP17 (Oct’17-Mar 2018). Progress against target (HTS_TST_POS) at baseline in COP 17 APR is at 32%, 72% linkage and 84% TX_CURR Every quarter there is demonstrated potential to start 1450 new clients on ART. In COP17, owing to targeted testing, and improved linkage systems, cluster 3 has the potential to increase this number substantially over the life of the project. The limitation to this is the demonstrated reduction in new HIV infections in the region at an incidence rate of about 1.8 per 1000 ( This is estimated, 2,400 new cases testing positive, in the facility catchment population in cluster 3 counties of about 1,350,000). Using estimated number of PLHIV in COP16 in Cluster 3 (through facility catchment population and prevalence of 1.8%), ART coverage at baseline stands at 78% (39627/50, 850).
Table 12: HIV testing among pregnant women County 2015 2016 2017 **2018 COP 17 (COP14) (COP 15) (COP16) (COP17) TARGET Number of pregnant women with known HIV status (includes women who were tested for 65,977 60,730 48,978 32,828 76,399 HIV and received their results, positive or negative) – (PMTCT_STAT) Number of pregnant women tested HIV positive (PMTCT_ POS) 2,279 2,079 1,397 1,012 2,396
Number of HIV-positive pregnant women who receive ART to reduce risk of mother-to- 2,362 2,217 1,368 1,004 2,276 child-transmission during pregnancy (100%) (100%) (98%) (99%) (PMTCT_ART) *Drop in COP 16 is associated with health care providers industrial action
Progress towards target for COP17 SAPR for PMTCT_STAT stands at 42%, PMTCT_POS at 44% and PMTCT_ART at 44%. There is performance gap of between 6-8% to be on trajectory to attain APR COP17 target. The trend requires that Cluster 3 employ innovative approaches as proposed in project strategies to meet the target by end of September 2018.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
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Table 13: HIV testing among HIV Exposed Infants County 2015 2016 2017 **2018 COP 17 (COP14) (COP 15) (COP16) (COP17) TARGET Number of HEI tested through PCR 1,961 2,552 2,472 1,125 2,276 Number of HEI tested through PCR before 8 1,310 1,732 1,296 597 1,821 weeks % of HEI tested by age 8 weeks (through DNA polymerase chain reaction – PCR testing 67% 68% 52% 53% 80% (target 80%)
Progress against target, at baseline (in COP 17 SAPR) is at 53%, the project is on trajectory to reach at least 80% by COP 17 APR through rigorous interventions. In Embu, Kiambu and Meru Counties 64%, 55% and 55% of the infants were tested before 8 weeks. HSDSA Cluster 3 will work towards improving the uptake of early infant diagnosis (EID) and integration of Immunization with EID in the 153 supported sites in order to achieve over 85% EID testing before 8 weeks of age. As at COP 17 SAPR positivity for HEI tested within 6-8weeks was at 3.4%, while 2-12months was at 4.9%. Kiambu and Tharaka Nithi had the highest positivity rate of PCR tests below 8 weeks of 4.8% and 3.8% respectively. HSDSA will work towards achieving elimination of mother to child transmission (EMTCT) of HIV with the goal of having transmission rate below 2% before 8 weeks of age and 5% at 18 months in nine cluster 3 counties.
90 % of all people receiving ART will attain viral suppression (The third 90) Consistent with the cascade approach to treatment, targeting the third 90 requires that long term, effective follow-up of clients on antiretroviral therapy, retention and ongoing viral monitoring for treatment success. Data for COP 16 and SAPR COP 17 show that none of the nine cluster 3counties achieved the minimum- targeted 90% viral suppression rate as illustrated by tables 13 and 14 below. In COP16 and SAPR COP17, the baseline viral load suppression stood at 83% and 82% respectively. The 7-percentage points gap to the 90% target mark, appears feasible to attain however, there are variations, which need attention. The suppression rates vary by counties, gender and age bands. This data suggests that viral load suppression rate seems to decrease with age Table 14: Baseline Viral load suppression rates in nine Cluster 3 counties in COP16 County Virally Suppressed Grand Total % viral suppression rate Yes No (Gap) All Embu 4,631 1,031 5,662 82% Kiambu 4,209 776 4,985 84% Kirinyaga 722 113 835 86% Kitui* 330 101 431 77% Meru 6,391 1,517 7,908 81% Murang'a 3,383 468 3,851 88% Nyandarua 1,729 402 2,131 81% Nyeri 1,275 261 1,536 83% Tharaka Nithi 1,303 369 1,672 78% Grand total 23,973 5,038 29,011 83% *Kitui county constitutes two FBO facilities A near uniform gap of about 8% is noted across counties; however, focusing on high volume priority counties of Meru, Kiambu, Embu and Murang’a will address 75% (3792/5038) of non-suppression in the regions.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
25 Figure 4: Baseline Viral Load Suppression Rates in Cluster 3 Supported Counties (COP16) 100%
80% 88% 86% 84% 83% 82% 81% 81% 78% 77% 60% VLS rate 40% 90% Target 20%
0% Murang'a Kirinyaga Kiambu Nyeri Embu Nyandarua Meru Tharaka Kitui Nithi
Table 15: Baseline Viral load suppression rates in nine Cluster 3 counties in COP17 SAPR County Virally Suppressed Grand Total % viral suppression rate Yes No (Gap) All Embu 2,298 449 2,298 80% Kiambu 3,069 541 3069 82% Kirinyaga 461 66 461 86% Kitui* 214 52 214 76% Meru 4,851 1,016 4851 79% Murang'a 2,329 255 2,329 89% Nyandarua 1100 207 1100 81% Nyeri 796 137 796 83% Tharaka Nithi 1300 304 1300 77% Grand total 13,391 3,027 16,418 82% *Kitui county constitutes two FBO facilities Viral suppression trends by age Young people have the lowest percentages of viral suppression across age groups. In COP 16, only 73 percent of those aged 10 to 24 years old had viral suppression, compared to 85% and 90% among 25-49 and 50+ respectively. Suppression rates are lower among 1-9 years old standing at 67%, over the same period. The largest gap lies among the adolescents 10 to 14 and 15 to 19, at 60% and 58% respectively. A similar picture is presented in COP 17 SAPR data. Table 16: Baseline Viral Load Suppression Rate by County and Age bands in Cluster 3 (COP16) Suppression Rate by Age bands County 1 to 9 10 to 14 15 to 19 20 to 24 25 to 49 50+ Overall Target Gap Embu 62% 57% 54% 72% 84% 89% 82% 90% 8% Kiambu 67% 69% 64% 80% 86% 89% 84% 90% 6% Kirinyaga 71% 68% 71% 60% 87% 93% 86% 90% 4% Kitui 58% 39% 56% 58% 85% 81% 77% 90% 13% Meru 69% 56% 54% 72% 83% 89% 81% 90% 9% Murang’a 70% 68% 60% 81% 90% 94% 88% 90% 2% Nyandarua 60% 68% 59% 60% 82% 90% 81% 90% 9% Nyeri 74% 74% 63% 61% 85% 87% 83% 90% 7% Tharaka Nithi 67% 42% 59% 66% 80% 88% 78% 90% 12% Grand Total 67% 60% 58% 73% 85% 90% 83% 90% 7% Target 90% 90% 90% 90% 90% 90% 90% Gap 23% 30% 32% 17% 5% 0% 7%
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
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Figure 5: Viral Load Suppression Rate by Age bands in Cluster 3 (COP17 SAPR)
18000 100% 16418 90% 16000 82% 85% 13751 14000 13391 80% 77% 11628 70% 12000 64% 62% 60% 10000 50% 8000 40% 6000 30% 4000 20% 2000 1339 400 621 827 536 707 10% 0 0% 1-9yrs 10-19Yrs 20-24Yrs 25+Yrs All ages
Viral suppression by gender trends Suppression gaps analysis across the counties shows that focus is required to close the gap in Tharaka Nithi (12%), Nyandarua (9%), Meru (9%) and Embu (8%). Gender variations, between the male and female is evident, 84% of females (17,035) are suppressed, compared to 80% of males (6,938). Gender variations play around the counties, as highlighted in Table 6. Kitui*, Kirinyaga, Tharaka Nithi, Meru shows more females are suppressed than men by about 5 percentage points. Table 17: Baseline Viral Load Suppression Rate by County and Gender in Cluster 3 (COP16) County Not Suppressed Total Suppression Target Gap Suppressed Rate F M F M F M F M F M Embu 687 344 3,353 1,278 4,040 1,622 83% 79% 90% 7% 11% Kiambu 511 265 2,935 1,274 3,446 1,539 85% 83% 90% 5% 7% Kirinyaga 66 47 497 225 563 272 88% 83% 90% 2% 7% Kitui 63 38 256 74 319 112 80% 66% 90% 10% 24% Meru 979 538 4,574 1,817 5,553 2,355 82% 77% 90% 8% 13% Murang’a 294 174 2,405 978 2,699 1,152 89% 85% 90% 1% 5% Nyandarua 269 133 1,219 510 1,488 643 82% 79% 90% 8% 11% Nyeri 159 102 877 398 1,036 500 85% 80% 90% 5% 10% Tharaka Nithi 244 125 919 384 1,163 509 79% 75% 90% 11% 15% Total 3,272 1,766 17,035 6,938 20,307 8,704 84% 80% 90% 6% 10% *Kitui county constitutes two FBO facilities
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
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Table 18: Baseline Viral Load Suppression Rate by County and Gender in Cluster 3 (COP 17 SAPR) County Not Suppressed Total Suppression Target Gap Suppressed Rate F M F M F M F M F M Embu 289 160 1,341 508 1,630 668 82% 76% 90% 8% 14%
Kiambu 358 183 1,726 802 2,084 985 83% 81% 90% 7% 9% Kirinyaga 49 17 275 120 324 137 85% 88% 90% 5% 2% Kitui 30 22 125 37 155 59 81% 63% 90% 9% 27% Meru 664 352 2,721 1,114 3,385 1,466 80% 76% 90% 10% 14% Murang’a 172 83 1,465 609 1,637 692 89% 88% 90% 1% 2% Nyandarua 135 72 622 271 757 343 82% 79% 90% 8% 11% Nyeri 85 52 458 201 543 253 84% 79% 90% 6% 11% Tharaka Nithi 210 94 669 327 879 421 76% 78% 90% 14% 12% Total 1992 1035 9,402 3989 11,394 5024 *Kitui county constitutes two FBO facilities Retention in care and treatment is associated with viral suppression; nevertheless, the strength of association is not clear from literature and there are implications for the test and treat approach to HIV prevention, emphasizing the crucial role retention plays in supporting viral suppression.11 Gaining a better understanding of the relationship between retention, age, and viral suppression may assist design interventions to improve treatment outcomes. Cluster 3 has developed learning questions to address some of unanswered questions to improve HIV services to clients as outlined in Table 33 under the project learning agenda. Differentiated Service Delivery (DSD) By COP17 SAPR, 76 health facilities in five Cluster 3 counties implemented Differentiated Care Model (DCM). These facilities had categorized patients and from 29,292 clients, 13,409 (46%) were stable, of which 86% (11504/13409) were on express clinic. At baseline, the project had established 60 community ART groups with 304 clients enrolled and receiving community PHDP services as they await the Counties to streamline the community ARVs supply system and monitoring. In the coming implementation years, cluster 3 will prioritize counties like Tharaka Nithi and Nyandarua County due to vastness and therefore poor accessibility of the facilities. This less intense follow-up for stable clients will reduce cost and inconvenience to clients, decongest health facilities, and improve quality of care by allowing healthcare workers to spend more time on advanced and/or unstable clients as needed.
Table 19: Differentiated service Models: Health facilties Implementing DCM in COP17 SAPR County No. of Total on TX Unstable Stable Current on express facilities clinic Embu 2 2,304 709 1,595 1,371 Meru 38 11,457 7,914 3,543 3,117 Murang’a 7 4,585 1,854 2,731 2,457 Kiambu 15 6,328 4,577 1,751 1,453 Tharaka-Nithi 14 4,618 829 3,789 3,106 TOTAL 76 29,292 15,883 13,409 11,504
Viremia Clinics Viremia clinics are necessary for multidisciplinary follow-up of patients not achieving viral suppression. With viral suppression rates of 82% and 83% in COP 16 and COP 17 SAPR respectively, it is critical to have
11 Yehia BR, Rebeiro P, Althoff KN, et al. The Impact of Age on Retention in Care and Viral Suppression. Journal of acquired immune deficiency syndromes. 2015; 68(4):413-419. doi:10.1097/QAI.0000000000000489. HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
28 functional viremia clinics to manage the non-suppressing clients for epidemic control of HIV to be realized. At COP 17 SAPR, the project had 20 Viremia clinics distributed across the seven out of the nine counties. Table 20: Number of Facilities with Viremia clinics by county in Cluster 3 County No. of facilities with viremia Number of patients registered clinics (COP 17 SAPR) Embu 4 143 Kiambu 3 109 Kirinyaga 2 15 Kitui 0 0 Meru 4 316 Murang’a 3 106 Nyandarua 2 25 Nyeri 2 26 Tharaka-Nithi 0 0 TOTAL 20 740
Electronic Medical Records Electronic capture of data is key to facilitating follow-up of clients through the continuum of care cascade. In Cluster 3, 90 out of 140 health facilities with comprehensive care centers had EMR as at COP 17 SAPR. These facilities account for about 90% of clients receiving ART. Of these EMR, 50% are functional and another 40% are Points of Care (POC). The project focuses on enabling full functionality of the EMR and supporting POC. Table 21: Number of Facilities with Electronic Medical Records by county (COP 17 SAPR) in Cluster 3 County No. of facilities with No. of facilities with No. of facilities with Current on ART at EMR functional EMR functional EMR and are EMR sites POC Embu 14 14 5 5259 Kiambu 13 13 9 5904 Kirinyaga 5 5 5 1080 Kitui 1 1 0 785 Meru 26 23 10 10201 Murang’a 7 7 5 5448 Nyandarua 8 5 8 6741 Nyeri 6 3 4 1637 Tharaka-Nithi 10 9 5 2348 TOTAL 90 82 51 39,403
Male Friendly services Cluster 3 has started implementing male friendly services with five facilities already started in in Meru County, with 230 Males enrolled in PSSGs by COP17 SAPR. In these five health facilities, health workers have started having defined roles of male peer educators, twining appointment of male clients with their spouses an having flexible clinic hours e.g. early morning hours and late evening. Cluster 3 plans to scale-up to 25 more sites in COP17 and increase steadily over the years to ensure men are reached with quality HIV services. Retention in these facilities at baseline has improved among men from 67% to 88%12.
Psychosocial Support Groups (PSSGs) By COP 17 SASPR HSDSA cluster 3, supported 96 PSSGs across 84 PMTCT sites reaching 2,500 pregnant and breastfeeding women.
12 APHIAPLUS KAMILI Project Progress Reports HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
29 Table 22: Number of Facilities with PSSGs by County in Cluster 3 County No. of facilities with PSSGs (COP 17 SAPR) Embu 21 Kiambu 15 Kirinyaga 5 Kitui 0 Meru 25 Murang’a 11 Nyandarua 10 Nyeri 4 Tharaka-Nithi 5 TOTAL 96
3.2 Organizational Capacity Assessment (OCA)
Organizational Capacity Assessment addresses heath systems strengthening under objective six. HSDSA Cluster 3 aims to keep county governments progressing towards increased ownership of HIV service delivery. OCA focused on baseline status of selected institutional/management capacities to develop individualized capacity building plans to address identified gaps at the county level.
The project adapted existing Organizational Capacity Assessment Tools (OCATs) to assess institutional/management capacities on leadership and governance, human resources for health; planning and budgeting, quality management, health Information systems/M&E , commodity management; mirroring the WHO Health Systems building blocks. Cluster 3 OCAT is simple, employing systems thinking, with a strong focus on quality of HIV services. The tool comprised of a maximum of fifteen Yes/No response questions. This approach minimized ambiguity relating to whether a particular capacity standard has been met or not. The questions were ordered from evaluating basic to more sophisticated/advanced competencies. Scores in advanced competencies will only count, if the basics competencies score positively, and are maintained through two audit cycles. This approach will help incentivize counties to maintain high quality standards and have little room for accepting deficiencies in the basic competencies. Where all or one basic competency score is rated zero (0), then scores in advance, competencies will not count for a particular county, until the gaps in the basic competencies are addressed.
During this assessment, the project prioritized three counties for the OCA, namely: Meru, Kiambu & Murang’a. These counties consistently account for about 65% of HIV services data across the nine cluster 3 supported counties and therefore, require immediate capacity development. The three counties, on average accounted for 60%, 63%, 65% of individuals newly started on ART (TX_NEW), Number of HIV positive clients identified (HTS_TST_POS), and HIV positive pregnant women who received ART (PMTCT_ART) respectively in COP 2016. The OCA Baseline summary scores highlighting four domains are tabulated by counties assessed. A full tabulation of capacity gaps and capacity development plans can be found in Annex F of this report.
Table 23: Planning and Budgeting, Performance (May 2018) Murang’a Meru Kiambu 1. AWP for current year available 1 1 1 2. Planning reviews done 1 1 1 3. Public participates in planning and budgeting 1 0 1 4. Budget is in Program Based Budgeting format 1 1 0 5. Budget Information availability and accessible 0 0 0 6. Health department gives clear direction on budgeting process 0 0 0 7. Health department has dedicated staff for planning and budgeting 0 0 0 8. Sector working group is functional 0 0 0 9. Health department does expenditure reviews 0 0 0 10. Planning and budgeting is aligned to MTEF calendar 0 0 1 Planning and Budgeting Baseline Score 4 2 3
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
30 Under this domain on planning and budgeting, the following key gaps were identified across the three counties assessed: 1. Information not available and no clear direction on planning and budgeting cycle 2. Expenditure reviews not conducted to inform subsequent budgetary processes 3. No dedicated staff to oversee the planning and budgeting process 4. The county budget is not in a program-based format.
Table 24: Leadership and Governance, Performance (May 2018) Murang’a Meru Kiambu 1. Vision & Mission statement available 1 1 1 2. Organogram available 1 1 1 3. Oversight by County Health Advisory Board (CHAB) 1 0 0 4. County health policy, and strategic plan available 1 1 1 5. Availability of County HIV/AIDS strategic plan 1 0 1 6. Stakeholder participation in planning, budgeting & performance 0 0 1 7. County Health stakeholder coordination mechanism in place 1 0 1 8. Supportive supervision plan supported by budget 1 0 1 9. Collaboration with the National Government on health policy and 1 1 1 systems 10. Regulation- Mechanism for enforcing health sector regulations in training 1 1 1 institutions, health facilities, public health law, pharmacy and Labs. 11. Rule of law: Mechanism in place for enforcing the rule of law within the 1 1 1 health department e.g. abuse of power, malpractice e.t.c. 12. Transparency and accountability to the health sector stakeholders, e.g. provision of information on allocation and use resources, performance 0 0 1 update Leadership and Governance Baseline Score 5 2 2 Under this domain on leadership and Governance, the following key gaps were identified: 1. CHMT is unaware of the existence of County Health Advisory Board (CHAB), in Meru & Kiambu Counties 2. No stakeholder participation in planning, budgeting & performance in Murang’a and Meru Counties 3. In Meru County alone: o County HIV/AIDS strategic plan has not been developed o County Health stakeholder coordination mechanism not in place o No budgetary provision for supportive supervision
Table 25: Human Resources for Health, Performance (May 2018) Murang’a Meru Kiambu 1. Health department has a dedicated staff to provide oversight for HR 1 1 1 2. Clear and transparent recruitment process 1 1 1 3. Staff Job descriptions clear, and available with scope and tasks 1 1 0 4. Personnel files available and stored safely 0 0 1 5. Staff retention mechanism in place 1 0 1 6. Availability of a policy in training and capacity development 1 0 1 7. Availability of clear staff disciplinary and rehabilitation procedures 1 1 1 8. Health department has functional performance appraisal system 1 0 0 9. Health department has a clear policy on collaboration with PSB 1 0 1 10. HRH staff are equitably distributed across the county 1 0 1 11. Availability of an updated Integrated Human Resource Information 1 0 1 System (iHRIS) 12. Health department has a gender policy in place 1 0 1 13. Availability of HRH Strategic plan 0 0 0 Human Resources for Health, Baseline Score 3 3 2
Under this domain on Human Resources for Health, the following key gaps were identified: In Meru county alone o Staff retention mechanism not in place o No training and capacity development policy o Lacks gender policy and no clear policy on collaboration with county public service board o County’s iHRIS is not updated No functional staff performance appraisal system in place in Meru & Kiambu Counties No HRH Strategic plan in place across the three counties
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
31
Table 26: Health Information System (HIS), Performance (May 2018) Murang’a Meru Kiambu 1. Dedicated staff for providing oversight for HIS services 1 1 1 2. Availability of mentors to conduct quarterly supportive supervision 1 1 1 3. Existing guidelines for continuous capacity development for HRIOs 0 0 1 4. Implementing standard MOH guidelines and SOPs for HIS 0 0 0 5. Conducting quarterly RDQAs and corrective action points followed up 1 0 1 6. DDIU: Performance review and dissemination plan in the current year 1 0 0 7. Availability of a current costed M&E procurement and distribution plan 0 0 0 8. Integrated EMR activities in the AWP and the CIDP 1 0 1 9. County has an M&E plan in place to strengthen county HIS. 0 1 0 10. Recognition system in place for best performing health facilities 0 1 0 Health Information Systems (HIS) Baseline Score 2 2 3
Under this domain on Health Information System (HIS), the following key gaps were identified: 1. The counties do not implement standards, guidelines and SOP for HIS 2. Data quality assessment not fully instituted in Meru County 3. No current costed HIS/M&E Plans 4. No recognition system for best performing health facilities in Muranga’ and Kiambu counties
Table 27: Five year Plan to improve OCA capacity scores Module assessed Scores and Projected Performance Baseline Y1 Y2 Y3 Y4 Y5 Murang’a county 1. Planning and Budgeting 2 4 6 8 10 10 2. Leadership and Governance 5 7 9 10 10 10 3. Human Resource for Health (HRH) 3 4 6 8 10 10 4. Quality Assurance and Standards 2 4 6 8 10 10 5. Laboratory Management 2 4 6 8 12 12 6. Pharmacy Management 2 5 7 8 10 10 7. Health Information System (HIS) 2 3 6 8 10 10 8. Information Communication and Technology (ICT) 4 5 6 7 8 9 Meru county 1. Planning and Budgeting 2 4 6 8 10 10 2. Leadership and Governance 2 4 6 8 10 10 3. Human Resource for Health (HRH) 3 4 6 8 10 10 4. Quality Assurance and Standards 0 3 6 8 10 10 5. Laboratory Management 2 4 6 8 12 12 6. Pharmacy Management 4 6 7 8 10 10 7. Health Information System (HIS) 2 3 5 7 10 10 8. Information Communication and Technology (ICT) 2 3 5 7 8 9 Kiambu county 1. Planning and Budgeting 3 4 6 8 10 10 2. Leadership and Governance 2 3 5 7 8 10 3. Human Resource for Health (HRH) 2 4 6 8 10 10 4. Quality Assurance and Standards 0 3 7 8 10 10 5. Laboratory Management 3 6 8 10 12 12 6. Pharmacy Management 8 9 10 10 10 10 7. Health Information System (HIS) 3 4 6 8 9 10 8. Information Communication and Technology (ICT) 2 3 5 7 8 9
Through the capacity assessment, overall, HSDSA cluster 3-capacity development will collaborate on the following broad actionable areas: The county health department will align planning and budgeting with the budgetary cycle and requirements as prescribed in PFM ACT 2012. The county health department will embrace the project supported HRH staff and gradually transition them to continue supporting the HIV service delivery under the devolved system.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
32 The county health department will align its activities to the Kenya Quality Model of Health (KQMH) to ensure improved efficiency and quality of services across board as well as have very vibrant teams that manage quality aspects in all program areas The county health department will be in a better position to manage laboratory, pharmaceutical and non-pharmaceutical commodities efficiently and effectively County health department will utilize information for decision making for planning, resource allocation, leadership and management. The county health department will leverage on ICT to improve and scale up service delivery of the health services.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
33 3.3 Health Facility Assessment
The assessment was designed to provide information on quality of HIV services at selected health facilities in cluster 3 counties. The facility assessment focused on collecting data on services offered, staffing, training needs, availability of tools and SOPs, job-aids and guidelines. The assessment provided county level information, which will be used to gauge the capacity of health facilitates and health workers to provide quality services and identify strengths and weaknesses of health services systems of support at the devolved units. The assessment was conducted under the authority of County Health Director and the CHMT. Key findings are organized around the sections assessed. A total 72 Health facilities were selected, with 66 (92%) facilities actual assessments completed. Selected facilities were distributed based on counties, ownership and KEPH levels.
Table 28: Distribution of Health facilities by County Table 29: Health facilities sampled by KEPH Levels County Total # of # Sampled Adjusted Assessed County Level 2 Level 3 Level 4 Level 5 Total supported (minimum) facilities Embu 6 3 2 1 12 Kiambu 4 4 2 0 10 Embu 46 12 12 12 Kirinyaga 1 1 1 0 3 Kiambu 33 8 10 9 Kitui 0 1 1 0 2 Kirinyaga 9 2 3 3 Meru 8 4 4 1 17 Kitui 2 1 2 0 Murang'a 2 2 2 0 6 Meru 63 16 17 14 Nyandarua 6 4 0 0 10 Murang'a 15 4 6 6 Nyeri 2 2 1 0 5 Nyandarua 34 9 10 10 Tharaka-Nithi 3 3 1 0 7 Nyeri 12 3 5 5 Total (sampled) 32 24 14 2 72 Tharaka-Nithi 22 6 7 7 Level 2- Dispensaries and clinics , Level 3 - Health Centers , Level 4-Primary Total 236 59 72 66 & secondary hospitals (sub-county hospitals/ other such hospitals) and Level 5 are the secondary hospitals
Data was collected from 26 (39%) dispensaries, 25 health centers (36%), 15 (21%) Hospitals. Of these 47 (71%) were public, 14 (21%) were faith-based, and 5(8%) were private health facilities. Key findings from the health facility assessment: Overall availability of specific HIV Services at health facility (HFs) assessed is highlighted in table 15.
Table 30: Availability of specific HIV Services at HFs in Cluster 3 Among all facilities surveyed, the percentage and numbers that offer specific services Percentage of facilities Number of facilities offering Services offered offering service service Voluntary counselling and testing (VCT) 51% (35/69) 35 Provider initiated testing and counselling (PITC) 91% (63/69) 63 Partner notification services 68% (47/69) 47 CD4 testing on-site 12% (8/69) 8 CD4 testing off-site 44% (30/69) 30 Antenatal care (ANC) 88% (61/69) 61 Elimination of MTCT 84% (58/69) 58 Early Infant Diagnosis (EID) 57% (39/69) 39 HIV care & treatment (adults & children) 74% (51/69) 74 TB diagnosis and treatment 86% (59/69) 86 Family Planning (FP) 68% (47/69) 47 Post- gender based violence(GBV) care 41% (28/69) 28 Youth friendly services 25% (17/69) 25 Male friendly services 13% (9/69) 9 *Providers were asked to report the HIV services offered at their health facility in a yes/no response question.
Among facilities that offer ART services 100% had at least one staff member who had received HIV Services related training. Top five training areas critically needed by staff across the counties were,
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
34 Adolescent package of care training 64%, Gender Based violence (GBV) 62%,Adherence counselling training 58%, Clinical management of survivors of sexual violence 56% and Trauma counselling 53%
Availability of guidelines, algorithms, SOPs, checklists and Job-aids was assessed. The status at health facilities is outlined in Table 34 in Annex C. 36% (23/66) of the health facilities assessed offer FP services integrated with HIV services (county/level/ownership), while another 73 %( 46/66), have integrated TB/HIV services at the CCC. 17/ 66 (26%) health facilities offer youth friendly services (these are mainly from health centers and above, of which 11 are Public, while 6 are FBOs facilities) – Meru (4), Nyeri (3) and Kiambu (2) and another 10/66 saidy they offer male-friendly services. Health Facility Infrastructure. Infrastructure assessment focused on availability of conducive and private space for critical services. o 83% (50/66) health facilities have a CCC clinic, of which 60% (30/50) reported having a conducive and private environment to offer services. 76% (38/50) reported having space for adherence counselling, which is conducive and private. Majority (98%) of facilities reported having space for HTS services, of which 62 %( 34/55) reported having a conducive and private space. HIV Testing Services are offered in the following service delivery points, as highlighted in the table below:
Table 31: Service Delivery points offering HTS Services at HFs assessed Service Delivery Offering Out of (n) % Point HTS services in VCT 26 55 47% Outpatient 44 58 76% Inpatient 24 54 44% TB clinic 47 58 81% ANC 58 63 92% Maternity 42 56 75% CCC 45 56 80% Laboratory 58 64 90%
86% (54/63) of the facilities said to be getting adequate test kits. 23%(14/61), said they run-out of test kits in the last one month (5/13), in the last 3 months (4/13) and in more than 3 months (4/13). Of the 14 facilities having reported experiencing stock-out, 12/14 are public health facilities, six are in Tharaka Nithi (seven facilities were assessed in Tharaka Nithi), while 3 are from Embu county.
Linkage to treatment at the health facilities o 68 % (43/63) have staff dedicated to linking clients newly testing HIV-positive at the facility o 72 % (45/62) reported having a system in place to track clients linked to ART outside the facility. Linkage systems reported include having a directory to map ART sites (51% (22/43), having a dedicated linkage officers (63% (27/43). Meru (10/15), Embu (10/12), Nyandarua 6/10), Murang’a (4/6), Kirinyaga (2/3) facilities assessed reporting to have linkage officers. o Most (76% (44/58) of the health facilities assessed reported same day initiation of ART to clients identified as HIV-positive, the rest reported initiating within two weeks (11/58) and more than two weeks (3/58). It is important to note that Murang’a had (2/2) ART facilities showing same day initiation while Kiambu had (2/5), had the lowest number of facilities reporting same day initiation of ART. Meru (11/12), Embu (7/7), Tharaka Nithi (4/4) reported ART sites offering same day initiation Retention to Treatment o Nearly all (96%) of health facilities HFs reported having a system in place to retain clients receiving ART. The systems in place include PSSGs, appointment diaries, phone tracing HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
35 o A similar proportion 98% said, they have a system in place to track clients with suspected treatment failure. These systems include PSSGs, viremia clinics, and MDT review of cases. Viral load suppression o 67% (35/55) of the health facilities reported having a dedicated health worker, who follows up clients for viral load tests. o 80% (43/54) of the facility laboratories are implementing Continuous Quality Improvement (CQI) Quality Assurance at health facilities o 41 %( 27/66) health facilities reported having Quality Assurance team in place and minutes were available. However only 16/27 had Terms of Reference. o Almost all (86% 57/66) facilities reported having been visited for supportive supervision in the last 6 months prior to the assessment. Most them reporting being visited at least twice in the over the period. Health Management Information System at facility level o 62 %( 39/63) facilities reported having a designated staff (health worker or other) tasked with reporting for the facility. 9/13 in Meru, 8/12 in Embu and 5/7 in Tharaka Nithi reported highest number with a designated staff. Fewer number of facilities reported much less e.g. Kiambu (4/10), Kirinyaga (1/3), and Muranga (5/10), except Nyeri 4/5 facilities had a designate person. o 66 %( 41/62) facilities, hold data review meeting at least on a quarterly basis. Few facilities in Kiambu (2/10) and in Meru (6/15) reported holding data review meetings. Kirinyaga (3/3), Nyandarua (8/10), Embu (8/12), Murang’a (4/6), had high number of facilities assessed reporting to hold these meetings. o 76 (31/41) health facilities reported having a functional EMR. The ten with non-functional EMR were in Embu (3), Meru (3), Kiambu (2), Kirinyaga (1) and Tharaka-Nithi (1). o 79 %( 50/63) assessed reported having progress charts displayed at their health facilities. Most the facilities without these charts were from Nyandarua (4/9) and Kiambu (3/8).
Site Improvement Monitoring System (SIMS): using SIMS data collected at baseline in selected facilities in COP16, priority health facility-level gaps were identified, to standardize site quality services through regular monitoring. Sites were rated and scored based on Core Essential Elements (e.g., HTS, Care and Treatment children and adults, PMTCT, testing interruptions, results and information management, biosafety, compliance with national testing algorithms, commodities management, waste management, proficiency testing of test kits and quality management systems). Table 18, highlights SIMS scores and gaps in selected health facilities in Cluster 3 counties. This approach will be used in the nine cluster 3 counties to identify gaps in with health facility team and develop a joint plan to address these gaps.
Table 32: Baseline County SIMS Scores in COP16 in selected 10 health facilities in Murang’a and Tharaka-Nithi Counties SIMS Aggregate Score Major gaps (Scoring red), to be addressed in COP17 Counties/ (COP 16) facilities MURANGA COUNTY 73% 1. Quality Management systems MARAGUA D.H 2. Early infant Diagnosis 3. Site level proficiency testing 4. Routine HIV testing for children of adult patients 5. TB diagnostic evaluation cascade 69% 1. Lacking quality Management systems MAKUYU H/C 2. ART Monitoring 3. TB diagnostic evaluation cascade 4. Pediatric ART Monitoring 5. Isoniazid Preventive Therapy 69% 1. Quality management systems (QMS) KIGUMO S.C.H 2. HIV testing of children and Adults
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
36 3. TB diagnostic Evaluation cascade-PMTCT 4. Early infant Diagnosis 71% 1. Quality management systems (QMS) ITHANGA H/C 2. Pediatric ART Monitoring 3. TB diagnostic Evaluation cascade-PMTCT 4. HTS referrals to HIV Care and treatment 84% 1. TB diagnostic Evaluation cascade SABA-SABA HC 2. Partner HIV Testing THARAKA-NITHI COUNTY 83% 1. Pediatric ART monitoring CHUKA SCH 2. ART Register-Paper-PMTCT 3. Early infant diagnosis 4. Routine HIV testing for children of adult patients 5. PITC for Maternity patients 6. Isoniazid preventive therapy (IPT) 7. TB diagnostic Evaluation cascade-PMTCT 8. ART Monitoring 84% 1. Waste Management KAJUKI HC 2. Data reporting and consistency_HTS_TST 3. TB diagnostic Evaluation cascade 68% 1. Patient rights, stigma and discrimination THARAKA SCH 2. Data reporting and consistency_HTS_TST 3. Data reporting and consistency_PMTCT_STAT 4. ART Monitoring 5. Isoniazid preventive therapy (IPT) 6. TB diagnostic Evaluation cascade 7. Pediatric ART monitoring 71% 1. Quality management systems (QMS) MUKUI DISP. 2. Site level Proficiency testing 3. HTS referrals to HIV Care and treatment 4. Patient rights, stigma and discrimination 5. Data reporting and consistency_HTS_TST 6. HIV testing of children of adult patients 7. System for family planning/HIV Integration 63% 1. TB infection control CHUKA COTTAGE 2. Data reporting and consistency_PMTCT_STAT 3. Medical dispensing 4. ART Register-Paper-PMTCT 5. Routine HIV testing for children of adult patients 6. Isoniazid preventive therapy (IPT) 7. TB diagnostic Evaluation cascade-PMTCT
Health facilities had challenges with Quality Management Systems and data reporting consistencies in PMTCT and HTS services. Other gaps include Pediatric ART monitoring and site level proficiency testing. Important criteria for targeting a site for focus include: 1) under performance based on targets, 2) low data quality 3) known gaps 4) introduction of new interventions at the site. Routine supportive supervision and performance review meetings will be used in collaboration with the CHMT/SCHMT and HSDSA Cluster 3 staff to address the gaps identified at health facility level.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
37 3.4 APHIAPLUS KAMILI project End-line Survey
This report includes an analysis of household survey data that was conducted to 1) evaluate the change in knowledge, health seeking behavior and health outcomes in APHIAPLUS KAMILI project and 2) to assess the level of uptake HIV services at health facility by the end of the project period. This report captures analysis of the HIV services household interview data for PMTCT, HTS and HIV Care and Treatment, in upper Eastern and Central Region. The household survey utilized Lot Quality Assurance Sampling (LQAS) methodology to identify study locations and participants. The ‘lots’ otherwise known as ‘supervision areas’ were defined at the sub-county level. Two sampled sub-counties from each county were sub divided into programmatically meaningful five (5) supervision areas (SAs), where nineteen interviews were conducted per SA, forming 95 interviews per sub-county, and therefore 190 per county, totaling to 1,710 interviews in 9 Cluster 3 counties. A high overall interview completion rate of 96% was achieved. Lower completion rate was noted in Nyeri, where interviews could not be completed in time due to unavailability of respondents owing to flooding and heavy rains. However, overall first-rate response rate was achieved. Table 33: Household Interviews Completed County Planned Interviews Interviews Completed Completion Rate
Embu 190 188 99% Kiambu 190 168 88% Kirinyaga 190 183 96% Kitui 190 221 116% Meru 190 225 118% Murang’a 190 171 90% Nyandarua 190 200 105% Nyeri 190 82 43% Tharaka Nithi 190 200 105% 1710 1638 96%
Among mothers interviewed, virtually (96%) reported receiving HIV test as part of their antenatal care services, denoting universal access to testing, across the counties. When asked if they were happy with the services, 82% said they would recommend the health facility to a friend or family member to deliver there. Table 34 highlights the responses across the counties. Kiambu and Meru had lower recommendation rates at 75% and 77% respectively. Considering these are high volume counties, it suggests need to improve quality of care at the two counties. Table 34: Among antenatal and post-natal mothers interviewed by county COUNTY % of Mothers tested for HIV Respondent Would Recommend Health as part of ANC Facility to a friend or family Member
Yes Yes Embu (n=188) 174 (92.6%) 164 (88.6%) Kiambu (n=168) 165 (98.2%) 133 (77.8%) Kirinyaga (n=183) 174 (95.1%) 155 (87.6%) Kitui (n=221) 212 (95.9%) 176 (80.7%) Meru (n=225) 218 (96.9%) 169 (75.4%) Murang’a (n=171) 164 (95.9%) 135 (81.8%) Nyandarua (n=200) 191 (95.5%) 169 (85.4%) Nyeri (n=82) 79 (96.3%) 71 (89.9%) Tharaka Nithi (n=200) 195 (97.5%) 168 (84.8%) Overall (n=1,638) 1,572 (96%) 1,340 (82%)
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
38 Almost all (99%) the respondents interviewed had had ever heard of an illness called HIV/AIDS. Consistent with the high knowledge of HIV/AIDS, 94% knew about prevention of HIV/AIDs, that a person can so something to protect themselves from getting HIV/AID. High scores of 97% was noted also among adolescents, with 92% saying they knew something to do to protect themselves from getting HIV/AIDS.
Table 35: Ever heard of HIV/AIDs and knowledge of HIV Prevention county Ever heard of an illness Can a person do anything to protect called HIV/AIDS him/herself from getting HIV/AIDS?
Yes Yes Embu (n=203) 190 (93.6%) 165 (81.3%) Kiambu (n=194) 191 (98.5%) 188 (96.9%) Kirinyaga (n=274) 273 (99.6%) 260 (94.9%) Kitui (n=239) 237 (99.2%) 224 (93.7%) Meru (n=267) 266 (99.6%) 251 (94.0%) Murang’a (n=269) 269 (100.0%) 264 (98.1%) Nyandarua (n=391) 390 (99.7%) 374 (95.7%) Nyeri (n=143) 143 (100.0%) 136 (95.1%) Tharaka Nithi (n=234) 233 (99.6%) 216 (92.3%) OVERALL (n=2214) 2,192 (99%) 2,078 (94%)
Across the counties respondents were asked to rate the HIV services they received, 73% rated as the services they received as of quality services. 76% said they are satisfied with the services provided. Another 84% rated the health workers as either competent or very competent in the work they do, as they offer HIV services at health facilities. Interview with the adolescent, revealed only 57% reported ever testing for HIV, with Embu and Tharaka Nithi reporting the lowest testing rates at 40% and 36%. Highest rates were found in Murang’a and Kiambu Counties at 74% and 72% respectively. This suggests targeted focus on testing adolescent strategies across the counties. Table 36 highlights the findings on adolescent sexual reproductive health and HIV testing.
Table 36: Adolescents / Youth Sexuality & Reproductive Health and HIV testing among Adolescents/ youth Ever tested Where would most adolescents and youths in this Would for HIV community prefer to get information about SRH recommend (Adolescents) use of condom to friends Yes Provider School Radio TV friend/peer Yes Embu (n=179) 72 (40.2%) 76 (42.5%) 93 (52.0%) 6 (3.4%) 4 (2.2%) 32 (17.9%) 59 (33.0%) Kiambu (n=156) 112 (71.8%) 39 (25.0%) 73 (46.8%) 33 (21.2%) 50 (32.1%) 33 (21.2%) 101 (64.7%) Kirinyaga (n=181) 93 (51.4%) 75 (41.4%) 69 (38.1%) 17 (9.4%) 31 (17.1%) 25 (13.8%) 106 (58.6%) Kitui (n=190) 100 (52.6%) 64 (33.7%) 81 (42.6%) 56 (29.5%) 32 (16.8%) 17 (8.9%) 75 (39.5%) Meru (n=172) 90 (52.3%) 67 (39.0%) 68 (39.5%) 40 (23.3%) 29 (16.9%) 16 (9.3%) 94 (54.7%) Murang’a (n=182) 134 (73.6%) 56 (30.8%) 83 (45.6%) 56 (30.8%) 43 (23.6%) 20 (11.0%) 133 (73.1%) Nyandarua (n=198) 132 (66.7%) 70 (35.4%) 107 (54.0%) 59 (29.8%) 48 (24.2%) 33 (16.7%) 119 (60.1%) Nyeri (n=79) 45 (57.0%) 6 (7.6%) 23 (29.1%) 15 (19.0%) 10 (12.7%) 7 (8.9%) 42 (53.2%) Tharaka Nithi (n=194) 69 (35.6%) 55 (28.4%) 96 (49.5%) 54 (27.8%) 34 (17.5%) 23 (11.9%) 66 (34.0%) Overall (n=1531) 847 (56.5%) 508 (33.6%) 693 (49.1%) 336 (23.5%) 281 (18.8%) 206 (14.8%) 795 (53.9%)
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
39 4. ACTIVITY LEARNING AGENDA
HSDSA Cluster 3 in line with the AMELP has identified key learning areas and developed a learning agenda, with priority questions that do not have right answers at baseline. The project will review these questions every year to know what works and what doesn’t work. Lessons learnt and challenges will be shared internally and externally to encourage synergy and collaboration across partners. Highlights of results and lessons learned will be communicated through written materials (e.g. brochures, bulletins, fact sheets), and these materials will be packaged and presented for their intended audience for action (e.g., by the project, S/CHMTs, private sector providers, MOH). Best practice fora (i.e. regional knowledge sharing annual meetings and TWGs) will provide an excellent venue for project counterparts to share results and lessons learnt.
Table 37: Proposed learning questions Technical/ Learning question(s) Methodology/ Rationale focus area approaches AGYW What are the characteristics of the Explore existing data to are and ensure that HTS, VMMC and male sex partners of AGYW? characterize the male treatment programs are targeting partners men with those characteristics What is the efficacy of core package Before and after analysis To identify and prioritize what works of DREAMS interventions in Kiambu of intervention in different settings County effectiveness HTS Which testing modalities are FGDs To gauge acceptability of testing acceptable to clients receiving HTS modalities to inform HTS and service providers? LINKAGE RETENTION Is there a relationship between Cross-sectional Gaining a better understanding of the AND LINKAGE retention, age and viral suppression? secondary data analysis relationship between retention, age, and viral suppression may assist design interventions to improve treatment outcomes. Is there an association between same-day Secondary analysis of To provide a basis for improving ART ART initiation and retention in care and care and treatment data protocols and guidelines to address treatment? retention challenges at facility level Linkage officers will ensure timely What is the effectiveness of Linkage initiation of ART for clients identified as Secondary analysis of data officers in promoting linkage and early positive. They will rovide treatment and FGDs p ART initiation? navigation to orient clients to the facility and intended client flow. Addressing linkage barriers will promote What are the barriers to optimal linkage Secondary analysis of data epidemic control, by helping adjust at low performing sites and FGDs interventions to align to recommendations. HSS How is HRH support impacting on Secondary analysis of data Enable monitoring to assess long term service delivery in CCCs in Cluster 3? and FGDs impact of HRH support
The project will develop the necessary tools and protocols for the learning questions and further set-up data collection systems to ensure that data collected during the implementation is credible and verifiable.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
40 5. CONCLUSION AND RECOMMENDATIONS
5.1 Conclusion In conclusion, therefore, HSDSA cluster 3 will work hand in hand with the county management teams as well as link with other partners where applicable in order to close in the gaps identified during this assessment to help build stronger and sustainable systems for improved efficiency of services across our region. The County Department of Health has the potential benefit to influence sustained increases in allocations to priority programs such as HIV, however, the department misses out on opportunities to influence budget growths due to lack of capacity on the budgetary cycle leading to non-alignment to health sector budget timelines. Strengthening capacity by having a dedicated staff to support planning, enhance timely public participation, mentor the health sector-working group and build competencies on expenditure reviews will put the county in a stronger leadership position to ensure sustained growth to offer quality HIV services with more control on domestic funding. The OCA capacity development plans in cluster 3 will focus on improving domain scores steadily over the years. Each domain is anticipated to have different capacity building plans; therefore attaining maximum possible score is not always feasible. Cluster 3 will therefore focus on addressing most critical gaps to strengthen quality service delivery. The table below summarizes the planned improvement on domain scores over the life of the project.
5.2 Recommendations
1. The project will prioritize the meaningful engagement of AGYW in planning, implementing, monitoring, and evaluating the activities targeting these girls/young women to ensure their needs, perspectives, and experiences are appropriately addressed. 2. To achieve the first 90 the following interventions will be implemented a. Targeted testing and improve testing yields through Partner notification services. Cluster 3 will use efficient testing strategies to reach sexual networks of recently identified HIV-positive clients. Self-test kits will be used to reach higher risk populations that do not come to clinics e.g. male partners and KP sexual contacts. b. Ensure coverage and early diagnosis for all men and link to treatment c. Laboratory continuous quality improvement (LCQI) to ensure timely, accurate and reliable results for appropriate management of clients. d. Ensure retention of women, children. Loss to follow-up is high among women initiation ART especially during pregnancy and breastfeeding. MCA & HCA will be conducted.
3. Cluster 3 needs to focus on building the capacity of CHMTs, SCHMTS, HIV service MDTs, HCWs, and CRPs to understand the DSM, and implement and monitor the progress in the DCM site. HSDSA should further facilitate the MDTs to conduct county and facility readiness assessment for initiation of fast tracking of stable clients and community ART distribution by CRPs and/ or healthcare workers. 4. Health workers play a critical role in health programming and therefore investment in human resources for health remains an important investment to realize good health outcomes. However, counties continue to face significant challenges in overcoming health worker shortages, low retention, as well as difficulty in attaining equitable distribution of HRH. Supporting the counties to develop cadre specific job descriptions, development/adoption of HRH policies including training, gender, HRH equity and strategy will help the county manage staff better and improve on retention. 5. HSDSA Cluster 3 will promote shared responsibility for reaching and sustaining epidemic control to ensure county leadership contribution on enabling policy environment, quality services, financing for human and capital investment needed to keep health systems operating optimally.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
41 6. HMIS/M&E a. For quality of data to improve, health workers need urgent training on the revised tools and health facilities must be supported urgently with much needed registers and reporting tools. This needs to be done before within the next one or two month, to ensure that data capture & reporting remain uninterrupted. b. The Online Tools Training Platform should be explored urgently by partners to cascade the needed training at facility level. The existing reporting systems must be enhanced through deliberate and consistent facility level presence to ensure complete and consistent reporting for 90-90-90. Regular data quality assessment and follow-up. c. Health facilities need provision of minimum set of national guidelines, job aids, or other reference materials for HIV care and treatment to facilitate reference, supportive supervision and mentorship d. For continuous learning and improvement, it is critical to institute a learning culture to identify and document what works and what needs to be dropped or continued. Cluster 3 must review existing data to rationalize and invest in effective interventions.
7. Counties expressed interest to have a dedicated person for QA/QI in to start reaping the full benefits of a vibrant QA department. Health facility assessment suggested needs to be strengthened by instituting quality assurance mechanism at facility level. QA system must systematically understand why sites may be under performing and identify what needs to be done to address the gaps. 8. A joint facility level plan need to be developed following SIMS, Data Quality Assessment (DQA) and supportive supervision to address gaps identify at the health facility team. The CHMT and SCHMT should recognize health facilities demonstrating notable improvement, using agreed criteria.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report
42
ANNEX A: INDICATOR REFERENCE SHEET
INDICATOR REFERENCE SHEET
Freq. Of Indicator Indicator definition Data source reporting Disaggregation(s)
Objective 1: increased availability and use of combination prevention services
Numerator: these are vulnerable AGYW aged 15–24 years Number (#) / percent (%) of vulnerable AGYW who are sexually active and identified through a vulnerability reached with a defined index reached with a defined package to promote the AGYW package of services to adoption of HIV prevention behaviors. intervention HIV status: pos/neg 1 promote the adoption of customized quarterly Vulnerability index Denominator: total # of vulnerable AGYW aged 15-24 project tools HIV prevention behaviors years in the eight counties. Objective 2: increased uptake of targeted HIV testing services Sex: male/female # / % of HIV-positive Numerator: # of individuals who tested HIV positive HTS lab & Age: <1, 1-4, 5-9, 10-14, 15-19, individuals identified during the reporting period. referral linkage Monthly 20-24, 25-49, 50+ through HIV testing Denominator: total # of individuals tested during the Service delivery point: ANC, L&D, 2 register services [htc_tst_pos] reporting period. <5 clinic, MCH, TB, STI, CCC, OPD, IPD, VCT, mobile
# / % of individuals Numerator: count of unique number of newly diagnosed County identified as positive HIV- positive individuals who are physically linked to a Pre-art through HIV testing treatment site by a link officer or HIV counsellor. register, Sex: male/female services and physically 3 Denominator: total # of newly diagnosed HIV-positive EMR Monthly Age: <1, 1-4, 5-9, 10-14, 15-19, linked to a clinical treatment individuals during the reporting period. 20-24, 25-49, 50+ facility Objective 3: improved linkage to treatment for individuals newly testing positive for HIV
4 # / % of patients receiving Numerator: # of clients with a recorded cd4 on initiation of ART register, Monthly Sex: male/female CD4 art
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 43
Performance indicator reference sheet
Indicator *PEPFAR indicator; Freq. Of $core indicator Indicator definition Data source reporting Disaggregation(s)
(within 2 weeks of a positive HIV diagnosis). Age: <1, 1-4, 5-9, 10-14, 15-19, on initiation of art Denominator: total # of clients initiated on art during the DAR, EMR 20-24, 25-49, 50+ reporting period.
Sex: male/female Numerator: # of adults and children newly enrolled on art in the # / % of adults and children ART Age: <1, 1-4, 5-9, 10-14, 15-19, reporting period within 2 weeks of identification. newly enrolled on ART within 2 register, 20-24, 25-49, 50+ weeks of identification Denominator: total # of adults and children newly enrolled on art EMR, 5 Monthly Pregnancy status [TX_NEW] in the reporting period. DHIS2, drug supply and breastfeeding mgmt. status System # / % of adults and children These are the number of adults and children with HIV infection Sex: male/female with HIV infection who ever who ever started on art regardless of whether they still exist or Art register, 6 Monthly Age: <1, 1-4, 5-9, 10-14, 15-19, started on art [CUM_ART] not. It includes those lost to follow up (LTFU), dead, transfer outs, etc. DHIS2, EMR 20-24, 25-49, 50+
Art register, # of adults and children These are the number of adults and children with HIV infection DAR, EMR, Sex: male/female who ever started art minus those patients who are not currently currently receiving art DHIS2, Age: <1, 1-4, 5-9, 10-14, 15-19, 7 on treatment at the end of the reporting period. Monthly [TX_CURR] mgmt. 20-24, 25-49, 50+ System # of TB cases with The number of HIV-positive new and relapsed TB cases on documented HIV-positive art during TB treatment. Sex: male/female status who start or continue TB register, 8 This indicator will measure the extent to which projects effectively Quarterly Age: <1, 1-9, 10-14, 15-19, 20- art during the reporting period DHIS2, EMR 24, 25-49, 50+ [TB_ART] link HIV-infected TB patients to appropriate HIV treatment.
Numerator: # of art patients who were started on TB # / % of art patients who were treatment during the reporting period. Sex: male/female screened for TB and receiving TB register, Denominator: # of art patients who were screened for TB at least Age: <1, 1-9, 10-14, 15-19, 20- 9 TB treatment [TX_TB] DHIS2, EMR Quarterly once during the reporting period. 24, 25-49, 50+
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 44
Numerator: # of art patients who completed a course of TB # / % of art patients who preventive or at least six months of isoniazid preventive therapy (IPT) during the reporting period. Sex: male/female completed a standard course of TB preventive therapy within Denominator: # of art patients who were newly started on TB Age: <15; 15+ the reporting period TB register, 10 preventive therapy (or who were continuing TB preventive Quarterly years Type of [TB_PREV] therapy from the previous reporting period but had received less DHIS2, EMR therapy than six months of IPT at the start of the reporting period).
Objective 4: increased uptake of and adherence to quality HIV treatment services
Numerator: # of supported facilities with “adequate staff” to carry out core HIV services. # / % of supported facilities that By key categories: clinical, have “adequate staff” to carry Denominator: total # of supported facilities: “adequate” will be Customized Semi- management, clinical support, 11 out core HIV services determined using client-to-service provider ratio (facilities will be project tools annually social service, lay, other counted as having “adequate staff” if they meet 80% of the threshold ratio).
Numerator: # of health facilities reporting HIV commodities at the # / % of sites reporting HIV end of the reporting period. Pharmaceutical and non- 12 DHIS2 report Monthly commodities stock-outs Denominator: total # of health facilities in the region. pharmaceutical
# / % of HIV-positive pregnant
women who received ARVs to Numerator: # of HIV-positive pregnant women who received By regimen type (mutually reduce risk of mother-to-child- exclusive choices): life-long ARVs to reduce risk of MTCT during pregnancy. ANC transmission (MTCT) art, maternal triple-drug, register, 13 during pregnancy and Denominator: # of HIV-positive pregnant women identified in the Monthly maternal AZT, single-dose DHIS2 delivery reporting period (include known HIV positive at entry). nevirapine tct_arv Numerator: total # of deliveries from HIV-positive women. # / % of pregnant women Maternity delivering at the hospitals 14 Denominator: total # of HIV-positive women at ANC (include register, Monthly who are HIV-positive known HIV positive at entry). DHIS2 Infants who received a virologic test Numerator: # of infants born to HIV-positive mothers who had a . Within 2 months of birth # / % of infants born to HIV- virologic HIV test within two months of birth. EID register positive women who had a . Between 2-12 months old Denominator: # of HIV-positive pregnant women identified in the (NASCOP virologic HIV test done within 12 Monthly Infants with a positive reporting period (including known HIV-positive women at entry website) 15 months of birth [pmtct_eid] virologic into PMTCT). test result . Within 2 months of birth . Within 12 months of birth
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 45
# / % of mother baby pairs Numerator: mother baby pairs retained in care at 18 months. retained in care at 18 Denominator: total deliveries from HIV-positive mothers within HEI register Quarterly Breastfeeding status 16 months the reporting period (quarterly). By outcome: Numerator: # of HIV-exposed infants with a documented outcome # / % final outcomes at 18 . HIV-infected – linked to by 18 months of age (collection of 18 month outcomes is art, not linked to art months among HIV- recommended at 24 months of age). HEI cohort exposed infants registered analysis . HIV-uninfected: Annually in the birth cohort Denominator: # of HIV-exposed infants registered in the register, EMR not breastfeeding, 17 [pmtct_fo] birth cohort at any time between 0 and 18 months of age still (including transfers-ins). breastfeeding, unknown . In care but no test done . Ltfu; died; transferred out Objective 5: long-term follow up of patients receiving care and treatment services including laboratory and logistics support
Indicator *PEPFAR indicator; Freq. Of $core indicator Indicator definition Data source reporting Disaggregation(s) Sex: male/female Numerator: # of adults and children who are alive and on Art register, # / % of adults and children Age: <1, 1-4, 5-9, 10-14, 15-19, treatment at 12 months after initiating art. DAR, art known to be alive and on 20-24, 25-49, 50+ Denominator: total # of adults and children who initiated art in cohort analysis treatment 12 months after Pregnant status and the 12 months prior to the beginning of the reporting period, register, Quarterly 18 initiation of art [tx_ret] including those who have died and stopped art (does not include DHIS2, EMR breastfeeding at art transfer outs). initiation, Retention at 24, 36 months Sex: male/female # / % of art patients with a Numerator: # of adult and pediatric patients on art with Age: <1, 1-4, 5-9, 10-14, 15-19, viral load result documented suppressed viral load results (<1,000 copies/ml) documented in MOH 257, art 20-24, 25-49, 50+ in the medical record and/or the medical records and /or supporting laboratory results within register, art routine, targeted, not laboratory information the past 12 months. cohort documented. systems (lis) within the past analysis, EMR, 12 months with a suppressed Denominator: # of adult and pediatric art patients with a viral load NASCOP Pregnant & breastfeeding. 19 result documented in the patient medical record and/or laboratory Quarterly viral load (<1000 copies/ml) website Results category: [tx_pvls] records in the past 12 months. undetectable
(<1000 copies/ml); detectable # / % of sites reporting HIV Numerator: # of health facilities reporting HIV commodities at the (>1,000 copies/ml) commodities stock status on end of the reporting period by 15th. Pharmaceutical and non- 20 DHIS2 report Monthly a timely-monthly basis Denominator: total # of health facilities in the region. pharmaceutical
Objective 6: strengthened institutional accountability for the management of community, facility and county HIV response
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 46
# of county AWPs that Numerator: # of county AWPs that reflect project activities and reflect project activities and activity budgets. 21 AWP reports Annually County activity budgets Denominator: total # of counties in the region.
# of sub-counties utilizing Numerator: # of sub-counties utilizing program-based budgeting program-based budgeting to to prioritize health and HIV needs. 22 prioritize health and HIV Project reports Quarterly Sub-county needs Denominator: total # of sub-counties in the region.
# of county governments that Numerator: # of county governments that progress as measured by progress as measured by the the organization capacity assessment tool. Capacity 23 organization capacity assessment assessment Quarterly County tool Denominator: total number of counties in the region. tool
These are the number of FTE positions, stated as a proportion Type of support when necessary, e.g., FTEs that receive some form of monetary # of health worker count of support – either salary, overtime, or stipends – from PEPFAR. This . Salary key categories [hrh_curr] HRH database 24 support would otherwise be provided by host country institutions Quarterly . Stipends (e.g., MOH, NGOs). . Overtime
Indicator *PEPFAR indicator; Freq. Of core indicator Indicator definition Data source reporting Disaggregation(s)
# of the health workforce Numerator: # of the health workforce delivering HIV services
delivering HIV services that have that have undertaken an HIV related update in the last 12 Traini By key categories: clinical, months. management, clinical support, 25 undertaken an HIV related ng Quarterly update in the last 12 months Denominator: total # of health workforce delivering HIV services in databa social service, lay, other the region. se
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 47
ANNEX B: ACTIVITY INDICATOR TRACKING TABLE
Baseline performance and targets review for year 1 (ITT targets will be updated once KENPHIA survey is completed.) SAPR Notes (baseline Baseline COP Data Reporting USAID sources, Indicator Disaggregation (Oct 2016- ‘17 Source Frequency Y1 Target explanations for Sep 2017) Achievem targets) ent Objective 1: Increased availability and use of combination prevention services Number (#) of vulnerable AGYW reached with a Girls 10 – 14, 15 - 1,344 7,980 defined package of services to promote the adoption – 19, 20 - 24 AGYW
of HIV prevention behaviors [PP_PREV] intervention customized quarterly project tools Newly Enrolled PrEP [PrEP_NEW] Pre-ART Monthly - - 157 register Objective 2: Increased uptake of targeted HIV testing services # of HIV-positive individuals identified through HIV Male & Female 6,548 3,859 12,345 testing services [HTC_TST_POS] <1, 1-4, 5-9, 10- 14, 15-19, 20-24, #/% of individuals identified as positive through HIV 95% 25-29, 30-34, 35- 5,167 2,791 testing services and physically linked to a clinical 39, 40-49 and 50+ treatment facility Objective 3: Improved linkage to treatment for individuals newly testing positive for HIV # of adults and children newly enrolled on ART within 2 Male & Female 5,167 2,791 80% weeks of identification [TX_NEW] <1, 1-9, 10-14, # of adults and children currently receiving ART 15-19, 20-24, 25- 39,655 42,534 50,966 [TX_CURR] 29, 30-34, 35-39, # of TB cases with documented HIV-positive status who 40-49 and 50+ 918 775 start or continue ART during the reporting period [TB_ART] # of ART patients who were screened for TB and receiving Male & Female 477 636 TB treatment [TX_TB] <15, 15+
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 48
SAPR Notes (baseline Baseline COP Data Reporting USAID sources, Indicator Disaggregation (Oct 2016- ‘17 Source Frequency Y1 Target explanations for Sep 2017) Achievem targets) ent # of ART patients who completed a standard course of TB 12,577 2,261 preventive therapy within the reporting period [TB_PREV] Objective 4: increased uptake of and adherence to quality HIV treatment services # of HIV-positive pregnant women who received ARVs to 1,373 1,004 2,185 reduce risk of mother-to-child-transmission (MTCT) during pregnancy and delivery [PMTCT_ARV] # of infants born to HIV- positive women who had a 2,011 1,125 2,276 virologic HIV test done within 12 months of birth [PMTCT_EID] # of mother-baby pairs retained in care at 18 months 90% # of final outcomes at 18 months among HIV-exposed 1,662 N/A infants registered in the birth cohort [PMTCT_FO] Objective 5: long-term follow up of patients receiving care and treatment services including laboratory and logistics support # of adults and children known to be alive and on 5,673 N/A 90% treatment 12 months after initiation of ART [TX_RET] # of ART patients with a viral load result documented in 23,973 13,391 52,043 the medical record and/or laboratory information systems (lis) within the past 12 months with a suppressed viral load (<1000 copies/ml) [TX_PVLS] Objective 6: Strengthened institutional accountability for the management of community, facility and county HIV response No of County AWPs that reflect HIV/AIDS activities across 4 the entire spectrum of prevention, care and treatment No. of counties that allocate domestic funds to HIV 4 prevention, care and treatment services. Number of PEPFAR-supported facility-based service 50 delivery points supported by HSDSA Cluster 3 that have a functional electronic medical record (EMR) system Proportion of the health workforce delivering HIV services 80% in high-volume facilities that have undertaken a minimum one-hour HIV related update in the last 12 months.
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 49
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 50
ANNEX C: HEALTH FACILITY ASSESSMENT TABLES
Table 38: Availability of Guidelines, Algorithms, Checklists, SOPs and Job-aids in Surveyed facilities in Cluster 3
Guidelines, Algorithms, Checklists, Sops, Job-aids: In the table below check if latest version of these documents are available at the health facility and ask to confirm # with latest version % of facilities Guidelines, Checklist, SOPs and Job-aid available (Yes) assessed with latest versions Guidelines 1. National ART guidelines 2016 53 59 (90%) 2. HTS national guidelines 2015 55 62 (89%) 3. Adolescent and youth reproductive health services 14 56 (25%) 4. National Guidelines on clinical management of sexual violence survivors 2013 14 55 (25%) 5. Biosafety/Biosecurity guidelines 38 67 (67%) Algorithms 6. HIV testing Services algorithm 59 62 (92%) 7. Algorithm for EID for HIV Exposed Children 49 57 (86%) 8. Clinical management for sexual survivors flow chart 23 57 (40%) 9. Viral load monitoring of Patients on ART(1st or 2nd line) 42 57 (74%) 10. GeneXpert Algorithm 49 58 (84%) 11. Pulmonary TB Diagnosis in Children 47 56 (84%) Checklists 12. Mentorship checklist 16 56 (29%) 13. ART readiness Assessment 41 55 (75%) Standard operating Procedures 14. Defaulter tracing SOP 41 56 (73%) 15. Testing SOP (1st, 2nd and 3rd) 58 60 (97%) Job aids 16. Couple counselling tools 28 54 (52%) 17. PITC counselling protocols 56 59 (95%) 18. FANC 41 58 (71%) 19. Pregnancy Initiation Assessment 33 57 (58%) 20. FP choices 46 58 (79%)
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 51
21. eMTCT Chart for Health Care Workers 38 58 (67%) 22. Oral Pre-Exosure Prophylaxis (PrEP) 29 55(53%) 23. TB in pregnancy 28 58(48%) 24. Infant and young child feeding 47 57(83%) 25. Adherence counselling 41 58(71%)
Table 39: Availability of reporting tools at health facility
Availability and use of latest version of reporting tools in health facilities survey in cluster 3 (check if latest version of these tools are available and in use at the health facility and ask to confirm) Register or summary tool available #/% with latest version #/% of facilities of tools available and assessed with in use (Yes) latest versions 1. Revised Maternity Register MOH 333 37/56 (66%) 56 2. Postnatal Care Register MOH 406 45/63 (71%) 63 3. Revised ANC Register MOH 405 48/64 (75%) 64 4. Revised Daily Activity Register (ART) MOH 33/58 (57%) 58 5. Revised HEI registers 14/57 (25%) 57 6. TB Register 41/62 (66%) 62 7. Presumptive TB register 41/63 (65%) 63 8. IPT register 37/62 (60%) 62 9. IPT cards 19/52 (37%) 52 10. EID (DNA-PCR) Sample and results Tracking Log 24/58 (41%) 58 11. EID (DNA-PCR) Laboratory Requisition Form 33/60 (55%) 60 12. DBS/PCR tracking logs 24/58 (41%) 58 13. Revised ART Registers 34/58 (59%) 58 14. Defaulter tracing register 28/59 (47%) 59 15. Facility-community linkage register 15/51 (29%) 51 16. VL Load tracking logs 27/59 (46%) 59 17. HUB Viral Load Log (in high volume facilities) 4/41 (10%) 41 18. HTS Register MOH 362 47/67 (70%) 67 19. Linkage register 39/63 (62%) 63 20. PNS register 14/52 (27%) 52
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 52
21. Revised HEI cards 14/53 (26%) 53 22. CCC appointment Cards 26/53 (49%) 53 23. TB patient appointment Cards 35/61 (57%) 61 24. Patient Green Cards 38/57 (67%) 57 25. Care and treatment appointment Diary- A4 23/56 (41%) 56 26. Care and treatment appointment Diary-A3 22/56 (39%) 56 27. Facility Monthly summary MOH 731 40/66 (61%) 66 28. Laminated Dual-kit tools 6/47 (13%) 47 29. SGBV Register MOH 365 14/46 (30%) 46 30. PRC forms MOH 363 15/45 (33%) 45 31. SGBV summary tool MOH 364 8/45 (18%) 45
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 53
ANNEX D: HSDSA CLUSTER 3 SUPPORTED HEALTH FACILITIES
MFL Code County Sub County Facility HTS PMTCT C&T EMR 1 11984 Embu Manyatta Dallas Dispensary 1 1 1 1 2 12790 Embu Manyatta Embu Children Hospital 1 3 12004 Embu Manyatta Embu Provincial General Hospital 1 1 1 1 4 12005 Embu Manyatta Emmanuel Kigari (ACK) Dispensary 1 5 12033 Embu Manyatta Gatunduri Dispensary 1 6 12035 Embu Manyatta Getrude Dispensary 1 7 12130 Embu Manyatta Kairuri Health Centre 1 8 12198 Embu Manyatta Karau Health Centre 1 1 1 1 9 12287 Embu Manyatta Kibugu Health Centre 1 1 1 1 10 12353 Embu Manyatta Kithegi Dispensary 1 11 12359 Embu Manyatta Kithimu Dispensary 1 1 1 12 12453 Embu Manyatta Makengi Dispensary (Embu) 1 1 1 13 12642 Embu Manyatta Nembure Health Centre 1 1 1 1 14 12718 Embu Manyatta Rukira Dispensary 1 15 16464 Embu Mbeere North Ishiara Sub-District Hospital 1 1 1 1 16 12164 Embu Mbeere North Kamumu Dispensary 1 1 1 17 12185 Embu Mbeere North Kanyuambora Dispensary 1 18 12271 Embu Mbeere North Kiambere Dam Dispensary 1 1 1 19 12333 Embu Mbeere North Kirie Dispensary 1 1 1 20 16467 Embu Mbeere North Mbeere District Hospital 1 1 1 1 21 11964 Embu Mbeere South Ccs Kiritiri Clinic 1 22 12023 Embu Mbeere South Gachuriri Dispensary 1 23 16463 Embu Mbeere South Gategi Health Centre 1 1 1 24 16465 Embu Mbeere South Kiambere Health Centre 1 1 1 25 12274 Embu Mbeere South Kiamuringa Dispensary 1 1 1 26 16466 Embu Mbeere South Kiritiri Health Centre 1 1 1 1 27 12431 Embu Mbeere South Liviero Dispensary 1 28 12441 Embu Mbeere South Machang'a Dispensary 1 29 12454 Embu Mbeere South Makima Dispensary 1 1 1 30 12506 Embu Mbeere South Mbonzuki Dispensary 1 31 12645 Embu Mbeere South Nganduri Dispensary 1 32 12722 Embu Mbeere South Rwika Dispensary 1 33 12838 Embu Mbeere South Wachoro Dispensary 1 1 34 12791 Embu Runyenjes Acef Ena Health Centre 1 1 1 1 35 12038 Embu Runyenjes Gichiche Dispensary 1 36 12179 Embu Runyenjes Kanja Health Centre 1 1 1 1 37 12203 Embu Runyenjes Karurumo Rhtc 1 1 1 38 12239 Embu Runyenjes Kathunguri Dispensary 1 39 12279 Embu Runyenjes Kianjokoma Sub-District Hospital 1 1 1 1 40 12298 Embu Runyenjes Kigaa Dispensary 1 41 12300 Embu Runyenjes Kigumo Model Health Centre 1 1 1 1 42 12550 Embu Runyenjes Mufu Dispensary 1 43 12673 Embu Runyenjes Nthagaiya Catholic Dispensary 1 1 1 1 44 12719 Embu Runyenjes Runyenjes District Hospital 1 1 1 1 45 12768 Embu Runyenjes St Michael Nursing Home 1 46 12820 Embu Runyenjes Ugweri Dispensary 1 47 10019 Kiambu Gatundu North Mangu (Aip) Dispensary 1 1 1 1 48 11034 Kiambu Gatundu South St Gabriel Health Centre 1 49 10058 Kiambu Githunguri Beta Care Nursing Home 1 1 1
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 54
50 10263 Kiambu Githunguri Githiga Health Centre 1 1 1 1 51 10269 Kiambu Githunguri Githunguri Health Centre 1 1 1 52 17953 Kiambu Githunguri Kiaibabu Dispensary 1 53 18608 Kiambu Juja Gachororo Health Centre 1 1 1 54 10438 Kiambu Juja Kalimoni Mission Hospital (Juja) 1 1 1 1 55 18391 Kiambu Juja Mugutha (CDF) Dispensary 1 56 10774 Kiambu Juja Munyu Health Centre 1 1 1 1 57 11141 Kiambu Kabete Uthiru Health Centre 1 1 1 1 58 10591 Kiambu Kiambaa Kihara Sub-County Hospital 1 1 1 1 59 17333 Kiambu Kiambaa Muchatha Dispensary 1 60 17219 Kiambu Kiambu town Kasphat Dispensary 1 61 10957 Kiambu Kiambu town Riabai Dispensary 1 62 11071 Kiambu Kikuyu St Teresa Nursing Home 1 1 63 10018 Kiambu Lari Ahadi Maternity Services 1 64 19998 Kiambu Lari Karatina Model Health Centre 1 65 10610 Kiambu Lari Kimende Orthodox Mission Health Centre 1 1 66 10655 Kiambu Lari Lari Level 4 Hospital 1 1 1 1 67 10831 Kiambu Limuru Ndeiya Health Centre 1 1 1 1 68 17248 Kiambu Limuru Rironi Dispensary 1 69 11104 Kiambu Limuru Tigoni District Hospital 1 1 1 1 70 10184 Kiambu Ruiru Focus Medical Clinic and Counselling Centre 1 71 11010 Kiambu Ruiru Siloam Medical Centre 1 72 10349 Kiambu Thika town Immaculate Heart of Mary Hospital 1 1 1 1 73 18433 Kiambu Thika town Karibaribi Dispensary 1 74 18432 Kiambu Thika town Makongeni Dispensary 1 1 1 75 10698 Kiambu Thika town Mary Help of The Sick Hospital 1 1 1 1 76 10740 Kiambu Thika town Mt Sinai Nursing Home 1 1 77 10869 Kiambu Thika town Ngoliba Health Centre 1 1 1 1 78 10765 Kiambu Thika town St Mulumba Mission Hospital 1 1 1 1 79 11097 Kiambu Thika town Thika Nursing Home 1 1 1 80 10738 Kirinyaga Kirinyaga Central Mt Kenya (ACK) Hospital 1 1 1 1 81 10388 Kirinyaga Kirinyaga East Kabare Health Centre 1 1 1 1 82 10545 Kirinyaga Kirinyaga East Kiamutugu Health Centre 1 1 1 1 83 10093 Kirinyaga Kirinyaga South Christian Community Services Wang'uru Dispensary 1 1 84 10110 Kirinyaga Kirinyaga South Difathas Health Centre 1 1 1 1 85 10471 Kirinyaga Kirinyaga South Kangu Dispensary 1 1 86 10806 Kirinyaga Kirinyaga South Mwea Medical Centre 1 1 1 87 10049 Kirinyaga Kirinyaga West Baricho Health Centre 1 1 1 1 88 10399 Kirinyaga Kirinyaga West Kagio Nursing Home 1 1 1 89 12587 Kitui Kitui West Muthale Mission Hospital 1 1 1 1 90 12789 Kitui Mwingi North Tei Wa Yesu Health Centre 1 1 1 91 12282 Meru Buuri Kibirichia Sub-District Hospital 1 1 1 1 92 12302 Meru Buuri Kiirua Health Centre 1 1 1 1 93 12426 Meru Buuri Lewa Downs Dispensary 1 1 1 1 94 17287 Meru Buuri Mboroga Health Centre 1 1 1 95 12631 Meru Buuri Naari Sub-District Hospital 1 1 1 96 12700 Meru Buuri Ontulili Dispensary 1 1 97 12717 Meru Buuri Ruiri Rural Health Demonstration Centre 1 1 1 1 98 12303 Meru Buuri St Theresa Hospital (Kiirua) 1 1 1 1 99 12801 Meru Buuri Timau Catholic Dispensary 1 1 100 12802 Meru Buuri Timau Sub-District Hospital 1 1 1 1 101 12174 Meru Igembe Central Kangeta Health Centre 1 1 1 1 102 12614 Meru Igembe Central Muutine Med Clinic 1 103 12675 Meru Igembe Central Nthambiro Dispensary 1 1 1
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 55
104 12293 Meru Igembe Central PCEA Kiengu Disp/Mat 1 105 12751 Meru Igembe Central St Joseph Catholic Dispensary (Igembe) 1 106 12816 Meru Igembe Central Tuuru Catholic Health Centre 1 1 107 12605 Meru Igembe North Mutuati Sub-District Hospital 1 1 1 1 108 16555 Meru Igembe North Theera Health Centre 1 1 1 109 11923 Meru Igembe South Akachiu Health Centre 1 1 1 110 11963 Meru Igembe South Ccs (ACK) Dispensary 1 1 111 12266 Meru Igembe South Kawiria Maternity and Nursing Home 1 1 112 12684 Meru Igembe South Nyambene District Hospital 1 1 1 1 113 12031 Meru Imenti Central Gatimbi Health Centre 1 1 1 114 12041 Meru Imenti Central Githongo District Hospital 1 1 1 1 115 12192 Meru Imenti Central Kaongo Health Centre 1 1 1 116 12289 Meru Imenti Central Kibunga Sub-District Hospital 1 1 1 117 12759 Meru Imenti Central St Lukes Cottage Hospital 1 118 11971 Meru Imenti North Chugu Dispensary 1 1 1 1 119 12015 Meru Imenti North Family Care Medical Centre (Meru) 1 1 1 120 12027 Meru Imenti North Gakoromone Dispensary 1 1 1 121 12036 Meru Imenti North Giaki Sub-District Hospital 1 1 1 1 122 12044 Meru Imenti North Gitoro Dispensary 1 1 1 1 123 12071 Meru Imenti North Igoki Dispensary 1 1 1 1 124 12234 Meru Imenti North Kathithi Dispensary 1 1 1 1 125 17468 Meru Imenti North Kiamiriru MCK Dispensary 1 126 12290 Meru Imenti North Kiburine Dispensary 1 1 1 127 12326 Meru Imenti North Kinoru Dispensary 1 1 1 1 128 12516 Meru Imenti North Meru District Hospital 1 1 1 1 129 12850 Meru Imenti North Woodlands Hospital 1 130 12067 Meru Imenti South Ichomba Clinic 1 131 12181 Meru Imenti South Kanyakine District Hospital 1 1 1 1 132 12283 Meru Imenti South Kiarago Health Centre (Imenti South) 1 133 12296 Meru Imenti South Kieni Kia Ndege Dispensary 1 1 1 134 12325 Meru Imenti South Kinoro Sub-District Hospital 1 1 1 1 135 12328 Meru Imenti South Kionyo Health Centre 1 1 1 136 12526 Meru Imenti South Mikumbune Sub-District Hospital 1 1 1 1 137 12533 Meru Imenti South Mitunguu Ccs Dispensary 1 138 12534 Meru Imenti South Mitunguu Dispensary 1 1 1 1 139 16229 Meru Imenti South Mweru Dispensary (Imenti South) 1 140 12666 Meru Imenti South Nkubu Dispensary 1 1 1 141 12670 Meru Imenti South Ntemwene Dispensary 1 142 12831 Meru Imenti South Uruku Health Centre 1 1 1 143 11928 Meru Tigania East Amugaa Health Centre 1 144 11967 Meru Tigania East Charuru Dispensary 1 145 12390 Meru Tigania East Kunati Health Centre 1 146 12525 Meru Tigania East Mikinduri Sub-District Hospial 1 1 1 1 147 12591 Meru Tigania East Muthara Sub-District Hospital 1 1 1 1 148 12799 Meru Tigania East St John of God 1 1 1 1 149 12315 Meru Tigania West Kimachia Dispensary 1 150 12391 Meru Tigania West Kunene Dispensary 1 151 12500 Meru Tigania West Mbeu Sub-District Hospital 1 1 1 1 152 16234 Meru Tigania West Miathene District Hospital 1 1 1 1 153 12598 Meru Tigania West Mutionjuri Health Centre 1 154 10040 Murang'a Gatanga Assumption of Mary Dispensary 1 155 17058 Murang'a Gatanga Gathanji Dispensary 1 156 10357 Murang'a Gatanga Ithanga Health Centre 1 1 1 1 157 10199 Murang'a Kandara Gaichanjiru Hospital 1 1 1 1
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158 18962 Murang'a Kandara Gituru Dispensary 1 159 16971 Murang'a Kandara Kagunduini Dispensary 1 160 10987 Murang'a Kandara Sabasaba Health Centre 1 1 1 1 161 10588 Murang'a Kigumo Kigumo Sub County Hospital (Muranga South) 1 1 1 1 162 17303 Murang'a Kigumo Mairi Dispensary 1 163 11086 Murang'a Kigumo Tata Hannah (African Christian Churches and Schools) Dispensary 1 164 16969 Murang'a Maragua Katipanga Dispensary 1 165 10512 Murang'a Maragua Kenol Hospital 1 166 10674 Murang'a Maragua Makuyu Health Centre 1 1 1 1 167 10686 Murang'a Maragua Maragua District Hospital 1 1 1 1 168 10627 Murang'a Mathioya Kiria-Ini Mission Hospital 1 1 1 1 169 10044 Nyandarua Kinangop Bamboo Health Centre 1 1 1 1 170 10481 Nyandarua Kinangop Karangatha Health Centre 1 1 1 171 10758 Nyandarua Kinangop Mukungi Dispensary 1 172 10786 Nyandarua Kinangop Murungaru Health Centre 1 1 1 1 173 10840 Nyandarua Kinangop Ndunyu Njeru Dispensary 1 174 16384 Nyandarua Kinangop Our Lady of Mercy (Magumu) 1 175 11183 Nyandarua Kinangop Weru Health Centre 1 1 1 176 10244 Nyandarua Kipipiri Geta Bush Health Centre 1 1 1 177 16806 Nyandarua Kipipiri Lereshwa Dispensary 1 178 10681 Nyandarua Kipipiri Manunga Health Centre 1 1 1 179 10832 Nyandarua Kipipiri Ndemi Health Centre 1 1 1 180 11173 Nyandarua Kipipiri Wanjohi Health Centre 1 1 1 1 181 10043 Nyandarua Ndaragwa Baari Health Centre 1 1 1 182 10419 Nyandarua Ndaragwa Kahembe Health Centre 1 1 1 1 183 10630 Nyandarua Ndaragwa Kirima Dispensary 1 184 10634 Nyandarua Ndaragwa Kiriogo Dispensary 1 185 18676 Nyandarua Ndaragwa Mastoo Dispensary 1 186 18480 Nyandarua Ndaragwa Mbuyu Dispensary 1 187 10829 Nyandarua Ndaragwa Ndaragwa Health Centre 1 1 1 1 188 10931 Nyandarua Ndaragwa Pesi Dispensary 1 189 11004 Nyandarua Ndaragwa Shamata Health Centre 1 1 1 1 190 11076 Nyandarua Ndaragwa Subuku Dispensary (Nyandarua North) 1 1 1 191 11139 Nyandarua Ndaragwa Uruku Dispensary 1 192 18675 Nyandarua Oljoroorok Huhoini Dispensary 1 193 10856 Nyandarua Oljoroorok Ngano Health Centre 1 1 1 194 10911 Nyandarua Oljoroorok Olbollosat Dispensary 1 1 1 195 10914 Nyandarua Oljoroorok Oljororok Catholic Dispensary 1 196 11009 Nyandarua Oljoroorok Silibwet Health Centre 1 1 1 1 197 10429 Nyandarua Olkalou Kaimbaga Health Centre 1 198 10732 Nyandarua Olkalou Mirangine Health Centre 1 1 1 1 199 10851 Nyandarua Olkalou New Mawingo Dispensary 1 1 1 200 10871 Nyandarua Olkalou Ngorika Health Centre 1 1 1 201 11059 Nyandarua Olkalou St Mathews and Sarah Dispensary 1 1 1 202 11122 Nyandarua Olkalou Tumaini National Youth Service Dispensary 1 203 10579 Nyeri Kieni East Kids Alive Dispensary 1 204 10741 Nyeri Kieni East Mt Kenya Narumoru Medical Clinic 1 205 16816 Nyeri Kieni East Narumoru Catholic Dispensary 1 1 1 1 206 18013 Nyeri Kieni East Ruguru Health Centre 1 207 10700 Nyeri Kieni West Mary Immaculate Hospital (Nyeri North) 1 1 1 1 208 10750 Nyeri Kieni West Mugunda Mission Dispensary 1 1 1 1 209 17576 Nyeri Kieni West St Joseph Brothers 1 1 1 1 210 10368 Nyeri Mathira East Jamii Hospital 1 1 1 211 10488 Nyeri Mathira East Karatina Nursing Home 1
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212 10870 Nyeri Mathira West Ngorano Health Centre 1 1 1 1 213 10582 Nyeri Nyeri Central Kiganjo Health Centre 1 1 1 1 214 10924 Nyeri Nyeri Central Outspan Hospital 1 1 1 215 11972 Tharaka-Nithi Chuka/Igambang'ombe Chuka Cottage Hospital 1 1 216 11973 Tharaka-Nithi Chuka/Igambang'ombe Chuka District Hospital 1 1 1 1 217 12081 Tharaka-Nithi Chuka/Igambang'ombe Ikuu Dispensary 1 218 12132 Tharaka-Nithi Chuka/Igambang'ombe Kajuki Health Centre 1 1 1 1 219 12162 Tharaka-Nithi Chuka/Igambang'ombe Kambandi Dispensary 1 1 1 1 220 12288 Tharaka-Nithi Chuka/Igambang'ombe Kibugua Health Centre 1 1 1 1 221 12546 Tharaka-Nithi Chuka/Igambang'ombe Mpukoni Health Centre 1 1 1 1 222 12563 Tharaka-Nithi Chuka/Igambang'ombe Mukuuni Dispensary 1 1 1 223 16233 Tharaka-Nithi Chuka/Igambang'ombe Presbyterian Ttc Rubate Health Centre 1 224 11942 Tharaka-Nithi Maara Baragu Health Centre 1 1 1 1 225 12272 Tharaka-Nithi Maara Kiamuchairu Health Centre 1 1 1 1 226 12445 Tharaka-Nithi Maara Magutuni District Hospital 1 1 1 1 227 12528 Tharaka-Nithi Maara Minugu Dispensary 1 228 12561 Tharaka-Nithi Maara Mukui Health Centre 1 1 1 229 12589 Tharaka-Nithi Maara Muthambi Health Centre 1 1 1 1 230 12597 Tharaka-Nithi Maara Mutindwa Dispensary 1 231 18080 Tharaka-Nithi Tharaka North Gatunga Model Health Center 1 232 16237 Tharaka-Nithi Tharaka North Karuguaru Dispensary 1 233 12560 Tharaka-Nithi Tharaka North Mukothima Health Centre 1 234 12793 Tharaka-Nithi Tharaka North Thanantu Faith Clinic Dispensary 1 1 1 245 12034 Tharaka-Nithi Tharaka South Gatunga Health Centre (Mission) 1 236 12795 Tharaka-Nithi Tharaka South Tharaka District Hospital 1 1 1 1 236 153 140 90
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ANNEX E: GIS MAPS FOR DISTRIBUTION OF HEALTH FACILITIES IN CLUSTER 3
HIV Services Delivery Support Activity (HSDSA) – Cluster 3, Baseline Report 59
ANNEX F: OCA CAPACITY GAPS AND PLANS
Person Responsible Capacity gaps Identified How they will be Resolved Murang’a Meru Kiambu (HSDA or leverage through a Partner) a) Planning and Budgeting Performance . Support the health department to document how it will leverage on 1. No clear mechanism of engaging the public in planning and the existing public participation forums to incentivise participation of x x x . HSDSA Cluster 3 budgeting decision making the public in planning and budgeting decision making 2. Although budget information is posted in the county . Support the Health department develop a communication strategy to . HSDSA Cluster 3 websites, the CHD is not very clear on how to enhance x x x outline how it will reach diverse audiences with budget information . World Bank access to the public . Support the health department to document and disseminate the 3. Lack of clear direction on how to approach the planning road map that will respond to the August 1st budget circular from the x x x . HSDSA Cluster 3 and budgeting cycle county treasury . Support the county develop a profile, and deploy a health 4. No dedicated staff to oversee planning and budgeting x x x . HSDSA Cluster 3 planner/economist . HSDSA Cluster 3 5. Budget is not in program-based format. . Train and mentor CHMT staff on program-based budgeting x x x . World Bank . Strengthen capacity of health planner to conduct regular expenditure 6. Lack of expenditure reviews to inform budget development x x x . CHMT reviews b) Leadership and Governance 1. Mission and vision statement not displayed . Design, print and display both Mission and Vision statement and the . County Government x x 2. Service charter not displayed not displayed. service charter . HSDSA Cluster 3 . Allocate sufficient funds for SS in the next planning and budgeting 3. Insufficient allocation or no clear budget for support . HSDSA Cluster 3 cycle and assist the county to conduct quarterly site SS and advocate x x supervision (SS) . CHMT for domestic funding progressively 4. Participation of stakeholders in planning, budgeting and . Assist the CHMT to include health stakeholders in planning and x . HSDSA Cluster 3 performance only at high level budgeting and performance at CHMT level 5. No clear transparency and accountability mechanisms . CHMT . Advocate for community and health stakeholder dialogue forums x available . HSDSA Cluster 3 . HSDSA Cluster 3 6. CHMT is unaware of the existence of CHAB . HSDSA to work with CHMT for linkage x . CHMT 7. Lack of stakeholder participation in planning, budgeting and . Assist the CHMT to include health stakeholders in planning and x . HSDSA Cluster 3 performance budgeting and performance . Assist the CHMT to have an updated list of health stakeholders in the . HSDSA Cluster 3 8. No stakeholder coordination mechanism available x county and organize regular stakeholder’s forums . Other partners 9. Lack of transparency and accountability to health sector . CHMT assisted by . Strengthen stakeholder forums, websites x stakeholders HSDSA Cluster 3 10. Organogram is available but there are some gaps such as . HSDSA to work with the CHMT to complete a new and clear . HSDSA Cluster 3 x absence of County Directors organogram of the county structure . CHMT c) Human Resource for Health (HRH) Support the Health department to prepare respective cadre job 1. Not all staff have job descriptions detailed with the scope descriptions with detailed scope and tasks. x x x . HSDSA Cluster 3 and expected level of performance.
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Person Responsible Capacity gaps Identified How they will be Resolved Murang’a Meru Kiambu (HSDA or leverage through a Partner) 2. Personnel files are stored either in unlockable cabinets . HSDSA Cluster 3 which can be accessed easily or keys are left accessible to Support the Health department to safely store personnel files x x x . County MOH none HR Staff 3. There is no county customised HRH retention policy in Support the health department to customised the National place, counties are utilising the policy from the National x x x . HSDSA Cluster 3 Retention Policy Government 4. Although trainings and capacity building is taking place there Support the county develop/adopt a capacity building policy that will are no clear policy guidelines and the information is not x x x . HSDSA Cluster 3 ensure updating of the iHRIS Platform posted in iHRIS 5. There is no functional performance appraisal system support the county develop/adopt PAS tools to be used for annual . HSDSA Cluster 3 x x x inclusive of the partner staff appraisal . MOH Develop a clear policy on the PSB/MOH engagement in recruitment 6. No written policy on PSB engagement in HRH Engagement. x x x HSDSA Cluster 3 and deployment 7. Although the counties are hiring and deploying there is no . HSDSA Cluster 3 Support to Adopt and customise the National policy x x x policy on HRH Equity . MOH 8. Although the counties are using the iHRIS system, they Collaborate with IntraHealth to support the uploading of staff in . HSDSA Cluster 3 x x x have not updated all the staff in the system iHRIS . IntraHealth 9. Not using National document on gender equity support the county to customised the National policy x x x . HSDSA Cluster 3 10. Lack of HRH Policy and strategy support the county to develop a strategy/policy x x x . HSDSA Cluster 3 d) Quality Assurance and Standards Need to form QIT/WIT for systematic follow up of quality concerns . CHMT 1. No QI/WI teams formed at the county level x x x and ensure they are addressed . Quality Ass. Lead Need to initiate regular review of data to identify gaps and initiate . QITs / WITs 2. Lacking regular / systematic review of data to identify gaps x x x QI activities . HSDSA Cluster 3 . Quality Ass. Lead 3. No documentation for completed QI initiatives Documentation for active and completed QI activities x x x . QITs / WITs . HSDSA Cluster 3 4. Members not trained on QA / QI Train S/CHMT on QA / QI and the KHQIF x . Other Partners . HSDSA Cluster 3 5. County plans not aligned to Kenya Quality Model of Health Train S/CHMT on QA / QI and the KHQIF and x x x . Other Partners (KQMH) Align county plans with the KQMH . Quality Ass. Lead 6. No dedicated personnel for QA / QI Have a dedicated personnel for QA/QI initiatives x x . CHMT 7. No dedicated budget for QA / QI activities Have a dedicated budget for QA/QI activities x x . CHMT 8. External Quality Assessment / PT not achieved Engage teams in External Quality Assessment / PT x . Quality Ass. Lead e) Laboratory Management 1. Reporting rates >95% for HIV commodities (RTKs) in the . HSDSA Cluster 3 Procure data bundles for sub county Medical Lab coordinators x x x last 3 months . Other IPs 2. Stock outs of commodity reporting tools (MOH 643,706) . HSDSA Cluster 3 Print and avail Commodity reporting tools x x x in the last 3 months . Other IPs . Review County commodity drawing rights . HSDSA Cluster 3 3. Shortages of laboratory related HIV commodities (RTKs, . Merge program targets with commodity allocations/ quantification x x x . CHAI Cartridges for GeneXpert/ CD4, VL/EID consumables) . Create commodity WhatsApp group for redistribution . County Pharmacist
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Person Responsible Capacity gaps Identified How they will be Resolved Murang’a Meru Kiambu (HSDA or leverage through a Partner) . IPs . CMLTs 4. County not yet transitioned from paper to electronic Support in the installation of inventory management systems targeting x x x . CHAI inventory management system mainly high volume facilities . HSDSA Cluster 3 5. There is no dedicated staff for commodity management in County to identify commodity management focal person with clear . CHMT x x x the county mandate. . CMLC 6. There is no system in place for training lab staffs on County Training matrix to be developed targeting lab staffs x x . C/SCMLTs commodity management 7. County do not hold regular continuous professional . CMLCs Sub county CMEs scheduled to be developed and shared with IPs for development (CPD) on commodity management targeting x x x . HSDSA Cluster 3 support lab staffs . IPs f) Pharmacy Management . Procure data bundles for sub county pharmacists . HSDSA Cluster 3 1. Reporting rates for ARVs and TB drugs below 95% x x x . Other IPs . Install electronic drug management tools targeting central stores at . HSDSA Cluster 3 2. Lack of electronic drug management tool x x x sub county level followed by high volume sites . CHAI . Adopt electronic drug management system . HSDSA Cluster 3 3. Lack of proper management of drugs before expiration date . Create County commodity WhatsApp group to assist in x . CHAI & Other IPs re/distribution . County Pharmacist . County pharmacists to take the lead and structure the Meetings- . County Pharmacist 4. Inactive pharmacovigilance committee Scheduled meetings x x x . HSDSA cluster 3 . Clear TORs for the committee . Other Partners . HSDSA Cluster 3 5. No clear standards for ordering drugs at the county/sub . County to streamline ordering systems at all central stores to reduce x . County Pharmacist county level on overstock/understocking . CHAI . Revive data review meetings on quarterly basis . Sub County & County 6. Inactive data Review meetings x . Develop Clear TORs for the meetings Pharmacist . Activate TWGs with clear TORs . HSDSA Cluster 3 7. Inactive County Commodity Technical Working group x . Meeting Scheduling-Quarterly . Others IPs g) Health Management Information Systems (HIS) 1. No guidelines & policies that include capacity building for Include capacity building for HRIOs in the developed guideline and . CHRIM x x HRIOs policies . HSDSA Cluster 3 2. Customized SOPs for the county not available Customize the National & partner SOPs for the county x x x . CHRIM 3. DQAs highly dependent on donor needs Systematic plan for DQAs and follow up activities x x . CHRIM Schedule systematic performance review and dissemination forums 4. Performance review and dissemination plan not in place x x . CHRIM to enhance DDIU 5. A costed M&E procurement and distribution plan not in Need to efficiently plan and allocate funds for M&E tools in case of x x x . CHMT place shortages from the National government 6. A costed EMR needs not in the AWP and CIDP Allocate funds for EMRs in the CIDP x x . CHMT . CHRIM 7. Lacks the M&E plan County needs to develop their M&E plan x x . HSDSA Cluster 3 8. Acknowledging best performing sites done but no reward . CHRIM Put in place a reward system for best performing sites in the county x x system in place . CHMT
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Person Responsible Capacity gaps Identified How they will be Resolved Murang’a Meru Kiambu (HSDA or leverage through a Partner) h) Information Communication and Technology (ICT) Support the county health department to develop a training policy 1. No existing training/refresher courses/short courses policy . HSDSA Cluster 3 for regular capacity building of staff. Link to partners that oversee x x x documented to guide user training and capacity building . Other partners and conduct trainings in HIS Support the Health department by sensitization on significance of 2. Work computers running on non-updated software x . HSDSA Cluster 3 running latest legal software Support the health department to create official critical position 3. County official use personal non branded emails for specific emails for continuity and organizational knowledge x x x . HSDSA Cluster 3 engaging in official communications management 4. ICT personnel does not participate in planning and Engage the county to intensively conduct needs assessment in ICT x x x . HSDSA Cluster 3 budgeting process by engaging staff, planning, budgeting and funding the budgeted items Support the county to develop and implement a comprehensive ICT . HSDSA Cluster 3 5. Lack of a comprehensive ICT policy in place x x x policy that documents use, access, security and data backups policies . Other partners 6. Lack of an integrated computer system implemented for Liaise with partners that develop the health information systems to x x x . HSDSA, Partners service delivery and reporting in health service sector support implementation and scale up in county health sector
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