Quarterly Progress Report

Child Health Outreach, Githogoro Informal Settlement, Nairobi

QUARTERLY PROGRESS REPORT

ACTIVITY TITLE: APHIA Plus Zone 2 – Nairobi/Coast AWARD NUMBER: USAID/Kenya RFA No. 623-10-000009 PROJECT DATES: 1 January 2011 – 31 December 2013 REPORTING PERIOD: 1 July – 30 Sept 2011 DATE OF SUBMISSION: 24 November 2011

ABBREVIATIONS AND ACRONYNMS

AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care AOP Annual Operation Plan APHIA Aids, Population and Health Integrated Assistance APHIAplus Aids, Population and Health Integrated Assistance Plus ART Antiretroviral Therapy ARV Anti-retroviral (Drugs) BCC Behavior Change and Communication BMI Body – Mass Index CFI ChildFund International CCC Comprehensive Care Center CBHIS Community Based Health Information System CBO Community Based Organization CHAP Community Health Action Plan CHC Community Health Committee CHEW Community Health Extension Worker CHS Community Health Strategy CHW Community Health Worker CME Continuous Medical Education CIPK Council of Imams and Preachers of Kenya CLUSA Cooperative League of the USA CME Continuous Medical Education CSA Community Self Assessment CST Community Support Team CSW Commercial Sex Workers CT Counseling and Testing CU Community Unit CYP Contraceptive-Year Protection DASCO District HIV/AIDS and STI Control Office DHMT District Health Management Team DHC Dispensary Health Committee DHIS District Health Information System DHMT District Health Management Team DHRIO District Health Records Information officer DHSF District Health Stakeholders Forum DMOH District Medical Officer of Health DQA Data Quality Analysis DTC Diagnostic Counseling and Testing DTLC District Tuberculosis and Leprosy Coordinator EID Early Infant Diagnosis EPI Expanded Program on Immunization ETL Education Through Listening FANC Focused Antenatal Care FBO Faith Based Organizations FGD Focus Group Discussion FHOK Family Health Options Kenya FOG Fixed Obligation Grant FS Facilitative Supervision FSW Female Sex Workers FP Family Planning

GBV Gender Based Violence GoK Government of Kenya GSN Gold Star Network GOK Government of Kenya HCS Home Community Support HCT HIV Counseling and Testing HIV Human Immune-deficiency Virus ITN Insecticide Treated Net HAART Highly Active Anti Retrovirus Therapy HBCT Home based Counselling and Testing HCW Health Care Workers HES Household Economic Strengthening HIV Human Immunodeficiency Virus ICRH International Centre for Reproductive Health HMT Health Management Team HTC HIV Counseling and Testing IDU Intravenous Drug Users IEC Information Education and Communication materials IGA Income Generating Activity IP Implementing Partner ITN Insecticide Treated Nets IUCD Intra Uterine Contraceptive Device KCPE Kenya Certificate of Primary Education KEMRI Kenya Medical Research Institute KEPH Kenya Essential Package for Health KNH Kenyatta National Hospital KEMRI Kenya Medical Research Institute LACC Locational AIDS Control Committee LOC Locational OVC Committee LCHW Lead Community Health Worker LIP Local Implementing partner LLITN Long Lasting Insecticide Treated Net LQAS Lot Quality Assurance Sampling MARP Most at Risk Population MEWA Muslim Education and Welfare Association MOGCSD Ministry of Gender, Children and Social Development MOH Ministry of Health MOMS Ministry of Medical Services MOPHS Ministry of Public Health and Sanitation MSM Men who have Sex with Men MTCT Mother to Child Transmission MCH Maternal Child Health MDH Mbagathi District Hospital MNCH Maternal, Newborn and Child Health MoH Ministry of Health MOPHS Ministry of Public Health and Sanitation MSM Men who have Sex with men NARESA Network of AIDS Researchers of Eastern & Southern Africa NHMB Nairobi Health Management Board OJT On Job Training ORT Oral Rehydration Therapy OVC Orphans and Vulnerable Children

PAC Post Abortion Care PASCO Provincial HIV/AIDS and STI Coordinator PDCS Provincial Director of Children services PEP Post Exposure Prophylaxis PHRIO Provincial Health Records Information officer PHO Public Health Officer PHT Public Health Technician PI Pathfinder International PITC Provider Initiated Testing and Counseling PLHIV People Living with HIV PMP Performance Monitoring Plan PMST Provincial Medical Services Team PMTCT Prevention of Mother to Child Transmission PSI Population Service International PwP Prevention with Positives QI Quality Improvement RH Reproductive Health RDQA Routine Data Quality Assessment SILC Saving and Internal lending for communities SOLWODI Solidarity with Women in Distress STI Sexually Transmitted Infections TA Technical Assistance TB Tuberculosis TBA Traditional Birth Attendants TBICF TB Intensive Case Finding TOT Trainer of Trainers TWG Technical Working Group UN United Nations USAID United States Agency for International Development VCT Voluntary Counseling and Testing VHC Village Health Committee VMMC Voluntary Medical Male Circumcision VYC Village Youth Committee YFPAC Youth Friendly Post Abortion Care YFS Youth Friendly Service

TABLE OF CONTENTS

NAIROBI PROVINCE ABBREVIATIONS AND ACRONYNMS ...... 2 LIST OF FIGURES ...... 8 LIST OF TABLES ...... 8 Executive Summary ...... 9 2.0 Program Description ...... 11 3.1 Increased availability of an integrated package of quality high-impact interventions at community and health facility levels ...... 13 3.1.1 Prevention of Mother to Child Transmission (PMTCT) ...... 14 3.1.2. HIV Counseling and Testing (HCT) ...... 15 3.1.3. Voluntary medical male circumcision (VMMC) ...... 16 3.1.4. Most at risk populations (MARPS)...... 17 3.1.5. HIV Care and Treatment ...... 17 3.1.6. TB/ HIV Integration ...... 22 3.1.7 Reproductive Health Services ...... 22 3.1.8 Maternal Neonatal Child Health (MNCH) ...... 24 3.1.9 Challenges and recommendations ...... 27 3.1.10 Planned activities for next quarter ...... 27 3.2 Increased demand for an integrated package of quality high-impact interventions at community and health facility levels ...... 28 3.2.1 Prevention of Mother to Child Transmission (PMTCT) ...... 28 3.2.2. HIV Counseling and Testing (HCT) ...... 28 3.2.3. Voluntary medical male circumcision (VMMC) ...... 29 3.2.4. Most at risk populations (MARPS)...... 29 3.2.5. HIV Care and Treatment ...... 30 3.2.6. TB/ HIV Integration ...... 30 3.2.7. Reproductive Health Services ...... 31 3.2.8. Maternal Neonatal Child Health (MNCH) ...... 32 3.2.9 Challenges and recommendations ...... 32 3.2.10 Planned activities for next quarter ...... 32 3.3: Increased adoption of healthy behaviors ...... 33 Most-at-risk-populations ...... 33 PwP ...... 34 Planned Activities for the next Quarter ...... 35 3.4. Increase program effectiveness through innovative approaches ...... 35 OVC QI ...... 35

RESULT 4: – Social Determinants Of Health Addressed To Improve The Well-Being Of Targeted Communities And Populations ...... 36 4.1: Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integrated with economic strengthening programs ...... 36 4.2: Improved food security and nutrition for marginalized, poor and underserved populations ...... 37 4.3: Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs ...... 37 4.4 Increased Access to Safe Water, Sanitation and Improved Hygiene ...... 38 4.5 Strengthened systems, structures and services for protection of marginalized, poor and underserved population ...... 39 4.6 Expanded social mobilization for health...... 41 5.0 Contribution to Health Systems Strengthening (Results 1 & 2) ...... 42 Quarterly Performance Monitoring Matrix ...... Error! Bookmark not defined. Strengthened Linkages and Partnerships ...... 46 6.0 Integration of Gender-related Activities ...... 47 7.0 Monitoring and Evaluation ...... 49 HMIS Strengthening/Capacity Building ...... 49 Data Quality Audit ...... 49 8.0 Communication and Documentation ...... 51 9.0 EMMR ...... 52

COAST PROVINCE 52 3.1 Increased availability of an integrated package of quality high-impact interventions at community and health facility levels ...... 54 3.1.1 Prevention of Mother to Child Transmission (PMTCT) ...... 54 3.1.2 HIV Counseling and Testing ...... 55 3.1.3 MARPS ...... 57 3.1.4 HIV Care and Treatment ...... 58 3.1.5 TB/HIV Integration ...... 60 3.1.6 Family planning and Reproductive Health ...... 60 3.1.7 Maternal, Newborn and Child Health ...... 62 3.1.8 Malaria ...... 62 3.1.9 HIV and Nutrition ...... 63 3.1.10 Planned activities for the next quarter ...... 63 3.2 Increased demand for an integrated package of quality high-impact interventions at community and health facility levels ...... 64 3.2.1 Support for Community Strategy ...... 64

3.2.2 MCH ...... 65 3.2.3 GATES Festival ...... 66 3.2.4 Screening of Shuga and small group discussions ...... 66 3.2.5 Small Group Communication sessions ...... 66 3.2.6 Magnet theatre community outreaches ...... 66 3.2.7 Factual film community outreaches ...... 66 3.2.8 MARPS ...... 66 3.2.9 Challenges and Recommendations: ...... 68 3.2.10 Planned Activities for the next quarter ...... 68 3.3 Increased adoption of healthy behaviors ...... 68 Challenges and Recommendations ...... 69 3.4. Increase program effectiveness through innovative approaches ...... 69 RESULT 4: Social determinants of health addressed to improve the well-being of targetedcommunities ...... 70 4.1 Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integration with economic strengthening programs ...... 70 4.2: Improved food security and nutrition for marginalized, poor and underserved populations ...... 71 4.3 Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs ...... 72 4.4. Increased access to safe water, sanitation and improved hygiene ...... 73 4.5 Strengthened systems, structures and services for protection of marginalized, poor and underserved populations ...... 74 4.6: Expanded Social Mobilization for Health ...... 74 Contribution to health systems strengthening (Result area 1 & 2) ...... 76 Quarterly Performance monitoring matrix: ...... Error! Bookmark not defined. Support Supervision ...... 78 Linkages with National Mechanisms ...... 78 5.0 Integration of Gender-related Activities ...... 79 6.0 Monitoring and Evaluation ...... 80 ANNEXES ...... 83 ANNEX I: Performance Monitoring Matrix – Nairobi Province ...... 84 ANNEX II: Performance Monitoring Matrix – Coast Province ...... 95 ANNEX III: Nairobi Office ANNEX IV: Coast Office

LIST OF FIGURES Fig.1: PMTCT Cascade APHIAplus Nairobi, Jul 2011 - Sep 2011 ...... 15 Fig 2: Trends of new, cummulative and current clients on ART, Jan 2010-Sept 2011 ...... 18 Fig.3: No. of OVC enrolled and served July - Sept 2011 ...... 22 Fig 4: Percent of new clients by contraceptive method - July - Sept 2011 ...... 23 Fig 5: Percentage of ANC clients receiving HIV prevention services ...... 55 Fig 6: Number of clients who received HCT ...... 56 Fig 7: HIV+ test rate by testing site ...... 57 Fig 8: Proportion enrolled for HIV care by entry point ...... 58 Fig 9: Referral trends from community to service delivery points ...... 65

LIST OF TABLES Table 1: Community leaders’ sensitization meetings conducted by district, number of participants and sex: July– Sept 2011 ...... 32 Table 2: Number of Health Facility Staff Requirements...... 46 Table 3: Uptake of FP methods and CYP in Coast Province ...... 61 Table 4: Human Resource Needs for Coast Province ...... 78 Table 5: Number of health workers trained by district and module...... 81

Executive Summary

APHIAplus Zone 2 is pleased to submit the quarter report for the period, July - September 2011.1 The project is progressing well, fulfilling its workplan in a timely manner. Project staff has held meetings with GOK authorities, primarily at the provincial and district levels where the project functions. Meetings were held with officials in the Division of Community Health Service, the Children’s Department, the two Ministries of Health, the Division of Reproductive Health, the Provincial Health Management Team, the 20 District Health Management Teams,. The Service Delivery and Community Outreach teams have made good progress with their work plan activities. At facility level, the goal is to address health concerns by strengthening HIV/AIDS, TB, Reproductive Health/Family Planning and Maternal and Newborn Health services. The main focus of the project, however, is HIV/AIDS prevention, care and treatment. To achieve this goal in Nairobi and Coast Provinces, the project supported this quarter: • 556 health facilities of which 246 are ART sites (57 GSN sites), 395 PMTCT, 166 TB, 480 HTC and 484 RH/FP. • PMTCT remains an area of primary importance for the prevention of HIV transmission. Among the 395 project-supported GOK, private and faith-based health facilities, 32,375 pregnant women were counseled, tested and received results of whom 1,149 (3.5%) tested HIV positive and of these, 1,179 (102.6%) received ARV prophylaxis. • Still in the realm of prevention, 149,168 clients accessed counseling and received their test results of whom 5.8% (8,615) were identified as HIV positive. • 123 supported facilities with TB/HIV integration • The project stresses the integration of HIV/TB thus in the HIV care and treatment setting, 697 HIV infected clients received treatment for TB. • 136,105 individuals receiving palliative care • The original, emergency goal of PEPFAR in Kenya was to make treatment available to as many HIV positive individuals as possible. In this quarter, 46,779 HIV positive individuals were receiving ART treatment at all the 236 project supported sites. • Another 3,361 clients were newly initiated on ART. • 23,580 people living with HIV were reached with Home & Community Based Care services. • Prevention messages, with strengthened focus on quality, reached 790 youth and 843 MARPs (MSM/MSW/FSW) and 1,671 individuals in small group education through listening (ETL) sessions. • Project works with 93 implementing partners (IPs)

1. The first year of the APHIAplus projects is following the twelve month calendar, January 1 through 31 December 2011.

• 41, 527 new FP clients and 90,159 revisiting FP clients • 1,326 CHWs were trained on MNCH • 17 CUs established in Nairobi in the quarter and among 100 functional CUs in the province, 49 are supported by the project while in Coast of the total of 101 CUs, 54 are supported by the project • Economic assessment of 52,132 Nairobi households concluded that 88% of households earn below Ksh. 200 per day and only 83.4 % can save up to ksh. 20 a day. However, 99 VS&L goups with 1,156 members had accrued a cumulative savings of Ksh 1,856,105 and given 3,386 loans to date. • Nairobi had 99 VS&L groups while at Coast, 205 CBOs had initiated individual and group livelihood income generating projects. • In Nairobi, 63,280 OVC are supported in ECD and primary schools. • 1,037 CHWs were sensitized on GBV prevention and response as were 399 community leaders in Nairobi. • The number of OVC supported rose to 134,074 with the addition to 93 IPs, formerly USAID supported Track I partners

2.0 Program Description

APHIAplus Nairobi/Coast supports integrated service delivery and addresses the social determinants of health in the technical areas of HIV/AIDS, malaria, family planning and tuberculosis, and MNCH, and to a lesser extent water and sanitation.. APHIAplus fits in an overall GOK and USG strategy that builds on achievements of APHIA II, the emergency driven comprehensive response to the AIDS pandemic. APHIAplus will ensure that gains achieved under APHIA II are not lost, particularly in HIV/AIDS, malaria, FP/RH and TB and will further • maximize the existing service delivery capacity combined with deliberate integration of MNCH, nutrition, water and sanitation interventions and apply resources to existing programs to accelerate coverage • strengthen broader health systems to further expand and sustain health impact, and to increase access, efficiency, and equity, especially for poor and marginalized populations. APHIAplus applies a double pronged strategy in integrating gender and gender based violence responses by (i) raising awareness on gender and GBV issues in the community, GOK facilities & structures, and consortium partners and by (ii) enhancing capacity in service delivery at both facility and community level in comprehensive GBV response and male involvement The zone “Nairobi and Coast” represents 6.3 million Kenyans and includes Kenya’s two largest cities - Nairobi and Mombasa. Public health services and medical services have worked together in increasing demand for services and improve access to quality services, but some challenges still need much more attention than currently offered. The zone has a population with significant HIV burden. In Nairobi, HIV prevalence is 9.2% in the 15–49 years age group (with 3.8% among youth 15-24 and 13.2% among 25-49), with significant disparity between male (6.5%) and female (10.4%) prevalence. Knowledge of HIV transmission and prevention is generally high in Nairobi, but over 70% of the population perceive themselves at small or no risk. HIV testing in Nairobi has increased since 2003. Nearly half of HIV-infected individuals in union are in a discordant relationship. In Coast Province, HIV prevalence is 8.8% (like Nairobi, it is nearly 20% higher among females). According to KAIS, while willingness to test is 77% among males, only 29% have ever been tested, and 12.6% of men reported having two or more partners in past year. Nairobi and Coast have in common that there is a high contribution of female sex workers, men- who have sex with men, and injection drug users to new HIV infections. Both provinces have have important gaps in services to youth and vulnerable women, have multiple interrelated MNCH/RH needs among most vulnerable groups, and experiences many barriers that reduce access to health services. Working with the government and other partners, APHIAplus will under all circumstances prioritize interventions that serve the marginalized, vulnerable and underserved populations including youth, MARPS, PLWAs and those on ARVs, orphans and children affected by AIDS; women of reproductive age (pregnant and post partum women), highly vulnerable girls, neonates and infants. APHIAplus works through the GoK structure, involving provincial, district and community levels, and works within GOK implementation frameworks. It adopts therefor the planning and implementation framework of MOH as its own planning and intervention framework. APHIAplus

uses the Results Framework as tool to prioritize among the multiple interventions that the Ministry of Health identifies in order to achieve NHSSP II or MTR or AOP objectives. APHIAplus Nairobi –Coast is designed to achieve results in two main result areas and several sub result areas. RESULT 3 : Increased use of quality health services, products and information 3.1. Increased availability of an integrated package of quality high-impact interventions at community and health facility levels 3.2. Increased demand for an integrated package of quality high-impact interventions at community and health facility levels 3.3. Increased adoption of healthy behaviours 3.4. Increase program effectiveness through innovative approaches

RESULT 4 : Social determinants of health addressed to Improve the well-being of targeted communities and populations 4.1. Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integration with economic strengthening programs 4.2. Improved food security and nutrition for marginalized, poor and underserved populations 4.3. Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs 4.4. Increased access to safe water, sanitation and improved hygiene 4.5. Strengthened systems, structures and services for protection of marginalized, poor and underserved populations 4.6. Expanded social mobilization for health

Nairobi Province

3.1 Increased availability of an integrated package of quality high-impact interventions at community and health facility levels

3.1.1 Prevention of Mother to Child Transmission (PMTCT) The project supported 57 private and faith based facilities (FBO) to implement PMTCT services.

• Technical assistance was offered with the DHMT focusing on completeness of data on the ANC register, HIV infected mothers’ follow up, establishment of support group for mothers and integration of care and treatment into MCH clinic. IEC material and consumables like JIK, spirit, cotton wool and gloves were provided to the facilities. • In sites that had not started offering EID, supportive supervision was provided during which starter packs were provided and as an outcome, 23 of the 57 facilities supported, reported DBS for HIV exposed infants. TA was offered to strengthen the linkage between ANC, MCH and CCC for follow up of exposed infants and linking them to care. • CME were supported in the districts at; Brother Andrea, Samaritan, Mama Lucy Kibaki Hospital, Makadara Health Centre, Mary Immaculate Clinic and Waithaka Health Centre. District wide CME were conducted at Langata, Kasarani, Dagoretti, Embakasi and Njiru districts. 248 Service providers were reached. The topics covered were PMTCT updates, IYCF, PMTCT during labor and EID. • Catholic medical mission board (CMMB) supported 12 FBO facilities across Nairobi through a sub grant.

• CMMB supported 2,644 pregnant women who visited for the first time and 6,563 revisits were offered ANC care. 2,619 mothers were counseled and tested and received their test results, and 113 positive pregnant women were provided with prophylaxis at the ANC. Of the 1,148 women delivered at the maternity, 27 women of unknown status were counseled and tested in the maternity and received their test results and 13 were provided with prophylaxis. 66 infants received prophylaxis and another 66 infants were tested for HIV using PCR-DNA and only one tested positive for HIV. Of the 6,644 mothers who learned their status this quarter, 305 (4.6%) were HIV positive and 246 (81%) were started on prophylaxis. In the maternity, 86 % received their prophylaxis while in the ANC, 77% received prophylaxis. Maternal prophylaxis was low in some facilities as they referred mothers to get prophylaxis elsewhere after counseling and testing them. This was due to erratic supply of drugs which arose when some central sites had their supply moved from Kenya Pharma to KEMSA. • Infant prophylaxis was provided for 222 (73%) infants, of whom a larger proportion was provided at the maternity compared to the ANC (compare 88/70 to134/235). The health care workers preferred to provide infant prophylaxis at the maternity but TA is being provided to ensure that this is given on first contact with the mother as per the guidelines.

Fig.1 : PMTCT Cascade APHIAplus Nairobi, Jul 2011 - Sep 2011

3.1.2. HIV Counseling and Testing (HCT) • The project supported 52 static VCT sites and 76 sites for PITC. Other services supported under HTC are HBCT and mobile VCT. Outreaches were supported to commemorate special days like the World Contraceptive day and during the RRI. • In all the nine districts, monthly counselor supervision sessions were supported. Counselors were from all sites whether supported by the project or other partners. Supervision created an opportunity to address emerging issues; counseling on MARPS and male circumcision were discussed. Other issues discussed were disclosure and discordant couples. • Counselors continued being contracted as some had gone for long periods without supervision as they had been left out in previous sessions. • CME covered review of PMTCT services, couple counseling and enhancing condom use among MSM. Sixty six counselors were reached. • Static sites were supported with consumables like, cotton wool, methylated spirit and gloves. • The National HIV Reference Laboratory (NHRL) provided the project with timers, job aids and standard operating procedures (SOPs) to distribute to sites in Nairobi for promotion of quality assurance. These were distributed to facilities as per the list provided and sensitizations on how to conduct the QA provided. • Patients who tested positive were referred for care and treatment to the nearest CCC. • During the quarter, 63,929 individuals were counseled and tested for HIV, up from 56,563 clients in the previous quarter. This was as a result of having the MARPS RRI in July. • More females were counseled compared to males across all the districts and partner sites. 36,761 (58%) females were counseled and tested for HIV compared to 27,168 (42%) males. The disparity was due to the successful integration of counseling and testing for HIV with cervical cancer screening.

• [HCS] Through the youth friendly desks at Mukuru Rueben and Dandora II Health Centres and the Resource centers, 3,037 young people (1,516 males and 1,521 females), accessed various services offered at the facilities including CT, FP, and ANC, IEC materials and condoms. • In partnership with HIV Free Generation (HFG), APHIA Health Communication and Marketing (HCM) and Safaricom Foundation, counseling and testing was done for 517 young people - none tested positive - during the Provincial and National Sakata Football finals held in Nairobi. Over 6,000 condoms were distributed and the youth leaders conducted demonstrations on condom use. • The project in collaboration with the DASCO supported VCT services for 35 males and 4 females (none tested positive), during the World Youth Day celebrations hosted by the Ministry of Youth Affairs. • In addition, during the small group sessions for Matatu drivers, touts and their partners, MVCT was offered to 60 people (49 males & 11 females), and none tested HIV positive (reference 3.2). • 1,171 OVC and caregivers were mobilized for counseling and testing out of whom 40 were HIV+. The HIV positive children were enrolled at the CCCs and their caregivers encouraged to assist them join support groups for more assistance. Those OVC and caregivers who were aware of their status were also counseled during the exercise.

3.1.3. Voluntary medical male circumcision (VMMC) • As per the work-plan, the project aims to support VMMC in five facilities; during the quarter plans to establish VMMC services were taken from the planning phase to the implementation phase. The project also plans to support VMMC teams on a temporary basis, equipment, consumables and minor renovations. • Assessment for readiness to start VMMC services was done in nine facilities in the month of July. These were Kenyatta National Hospital, Mbagathi District Hospital, Jericho Health Center, Westlands Health Center, Mathare North Health Center, Baba Dogo Health Center, Bahati Health Center, Dandora II Health Center and Mama Lucy Kibaki Hospital. Represented during the assessment were the project SD team, Nairobi City Council, Nairobi Health Management Board and the PHMT. • Five facilities were identified for the initial phase of implementation and are being prepared to provide VMMC services: Mathare North Health Center, Dandora II Health Center, Mbagathi District Hospital and Mama Lucy Kibaki Hospital. Sensitizations on VMMC have been conducted in these sites. • Staffing: with assistance from Capacity Project the advertisements for five teams were sent out; each team is to include a clinical officer, a nurse, a counselor and a hygiene officer. The staff was later shortlisted and interviewed. Recruited teams will undergo training under Nyanza Reproductive Health Services (NHRS) and later be deployed to the five facilities to commence offering VMMC services. • Procurement for VMMC kits and equipment such as autoclave machines and couches to support operations is in the process and will be delivered to the facilities. By mid next quarter VMMC services will have began in these five facilities. .

3.1.4. Most at risk populations (MARPS) • Three facilities are supported to provide MARP friendly services, namely Kangemi, Dandora II and Westlands Health Centers. Plans are underway to establish MARP friendly services at Mbagathi District Hospital as the fourth facility in Nairobi. • At Kangemi Health Center, FGD, was conducted on MARPS that informed the project on specific ways in which to implement the program as per the needs on the ground. Seven females and four males participated. Issues of confidentiality were raised as most participants feared that the HCW shared information with the community. Westlands Health Center was preferred in terms of confidentiality while most men preferred private facilities. The participants commented on the need for speed in service delivery and also for updates on health information. • FGD was conducted at Kangemi Health Center with MARPs as participants who discussed the feasibility of establishing services there. They raised the issue that since they were from the neighborhood the HCW knew them and therefore would not be comfortable being attended to by them. The in charge was given feedback and suggested a follow up exit interview which is scheduled for the coming quarter. • Whole site sensitization was held at Dandora II Health Center; this was the first OJT aimed at preparing the staff at initiation of services. The focus was on reduction of stigma towards MARPs by service providers.

• Interventions were based on the core package of services for MARPS addressing the behavioral and structural aspects as well as the link to biomedical services. Sex workers’ attending the small group sessions also benefitted from cervical cancer and STI screenings that were organized jointly with the DASCOs. In addition, PLHIV advocates provided post- test counseling for 12 who tested positive. • SAPTA, a sub-grantee, was supported to implement IDU initiatives. Dandora and Kangemi were identified as drop-in-centres for the IDU and will be operational in the next quarter. The centers will have a nurse/clinician and an addiction counselor. The nurse will offer HTC, vein and abscess/ulcers care, referral for suspected TB, STIs, Hepatitis according to the symptoms presented, ART adherence support, drug overdose management and nutritional support. The addiction counselor a former IDU will offer evidenced based approaches to counseling, one on one and group counseling, referral to inpatient rehabilitation for severe cases and support outreach activities.

3.1.5. HIV Care and Treatment • The project supported HIV care and treatment services in 98 facilities in the nine districts, 57 of these sites are supported under GSN. Comprehensive and integrated services are provided at these facilities, staff were capacity built through OJT, CME, exchange visits, and mentorship. Mbagathi District Hospital, Gertrude’s Children Hospital and Nairobi Women Hospital are also supported as grantees to support HIV care and treatment in these facilities. • Multi-disciplinary team meetings at the CCC continued being supported as well as inter- departmental meetings. These were held to strengthen care and treatment services. During the meetings, case discussions were held and issues arising concerning quality of care of patients were discussed.

• 10 multi-disciplinary meetings were held at different times in facilities that provide care and treatment; the facilities where this meetings were held are, in Kamukunji, Starehe District, Makadara Health Center, Westlands Health Center and Dagoretti District. Issues pertaining to patient care were discussed in these forums. • Three day commodity management sensitizations was supported in four districts; Kamukunji, Starehe, Kasarani and Njiru Districts. 120 service providers were reached. The commodity management trainings were a follow up to a report on data quality assurance conducted at the facilities in the previous quarter. They aimed at strengthening record keeping at facility levels for better commodity supply chain and management. • Thematic CME was supported in Njiru District and 33 participants were oriented on HBC and 31 on adherence counseling. In Dagoretti District, 46 HCW attended a CME on adherence counseling. • Pharmacovigilance sensitization for 28 service providers was conducted in Makadara District.

Fig 2: Trends of new, cummulative and current clients on ART, Jan 2010-Sept 2011

Trends of Cum, Current & New clients on ARVs by Quarter 25000

20000

15000

10000 No. of Patients 5000

0 Oct-Dec Apr-June Jan-Mar '10 Apr-Jun 10 Jul-Sept 10 Jan-Feb '11 Jul-Sep '11 10 '11 New Clients 928 792 996 1,187 976 1,146 1,331 Cumulative Clients 19,626 18,869 19,944 20,108 20,125 22,067 23,163 Current Clients 16,457 15,431 16,770 17,470 17,531 19,020 19,755

• 1,331 new patients were started on ARVs, while a total of 19,755 accessed ARV therapy between the months of July to September. This was an increase compared to the previous quarter when 1,146 patients had been initiated on ARVs and 19,020 patients had accessed ARVs. Pre ART health treatment literacy was introduced during the quarter to prepare patients better for ARVs; in addition, more patients accessed CD4 count during the quarter. No new facilities were established during the quarter. The main contributor to this quarter’s ART data was Nairobi West region which comprises, Dagoretti, Langata and Westlands Districts. The region is populated by high volume sites like Kangemi HC, Mbagathi District Hospital, Gertrude’s Children Hospital and Nairobi Women’s Hospital. There are more female patients on ART per zone than male; this is also reflected in the uptake of women wanting to know their status through counseling and testing. The trend was consistent in all the zones and is an indicator of poor male involvement in health service uptake and also the

lower prevalence of HIV among men compared to women (4.4 % male compared to 8.0% female). KDHS 2009 • Capacity building to strengthen cancer of the cervix services through OJT and CME; 57 service providers were taken through OJT in, Starehe, Kasarani and Embakasi Districts. At Mbagathi District Hospital, 11 participants were trained. CME on cancer of the cervix was conducted at Njiru and Kamukunji districts attended by 48 participants. • Cancer of the cervix screening was introduced as a new service in Ngaira Health Center and STC Casino. • Training for cryotherapy use was provided: 20 staff received OJT at Mbagathi District Hospital on use of the cryotherapy machine to treat cervical precancerous lesions; two of the participants were from Mbagathi District Hospital. Four machines were distributed for provision of services: Two cryotherapy machines were retained at Mbagathi District Hospital for training purposes of which one later will be re-located to another facility, one cryotherapy machine was given to Dandora II Health Center as well as one for Mathare North Health Center. • The laboratory network continued to support the CD4 testing at the supported sites. 3,038 samples were transported, 1,302 samples to Lunga Lunga Health Center, 626 samples to Mathare North Health Center, 180 samples to STC Casino, and 930 samples to KEMRI. Twenty-nine facilities are supported in the laboratory network. The total samples processed by the laboratories was, 9,275: 3,067 at Mbagathi District Hospital, 974 at STC Casino, 1,658 at Lunga Lunga Health Center and 3,576 at Mathare North Health Center. • Exchange visits were supported for 2 clinical officers working in Jericho and Makadara Health Centers to Mbagathi District Hospital each for 5 days in the month of July. During this period they learnt best practices and skill were improved for better management of patients.

Mbagathi District Hospital The CCC at MDH is a center of excellence that provides high quality comprehensive care with no charges to the patients. Project support to MDH includes staff support, air-time, and transport for home visits, hot lunch for children attending family clinic with their caretakers/guardians, support groups for mamas (expectant mothers) teens and pre-teens support groups and non-pharmaceutical commodities. • The CCC has a total of 30 staff, 21 of whom are supported through the USAID, Capacity Project. There is one medical officer who heads the CCC, an administrative officer who assists the CCC with logistical running, a senior clinical officer to supervise eight clinicians, four nursing officers and four others from the MOH all headed by a MOH nursing officer in-charge of CCC. In addition, the USAID Capacity Project supports a peer educator, a senior counselor, 2 counselors, a lab technologist, a social worker, 2 health records officers and an office assistant. NASCOP supports two data clerks while MOH supports one other CO, two senior nursing officers, a subordinate staff and two pharmacists. The facility has CHWs based at the CCC who provide linkage to the community. • Staff at Mbagathi District Hospital CCC were provided with various orientations during the quarter, different staff attended the following trainings: integrated management of a adult illnesses (IMAI), cancer of the cervix screening, cryotherapy, E-learning tutor, GBV sensitization, HIV testing and counseling, data for decision making, prevention with

positive and COPE (client oriented provider efficiency). CMEs were provided to the CCC staff. • During the quarter, 212 patients 202 adults and 10 children were enrolled to care. 104 patients, 97 adults and 7 children, were initiated on ART. The total number of patients now on ARV is 4,073. • 27 patients transferred out and 38 were lost to follow up. Defaulter tracing was supported for tracing of the defaulters. • There were 75 clients seen in the FP clinic, 18 new clients and 57 revisits. 342 new clients were screened for cancer of the cervix. 44 clients with abnormal lesions were managed at Mbagathi District Hospital since they had started providing cryotherapy services during the quarter, 11 were treated for STI and 24 clients were referred for further management. • Nutrition assessment continued for clients especially for the children, pregnant women and post- partum women. In the laboratory, a fac caliber machine was installed for CD4 testing, 3,067 CD4 tests were run, 1,387 creatinine samples (283 were abnormal), and 88 samples were sent to NHRL for viral load. Prevention with positives has taken root in the clinic and all cadres have been brought on board. Feeding of children on family day and support groups for teens and pre-teens continued, while treatment literacy class for newly initiated clients was held in September. • To assist tracking of consumption of OI drugs from the CCC a software program from MSH was installed at the pharmacy.

Gold Star Network (GSN) • GSN is a franchised health care model that is implemented as a network for the private- sector integrated HIV care and treatment program working in collaboration with Kenya Medical Association (KMA), Kenya clinical officers association, national nursing association, other health professional organizations and the ministry of health. Gold Star Network facility support includes, private clinics, medical centres, FBO/ NGO/CBO facilities, workplace health/ medical centers and for profit hospitals providing safe and affordable integrated HIV care and treatment. • GSN in collaboration with the DHMTs conducted supportive supervision in nine facilities, namely; Mariakani Hospital, Metropolitan Hospital, Karen Hospital, Avenue Hospital, Langata Hospital, and Meridian Equator Hospital, South B Hospital, Komarock Modern Patient Hospital and Buruburu Health Services. • Drugs were supplied through an MOU with distributors such as Phillips Pharmaceuticals Limited and selected pharmacy outlets for supply of registered ARV drugs to GSN members and their clients at preferential prices. 11 prescriptions were serviced under track 1. For those patients who were not able to afford the track 1 drugs, 1,821 prescriptions were dispensed under track II at Amurt Health Center. 132 prescriptions were serviced for PEP. • 4,681 HIV rapid test kits were distributed to GSN sites through SCMS and 190 vacutainers for CD4 samples. • GSN has partnered with Pathologists Lancet, Nyumbani Children’s Home and Nairobi University Immunology Laboratory for discounted services. Amurt Health Center and STC Casino were also able to support services for those who could not afford to pay for lab services. 109 CD4 tests were done, 3 viral loads and 2 PCR tests were run.

• Orientation and ongoing mentorship was supported for laboratory personnel. With support from TB care, 28 GSN sites were assessed and 19 trained on infection prevention. . • GSN members provided HIV counseling and testing services to 3,386 clients • Two continuous professional development sessions were held for GSN members.

Home and Community-based Care for PLHIV • In an effort to expand coverage of Home and Community-Based Care (HCBC) services, 270 CHWs were trained. The training aims to strengthen the capacity of Community Units (CUs), to provide services to PLHIV in their catchment areas. The trainings also increase knowledge and skills on HIV & AIDS, addresses stigma towards PLHIV, and promotes care for PLHIV at level 1 service delivery - individuals, households and community level. Two of the CUs - Kianda and Githogoro trained in HCBC in July & August have enrolled PLHIV in the program which resulted in an increase of clients from 11,366 in last quarter to 11,992 this quarter. • To strengthen skills and knowledge at support group level, topical updates were provided to 110 support groups. The topics included disclosure, tuberculosis (TB), cervical cancer, community PwP concept, family planning (FP), adherence, and stigma. The clients appreciated the updates on FP and cervical cancer. Eight (8) new support groups were formed bringing the total number of support groups in the project to 159. • Among the 47 IPs that the project works with, 38 have functional OVC support groups with a clientele of 2,100 OVC. Ten (10) new OVC support groups were established and OVCs were tested and counseled on HIV/AIDS and awareness created among them on PEP (refer to IR4.3). During the sessions, youth leaders conducted education through listening - ETL sessions focusing on children’s’ knowledge and understanding of HIV/AIDs, modes of transmission, drug adherence, teenage pregnancy, self- esteem, adolescence and body changes. In some IPs, discussions on basic communication skills were held to help the OVC become better communicators especially to their peers, guardians and teachers. Physical exercises were incorporated. • CHWs attached to CCCs and TB clinics were supported to assist in defaulter tracing and linking PLHIV to HCBC services through the CHWs in the community. • An assessment for disabled children (reference IR3.2) was conducted in partnership with the Association for Disabled Persons of Kenya (APDK), 17 OVC were referred to Level 2 facilities for treatment and occupational therapy services while 2 OVC with cerebral palsy were provided with drugs to last them 6 months. • A total of 80,835 OVC were enrolled in out of which 72% (57,983) were served with primary direct and supplemental services. Of the total 57,983 served with essential services, 56,258 were served with 3+ services representing 97% Primary Direct coverage an improvement from the last quarter. This was made possible by implementing partners’ commitment and community health workers in ensuring only deserving children benefit from the project as illustrated below.

Fig.3: No. of OVC enrolled and served July - Sept 2011

OVC Enrolled 80,835

57,983 Total OVC served

OVC receiving 3+ 56,258 services

‐ 20,000 40,000 60,000 80,000 100,000

3.1.6. TB/ HIV Integration • The project supported TB/HIV integration in 51 public, private and faith based facilities. The support was aimed at ensuring that TB screening and management was strengthened in the CCC while HIV counseling and testing and HIV management were addressed at the TB clinic. • 453 clients receiving care and treatment for HIV were given TB treatment. 52,577 patients received palliative care including TB treatment. There are more women (34,505) on palliative care than men (18,072). Nairobi North Zone had the most patients (267) on TB treatment while Nairobi West zone had most patients (23,055) on Palliative care. • Thematic CME conducted during the quarter included a TB/HIV CME at Waithaka HC for 24 service providers. • PITC was supported in the TB clinic and TB ICF in the CCC. Tools for TB ICF were introduced and distributed to CCC supported by the project. • An integrated counselor supervision session was introduced in some districts during the quarter for service providers offering TB and CCC services. During the supervision sessions the issues discussed were, importance of supervision, client confidentiality, PWP key messages, importance of counseling at the laboratory before issuing results and when to initiate HAART to clients on TB treatment • Embakasi District where there are 5 patients being treated for MDR TB at EDARP site and here, sensitization was done on TB infection control. Total of 80 participants were updated on revised infection control guidelines. • Langata District held its TB/HIV integration meeting. 3.1.7 Reproductive Health Services Family planning services, youth friendly services and post abortion care services were supported in 86 FP sites, 5 PAC and 2 YFS site.

Family planning • A total of 19,987 new clients were seen while 29,767 clients were seen on subsequent visits. With frequent outreaches, male involvement at community level and community education, contraceptive use is gaining popularity around supported facilities.

Fig 4: Percent of new clients by contraceptive method - July - Sept 2011

34.0 35.0 28.9 30.0

25.0 21.4

20.0

15.0 9.3

10.0 5.6 5.0 0.8 0.0 0.0 Orals Injections IUD Implants Steriliz. Condoms Other

• Equipment and consumables were supported to strengthen the FP services. At Makadara Health Center a jadelle removal kit was procured and provided. • Thirty SPs were sensitized on FP commodity management and FP tools at Starehe District. • In Njiru District, FP compliance CME were provided to HCW and transport was provided to the RH coordinator for FP commodity redistribution by the project. • Condoms gained popularity as a method of family planning, this may have been as a result of promotion during outreaches for use as dual method for prevention of both HIV and pregnancy. Depo injection has retained popularity among clients although implants are becoming accepted as a method that could be used instead of depo. • FP commodities were generally available except in Dagoretti District where they reported stock out in depo provera in some facilities, in Langata District only a few COCs had been supplied, and in Makadara District there was erratic supply of jadelle and depo provera. Facilities which were lacking commodities were supported with commodities from those which had by redistribution of the missing commodity.

Youth friendly services • The project aims to support five youth friendly centers by the end of the year. The services are ongoing at Dandora II Health Center and the process of establishing services began at Jericho Health Center and Kangemi Health Center in this quarter. • The youth friendly desk at Dandora II Health Center supports provision of information on family planning and other RH services to youth visiting the facility. The desk is linked to the resource centre where the youth access VCT services and condoms. • Exchange visits were supported: At Jericho Health Center, five youths were taken for an exchange visit to Dandora II Health Center. The youth will however still require training to enable them to provide talks to other youth and gain more confidence in order to do condom demonstrations. At Kangemi Health Center, the youth and staff had an exchange

visit to Dandora II Health Center, to enable the youth there establish YF services at their facility. • Youth friendly services were established at Mukuru Ruben Center to give information on reproductive health services and the facility will also provide CBD activities after the youths manning the desk are trained on CBD. • CME on reproductive health issues was provided with 28 youths from supported sites in attendance. • PAC services were supported in five facilities; consumables and TA were provided to strengthen PAC services at these facilities. Some facilities reported inadequate MVA kits and the project is not in a position to procure these. • During the Sakata Football events, the project supported distribution of condoms in which the youth leaders conducted demonstrations on correct and consistent condom use. APHIA HCM provided IEC materials on the C-word and “Chill” comic strips.

3.1.8 Maternal Neonatal Child Health (MNCH) • Forty sites were supported for MNCH activities but focus remained on district activities as most project supported sites were private and FBO facilities, whereas in the public facilities another partner supported PMTCT. • MNCH activities included: thematic CME, World Breastfeeding Week support, outreaches, HCW sensitization and support for maternal death audit in facilities with maternity units. At Makadara District, 18 facility in charges were sensitized to empower them with adequate knowledge so that they can form maternal death review committees in their respective health facilities and hence be able to review the maternal and neonatal deaths, fill the necessary forms and pass them to district and provincial level as well as take necessary action on them. • The World Breastfeeding Week was celebrated between 1st and 7th August. The theme was Talk to me! Breast feeding- a 3D experience. DHMT members were supported to provide supervision during the WBW in all the nine districts.

A breastfeeding moment during the launch

• Support was provided for sensitization of HCW in breast feeding and the baby friendly hospital initiative (BFHI), guidelines on vitamin A supplementation, maternal diet, replacement feeding, immunization schedule and the ANC register. One hundred and sixteen HCW were sensitized at Embakasi, Njiru, Makadara, Langata, Westlands and Dagoretti Districts. • The project supported 15 CME; 435 service providers were reached with various topics, like immunization and disease surveillance, IYCF, malaria in pregnancy and diarrhea case

management. The project also supported CME on maternal and perinatal deaths at Makadara District. Service providers mainly from both public and private health facilities were oriented on Expanded Program of Immunization (EPI) and Disease surveillance. Emphasis was on the outbreak of the polio case detected in the country (Rongo District) and other outbreaks experienced such as measles and cholera • ORT corners have been established at Jericho and Lunga Lunga Health Centers but due to inadequate space thet are now in the pharmacy. • IEC materials were photocopied and distributed in Makadara District. • In forty facilities that were supported, 4,186 children received their measles vaccine while 3,091 received their Vitamin A supplementation at under 1 year of age. Of those over one year, 4 received the measles vaccine and 2,261 were supplemented for Vitamin A. • Nutritional assessment was conducted for 30,096 children under five years of age, 1,120 (3.87%) were underweight while 170 (0.6%) had marasmus, 20 (0.1%) had kwashiakor, 46 (0.15%) were anaemic and 578 (2%) had a faltering weight.

In the project’s effort to contribute towards increased awareness and create demand for MNCH services at community level, the following activities were undertaken: • A total of 1,326 CHWs were trained on MNCH. The CHWs are expected to visit mothers with new-borns to promote small achievable actions such as breastfeeding, care of the newborn including assessing danger signs, personal hygiene for mother and baby, immunization, information on ANC, PAC, FP, HTC, cervical cancer screening services and referral in case of illness. As a result of the training, some facilities, such as State House HC have reported an increase in cervical cancer screening clients and FP clients from 3-5 clients per day to 7-10 clients per day. In Jina clinic of Langata District, the sister-in-charge and District Public Health Nurse (DPHN) reported a notable increase in children being referred for immunization, as well as mothers seeking ANC and PNC services. These are referrals from CHWs following training in MNCH. Mentor mothers’ support group was formed in State House Community Unit (CU), as one of the strategies to improve MNCH services. The group currently has 8 members who have been oriented on FANC by the sister-in- charge, bringing the number of community Mentor mothers support groups to two (2). The project anticipates to expand this initiative to at least two per district through the CUs. These support groups target all pregnant and breast-feeding mothers regardless of their HIV status. • In the previous quarter, a simple tool had been developed to collect information from the TBAs on how they would want to re-position themselves in MNCH service delivery at Level 1 and health facilities as referral agents and birth companions. TBAs identified were supported to participate in small group discussions to initiate TBAs engagement in promoting MNCH/FANC in level 1, and encourage health facility deliveries. Small group discussions bring better understanding of TBA’s perception of the dangers of home deliveries to both mother and baby, in addition to addressing gaps in knowledge and skills for support of MNCH. The issues emerging from the small group discussions led to training of 53 TBAs from Langata, Dagoretti and Westlands in community FANC. The training emphasized the recognition of danger signs in pregnancy, referral of pregnant mothers for ANC services, preparation of birth plans, the role of TBAs as referral agents and as birth companions in health facilities. It was facilitated by District RH Coordinators. Kangemi Health Centre, the TBAs have already introduced themselves to the sister in- charge and agreed on modalities for being birth companions.

• Thirty four (34) School Holiday Child forums were held during the quarter, whereby 18,870 OVC were de-wormed and supplemented with vitamin A, in partnership with the link health facility staff, CHWs and caregivers. Also in partnership with the link health facilities, a total of 6,006 children (3,102 male and 2,904 female) benefited from a medical camp conducted in 31 schools and 7 community sites at Fuata Nyayo and Kayaba in Makadara District. The children were growth monitored, treated for minor ailments, de-wormed, and those suffering from illnesses that could not be attended to at the camp were referred for treatment. The response was encouraging as community members turned out in large numbers during medical camps. Such activities are part of the strategies by the government to increase demand for services. Support for Community Strategy The project continues to support the DHMTs to strengthen capacity and functionality of the Community Units (CUs) to provide preventive and promotional health services at Level 1 with the aim of improving the overall system to provide universal access to quality services. For instance, HIV interventions require responsive community-based systems and structures with effective linkages for clinical care. • DHMTs were supported to roll out the Community Strategy in all the districts through training of Community Health Committees (CHCs) and CHWs, mapping and household registration for newly established CUs. Seventeen CUs were established during the quarter bringing the total number of supported/functional CUs to 49 out of 100 functional units in the province covering roughly 500,000 people. Although the project has surpassed the annual target of 18 CUs planned for Nairobi Province, 14 CUs will be supported in the next quarter. • Existing CUs were strengthened through training in MNCH, HCBC, and Infant and Young Child Feeding - IYCF as described above. The project also initiated and supported progress review meetings for District Community Strategy Coordinators (DCSC), CHEWs and facility In-charges. • Community dialogues were held through CUs in all the districts. Topics discussed were based on needs expressed by the community members that included HCBC for PLHIV, FGM, PAC, GBV and sanitation. In some CUs, the dialogues required follow-up through action days. Some of the activities for action days included community clean-ups and door to door sensitization on hand washing (Eastleigh & Mathare) – reference social determinants 4.4. Some of the CU involved included Mtumba, Kiambiu, and Pioneer in Umoja, KWAPI, Kware Pipeline, MUCESHA, Kayole Soweto and Gitari Marigu B. In total, the project participated in 55 dialogues and 23 action days. • In response to some of the problems identified during a dialogue meeting, an orientation for CHWs on community PAC was done at the State House CU where CHWs identified and referred 2 cases of incomplete abortions. Some of the trainings mentioned above were also as a result of community needs and knowledge gaps identified through community dialogue meetings. • The project continues to supports about 545 CHW with monthly transport reimbursement to facilitate linkages and services at level 1, especially HBC services as well as enhancing referrals and linkages to link health facilities

3.1.9 Challenges and recommendations 1. The facilities supported have not been able to provide HIV testing for postnatal mothers or they do it only occasionally. The reason is staff shortage and increased workload. Despite Capacity Project supporting additional staff, the work load in various facilities remains high as the ratio of public facilities to the population in Nairobi is very low. Most health centers operate with a work load of a level 4 facility and will require additional staff. Therefore there is a shift to adopt group counseling for post-natal mothers who bring babies for immunization and had sero-negative results three months previously, this will save time while still maintaining quality service delivery. 2. There is need for a service contract for the laboratory equipment to cope with break-downs due to the high work load. Discussions with SCMS are ongoing to solve the issue. 3. Poverty and overcrowding has resulted in a high TB burden in the slums. The project is supporting TB ICF in the facilities to assist in identifying and management of TB infected patients. 4. HCW in private and public facilities do not attend updates due to staff shortage, therefore they are not updated on recent guidelines and intense TA has to be given to those facilities. Counselors in these facilities do not also attend supervision resulting in burn out. The DASCOs in various districts have been following up to ensure that the counselors attend supervision. 5. The laboratory transport network for CD4 is strained as there are very few machines in Nairobi therefore resulting in overloading and frequent break down. The transport network is also not strongly supported for hematology and biochemistry essential baseline tests; a laboratory coordination team has been put in place to look into the issues of lab. 6. Lack of stipends for CU CHWs has resulted in attrition of CHWs in the older CUs thus weakening services delivery at level 1. The project will continue to collaborate with other development partners in search of sustainable approaches. 3.1.10 Planned activities for next quarter 1. Plans are underway to establish family days in two other high volume CCC sites as well as support hero book training in others. 2. Integration of sexual and gender based violence activities will be stepped up in the next quarter. 3. Support of the laboratory coordination meeting and district quarterly clinical meetings which are now in the process of being formulated. 4. MNCH activities will be accelerated in the next quarter including the 1000 days campaign. 5. Whole site sensitization will be conducted with focus on MNCH, MARPS, VMMC, and YFS. 6. There will be whole site sensitization on MARPs. 7. OJT on cryotherapy for extra staff at the fifteen facilities supported with cryotherapy machines. 8. Team building for DHMT in the three regions, PHMT and MDH staff. 9. CME will be provided in TB case management in all districts. 10. VMMC services will be established in five sites, Dandora II Health Center, Mathare North Health Center, Jericho Health Center, Mbagathi District Hospital and Mama Lucy Kibaki Hospital. 11. PMTCT will be integrated into Tunza sites. 12. OJT on EID will be conducted and PMTCT updates conducted. 13. ORT nutrition corners will be established and existing ones strengthened.

14. Following site rationalization among partners, there will be re organization in the way services are supported to a more wholesome approach. 15. Strengthen CU through training in IMCI, MNCH, HCBC and CBD. 16. Conduct religious and community leaders’ sensitization by providing an integrated package of messages in HIV&AIDS, MNCH, and RH/FP. 17. Orient selected TBAs to support mothers as birth companions and to support FANC at community level. 18. Support DHMTs to establish new CU in priority areas, and provide working tools for the CUs (wheelbarrows, shovels, rakes, gumboots etc). 19. Support coordination meetings for DASCOs, HBC Coordinators, District Community Strategy Coordinators, In-charges, CHCs and Community Health Extension Workers (CHEWs).

3.2 Increased demand for an integrated package of quality high-impact interventions at community and health facility levels 3.2.1 Prevention of Mother to Child Transmission (PMTCT) • PMTCT activities were integrated in the Malezi Bora campaigns; mothers were encouraged to deliver at the hospital, access ANC and PMTCT services and practice exclusive breast feeding. Mothers were also provided with health talks at the outpatient as they waited to be served. Group counseling for PMTCT was supported in the high volume sites.

3.2.2. HIV Counseling and Testing (HCT) • Outreaches and in-reaches were carried out under project support: In Makadara District, HCT services were offered during the Sakata ball tournament on 24-25th July at the City Stadium. During the tournament, 292 people were tested, 2 tested positive and were referred for care and treatment and another 5 were referred for VMMC services at Loco Health Center. In Westlands District, of 572 clients who were counseled and tested for HIV, 30 (5.2%) tested positive. 28% of those tested were youth and only 15% were men. At Mbagathi District Hospital, an in-reach was held; 3 days in July, 6 days in August and 9 days in September; 1083 people were tested, 70( 6.6%) tested positive for HIV and 7 (14.3%) out of 49 couple tested discordant. In Starehe District HTC for children was conducted at the Redeemed Gospel Church on 2nd to 5th August. A total of 624 children were counseled and tested. 6 who tested positive were referred to Huruma Lions Health Center. Embakasi and Njiru Districts door to counseling and testing services for HIV/TB continued. In the Dandora phase four dumpsite areas, a total of 616 were tested and 6 (1%) clients who tested positive were referred to the nearest CCC. In Embakasi District, a total of 1305 were tested and a total of 10 (1%) were positive and referred to CCC for care.

To stimulate demand, utilization of services and referrals for the KEPH services at Level 1 health facilities, the project endeavored to address the various barriers to health such as stigma, inadequate knowledge and understanding and social cultural barriers to health through outreaches,

sensitizations, community mobilization, training, assessment, referrals and linkages as outlined below. • Magnet theater sessions were conducted both at Level 1 - community and facility level reaching 10,823 (4,771 males & 6,052 females) people. CU reached include Gitari Marigu A, C, Soweto, Mombasa, Mathare, Eastleigh, Mwiki, Korogocho, Kangemi Central and Mbotela. Aspects communicated during the outreaches varied from one community and facility to another depending on the identified gaps, e.g., condom use, concurrency, VCT, FP, teenage pregnancy, drugs and substance abuse and cross-generational relationships. MT groups were recruited from Level 1, by the community and thus they versed with the challenges and were well received during the outreaches. 3.2.3. Voluntary medical male circumcision (VMMC) • VMMC is relatively new as a program in Nairobi and especially for the project supported facilities. It was therefore important to find out what the target population’s perception would be and what sort of services they expected before roll out. FGD were used to interact with the community; at Jericho Health Center, a FGD for ten men was conducted to assess their perception and willingness to access services. Preparations are underway to commence services there and in the meantime clients in need of services are being referred to Loco Health Center under NRHS. • Two FGDs were conducted at both Babadogo and Mathare North Health Centers to identify barriers to VMMC services and opinions about the services. The community members sited culture, pain ,reduced libido, lack of knowledge, fear, discrimination, over age and lack of services as some of the barriers. After discussion, the members identified ways of breaking the barriers such as: community empowerment, availability of services, health education campaigns during chiefs, barazas, mobile clinics, workplace services, official launch of the services, and IEC materials. They would not mind a male or female provider to offer the services and that the services should be offered on daily basis. • Through established structures for community mobilization; for example, in Mathare slums, a VMMC film was screened through a partnership between Film Aid and Slum TV a local organization that uses film based education methodologies. Through their networks, 4 mobilizers were trained who will also serve as facilitators during the screenings. Twelve (12) VMMC daytime screenings were conducted in different venues in Mathare; Community Transformers, MICEDO, Mathare Roots, Kinoti hall, Mabatini hall and Pequininos. The daytime screenings reached 251 males and 49 females. In Kibera, 4 VMM screenings were done in the month of September. The screenings were done at the Kianda Orthodox Church hall, Lindi ODM office and in Gatwekera bio-centre reaching a total of 74 males and 26 females.

3.2.4. Most at risk populations (MARPS) Focus has now shifted to most at risk populations, an important group where HIV transmission is aconcern. The project has started implementing MARP friendly services in supported sites with the aim of reducing barriers to access for preventive and curative services to this population. Described below are activities that were undertaken this quarter towards this aim.

• A MARP RRI was held in July in all the districts in Nairobi Province. During the RRI, sex workers were mobilized and supported with cervical cancer screening, counseling and testing

for HIV and referral to facilities near them. In Kamukunji District, 425 SW were reached with HTC services, 2 (0.5%) tested positive and were referred for care and treatment. In Makadara District, bar hostesses mobilized female sex workers for the RRI, 49 women were screened for cancer of the cervix, 2 were referred for further management to MDH and 9 clients were referred for STI management. • In Kasarani District an in-reach was held at Kasarani Health Center, 46 women were screened for cancer of the cervix; 3 were positive for VIA/VILLI and were referred for further management while 10 were treated for STI. 132 female and male sex workers were offered HCT and 11 (8.3%) tested positive and were referred for care and treatment. • In Embakasi District counseling and testing continued to be offered during outreaches and door to door campaigns. A total of 557 MARPS were screened for HIV of these males (248) and females (304). 12 (2.1%) tested HIV positive and all referred for care and treatment. Condoms dispensed during these activities. 3.2.5. HIV Care and Treatment • Treatment for HIV disease and care to prevent compromised health by opportunistic infections was undertaken during the quarter. It must be noted that most patients will not be aware of the services unless information is given or services are taken beyond the CCC. • Cervical cancer has been reported to affect those whose immunity is compromised and yet only women visiting the CCC regularly are able to access the services. The project therefore undertook outreaches to provide cervical cancer screening. In Westlands District seven outreaches were conducted: Githogoro, Kabete Approved School Dispensary, Padens, St Joseph the Worker, Kangemi Health Center, Westlands Health Center and State House Clinic. A total of 1,258 clients were screened and 507 were treated for STI while 67 turned positive by VIA/VILLI. In Kasarani District 6 sites conducted both in-reaches and out reaches. 385 women were screened and 18 were positive for VIA/VILLI, 32 were treated for STI. Outreaches were conducted in Kiambiu slums and at City Carton in Kamukunji District. In Embakasi District 64 women were screened for cancer of the cervix, 5 with suspicious lesions were referred to Mbagathi District Hospital for cryotherapy. In Njiru District 82 women were screened. • At Mbagathi District Hospital information on HIV management was provided to clients at the CCC 454 adherence counseling sessions were conducted and 4 education sessions given to 28 mothers both aimed at improving adherence. 55 health talks were given to clients by peer educators and CHW. One teen and one pre-teen support groups were held in the month of September. PITC was provided to family members of the clients at the CCC, 10 children and 49 adults were tested while 37 infants were tested using PCR. 3 children and 15 adults tested positive for HIV. • The GSN call centre provided support to 1,186 calls for psychosocial support, adherence counseling and defaulter tracing

3.2.6. TB/ HIV Integration • In Kamukunji, all TB clinics were provided FP demonstration kits to provide an increase in access to RH services in the TB clinic and thus enhance knowledge sharing for TB clinic patients on RH and HIV prevention as a way to attain a healthier life.

• At Gertrude’s Githogoro and Kangemi Health Center, 781 clients were screened for TB in the CCC and 98 were suspect for TB. Of the suspected TB cases, 5 were positive for AAFB • A total of 1,295 clients were screened for TB at Embakasi District with 4 suspicious cases being referred to Kayole Health Center and another 3 suspicious cases to Mukuru Ruben Center. 3.2.7. Reproductive Health Services • During the World Contraceptive Day, RH services were initiated at Ngara and STC Casino Health Centers. Makadara and Lunga Lunga Health Center held in reaches where all the FP methods were offered. The in-reaches were integrated with cancer of the cervix screening. During the period, a three day in-reach was supported at Kangemi Health Center. Njiru District 3 day integrated in reaches were conducted at Kinyago area in Dandora and a total of 102 patients were offered FP services. Integrated outreaches were held at Kasarani District, and long acting FP methods were provided. A total of 62 women were reached; Depo Provera (15), jadelle (13) IUCD insertion (10) and removal (2) and clients issued with pills (22). Six day integrated outreaches/in-reaches were carried out at Embakasi District, Mukuru Kwa Ruben at Ruben Center, Mukuru Kwa Njenga and Alice Nursing Home which are both underserved with reproductive health services , a total of 102 patients were offered FP services both long term and shorter inclusive. • FGD were conducted on YFS. At Kamukunji District during the FGD, youth expressed the need for a 24 hour service and requested more information on PAC, abstinence, condom use, career guidance, FP and the importance of seeking medical attention and self-awareness. At Mukuru Ruben, in Embakasi District, one YFS FGD was conducted with 12 participants. • Magnet theatre sessions have now commenced at Kangemi Health Center by youth based there. This takes place every Monday at the facility outpatient department and a youth desk will be set up in the next quarter. Training on issues of reproductive health will also be provided for the team to capacity build them further. • At community level, RH/FP activities included: FGDs, sensitizations and training. Seven out of the nine planned FGD were conducted with 71 individuals (35 males and 36 females) to identify myths and misconceptions about family planning (in Kamukunji, Kasarani, Starehe, Langata and Westlands Districts of Nairobi). The results were subsequently used to inform community leaders’ sensitizations. • Seven of the nine planned community leaders sensitizations were supported to create awareness on RH/FP, HCT, immunizations, GBV, PAC and WASH in six districts of Nairobi (Starehe, Kasarani, Langata, Njiru, Westlands and Kamukunji Districts). The events involved 692 leaders 260 of whom were men and the rest (432) were females as per the table below. The leaders were sensitized on HIV/AIDS and RH as they are important agents in promotion of RH, prevention, treatment and support services for PLHIV due to their wide reach and strong influence.

Table 1: Community leaders’ sensitization meetings conducted by district, number of participants and sex: Jul y– Sept 2011 Name of District Male Female Total Starehe 42 51 93 Kasarani 43 57 100 Langata 51 49 100 Njiru 33 66 99 Westlands - Githogoro 27 73 100 Kamukunji 32 68 100 Westlands – State House 32 68 100 Total 260 432 692

• Religious leaders formed groups to support one another to pass RH information with their congregations with support from OAIC. In Kibera for instance, some of the leaders have already held short sensitizations for members of their congregations. • As planned, 100 (19 males and 81 females) CHWs were trained in two groups of 50 each as CBD Agents in two CUs (Gitari Marigu “C” and – HDD Dandora) in Njiru District, Nairobi. The trained CBD Agents are expected to provide information on RH/FP and distribute pills, condoms and refer for other RH/FP services. 3.2.8. Maternal Neonatal Child Health (MNCH) An outreach was conducted at Kiambiu slum in Kamukunji District where 249 children were de- wormed and given vitamin A supplementation, 79 were nutritionally assessed and 9 found to have moderate malnutrition.

3.2.9 Challenges and recommendations 1. Male involvement in reproductive health has remained a challenge. ANC mothers are encouraged to come with their partners for antenatal clinic by provision of express services to those mothers who come with partners and sending out partner invitation cards. HCW were involved and any partner that comes to the clinic is given the opportunity for HIV testing. 2. Late attendance of ANC mothers to the clinics and home deliveries still affects timely and correct PMTCT intervention. Advocacy through word of mouth by nurses to the mothers to encourage their colleagues who are pregnant to attend ANC early was given. Community mobilization through the CHW will be adopted in order to ensure early ANC attendance and prompt identification of exposed infants so that interventions can be offered early

3.2.10 Planned activities for next quarter 1. In the coming quarter, Malezi Bora activities, HTC and VMMC RRI, focus to MNCH activities and cancer of the cervix screening and management will be key among others.

2. YFS desks will be established at Mbagathi District Hospital, Jericho Health Center, Mathare North Health Center and Kangemi Health Center. 3. Conduct community FGD with different groups in all districts. 4. Continue to support community/religious leaders’ sensitizations on RH/FP, HCT, immunizations, GBV, PAC and WASH. 5. Support training of CHWs as CBD agents and refresher training for existing CBDs. 6. Support training of male champions for FP advocacy on all methods of FP to increase uptake.

3.3: Increased adoption of healthy behaviors

Major activities involved outreaches at community, schools and health facility levels to sensitize on healthy practices including integrated messaging on harm reduction, partner and stigma reduction in addition to other preventive and promotional health messages targeting MARPS and general population. Trainings were conducted at community level to strengthen the capacity of CBOs and community health workers to mobilize and sensitize communities to improve their health seeking behaviors for overall health as elaborated below. Most-at-risk-populations

Sex workers

• Small Group Communication (SGC) was conducted in all the districts in Nairobi with special emphasis on the informal settlements reaching out to 1,010 sex workers (115 MSW & 895 FSW). It was observed that some of the female sex workers in Eastleigh are brothel- based offering their services 24 hours a day. These sex workers received prevention messages and benefitted from cervical cancer screening, STI screening and HTC organized by the Kamkunji District DASCO. PLHIV Advocates provided post-test counseling for those who tested HIV positive. • SGC was also carried out in Hazina - Mukuru slum. These sex workers operate in Mukuru slum and along Mombasa Road and the majority of their clients are truck drivers from Mlolongo area. FSWs prefer using female condoms as majority of male clients refuse to use a condom. The sessions empowered the sex workers on correct and consistent condom use, condom self-efficacy and the importance of partner reduction. • Alcohol reduction sessions were conducted for 25 MSM and 25 FSW in response to earlier SGC and health literacy sessions in which alcohol and drug abuse featured strongly. These sessions were conducted in partnership with Support for Addictions Prevention and Treatment in Africa (SAPTA), an organization that addresses alcohol and substance abuse and offers professional support to addicted persons. AUDIT, (Alcohol Use Disorders Identification Test), indicated that some of the FSW & MSW were addicted to alcohol. MSW showed that some of their clients give them a lot of alcohol often making them forget to negotiate for condom use. • The effects of drugs and their interaction with ARV drugs were emphasized. Participants identified ways to reduce their alcohol intake, e.g., reducing the number of hours they spend in the pubs and while waiting for clients one can opt to take juice instead of alcohol.

Matatu drivers & touts • Sessions were facilitated by the PLHIV Advocates targeting matatu touts, drivers and their sexual partners. A total of 15 SGC’s were conducted in Dagoretti, Westlands, Starehe, Kamkunji and Makadara Districts reaching 372 people (281 males and 91 females). During the condom demonstration sessions, it was noted that most of the participants had little knowledge on correct use of condoms. Topics included basic HIV/AIDS facts, VCT, condom efficacy and concurrent sexual partnerships (CSP). Some participants were accompanied by their spouses /sexual partners

Youth . • Youth sessions mainly focused on the OVC and were done through the implementing partners reaching 1,381 OVC (640 males & 741 females). Counseling and appropriate responses were provided by the youth leaders to address emerging issues. Topics covered included sex education, relationships, parent/child communication, assertiveness, good and bad touches, peer pressure, drug abuse, hygiene and cross generational relationships. • KGGA, an implementing partner, conducted small group sessions in schools reaching 13,067 children (5,850 males & 7,218 females). More outreaches were conducted to secondary schools including Nairobi school reaching 11,091 students (5,039 males & 6,052 females). • “Chill” sessions in collaboration with Safaricom Foundation were conducted for 150 (100 males & 50 females) young people aged between 15-19. An appreciation note from Safaricom: “Thank you very much for the team you sent us. It was a blend of entertainment and peer talk packaged in a language, tone and skill that kept everyone laughing yet learnt a lot. Soon after the session, I started getting calls and sms’ requesting for another session in December after schools close. • HFG requested support during Liverpool’s dissemination of their HIV findings among MARPS in Korogocho. Since many young people were expected at the event, the project supported two youth leaders to help with Shuga DVD screening and facilitation. The youth watched Shuga together then the group was divided into smaller groups for in-depth discussions. PwP • Support groups and CBO sessions were facilitated by the PLHIV Advocates and the CHWs. The Advocates conducted the sessions through the HBC support groups reaching out to 7,233 people (1,110 males & 6,123 females), while the CHWs addressed participants through their respective CU and reached 4,962 people (675 males & 4,287 females). Topics covered included; positive living, treatment literacy, disclosure, condom efficacy CSP, adherence and gender issues. These were conducted at Riruta Health Center, STC Casino, St Dominic Mathare, and KENWA among others. Disclosure emerged as a significant issue; some HIV positive clients admitted that they were unable to tell their partners about their HIV status and hence continued to have unprotected sex thus putting their partners at great risk of being infected.

• A total of 1,932 PLHIV attended health literacy training which provides a package of integrated messages, i.e., facts on HIV/AIDS, PMTCT, ART TB, FP/RH, HCT, positive

living, disclosure, advocacy and human rights approach to health and gender-based violence. Health literacy promotes positive living and adherence, and empowers PLHIV to take control of their health. Participants included discordant couples, HIV+ concordant couples, commercial sex workers, MSM and youth. • Further, a four-day health literacy training was conducted for HIV positive female and male sex workers reaching 50 MSW and 105 FSW in groups of 25 people. Some of the Sex workers reported sharing ARV’s once they got to know that they were HIV positive without professional medical consultation. Medical help was emphasized instead of self-medication. • The project supported a five-day training of fourteen theater groups (10 persons per group) on Magnet Theater and messaging in an effort to promote positive and healthy behaviors. In addition, 30 CBO/CHW underwent a five day training as facilitators on HIV prevention and ETL methodology. The facilitators ranged in age between 15-24 years and 25 years and above. Participants were both males and females expected to address the specific needs of these age groups.

Planned Activities for the next Quarter 1. Conduct health literacy training for PLHIV support groups and incorporate Prevention with Positives (PwP) key messages. 2. Continue supporting small group sessions for FSW/ MSW & MSM, youth and the adult populations. 3. Support MT outreaches to CU’s, health facilities and secondary schools. 4. Complete training of CHW’s & CBO’s on small group sessions’ techniques within CUs.

3.4. Increase program effectiveness through innovative approaches • Orientations on Afluatoun (refer to 4.1), CLASSE and child friendly safe spaces (refer to 4.3) were carried out and the QI collaborative approach rolled out.

OVC QI • The OVC QI service standards and self assessment guide does provide a road map and an opportunity to OVC implementing partners to reflect/ assess their performance. • The project supported the roll-out of OVC QI service standards in two Community Based Organizations (NOFI and Mitumba) that support OVC care in two districts - Njiru and Langata. The two CBO with support from their respective District Community Strategy Coordinator, District Children’s Officer and Local Area Advisory Council (LAAC) undertook a self assessment of the CBO’s OVC program, identified gaps and priority areas as per the OVC QI service standards. Subsequent to this, two (2) QI teams of fifteen (15) persons (including CHWs, care givers and older OVC) per OVC CBO were formed and trained. The two QI teams developed action plans which they will implement over the next six months. • The improvement/ action plans developed by the QI teams provided them with an opportunity develop home-grown and community owned solutions/changes they would like to play with and test (pilot) to better address and improve the quality of services being provided to OVC.

Activities planned for the next quarter: 1. Support OVC team to form and train two more QI teams 2. Support and monitor QI teams in implementation of their action plans

RESULT 4: – SOCIAL DETERMINANTS OF HEALTH ADDRESSED TO IMPROVE THE WELL-BEING OF TARGETED COMMUNITIES AND POPULATIONS 4.1: Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integrated with economic strengthening programs

The review of the OVC household economic assessment indicated that in Nairobi out of 52,132 households assessed, the main source of income was casual labor. Available resources/assets were stove, jiko, furniture and lanterns. Only 23 households were linked to the GOK cash transfer which does not reflect the need on the ground. Further, 88% of households earn below Ksh. 20 per day and only 83.4% can save up to Ksh. 20 daily. The OVC database gives a detailed account of household economic status and will continue to influence decisions on household economic strengthening activities during the life of the project (refer to OVC household assessment) and further analysis will be done and additional information gathered as appropriate. • By end of September 2011, Nairobi Integrated Program (NIP) had 99 VS&L groups with a membership of 1,156 (M-123 & F-1,033), cumulative savings of Ksh. 1,856,105 and total of 3,386 loans given to date. A field officer oversees about 289 members. This was one of the pioneers of VS&L initiative that began during the APHIA II implementation and has continued to grow. Another vibrant OVC IP in economic strengthening initiatives is Mukuru Promotion Center that has about 112 groups and 1,305 members (M- 158 & F- 1,147) an increase from 97 groups and 1,280 members from the month of August. They have a cumulative savings of Ksh. 3,655,380 and 358 active loans. • 20 VS&L group leaders were trained in Selection, Planning and Management (SPM) of income generating activities while 3 community volunteers were trained as community based trainers on VS&L to assist with skills transfer, follow-up, monitoring of the group activities to track progress. Other IPs with strong VS&L groups are: St. Francis, Mitumba CU, and Kahawa group, ROFO, NOFI, Highridge, KENWA and Redeemed Gospel Church. There are 146 groups with about 2,600 members with over Kshs. 3 million savings per year. The project team met with 14 of the active VS&L TOTs to establish refresher training needs. New TOTs were selected and training scheduled for October 2011 to strengthen VS&L programs. The groups are involved in various economic activities aimed at strengthening their economic and social safety nets. Further, one of the support groups in KENWA was linked to Equity Bank which has given the members training on savings and business entrepreneurship. The group can access loans from the bank either as a group or individuals. • A staff sensitization on VS&L, SPM of small businesses and Aflatoun (financial/social education for children) was carried out to enable staff effectively guide IPs during the implementation of VS&L, Aflatoun and Selection, Planning and management (SPM) activities.

• A total of 55 OVC (26 male and 29 female) from Kasarani, Kamukunji and Starehe Districts were taken through career counseling. They were informed about different types of vocations, their advantages, career decision making, and basic skills in small business management, planning, marketing and budgeting, factors to consider when choosing a preferred course, life skills and how to address challenges during the vocational courses.

4.2: Improved food security and nutrition for marginalized, poor and underserved populations • Mbagathi District Hospital has allocated a piece of land for a demonstration kitchen garden and for sale of farm produce for CCC clients. Discussions took place with the hospital and the Ministry of Agriculture to solicit training of the support group members who will have responsibility of managing the garden. The project will support a water tank, irrigation pipes and seedlings. • The project supported 2,100 OVC attending support group sessions with 2kg maize flour each to take home. • Runjekwa and KAHOBACA IPs have vegetable gardens for caregivers used for demonstrating the various methods of food production, preparation and preservation. This knowledge has been cascaded to other IPs with the expectation that they will initiate household food security initiatives. • Food supply to OVC by the project has been diversified to include beans and cooking oil. In addition, 5,166 children (2,609 boys-2,557 girls) in 26 ECDs were provided with 445 bags of Unimix for their mid-morning snack at school. • In an effort to strengthen the capacity of IPs to improve food security and nutrition, 3 peri- urban IPs, NOFI, St. Francis and ROFO, were provided with green houses. These complement existing vegetable gardens with a plan to reach more OVC households. Caregivers are expected to grow vegetables for their household consumption as well as for sale. The Ministry of Agriculture extension officers from Njiru and Kasarani Districts will advise the IPs on efficient farming methods and appropriate vegetables to grow. • As an emergency response to the Sinai slums fire outbreak, the project provided food to 10 OVC households. • Further, a total of 900 Caregivers from Kasarani, Starehe and Kamukunji Districts were sensitized on nutrition and HIV/AIDS. The caregivers were able to understand the relationship between poor nutrition and increased vulnerability to infections often leading to poor health and AIDS progression. • The project linked some CUs with the district administration to access government relief food for most vulnerable households and out of this initiative, some families in Kiambiu of Kamukunji district have received food through this initiative.

4.3: Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs • Caregivers from Njiru, Embakasi and Makandara Districts held forums in 10 locations to address the barriers to ECD enrollments and reasons for school drop-out. The forums involved ECD teachers from the locations, LAAC members and local leaders in the discussions. They highlighted lack of school levies and educational materials, frequent migration of households and poor enforcement of the Free Primary Education Policy as the

• OVC forums were held in 34 IPs during the August school holiday for enrolled children in the project. Discussions focused on gender based violence, drugs and substance abuse, sexuality, rape and how to avoid it, PEP, how to improve one’s self esteem and manage peer pressure were held with age appropriate OVC during the forums. The children also took part in outdoor games and watched magnet theatre, which portrayed gender based violence messages. All OVC who attended the forums were given cooked lunch provided by the project. The District Officer, 2 chiefs and a CCN social worker visited the OVC during the forums and addressed them. • Embakasi and Njiru DHMTs in collaboration with the project mobilized 200 school head teachers from public and private schools for a 1 day sensitization on the School Health Policy which will be held in October. Invitation letters to the school head teachers were sent out. • Forty-six teachers and 24 caregivers from 11 day care centers attended a one day sensitization on ECD enrolment and retention rates, feeding programs in ECDs, record keeping, effective teaching methods and teaching material development. They agreed to provide a transfer letter to OVC moving from one ECCD/day care center to another, a solution which they said would curb low retention rates. • The project supported OVC with educational materials whereby 48,656 OVC in ECD and Primary schools received exercise books after it had emerged that lack of writing material continued to be a major barrier to school attendance for OVC. The project has 63,280 OVC in ECD and primary school. • In addition, school fee balances and 3rd term school fees for 15 OVC were paid in the quarter and those who had been out of school due to lack of school fees are now back. • Project (OVC) staff participated in a two day briefing session on Child Fund’s (CFI), CLASSE model and ECD programming which was facilitated by the CFI ECD specialist to enable them implement the model and ECD activities more effectively. • A request for equipment to support these safe spaces was made through Doc-to-Doc, and it is expected that these items will be available in year 2.

4.4 Increased Access to Safe Water, Sanitation and Improved Hygiene • Community clean-ups and sensitizations on environmental hygiene and sanitization were conducted in collaboration with Embakasi and Njiru DHMTs. The Coca-Cola Company, Nairobi bottlers supported the activity with refreshments. City Council of Nairobi, community schools, churches and other well-wishers availed tools for use during the exercise. In Soweto, the Area Councilor took part in the clean up to demonstrate collective responsibility in maintaining a clean and safe environment while participating CHC members called upon the communities to engage actively in management of health issues of their communities.

Kosovo Unit members in a combined effort to make their environment clean.

• Mitumba CHC held a meeting to discuss the implementation of the community-led total sanitation (CLTS) which will include installation of water storage tanks and construction of pit latrines for slum dwellers. A transect walk in the informal settlement was carried out by the CHC and the Langata PHO and an inspection report provided. Poor sanitation and waste disposal emerged as the main problem. • Thirty-six formal and informal schools were supported with 10,000 litre water tanks. In addition, 52,109 OVC received 150ml of water guard estimated to treat 15,632,700 liters of water in OVC households. Another 300 OVC received with sanitary pads at the beginning of the school term. • WASH activities have been integrated into the basic modules of CHW training in community strategy, as well as in health literacy for PLHIV. This has increased the use of leaky tins at household level e.g. in Mtumba and Mukuru areas. • Experiential-EXP Momentum was contracted by the project to conduct SGC’s on diarrhea prevention (zuia kuhara) and safe water. Sessions were conducted through CBO’s and reached 743 people (183 males & 560 females).

4.5 Strengthened systems, structures and services for protection of marginalized, poor and underserved population Support was provided to various sectors to strengthen structure to improve service delivery. These were mainly the Children’s Department, Social Development and Ministry of Education as indicated below: • Six Locational Area Advisory council (LAAC) trainings in Embakasi, Makadara and Westlands Districts were held in which 172 LAAC members were trained on the Children’s Act 2001, AAC implementation guidelines, child rights, child participation, child abuse, GBV and CCI regulations. In Langata, the participants requested that the Chiefs introduce them to the community during barazas for community buy-in.

• Njiru and Embakasi District LAACs in collaboration with the project sensitized 1,200 CHWs, Community Health Committees and community leaders on child rights, child protection and gender based violence. Highlights were given on the Children’s ACT 2001, Kenya Constitution 2010 and AAC guidelines. The participants vowed to work hand in hand with the LAAC’s towards improved systems and structures and service for the protection of children. • The project supported 3 Area Advisory Councils (AAC) meetings in Westlands, Dagoretti and Langata Districts. The meetings reviewed CCI inspection reports and gave recommendations; discussed recruitment of VCOs and establishment of children assemblies. The Gender Social Development Officer reported that persons with disability were eligible for the cash transfer program. Eleven VCOs have since been recruited to serve Riruta, Kawangware, Uthiru/Ruthimitu, Waithaka, Mutuini and Golf Course locations. In Dagoretti District, a children’s assembly with 45 members was established and officials elected. • 50 CCI managers and social workers were trained on the minimum service standards for quality improvement of OVC programs. This training aimed at improving management of CCI and strengthening networking among them. The managers were advised to ensure that the homes were regularly inspected by public health officers, that they had valid registration licenses and that all children in their homes had committal orders. • The project supported MOE to train 90 teachers from Nairobi province as ToTs on the Sexual Offences Act. TSC will ensure that the trained teachers will cascade this training to other teachers in the province. During the training, the teachers were also sensitized on the TSC circular on protection of pupils/students from sexual abuse. • A meeting with the Chief Children’s Officer, Nairobi City Council was held in the quarter to plan a ‘census’ of street families in Nairobi. The City Council supports 300 children in 3 children homes and places another 400 monthly from streets back to their households. A meeting with the National Bureau of Statistics to plan on the census during the next quarter has been sought.

• A total of 55,536 OVC were reached with PSS at household level by CHWs and during the child forums (refer to 4.3). CHWs conducted home visits and discussed with OVC and their caregivers on their well-being, offering advise where needed. • The Provincial Children’s Department and the Provincial Commissioner were supported to host the first provincial forum on child protection. The main objectives were to share protection issues that emerged during previous district meetings and to address gaps which hinder positive and appropriate responses. Some of the issues included inadequate of financial resources for VCO/LAAC/DCO, inadequate police support, poor coordination and networking at both district and provincial level. In response to the district presentations, the Deputy Secretary in the Department of Children Services, Prof. Oduol, said that she will hold conversations at different stakeholders’ levels, e.g., quarterly meetings of ministers and with other ministry departmental heads on these issues. Further, she indicated that the Child Protection Strategic Framework was going to be launched soon, and that she was going to encourage other provinces countrywide to follow the project’s and Provincial Children’s Department’s process to tease out child protection issues. A report on the presentations was produced.

• In collaboration with NHIF, an orientation was provided for 6 support groups on the health insurance fund in Kasarani District. As a result, 10 members registered with NHIF.

Plans for Next Quarter 1. Establish/strengthen growth monitoring outposts at CU and IPs for children under 5 years. 2. Train CHWs on pediatric counseling. 3. Raise awareness on drug and substance abuse to OVC 4. Conduct gender responsive school holiday forums for OVC boys and girls to reduce vulnerability to exploitation and abuse. 5. Roll out safe schools initiative using the CLASSE approach 6. Provide ECD Centers with learning and play materials 7. Disseminate the National School Health Policy and Guidelines and the Gender in Education Policy

4.6 Expanded social mobilization for health. Assessment of disabled children • A total of 49 OVC from 15 IPs in Makadara, Njiru and Embakasi Districts were assessed by APDK with project support. Fifteen children had cerebral palsy, 4 were deaf and dumb, 1 was deaf and blind, 3 were deaf and the rest had either hydrocephalus, Down’s syndrome, epilepsy, mental retardation, convulsions or had physically impaired limbs. APDK’s recommendations to assist them varied from procuring special aiding equipment and tools, surgery and medical treatment, to provision of school fees for special education, home based therapy, food support and IGA support for the caregivers. • 40 CHWS, IP coordinators and a CHEW from Kasarani District were trained as ToTs on disability management. They will cascade this training to other CHWs in their respective IPs in the next quarter. • World Youth Day Celebrations – the project participated in the celebration hosted by Ministry of Youth and HIV Free Generation (HFG) at the Ndurarua grounds in Dagoretti District. Counseling sessions were held for the youth on family planning methods and condom demonstrations done. • A total of 390 CHWs from all Districts in Nairobi were trained in IYCF as part of support for World Breast Feeding Week. The CHWs raise awareness on IYCF at community and household level. Trained CHWs are able to identify malnourished children and refer to their link health facilities. This was highlighted in the AOP review for Githogoro and Kangemi Central. • In collaboration with NACC, the project supported implementing partners (IPs) to participate in the Nairobi International Trade Fair, to showcase the agricultural produce and IGA products made by their support groups. The project received a trophy for having one of the best stands. This year’s theme was ‘driving agri-business towards attaining vision 2030 and improving livelihood through agribusiness’. • The project participated in the Sakata Ball - Nairobi Provincial and National Finals events, in collaboration with HFG, APHIA HCM and Safaricom who sponsors of the event. Counseling and testing was supported by the project (ref. 3.1).

• In partnership with Carolina for Kibera (CFK), an NGO supported by CDC, two CUs were established in Kibera. The project conducted the CHC and CHWs trainings while CFK supported mapping and household registration.

5.0 Contribution to Health Systems Strengthening (Results 1 & 2)

Capacity building and support to facilitative supervision and Client Oriented Provider Efficient services (COPE) • Project staff participated in DHMT and stakeholders’ meetings during which planned activities were shared, implementation of AOP 7 was reviewed and areas of priority for demand creation were agreed upon. • The project supported two 3-day orientations for a total Provincial and District Health Management Team on Facilitative Supervision. The 3-day orientation content was adapted from the MOH Facilitative Supervision Manual for Supervisors of RH services (2005) and training materials. The 3-day orientation aimed to capacity build district and provincial managers on facilitative supervision, encouraging DHMT to conduct regular quarterly supervision of their respective facilities using the MOH district supervision tool. DHMT members were exposed to a practicum session on use of the supervision tool, client exit and provider interview forms. Subsequently during the quarter, 66 in-charges and DHMT members were sensitized on facilitative supervision through two continuous medical education sessions in Embakasi and Makadara Districts. The CME for in-charges in Makadara District also incorporated an overview of Client Oriented Provider Efficient (COPE) quality improvement approach. In addition, the PHMT was supported to revise and pilot the provincial supervision tool. The need for revision of the provincial supervision tool had been identified in the AOP 7 and will better enable the PHMT to supervise its nine DHMTs. The revised provincial team supervision tool will be disseminated to the district teams during the next quarter so that DHMT members may be aware of activities and issues that the PHMT will supervise.

The DMOH Kasarani providing feedback at the training on the integrated health services facilitative supervision tool following a practicum session at St. Mary’s Hospital, Nairobi

• The project supported the orientation of provincial and district trainers on a quality improvement approach known as ‘Client Oriented Provider Efficient services (COPE)’. The spirit of COPE is embodied by the idea that changes in quality will be most successful and lasting when they are initiated by staff working together within the facility, using their expertise to identify problems and develop recommendations for solving these problems. COPE, which is a process with a set of practical, easy-to-use tools, helps all levels of staff and supervisors to work together as a team to continuously improve the quality and efficiency of services provided at their facility and make them more responsive to their clients’ needs. • During the quarter, two mentorship meetings were held with the PHMT to introduce and discuss the provincial mentorship strategy. The mentorship strategy was agreed upon and a focal mentorship person identified with whom the project team will liaise with to coordinate mentorship activities. Later during the period a half-day meeting was held to discuss mentorship with service delivery stakeholders, PHMT and DMOHs and thus get their buy in and support in the roll out of the provincial mentorship strategy. • A one-day orientation was held for PMST, PHMT and DMOHs on mentorship in which nineteen provincial and district managers were oriented. Subsequently the mentorship strategy in Nairobi was rolled out with a focus on providing coaching by master mentors to the district mentors in the central sites who would then cascade this mentorship to their satellite sites. The Province had a list of trained mentors which was shared with project and the team paired up with project mentors. • During the months of July and August the project master mentors for Pharmacy and Health Management Information System undertook mentorship site visits in eighteen sites identified in the NASCOP DQA. In collaboration with the service delivery team and P/DHMT, they were able to address the majority of the issues raised in the NASCOP DQA. The project will continue to tackle and support the recommendations made in the report.

• In September, three day working meetings were held with DHMT members and facility staff from 3 cadres: laboratory, pharmacy and HMIS. The purpose of these meetings was to create better linkage and coordination between the mentorship team, service delivery, monitoring and evaluation team and the P/DHMT. The forums facilitated the three components to discuss issues raised in the NASCOP DQA report with regards to commodity security and logistics under lab and pharmacy, challenges in data collection, compilation, tools availability and use of data for decision making. The laboratory and pharmacy departments’ meeting also provided for collaboration between the project and the national mechanism project: Health Commodities and Services Management Program (HCSM). Recommendations were agreed upon to address challenges raised and teams/ committees formulated to follow up on them. Focal pharmacy and laboratory staff from HCMS do play key role in strengthening lab and pharmacy commodity security and logistics under the newly formulate laboratory and pharmacy sub-committees. A total of 63 MOH staff of various cadres was in attendance. • The master mentors conducted visits to nine central sites (1 per district) and were involved in supporting various MOH-identified mentors to initiate mentorship activities in their facilities.

Quarterly Performance Monitoring Matrix • Fifty four (54) P/DHMT were oriented on Facilitative Supervision; • Thirty three (33) provincial and district trainers were oriented on Client Oriented Provider Efficient services (COPE); • Nineteen (19) DMOH were oriented on mentorship; • Three coaching sessions targeting Laboratory, Pharmacy and Records departments were held where a total of sixty three (63) MOH staff were in attendance; • Seventy two (72) mentorship site visits were conducted in eighteen (18) sites identified in the NASCOP DQA report; • Forty (40) mentorship visits were conducted to nine central mentorship sites (Mbagathi District Hospital, Kayole II H/C, Mathare North H/C, Makadara H/C, Dandora II H/C, Casino STC H/C, Westlands H/C, Bahati H/C and, FHOK Langata Road).

Expected outcomes: • Following the 3-day orientation of the district mangers in Nairobi on Facilitative Supervision, it is anticipated that supervision will be revived, undertaken regularly and better understood as being part and parcel of the job description of a district manger (not project/donor driven but could in some instances be project supported, e.g., transport). The orientation also aimed at ensuring that apart from program specific supervision, DHMT members are able to go out as a team as per an agreed upon schedule, conduct integrated supervision thus enhancing teamwork within the DHMT and better understanding of how the various service areas/component integrate, interface and support each other. The district team would can thus focus on processes rather than individuals, encourage a team approach at facility level recognizing that improving performance is not dependant on the actions of a single individual but a complex interaction of systems, staff and resources. • The PHMT is in support of the district teams undertaking integrated supervision and will be following up on the implementation of the districts’ supervision activities by conducting

• The orientation of district trainers on COPE as a quality improvement approach was well received and is being supported by the provincial team. The pool of COPE facilitators that has been set in motion will be used to cascade down COPE to facility staff and help institutionalize COPE in the 8 targeted sites. The COPE process provides a forum for facility staff to undertake a self assessment with regards to provision of quality services by satisfying client rights, observing staff needs, ensuring good record keeping practices and obtaining client feedback on service provision. By applying the quality improvement principles in service delivery, the anticipated change is quality services to clients. • The department meetings served as forums to bring to reinforce issued and gaps raised in the NASCOP DQA report as well as other challenges being faced within the province with regards to laboratory, pharmacy and M & E. The sub-committees formed will hopefully subsequently help to build systems to support and strengthen commodity security, commodity logistics, availability of M & E tools, HMIS data collection, compilation and use of data for decision making.

Activities planned for the next quarter: 1. Support sensitization of DHMT and facility in-charges on facilitative supervision and COPE 2. Support COPE Facilitators implement 1st COPE exercise for facility staff at selected sites 3. Support the PHMT & PMST implement the provincial supervision tool 4. Support implementation of supervision by DHMT & PHMT at facility and district level respectively 5. Support PHMT & PMST in conducting orientation of DHMT & HMT on their roles and responsibilities 6. Support P/DHMT to conduct orientation of health facility committees 7. Support a review meeting for the office of Provincial Public Health Officer/ Provincial Community Strategy Coordinator to discuss the proposed provincial community strategy alignment checklist 8. Support UNITID fellow to pilot and finalize the community health committee planning tool kit 9. Continue to support coaching of MOH mentors 10. Continue to support mentorship activities at the identified 9 central sites on the following topics - adherence counseling; HIV testing and counseling; clinical approaches to the HIV infected adult and child with focus on relevant history taking and examination; recognition of common OIs and case scenarios on WHO clinical staging of HIV disease in both children and adults and report writing with focus on including within the reports mentee assessment 11. A move towards standardization of CMEs, encouragement of mentors to share case scenarios in order to facilitate this 12. Mentorship forum for all the districts to allow for sharing of experiences, peer review among the teams and in order to determine the mentorship needs of the province as well as for peer review of the teams 13. Better documentation of in house activities within the central sites including meetings held and CMEs

Linkages with national mechanisms The Capacity Project supported fifty-eight staff at the facilities supported by the project for care and treatment; however, there are ninteen positions that need to be filled as shown in the table below:

Table 2: Number of Health Facility Staff Requirements. Cadre Number filled Number needs to be filled Medical officer 1 0 Senior clinical officer 1 0 Registered clinical officer 23 1 Kenya registered nurse 7 10 Health information and records officer 4 6 Medical laboratory technologist 9 1 CCC administrative officer 1 0 CCC peer educator/ administrative 1 1 assistant Social workers 2 0 VCT counselor 3 0 Information technology officer 1 0 CCC patient attendant 1 0 CCC counselor in- charge 1 0 CCC counselor 2 0 Office assistant 1 0 Total 58 19

• During the month of August, the service delivery team conducted assessment for equipment, staffing and training needs in supported facilities and the findings were shared with USAID for later linkages to the national mechanisms. Strengthened Linkages and Partnerships • During the Sinai fire disaster, the project supported the DMOH for Makadara with consumables for the victims who were accommodated at the Tom Mboya Hall. These included gauze rolls, methylated spirit, sanitary pads, diapers, normal saline, clean gloves and Sofratulle. • DHMT meetings were supported in all the nine districts as well as district stakeholder’s meetings. • Visitors who visited the sites during the quarter included: o A team from Division of Reproductive Health (DRH) to Dandora II Health Center o HIV/AIDS USAID team leader, Berger Rene, to Mbagathi District Hospital • Meetings attended by the team included: o Kenya Pharma stakeholder’s meeting o Mainstreaming deafness in program work o Study Dissemination on Empowering Young people by DSW o Condom use survey results by PSI o MARPS TWG by NASCOP

6.0 Integration of Gender-related Activities

Planned Activities During this quarter, planned activities included training on GBV prevention, response and coordination for Makadara, Dagoretti and Kamukunji district stakeholders towards the formation of the GBV working groups according the National Framework on GBV Response in Kenya. Support for the Kibera GBV Working Group meetings and team building exercise was to be provided. In addition, gender integration activities to raise awareness on prevention and response to GBV were planned for OVC caregivers, CHWs, community leaders and teachers. Sita Kimya docudrama screenings were to be undertaken while drama groups were to be sensitized on GBV awareness. HCWs were to be linked for training on GBV response and Sexual Assault Forensic Examiner (SAFE) to enhance their response to GBV survivors that present in facilities. A grant was to be made to CREAW to undertake community sensitization forums on GBV and the Sexual Offences Act and provide legal aid to needy cases. The project also planned to map and strengthen/establish shelters in the Makadara, Dagoretti and Kamukunji districts and initiate male champions’ networks in these districts. Substantial progress has been made in the implementation of the above activities and this has been a very vibrant quarter in terms of mainstreaming gender in community level activities of the project.

Activities Undertaken • Following the GBV stakeholder sensitization meetings held in the last quarter, training workshops on GBV prevention, response and coordination were supported for Makadara, Dagoretti and Kamukunji for representatives from various Government and non-Government departments and organizations. A total of 134 (m-49; f-85) participants attended these three (3) workshops. As a result of the above training workshops, the GBV working groups have been formed and their new members have greater capacity to coordinate their activities in their areas more efficiently as well as respond to cases of GBV having understood the role of each sector. • During the quarter, monthly meetings for Makadara, Dagoretti and Kibera GBV working groups were supported within the respective community. During these meetings updates on ongoing GBV response activities and difficult cases were discussed. The new groups are now in the process of establishing structures and electing officials to lead the groups. The Department of Gender is playing an active role in coordinating and mobilizing group members in each of the districts. Notably, the Kibera GBV Working Group has had meetings with the agenda of peace in social and political spheres in anticipation of the upcoming general elections and the rising costs of living. The group has also been consistently represented at the National GBV Working meetings held monthly. • The project supported a one day GBV stakeholder sensitization meeting for Government and non-Government actors in Kamukunji district. This community entry meeting that brought key GBV response stakeholders in the district together for better coordination towards enhanced efficiency of resources and effectiveness of interventions. • The Kibera Male Champions’ Network monthly meetings were supported by the project during the quarter. The male champions are now registered by the Department of Social Services as a CBO and have been facilitated to meet the provincial administration to enhance their legitimacy. A total of 51 male champions were supported to receive training on institutional capacity building to strengthen their strategic planning and resource mobilization efforts. As a result of this support the male champions have been undertaking awareness in the community on the

Sexual Offences Act. The Network has been working closely with young mothers to educate them on how to prevent sexual abuse of their children since the male champions group had noted a rise in defilement cases. • The project supported a teambuilding meeting for the Kibera GBV Working Group to address group dynamics and strengthen leadership through joint vision building. As a result, all the various groups supported through WJEI now understand that they are ultimately united under the working group for coordination purposes. However, team building efforts through the monthly meetings will continue to ensure that consensus in built on leadership and approaches to GBV response. • GBV prevention and response sensitization sessions were integrated in child protection training workshops for local area advisory councils/ local OVC Councils in Githogoro, Kamukunji and Embakasi with a total of 76 (m-33; f-43) participants. • A total of 399 (m-124; f-275) community leaders in Starehe, Kasarani, Langata, Njiru, Githogoro, Kamukunji and State House were sensitized on GBV prevention and response during awareness meetings on FP/RH and Water, Sanitation & Hygiene (WASH). • A total of 1,037(m-282; f-755) CHWs from CUs in Lumumba, Mukuru kwa Reuben, Gitari Marigu, Njiru, Mukuru kwa Njenga, Mukuru Kware, Embakasi and Kayole were also sensitized on GBV prevention and response during child protection awareness sessions. • As a result of the above sensitization sessions, the community in these areas is more aware on what constitutes GBV, how to prevent and respond to incidences. One CU in Makadara reported that it had responded to several cases as a result of the awareness they had received in GBV from the project. • Some supplies were distributed by the project to safe spaces/shelters in Kibera, Dagoretti and Mathare. This will enhance their capacity to support GBV survivors and encourage them to continue receiving them. • The staff training on Healthy Images of Manhood (HIM) was completed during the quarter.

Planned Activities 1. Support monthly GBV working group meetings for Kibera, Dagoretti, Kamukunji and Makadara to assist them develop TORs and action plans 2. Mark the Slum Women’s Voice Day in Kibera in October 2011 and the 16 Days of Activism against GBV in the districts above; activities will integrate HIV and RH/FP 3. Provide CREAW with a grant to hold sensitization forums in Dagoretti, Kamukunji and Makadara and provide legal aid to needy cases 4. Support the monthly shelter review meetings in Kibera in coordination with partners such as WEL and CREAW 5. Hold planning meetings with CREAW to map out USAID inputs to activities in Kibera as they have separate funding for some activities in Kibera 6. Continue integration of awareness activities on gender equality and GBV in other thematic components of the project 7. Undertake mapping of new shelters in Dagoretti, Kamukunji and Makadara; this will continue into the 2nd year of the project. 8. Facilitate the participatory development of TORs for undertaking GBV health facility preparedness assessments for Nairobi and Coast; MOMs/MOPHS and Ministry of Gender to be involved; The strategy for undertaking this exercise has been changed to embrace a

7.0 Monitoring and Evaluation • A wide range of support was provided to the province in order to fulfill the project’s broad mandate of assisting to build the capacity of the MOH M&E system. The team worked closely with Provincial and District Health Management teams by liaising regularly with the Provincial Health Records Information Officer (PHRIO), the District Health Records Information Officers (DHRIOs), the Provincial AIDS and STI Coordinator (PASCO) and the District AIDS and STI Coordinators (DASCOs). The M&E Team works closely with program coordinators in conjunction with liaising with GoK data staff. A typical supervision support team consists of a member of the M&E Unit, a program coordinator and a member of the district data team (DHRIO or HRIO). • The M&E Unit provided complete and accurate data to project staff for use in programmatic decision making and reporting working closely with the project result areas to assist in evaluation and analysis of performance. • The Unit (notably the Data Manager) has continued its strong support of the PEPFAR reporting system and has worked closely with the USAID SI team and APHIA Info (contracted to assist the former) during the APR reporting period to address a number of issues arising with the KePMS. The APHIAplus mandate clearly specifies the role of the project vis-à-vis strengthening the M&E system. This is especially important during this period of transitioning from the PEPFAR dedicated KePMS to the broader national DHIS system. HMIS Strengthening/Capacity Building • The M&E team continued monitoring program activities by offering feedback and suggesting corrective measures to the districts and health facilities as per the ART bi-annual audit done in June 2011. • During the quarter the province unveiled the use of DHIS 2 web based system for reporting to replace the Excel/FTP system. The DHS2 was embraced with by all Ministry of Health staff and Partners alike . The M&E team has supported data transmission from the District Health Records Offices and also by deployed temporary data clerks to 6 districts to assist in entry of data into the system retrospectively. • On 14th September 2011 there was a M &E meeting for Nairobi DHRIOs, HRIOs and the project M&E team district including the HMIS mentors held at Lenana mount hotel. This meeting was held to review data audit report disseminated by NASCOP and mentorship report with the aim of working out a favorable way forward as a response. Data Quality Audit • Data quality dissemination meeting for westlands District where 26 participants attended on 23rd September 2011 with 26 participants. The M&E Team, with the help of the SDC and DHRIO’s office, performed RDQA on ART and palliative care in 12 health facilities in Nairobi Province: Melchizedek Hospital, Kivuli VCT, Amurt HC, Kangemi HC, Soweto Kayole PHC, Reuben Center Clinic, Lunga lunga HC, Jericho HC, Remand Prison HC, Brother Andre Clinic, Samaritan Medical Center, Mathare North HC and

Dandora II HC. This activity helps to ensure that the data generated from facilities are accurate, hence OJT was also performed during the process. NASCOP Tools Roll-out • During the quarter the project supported the distribution of the revised NASCOP tools as part of HMIS strengthening; transport was provided to the DHRIOs and DASCO who coordinated the distribution of the tools. • The project was commended by USAID – Kenya OPH for its swift response to the NASCOP tools orientation request by orienting 234 service providers by end of September 2011. The M&E Unit supported the production of 12,000 patient files in response to an emergency stock-out and these were distributed alongside the NASCOP tools. In September, orientations for Makadara , Dagoretti and Starehe Districts was carried out on the NASCOP tools. A facility-based orientation on the revised NASCOP tools took place at Dandora II Health Centre with 13 service providers in attendance. • The DHIO Njiiru was supported to conduct OJT at two sites new to the project. • The DHRIO Embakasi was supported to conduct MFL updates.

Trainings, CMEs and Stakeholder Meetings Participation. • The M&E team was represented by one of its team members On 12th to 13th July 2011 at a two-day USAID technical meeting on quality improvement and service standards for HIV/AIDS held in Eldoret with the aim of sharing experiences on working with Government of Kenya and for USAID sharing ideas on the standard package of services. • On 22nd September 2011the two M&E team members and the Project director attended the PRE-APR PEPFAR Implementing partners at Panari Hotel. • On 19th August 2011 the M&E team participated in the NACC KDHS dissemination meeting held in Utalii Hotel and included discussions that revolved around the HIV/AIDS indicators. • Household Economic Strengthening Sensitization – This was conducted by Child Fund Kenya and brought more understanding on OVC programming. • In order to strengthen the NACC reporting system on COBPAR the M&E team held 3 meetings with the NACC regional team in order to ensure that all the Local Implementing Partners are reporting effectively. • PMTCT data update meeting with five CMMB sites held at the CMMB office boardroom.

Next quarter planned activities 1. Hold the DHRIO Quarterly meetings 2. Data reconstruction in at least 6 ART sites in Nairobi province. 3. Conduct Data Quality Audits with the DHRIOS to various supported health facilities. 4. Provide facility based analysis to strengthen program activities. 5. Support further orientations on the NASCOP tools

Meetings during the quarter • Partners meetings (PSI in July) etc.

• AOP7 review meetings (Aug) • NACC/NASCOP/HMIS with Peter at Lenana Mount re:DHIS support - Sept

8.0 Communication and Documentation • PMOs Website: Meetings were held with the PMO’s team to develop a website that will be a one stop shop for all health issues in the province. The team of seven developed a template to collect information from the districts. The template was sent to key people at the districts to fill. The main aim of the website id to help the province document its success stories. • Documentation and Collection of information for the first newsletter: throughout this quarter, the project Communications Advisor visited many programs events and activities to gather information and photographs for documentation especially targeting the for first APHIAplus Zone 2 newsletter which will be bi-annual this year and quarterly as from next year. Some of the activities covered are: TBA meetings (TBAs as birth companions), FP outreaches, start up of MARPS (CSWs and MSMs) activities among others. The newsletter has been edited and ready for printing • Communication materials including brochures folders, banners and posters were produced.. • Branding: The CA developed branding templates for use by APHIAplus Zone2. They included presentation templates, envelopes, letterheads among others. These had the latest APHIAplus logo together with the USAID logo and adhered to the guidelines provided by USAID. The office was also branded with APHIplus posters. • Pitching of good practices for media coverage: One practice (the transformation of traditional birth attendants to birth companions) was pitched to various media houses. Three showed interest in covering the story. They were Nation TV, Aljazeera News Network and Science Africa. There are plans to take them to cover the story in the next quarter. • Development of a photo database: This quarter, the APHIAplus NC photo database was updated with the latest photographs taken since the beginning of the project this year. • Production of Monthly Updates: During the reporting period, the Communications Advisor (CA)produced three monthly updates featuring articles from both Nairobi and Coast. The monthly updates featured stories from all the areas of support covered by the project including HCS, BCC (prevention) and Service delivery. • Slogan Development: After even months of review and evaluation, the search for an APHIAplus Nairobi Coast slogan was completed this year with the slogan ‘pamoja kwa afya bora’ being the official Zone 2 slogan. • Abstract Development: Abstract titled ‘Pairing people living with HIV to improve psychososial support and adherence to treatment’ was submitted for the Social Aspects of HIV/AIDS Research Alliance conference to be held at Port Elizabeth, South Africa and was accepted for poster presentation. • Media Training: Met with potential trainers and Internews to plan staff training on presentation skills and media relations. Training is planned for the next quarter or beginning of next year.

9.0 EMMR • Support for the facilities in waste management continued. Casual workers were facilitated to burn refuse at the incinerators and transport was provided for waste disposal. • Expired drugs from the nine districts were transported to a central site in Kaloleni for disposal and further incineration.

COAST PROVINCE

3.1 Increased availability of an integrated package of quality high-impact interventions at community and health facility levels

The project supported Provincial and District Health Management Teams (MOMS and MOPHS), and health care providers in both public and private health facilities to provide leadership and offer high quality integrated HIV and AIDS prevention, care, treatment and support, Maternal, Newborn and Child Health, Family Planning (FP) and Reproductive Health (RH), Tuberculosis and Malaria services. 3.1.1 Prevention of Mother to Child Transmission (PMTCT) • Project staff participated in the PMTCT stakeholders and quality improvement and service standards meetings. In these meetings gaps in PMTCT implementation and the standard package of care for PMTCT services were discussed. These formed the basis for prioritization of activities that were supported during the quarter. • Facility staffs were supported to attend CMEs, sensitizations and updates on the new PMTCT guidelines. On Job Training (OJT) to build health workers confidence in harvesting and packaging quality dry blood samples (DBS) for Early Infant Diagnosis (EID) was conducted. All districts were supported to conduct quarterly PMTCT and ART providers’ meeting and a mapping exercise conducted to determine the central and peripheral PMTCT sites in the districts. • The Coast Provincial General Hospital (CPGH) EID lab was supported with stationery and the providers given technical assistance and mentorship to streamline ordering of supplies and reagents. Five sites (CPGH, Tudor, Port Reitz, Likoni and Bomu) continued to take DBS EID samples for DNA PCR to the CPGH lab, a total of 614 samples were analyzed which included a backlog in July when there was a shortage of reagents. 65 samples had a positive result while 549 had a negative, no indeterminate results were reported. The turnaround time for samples has now improved to one week which is quite commendable. There are considerations to open the lab to more facilities within Mombasa and Kilindini Districts. • A total of 143 PMTCT sites sent samples to the KEMRI lab in Nairobi. 655 samples were analyzed and 51 of these had a positive result. Overall, 1269 samples for DNA PCR were analyzed from Coast facilities and 9.1% of them had a positive result. The average age of testing is still four months and the project will support facilities to put in place effective tracking mechanisms to reduce the testing age to less than two months. • Analysis of PMTCT uptake in the supported public health facilities in Coast Province revealed that, 21,778 new ANC clients were served. 21,915 ANC HIV tests were conducted with a testing uptake is at 100%. The prevalence of HIV in women tested at ANC was 3.2%. Preventive ARVs were issued to 681 out of the 693 identified HIV positive pregnant mothers at ANC. This translates to 98% a great improvement compared to 64% in the previous quarter. • 382 doses of infant ARVs for prophylaxis were provided at ANC translating to 55% coverage of the identified HIV positive mothers while 285 doses were administered at maternity against 151 women found positive. Mentorship and support for documentation

will be provided to improve this. 298 deliveries from HIV positive women were conducted by skilled attendants in delivery units of supported facilities. Fig 5: Percentage of ANC clients receiving HIV prevention services

120%

97% 101% 98% 100%

80% 64% 55% 60% April‐June 41% July‐Sept 40%

20%

0% PMTCT ANC test rate Mothers on ARV Infants on ARV prophylaxis at ANC prophylaxis at ANC

3.1.2 HIV Counseling and Testing • Three hundred and thirty eight (338) public health facilities were supported to provide quality HTC services. APHIAplus supported all the 11 districts to conduct counselor supervision meetings. These meetings were very important in addressing counselor burnout and other issues affecting quality of HTC services in the service outlets. 20 meetings were supported with an average of 40 counselors per meeting. Targeted supervision for counselors depending on need basis was then conducted as follow up from these meetings. • Orientation on the revised HTC guidelines was provided to 56 health workers. In the effort to expand availability for HIV counseling and testing services, all HTC strategies were employed. Mobile HTC outreach services we supported to target youths during the GATES festivals and Sakata Ball events (see result 3.2) as well as moonlight outreaches in sex workers hot spots to target key populations. • Clients who accessed HTC services in public health facilities through their own initiative were 40,518. Out of these, 39,931 (21,561 female and 18,596 male) were tested for HIV translating to an uptake of 98.6%. This quarter, more clients were reached through VCT compared to 26,806 in the previous quarter (see figure 6 below). • The project supported mobile and moonlight integrated VCT outreach activities. 15,615 youths 15-24 years were tested compared to 10,040 in the previous quarter. This achievement is due to integration of counseling and testing activities during the Sakata Ball and GATE events whose audience was mainly the youth. • 1,886 (1,233 Female and 653 Male) HIV positive individuals were identified translating to a positivity rate of 4.7% slightly lower than previous quarters 5.1% (1,364). The positivity rate

among female clients (5.7%) was higher than male clients (3.6%). Analysis further revealed higher HIV prevalence among adults (>24 years) than youth (15-24 years). • A total of 2,721 couples were counseled for HIV and 2,655 (97.5%) were tested. The results revealed that, 97 (3.7%) couples were concordant positive and 123 (4.6%) were discordant. • In Provider Initiated Counseling and Testing, 47,615 (45,278 outpatient, 2,337 inpatient) clients received counseling for HIV and 45,308 accepted testing and received same day results. 2,040 (1,824 outpatient, 216 inpatient) HIV positive individuals were identified giving a prevalence rate of 4.5% (8.8% inpatient and 4.3% outpatient). • Coast People Living with HIV (COPE-KENYA) linked 14 CHWs trained on counseling and testing skills to 14 high volume public health facilities, including Coast Provincial General Hospital, Kinango District Hospital, Lamu District Hospital, Mariakani District Hospital, Moi Voi District Hospital, Malindi District Hospital, Kwale District Hospital, Rabai Health centre, and Gede health centre. The CHWs made home visits using index clients and conducted counseling and testing 1400 households. A total of 1268 people were tested. • Seven COPE-CHW/Counselors conducted two- day door to door counseling targeting seventy (70) households in collaboration with DASCO Mombasa, Assistant Chiefs and Slum Village elders. This took place in the densely populated slums of Kongowea, Kisumu Ndogo and Shauri Yako. 280 people (112 children, 98 men and 70 women) were counseled and tested.

Fig 6: Number of clients who received HCT

50,000 45,308 45,000 39,931 39,987 40,000 35,000

30,000 26,806 25,000 April ‐ June 2011 20,000 July ‐ Sept 2012 15,000 10,000 5,000 ‐ VCT PITC

As illustrated in the figure below, positivity among clients tested in TB clinics is higher compared to other testing sites.

Fig 7: HIV+ test rate by testing site

40.0% 34.3% 35.0% 30.0% 25.0% 20.0% 15.0% 8.8% 10.0% 4.7% 4.3% 4.0% 5.0% 3.0% 0.0% HIV+ test HIV+ test HIV+ test HIV+ test HIV+ test HIV+ test rate ‐ VCT rate ‐PITC ‐ rate ‐PITC ‐ IP rate ‐PMTCT‐ rate ‐ rate ‐TB OPD ANC Maternity

• The Tunza network facilities were able to counsel and test 1,733 women and 475 men, and provide them with their test results. 173 couples were counseled and tested together, 2 of the couples tested had discordant results while 3 had concordant positive and the rest concordant negative. 3.1.3 MARPS • Male and female sex workers continued to utilize the several drop in service centers in Mombasa Island, Likoni, Kisauni and Ukunda for peer education sessions, access to HIV testing and counseling, STI screening and treatment, FP services as well referral for different services not offered. • In Kisauni Drop in Service Centre (DISC), 549 clients received HTC (160 MSM/MSW), 30 accessed FP services while 36 received STI treatment. • The Likoni DISC served 106 clients with HTC services, 107 with FP and 56 received STI treatment. • A total of 126 clients accessed HTC services at the Ukunda DISC. About 12200 condoms were distributed. • At the Mombasa DISC, 209 clients accessed HTC services and 37880 condoms distributed. • One moonlight VCT was conducted at Ziwa la n’gombe, Bombolulu reaching 180 people (4 M; 3F HIV+). 21,000 male and 56 female condoms were distributed alongside 1,700 pieces of IEC material. • Condom distribution was carried out at 10 hotspots with a total of 161,800 male condoms and 971 female condoms distributed in FSW sites and 32,100 male condoms in MSM/MSW sites. • SOLWODI counseled and tested 26 female sex workers. • Four outreach workers from OMARI Centre referred and accompanied 12 injecting and 88 non injecting drug users (64 males and 36 females aged between 14 and 25yrs) to HTC sites in Malindi area around Majengo, Shella, Mbuyu wa kusema, Serena, Muyeye, Mtangani,

Ngala Phase 1, Maweni, Majengo Mapya, Msoloni and the OMARI drop in centre. Ten condom outlets in the same areas were supplied with condoms. • 10 drug users (4 male; 6 female) who turned positive upon testing, were enrolled to a CCC and Post Test Club by outreach workers.

3.1.4 HIV Care and Treatment The project supported several activities to ensure improved access to high quality HIV care and treatment services at all levels. • Staffs at Eldoro Dispensary in Taveta were mentored to start providing adult ART. • Project staff participated in provincial and district ART stakeholders’ meetings convened to discuss challenges affecting the ART program and chart a way forward. • The project supported meetings where sensitization on the GOK recommended minimum package for HIV and AIDS services and other relevant updates in HIV care and treatment were shared. Orientations were done on pediatric HIV care and treatment to 44 SPs. • CMEs on PwP, Nutrition and HIV, CVD in HIV were supported. • Facilities were supported to send patient samples for CD4 to CPGH and Malindi for testing with the facs caliber machines. The labs were also supported with stationery and pipettes to strengthen their operations. 1464 and 4204 samples were analyzed in Malindi and CPGH labs respectively. • During the reporting period, 3,932(2,995 female and 937 male) clients were enrolled for HIV care. The entry point of majority of new clients enrolled within the month for HIV care was from PITC which falls in all others. VCT and PMTCT contributed to a large proportion as well, 27% and 21.6% respectively. Figure 3 below shows the proportion of new patients enrolled for HIV care by entry point.

Fig 8: Proportion enrolled for HIV care by entry point

21.6% PMTCT VCT TB patients 56.8% In‐patients 27.0% CWC PITC

0.3% 2.1% 3.0%

• Cumulatively, 70,840 persons (6,345 Children and 49,243 adults) have ever been enrolled for HIV in the Coast province ART sites. New clients started on ARVs were 2,303 (212 Children and 1,818 adults).

• Cumulatively, 34,932 individuals have ever been initiated on ART and 27,024 are reported to be currently receiving ART. The retention to treatment is therefore 80%. • A validation and needs assessment of PLHIV clients handed over from APHIA II Coast was done yielding a total of 14,900. Enrollment continues through CHWs supported by COPE and the Home and Community Support program. • The Kenya Network of Post Test Clubs (KNEPOTEC), an integrated youth organization began implementation of a project themed “Healthy Youth living with HIV Healthy Society” with project support. The aim of the project is to provide post test services and capacity building for positive youth on PwP to help them deal with social, economical and psychological challenges once they learn their positive status. • KNEPOTEC reached 47 couples in a Youth-Partner HIV Testing initiative in Miritini and Chaani that reached 158 Clients. Of the couples tested, 6 were discordant, 4 concordant positive and 37 concordant negative. Peer educators held one on one counseling sessions with clients after the performance and made 10 referrals for medical attention (3-STI treatment, 1-TB, 4-counseling and 3-CCC) • Seven community health workers (COPE- K) based in the six Coast counties (Mombasa, Kwale, Kilifi, Lamu, Malindi and Taita/Taveta) worked with facility records clerks and adherence counselors to trace 14 treatment defaulters. Five defaulters reported back to respective facilities for treatment. • There are 101operational community health units (CUs) in the province. The project has supported 54 against a target of 60 in year one. Community strengthening activities range from CHW and CHC orientations and training to providing lunch and transport allowances/stipend to CHWs during their monthly feedback meetings. • 2 CUS were identified in Kinango District for strengthening with 93 CHWs (44male and 49 female) given basic training in community strategy. Mapping and household registration was done for 9 new CUs. 10,524 HH were registered, 460 CHWs and 120 CHC members identified for training in the coming quarter. • A total of 17 outreaches and11 Health Action days were conducted. A total of 2,907 (1,423 children and 1,434 adults) received curative services, 2,144 (954 male and 1,190 female) under fives were immunized, 81 pregnant women (23 first timers and 58 revisits) attended ANC, 185 received PMTCT services with 164 being counseled and 21 being counseled and tested. 497 were attended for FP services out of which 6 were new and 491 were revisits. A total of 10,512 condoms (10,172 to men and 340 to women), 330 ITNs and 595 IEC materials were distributed. • About 159,900 free GoK condoms were distributed by youth CBOs and CHWs. These condoms were accessed through the PSI free GoK condom distribution program and were channelled through the Public Health Officers in the respective community units. • A total of 76,091 OVC (male 35,905 female 40,186) were served. Of this total, 65,712 or 86% OVC (male 31,152 female 34,560) received primary direct support while 10,379 or 14% OVC received supplemental direct support (male 4,753 female 5,626).

• Additionally, a total of 210,395 (male 103,539 female 106,856) indirect beneficiaries were supported during the province wide integrated school health program. Activities included;- health education, personal hygiene and hand washing, immunizations, de-worming, health screening/ onsite treatment, vitamin A supplementation, oral health and dental checks, nutritional assessment, eye checkups for targeted children, referrals for 579 children requiring additional facility follow up and checks on school health and water and sanitation.

3.1.5 TB/HIV Integration • The project supported TB/HIV integration CMEs where 124 providers were reached. • MDR-TB orientations were conducted in level 4 facilities reaching 96 providers. • Twenty (20) Kaloleni DHMT members were oriented on community TB DOTS, this created an opportunity for integration of TB programs in the community units. • The number of new TB cases detected in the TB service outlets were 2,365 of whom 923 of these were smear positive. Testing results revealed that 95% of TB patients were tested for HIV, 34% were found to be TB HIV co infected and 95% of those co infected had been enrolled for care and were on cotrimoxazole prophylaxis.

3.1.6 Family planning and Reproductive Health • The number of clients who received post abortion care services was 396 (336 MVA and 58 D&C). All were provided with family planning. • Project staff participated in the service delivery toolkit dissemination meeting for use of misoprostol in post abortion care. • In STI screening and syndromic management, 1,821 males were treated for urethral discharge while 542 males and 280 females were treated for genital ulcer disease.

Family planning • In public health facilities, Continuous Medical Education (CME) sessions on family planning (FP) compliance were supported for staff in Tudor, Malindi, Kilifi, and Kinango District Hospitals. • Integrated outreaches which included provision of family planning methods both short and long acting as well as screening of cancer of the cervix by visual inspection were supported. • 81,664 clients received family planning services. New clients and revisits were 21,541 and 60,123 respectively. Majority of the clients received injectable contraceptives followed by pills, implants then IUCDs. The estimated Couple-Years of Protection (CYP) provided by family planning services during a one-year period, based upon the volume of all contraceptives distributed in public health facilities was 44,230.30.

Table 3: Uptake of FP methods and CYP in Coast Province CYP Method Quantity/Units Distributed Pills 11,486 766.10 Injectables 55,022 13,755.50 IUCD 1,375 4,812.50 Implants 3184 11,144.00 Sterilization 369 2,952.00 Condoms 1,154,000 9,578.20 All others 611 1,222.00

TOTAL 44,230.30

In the private sector, Tunza facilities served a total of 10,662 clients and the method mix was as shown in the pie chart below.

Tunza Coast

IUCD Implants Injection condoms Pills EC Clients

2% 4% 7%

14% 17% 56%

3.1.7 Maternal, Newborn and Child Health • The project supported CMEs on enhanced diarrheal management reaching 64 health workers. As a result, ORT corners for management of diarrhea and education on safe water and hygiene were strengthened. • CMEs were conducted on FANC reaching 50 health workers and IYCF reaching 98 health workers. This has made providers stress on the importance of four ANC visits as well as exclusive breastfeeding for six months and appropriate complementary feeding thereafter to the clients. • DHMTs were supported during the breastfeeding week to carry out supervision and sensitize health workers on the same. • 30 health workers from level four facilities (Moi, Wundanyi, Wesu, Mwatate and Mwambirwa) were supported to attend an orientation on maternal, postnatal and newborn care which included AMTSL. • Retired midwives meetings to update them and encourage facility referrals were conducted through the projects support in Taita, Kwale and Kilifi counties. 78 retired mid wives were reached in these meetings. • TBA meetings were also conducted in Kinango, Taveta, Taita, Kilifi and Malindi and Kaloleni Districts to discuss on the role of using TBAs as birth companions in order to minimize maternal and neonatal mortality. • Immunization updates including PCV 10 were provided to 40 health workers and support for vaccine distribution to hard to reach facilities in Lamu East and West were also supported to ensure all vaccines are available and children access them • During the quarter, 21,778 and 38,983 ANC clients were served as new and revisits respectively. Expectant mothers reported to have completed four focused antenatal care visits were 9,416 while 19,913 received 1st dose of IPT, 17,409 received 2nd dose and 20,281 were distributed with ITNs. • A total of 10,391 deliveries were conducted under skilled attendance with 721 accessing emergency obstetric care as 15 and 61 maternal and neonatal deaths were reported respectively. • Immunization coverage against measles for children under one year was 90% (27,544) and 67% (20,537) of children under one (1) year of age were fully immunized. Children less than 5 years (< 5 yrs) receiving vitamin A supplement were 56,026 (113%). • Within the CUs, CHWs intensified immunization campaigns and defaulter tracing. Thus the number of under fives immunized increased by 34%; from 13254 to 17789.

3.1.8 Malaria • CMEs on Malaria case management and orientations on malaria in pregnancy (MIP) were conducted in the facilities through the projects support. • EQA on malaria diagnosis was also done in 8 facilities in Lamu County where 2 false positive results were found. Recommendations on quality testing for malaria were given and more mentorship is planned. • CHWs intensified malaria eradication campaigns through health education and Household dialogue sessions. In most CUs CHWs and CHCs have organized themselves into CBOs and linked to PSI for supply and distribution of INTs.

• Community health improvement plans aimed at malaria incidence reduction were re- engineered to include drainage of stagnant water and clearing of bushes near homesteads. • The number of HH sleeping under ITNs rose from 19749 (last quarter) to 27963 (42% increase). This coupled with fumigation and reduction of mosquito breeding places contributed to the decrease in the number of malaria cases as compared to last quarter.

3.1.9 HIV and Nutrition • HIV positive patients continued to receive nutritional assessments using the relevant anthropometric measurements. Vulnerable malnourished patients received food supplementation from NHP. • In Kilifi and Mariakani Hospitals 8,466 individuals who included 900 index clients benefited from food support for vulnerable HIV infected individuals and their families through a collaborative effort of the project, WFP and MOH. 50.629 MT of cereals, 15.274 MT of pulses, 3.762 MT of vegetable oil and 6.415 MT of corn soya blend were distributed to these beneficiaries. • A total of 42 support groups were identified for purposes of linking index clients; 27 are in Kilifi and 15 in Kaloleni districts. In Kilifi, 115 clients on food support were linked to these groups for support while in Kaloleni, a total of 38 clients have been linked. • 89 (20 males and 69 females) index clients and 65 (17 males and 48 females) other beneficiaries were linked to self employment, training skills and/or microcredit facilities while on food support. This will help in sustainability so that after graduation clients remain nutritionally stable and don’t get re admitted to the program. • The project put in a requested for seeds from the Ministry of Agriculture through the District Agricultural Officer in Kilifi, Ganze and Kaloleni districts. This is to support clients in support groups for the short rains season. • Ongoing activities with index clients include: Table banking (merry-go- round-kind of saving) to support existing income generating activities as well as support needy clients with “soft” loans. • Gunny bag farming demonstrations have been established at Kilifi and Kaloleni food stores (FDPs) for clients on food support to teach them farming technique for possible replication in their homes.

. Kales and Tomatoes at Kilifi Food store 3.1.10 Planned activities for the next quarter 1. Support transportation of samples to testing laboratories. 2. Conduct targeted OJT, mentorship, sensitizations, orientations and CMEs on needy service delivery areas to health workers. 3. Conduct an orientation of health workers on pediatric HIV care and treatment.

4. Support World AIDS day activities and Mobile VCT to hard to reach areas and marginalized communities and provide consumables. 5. Support HIV counselors supervision and ART and PMTCT providers’ meetings. 6. Sensitize SPs on YFS and on how to integrate YFS in the health facilities. 7. Support minor facility renovations and procurement of basic equipment and supplies. 8. Orient CHEWs, CHCs, and CHWs on maternal verbal autopsy to increase community awareness on causes of maternal death. 9. Re-orientation of TBAs as birth companions to refer pregnant women for safe and skilled delivery. 10. Hold monthly in-charges meeting with health workers. 11. Support provincial and district teams to conduct regular support supervisory visits. 12. Identify 9 CUs for strengthening and support. 13. Support and participate in DHMT supportive supervision to CUs 14. Train more CHEWs to supervise new CUs 15. Train CHWs in Community Strategy for the new CUs 16. Target at least 75% of enrolled OVC with 3 or more services. 17. Train 90 OVC point persons in 45 CHUs on core OVC issues including monitoring and evaluation.

3.2 Increased demand for an integrated package of quality high-impact interventions at community and health facility levels 3.2.1 Support for Community Strategy • 856 community household (HH) dialogue sessions aimed at increasing awareness and knowledge of health issues at the community as well as HH level were conducted. • A total of 11,815 community members (3,738 male and 8,067 female) were reached with health messages. • 4,687 referrals (1,255 male and 3,432 female) were made from the community to link facilities for various health services. These included 1175 (473 male and 702 female) for VCT, 122 (48 male and 74 female) for CCC, 397 pregnant women for PMTCT, 622 women for MNCH, 300 (116 male and 184 female for TB, 919 (110 male and 809 female) for FP and 1,149 (507 male and 642 female) for malaria. • A total of 25,460 condoms (24,594 to men and 866 to women).

Fig 9: Referral trends from community to service delivery points

1,600 1,400 1,200 1,000 Jan ‐ March 800 Apr ‐ June 600 July ‐ Sept 400 200 ‐ HCT CCC PMCT MCH TB FP Malaria

3.2.2 MCH

• CHWs continued to track pregnant women and infants (u1s and u5s) in the HH register. The CHWs monitor ANC visits, provide education on safe motherhood and facilitate formulation of a birth plan by the pregnant women. The women are not only encouraged to deliver at facilities but those who deliver at home are assisted to attend post natal clinics and start the newborns on the immunization program. • CHWs intensified immunization campaigns and defaulter tracing. Thus the number of under fives immunized increased by 34%; from 13,254 to 17,789. • The project supported several events aimed at increasing access and reducing barriers to quality health services, information and products among the youth between the age of 15 and 24. To achieve this, the project alongside the MOH, MOYA, youth serving IP’s and the private sector joined together to provide youth friendly services, information and products on HIV, RH/FP, economic empowerment among others. The events conducted were as follows:

Demonstration on condom use o The project took advantage of the private sector efficiency in youth mobilization to reach the youth. The Safaricom Coast Region Sakata Ball Competition provided a tremendous opportunity. The linkage with Safaricom was made possible by a partnership with the HIV-Free Generation.

o 76(49 Male and 27Female) watched Shuga, a movie on risky sexual behaviours among the youth in relation to HIV, after which they engaged in small group discussions. o 690 youths were counselled, tested and received their results. o Condom demonstrations followed by distribution of 3,000 condoms. o 1,690 IEC materials on HIV, FP, drug abuse and economic empowerment were also distributed. 3.2.3 GATES Festival Three County Gpange Annual Talent Explosion (GATE) events were held. This is an annual event that provides an opportunity for out of school youth to access services, information and products while showcasing their talents and creativity. It also a rallying call for youth to take responsibility in avoiding risky behaviors and adopt safer sex practices.

• 60 youth groups participated in categories such as play, comedy, poetry, dances, song, among others. • 1,600 youths were exposed to messages on HIV, drug use, GBV, economic empowerment for two days. • 200 youth were counseled, tested and received their results. 3.2.4 Screening of Shuga and small group discussions • Nine hundred and twenty seven (345 male, 582 female) first year students at the Mombasa Polytechnic University watched the Shuga movie and participated in small group discussions. The sessions were facilitated by peer educators who had undergone training on the Shuga/Staying Alive in a Box Tool Kit and facilitation guide. Topics addressed included condom use, partner reduction, relationships and positive living. • Another Shuga activity that took place was the participation of 2 Malindi youth groups in the filming of the MTV Shuga 11 movie that will be released early next year. They participated in a scene that was filmed in Malindi. 3.2.5 Small Group Communication sessions • 10 CBOs and 30 Tunza mobilizers conducted small group sessions and reached 38,306 among them 14,409 male and 23,897 female with HIV prevention messages. They reached 1,012 men and 1,965 women were reached with 3 visits. Facilitators included CHWs and peer educators from 10 CBOs and 23 volunteers who conducted mobilization for Tunza clinics. 3.2.6 Magnet theatre community outreaches • A total of 8 magnet theare community outreaches were conducted in Majengo, Maweni, Shella and Kisumu ndogo zones in Malindi during the last week of Sepetember 2011. They were conducted by 2 theatre troupes who are also volunteers to MEDA programmes. 3.2.7 Factual film community outreaches • A total of 4 factual film community outreaches were conducted in Majengo and Maweni zones in Malindi during the last week of September 2011. The outreaches were conducted by MEDA youth volunteers. 3.2.8 MARPS Female Sex workers

• ICRH used 220 trained peer educators from the eight FSW priority sites (Likoni, Mombasa Island, Chaani, Bangladesh/Maporomokoni, Bombolulu, Kisumi ndogo, Shanzu and Kisauni) to conduct several activities including; recruitment of peers to attend peer education sessions, participatory peer education sessions, referrals for various reproductive health services, condom promotion and distribution, and mobilization for moonlight HTC. • 403 group sessions were conducted in September 2011 reaching 4,226 contacts out of which 869 were new peers (250 males and 619 females). A total of 2,774 (1,084 male and 1,690 female) received HTC and 1,341 were treated for STI (476 males and 865 females). 508 (181 male and 327 female) sex workers were referred for CCC services. • SOLWODI worked with the Ministry of Health, Community leaders and other stakeholders to select 15 peer educators per district. Following the selection, a peer educator’s refresher trainings were organized to update them on current concepts, techniques and interventions in peer education.. • Through the Prevention with Positive (PwP) approach, SOLWODI (K) has established and strengthened quite six support groups in every area of operation and is currently in the process of forming three support groups in Shanzu through working closely with a nearby CCC. • The organization also continued to provide individual and group counselling for PLHIV. SOLWODI (K) has facilitated group therapy sessions for both PLHIV and peer educators.

MSM/MSW • ICRH through 100 trained peer educators from the three MSM/MSW priority sites (Lamu, Mombasa and Ukunda) conducted participatory peer education sessions, referrals for various reproductive health services and condom promotion and distribution. A total of 132 group sessions were conducted in September 2011 reaching 1,256 contacts out of which 268 new peers. Referrals were also made with a total of 1,331 MSM for HTC and 251 for STI treatment. 100 MSM/MSW were referred for CCC services.

IDU • MEWA conducted a refresher course for 20 peer/outreach workers. The course addressed HIV and Drug use, development of harm reduction messages, prevention of relapse and how to make effective referral system. • 78 males and 32 females drug users 13 IDU’s and 97 DU’s were provided with information and education by the Outreach workers in Malindi area around Majengo, Shella, Mbuyu wa kusema, Serena, Muyeye, Mtangani, Ngala Phase 1, Maweni, Majengo Mapya, Msoloni and Drop in Centre, between the 5th to 30th September 2011. • 100 drug users (13 IDU’s & 97 DU’s) received one on one risk reduction sessions in Malindi. • One hundred (100) drug users were referred and/or accompanied to HTC for first and repeat HIV testing. • Ten drug users (4 male; 6 female) who turned positive upon testing were accompanied to CCC.

3.2.9 Challenges and Recommendations: 1. One of the main challenges in rolling out MCH is deliveries performed by traditional birth attendants (TBAs) who are said to handle pregnant women better than facility staff. CHWs have been advised to work closely with TBAs as community resource persons to be included in the individual birth plans. The TBAs are advised to refer the pregnant women to deliver at the nearest health facility. 2. The main challenge in malaria eradication has been erratic supply and unorganized method of distribution of ITNs by PSI. Consultations with PSI to recognize CBOs and use them as distribution agents for ITNs should be made. 3. During HCT events targeting the youth, it was observed that only about 10% were tested for the first time. This is a challenge because 80% of PLHIV in Kenya do not know their HIV status and yet HCT is an entry to treatment and care. This will be addressed by targeting the hard to reach areas where counseling and testing is not accessible and targeting of first year students in learning institutions

3.2.10 Planned Activities for the next quarter 1. Continue with health education at the community level. 2. Organize follow up meetings with PSI to streamline supply and distribution. 3. Conduct refresher updates on MCH for the CHWs. 4. Conduct sensitization workshops for TBAs. 5. Youth groups to participate in the national GATE festival. 6. Continue screening of Shuga movie and conducting small group discussions. 7. Radio activations, community events and school sessions on drug use and abuse in relation to HIV.

3.3 Increased adoption of healthy behaviors • 445 volunteers among them CHWs, peer educators and magnet theatre volunteers were equipped with ETL knowledge and skills for effective interpersonal behavior change communication. • 16 ETL facilitators were selected and trained as TOTs after which they embarked on training CHWs and peer educators on the methodology. • 225 volunteers were trained on magnet theatre skills and specific health messages on HIV/AID and reproductive health. All sessions on health messages were conducted by the Ministry of Health staff while theatre experts trained on magnet theatre. • The project piloted small group discussions with 6,084 (3,257 male, 2,827 female) adolescents aged 10-14 after magnet theatre sessions. Topics addressed included abstinence and HIV prevention. • 8,517 (4,165 male, 4,352 female) youths aged between 15 and 24 years were reached with HIV prevention messages (Condom efficacy and HCT) through small group sessions. These sessions were facilitated by youth CHWs and peer educators. • 39,264 (11,185 male, 28,079 female) adults 25 years and above were reached with HIV prevention messages during Magnet theatre outreaches targeting the general population. These outreaches focused on condom use, partner reduction and HTC. • 23,552 people were reached with RH/FP and HIV messages through community level small group communication sessions by a cadre of volunteers known as Tunza mobilisers. Among

those reached and referred 10,662 received services in the Tunza clinics. (Refer to 3.1 for specific services). • Individuals working for the matatu2 sector were reached in collaboration with the Ukunda Matatu Association (South Coast). Small group communication sessions were conducted by a group of 20 trained peer educators who previously were supported and reached 719 (118 male, 601 were female) among the matatu drivers, conductors, spouses and other vulnerable groups they interact with in and around the matatu terminus e.g. hawkers and khat sellers. The sessions addressed condom use and concurrent sexual partnerships mpango wa kando.

Muslim Scholars at refresher training • Coast Imams and Preachers of Kenya (CIPK) held a planning workshop with 14 focal persons to kick off activities under APHIAplus. This was followed by a two day refresher meeting of 16 Muslim Scholars during which participants deliberated on the Islamic perspective on HIVand Aids and increased their understanding on PMTCT, TB, Malaria, FP and MCH.

Challenges and Recommendations 1. The low male involvement in RH/FP will be addressed by mainstreaming the Healthy Images of Men in trainings of IPs.

Plans for next quarter 1. Small group sessions for youth and adult populations on HIV, RH/FP and Safe water. 2. Magnet Theatre outreaches in the community and schools. 3. Training of CHW’s/CBO’s, youth groups, CHEWs/ PHOs on ETL. 4. Linkages with HFG on youth activities.

3.4. Increase program effectiveness through innovative approaches

• Project staff attended the National Learning and Validation Conference on QI which was held at the Silvers Springs Hotel between the 27th and 28th of July 2011. The QI service standards which had been in draft were validated and adopted for use in OVC programs in Kenya. • The project in collaboration with USAID’s Health Care Improvement Project supported a five- day training on OVC QI service standards. 18 OVC QI coaches were trained. These included District Community Strategy Coordinators, District Children Officers, Local Area Advisory Council representatives from Taita, Kilifi and Mombasa; and project staff from OVC and community teams. • All district teams developed action plans on how the OVC QI service standards would be cascaded downwards. The OVC QI Coaches will be

2 Public transport

used to cascade down the OVC QI service standards to community units (CU) and community based OVC implementing partners (IP) in three districts. The OVC QI service standards will help OVC programs and QI teams to identify gaps, develop solutions to better address and improve the quality of services being provided to OVC.

Activities planned for the next quarter: 1. Support CUs and IPs undertake self assessment of OVC services and form QI teams to address the prioritized gaps. 2. Support OVC team to form and train QI teams. 3. Support and monitor QI teams in implementation of their action plans.

RESULT 4: Social determinants of health addressed to improve the well-being of targeted communities 4.1 Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integration with economic strengthening programs • Community orientation meetings on economic strengthening were conducted with a purpose of introducing the project to have a buy in with other stakeholders and the community at large. This took place in 54 community units and was attended by 2,793 community members representing 1,242 men and 1,587 women. • In order to equip them with concepts of economic strengthening 23 field officers were oriented on household economic strengthening with the view of cascading this to the CHWs down to their respective CUs. • Community members have been mobilized to form and register common interest groups (CIGS) for the purpose of mobilizing resources. Whereas they have taken up the activities with zest and enthusiasm the outcome/results is not only impressive but promising and encouraging. • 205 CBOs formed at community level have initiated individual and group livelihood income generating projects to increase individual and group incomes. • 35 community structures composed of CHWs and CHC members have been linked to micro- finance institutions for the purpose of household saving and access to credit facilities. • 38 CHWs groups and 29 CHCs have been able to register as CBOs for the purpose of resource mobilization. • 25 community groups are participating in SILC activities with the aim of individual savings and access to credit facilities to benefit 5,000 households. • Economic Strengthening activities continued to be built on the gains from APHIA II through SILC activities for caregivers/ Guardians. Caregivers were linked to existing SILC groups to improve their economic well being. • SILC groups increased from 132 to 145. With the support of APHIAplus community mobilization team, the Ministry of Agriculture officers were linked to caregivers in community units to support livelihood activities in OVC households. • Guardians/caregivers supported 20,058 OVC (male 8,867; female 11,191) through improved household economic activities. This has improved caregivers’ access to small group loans and in turn enabled them start income generating activities for self reliance. SILC groups have played a big role in reducing economic dependency from external assistance to meet OVC needs at the household level.

Planned activities for next quarter 1. Conduct community self assessment for economic strengthening interventions. 2. Formulation of HH economic improvement/action plans 3. Facilitate CU/CBO linkage to other partners and financial institutions for micro credit opportunities. 4. Train 90 OVC point persons in 45 CHUs on core OVC issues including monitoring and evaluation. 5. Facilitate VSLA/SPM training for 45 CUs

4.2: Improved food security and nutrition for marginalized, poor and underserved populations • Project field officers, CHEWs and CHWs were trained on food production and marketing with the aim of rolling out the same to CHWs in the 5 counties in the province. • CHWs participated in practical demonstration with 15 demonstration plots set up in the training sites (5 in primary schools and 10 at the health facilities) for horticultural multi story gardens. • A total of 8 project staff 46 CHEWs and 1,112 CHWs (508 men and 604 women) in 23 CUs which are viable for agriculture and livestock production were trained. 90 technical staff from the ministry of agriculture fisheries and livestock development facilitated the training. A total of 22,240 HH will benefit from the training which will be cascade down to the community members in the HHs. • With the strengthened partnership with the ministry of agriculture 213 CHWs were involved in distributing certified seeds to 4,300 households in Taita-Taveta, Kilifi, and Malindi districts. A total of 4,000 kgs of certified seeds comprising of beans, green grams, Sorghum, maize and cow peas were distributed in the month of September. • OVC and caregivers were equipped with knowledge in nutrition education including: kitchen gardening, utilization of traditional high value foods; proper preparation and handling of foods. Caregivers were encouraged to scale up their IGAs to ensure food for the HH. 27,930 OVC (male 13,278, female 14,652) were reached with food and nutrition education/ service. • 17,312 OVC (male 7,938, female 9,374) were screened for nutrition and growth monitoring during the integrated school health outreach. Among these, 400 OVC were referred for corn soya blend from the APHIAplus/World Food Program Food by prescription program in Kilifi District. • CHWs continued to lobby various stakeholders working in CHUs to provide food support to targeted HHs with needy children. 800 HHS benefitted from this effort reaching 3,200 OVC in Mariakani with maize while in Lamu, 600 OVC and 1,442 indirect beneficiaries received supplemental feeds (Unimix) through 12 primary schools.

• APHIAplus in collaboration with the Ministry of Agriculture trained CHWs in 45 CUs to improve their Economic Livelihood knowledge and skills who in turn are cascading the same to the community.

Challenges and Recommendations 1. Prolonged drought is hampering implementation of agricultural activities by community members. More emphasis will be laid on water harvesting initiatives for preservation and use during drought period. The project will also intensify linkages with development partners with programs on water conservation to initiate water pans, irrigation farming and green house farming in drought stricken communities. 2. Prolonged period of hunger spell leading to most community members spending most of their time searching for food instead of attending livelihood improvement activities. This is also made worse by the fact that many community members, especially youth and men, do not embrace agriculture as a house hold business for income other than mere subsistence. MOA and other partners will be brought on board to promote farming as a business enterprise, recognizing the roles of men and women in the farming household. 3. Inadequate technical staff to offer technical support to farmers at HH level. The project will facilitate and support the MOA and MOLD to avail extension services to farmers. 4. Poor attendance by youth and men in community awareness meeting hence little support for implementations.

Planned activities for next quarter 1. Training the field facilitators in nutrition. 2. Formation and training of farmers group on food production and nutrition. 3. Facilitate establishment of community food banks. 4. Orientation DFFs and CHEWs on nutrition education. 5. Orientation of CHWs in nutrition education. 6. Cascade nutrition education to household by CHWs. 7. Establish and strengthen kitchen gardening at household level. 8. Facilitate quarterly exchange visits by farmers group. 9. Formulation of food production and marketing action plans. 10. Work with MOA to enhance planting of high value nutritional and drought tolerant crops among vulnerable household. 11. Strengthen CU's linkages with other development partners for value chain addition.

4.3 Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs

This service continued to respond to marginalized poor and underserved groups increasing access to education, life skills and literacy initiatives through coordinated and integrated education services. • A total of 73,933 OVC (male 35,565, female 38,368) accessed education integrated with health, PSS, child protection and nutrition services. • 27 OVC (19 male, 8 female) previously supported by HEART received direct school fees payment to enable them continue retention in schools.

• 70,546 OVC in primary school received support for scholastic materials, integrated school health program and child rights awareness. Child rights awareness was supported by the District children’s officers to promote equity and fair representation, for example encouraging schools to nominate children with disabilities as bell ringer or head prefect to make their participation fair and equitable within the school. • 12,436 girls supported with sanitary towels for 6 months during the last quarter have been reported with increased progression in schools performance due to continuous attendance evidenced by school attendance records reviewed by social workers and CHWs. A total 1,273 new girls identified as needy were provide with 6 months supply of sanitary towels during this period under review. • 3,360 (male 1,728 female 1,632) OVC were provided with an opportunity to access education foundation learning in early education centers (ECDs) through payment of levies totaling Ksh. 4,733,464. • Children in ECD centers also received health checks-ups for immunizations, treatment of minor illnesses as well as de-worming and vitamin A supplementation. This was done to ensure continuity and retention of OVC in Early Education Centers (ECD), primary schools and to lesser extent secondary schools. • CHWs also visited schools to promote hand washing with soap along with other issues including OVC with low performance; lobbying OVC retention in schools for needy children and increased awareness on rights of children. • 372 primary schools committed to continuously improve the learning environment through participative interaction with children supported by officials from the ministries of education and the department of children services. • OVC project staff received orientation on Child Fund CLASSE model on ECD and this is expected to add value in the implementation of safe spaces for children and ECD activities in the coming plan period.

Planned activities for the quarter 1. Recruit and train 60 OVC point persons in primary schools (Teachers). 2. Support 900 street children through WEMA centre.

4.4. Increased access to safe water, sanitation and improved hygiene • As part of the campaign dubbed zuia kuhara (prevent diarrhea), 52 small group communication sessions were conducted in Kinango District. The sessions were carried out in women groups, churches and Chief baraza's reaching 1,543 (196 male, 347 female) people with comprehensive knowledge and skills on water treatment at point of use and hand washing. • 67,500 OVC (male 31,678, female 35,822) were served in collaboration with 2,486 CHWs. Caregivers were sensitized on safe water and oral and personal hygiene practices ( including hand washing with soap among OVC and their guardians). • The project continued to link with public health officers from MOPHs to map and encourage HH with inadequate sanitation facilities to put appropriate and low cost toilets.

Challenges and Recommendations

1. Some of the water treatment products were not available in the kiosks near where the sessions were conducted. The project will address access to health products by promoting social marketing through CBOs.

Planned activities for the quarter 1. Continue with Safe Water small group sessions. 2. Radio activations on safe water with Kaya FM. 3. Conduct 3 safe water and hand washing events dubbed Zuia kuhara . 4. Support WASH activities in 50 primary schools.

4.5 Strengthened systems, structures and services for protection of marginalized, poor and underserved populations • The DCOs, LOC members, paralegals and VCOs) reached 56,064 (male 25,638, female 30,426) OVC with child protection messages through their respective primary schools. This activity was not confined to just the OVC and reached over 274,906 children (133,924 male, female 140,982) and 997 adults in 372 schools. • The project supported the strengthening of OVC structures (DOCs, LOCs and AACs) to enable them become policy discussion and action forums on child protection and advancement. As a result; hospital bills for 15 OVC were waived; there is increased coordination and networking of OVC services among various organizations and; revival and strengthening of OVC structures below the district OVC Committees

Planned activities for the quarter 1. CHEWs review meetings. 2. CHWs refresher and updates. 3. Joint CHC/FMC meetings. 4. Support OVC structures such as DOC. LOC and AACs.

4.6: Expanded Social Mobilization for Health • The project team supported and participation in the World Breastfeeding Week and World Contraceptive Day. • Several meetings were held with 631 CHC members (341 men and 285 women) to share with plans of action regarding Community Strategy implementation in their respective areas. • In order to effectively address the socio-cultural structures and norms that impact health, the project sought to meaningfully engage and involve local leaders and communities because of the key role they play in social mobilization. This was done as follows: o The social profiling exercises that commenced in the previous quarter flowed into the current quarter. This was done at the Vipingo Community Unit in Kilifi district which is home to one of the largest sisal plantations in Kenya. The objective of this exercise was to understand and identify the key health issues that the CHWs in Vipingo Community Unit and the Vipingo youth group will address. 24 youths and 24 participated in the exercise.

o The factors identified as prevalent in the area were STIs, morbid fear of HCT, abortion among girls, early pregnancies, low use of family planning, seeking health services from traditional healers, idle youth, poverty and low income levels. o 3 community entry meetings targeting local leadership were held in Bomeni, Bura Ndogo and Gongoni CU’s. The meetings were used to disseminate the information gathered during the social profiling exercises and to get feedback. These forums were also used to level and match community expectations with the APHIAplus mandate and scope. In total, 90 community leaders among them the local administration, facility staff including the local administration, local facility staff, the local business community, CHEW, CHCs, CHWs, CBOs leaders, women and youth group representatives participated. • 44 Community Units and youth CBOs were identified to conduct BCC activities this year. The process of engagement circulating the expression of interest and the selection process through the DHMTs. The CBOs are currently undergoing the process of signing MOU’s and are being trained facilitation and messaging. • Social mobilisation was also conducted to mark the Youth International Day, World Population Day and the World Contraceptive Day in Mombasa, Voi and Malindi. The support offered included mobilisation and health education through edutainment by the youth groups. • During the quarter under review, 66,652 (male 32,511, female 34,141) or 83% of all enrolled children accessed PSS. This was due to program prioritization to follow up newly enrolled OVC and children targeted for PSS during the validation exercise reported in quarter two. Support was through 2,486 CHWs within Community Health Units. CHWs support also included reaching OVC and their guardians at the HH level with health information on personal hygiene, water and sanitation, nutrition, HIV, reproductive health, maternal and newborn health including referrals. • A learning and fun outreach was organized in Kwale, Msambweni and Mombasa Districts in collaboration with area DCOs reaching 10,006 OVC (male 4,153, female 5,853 of children). 96 (male 44 female 52) OVC in pediatric support group received training on hygiene and disclosure and drug adherence counseling. • Community Health Dialogue Days took place in 52 community health units. These were attended by 26,356 people representing 11,676 men and 14,680 women. The CHCs and CHWs shared their progress reports, best practices and challenges and with the community members agreed on a plan of action for the next month. The CHC member also addressed the issue of none performing CHWs and the communities resolved to replace them in the community unit meetings.

Activities planned for the next quarter 1. Social mobilization for Malezi Bora, RRI and the World AIDs Day. 2. Continuation and scaling up of safe water sessions in Kinango and other districts. 3. Community health Dialogue Days. 4. Community Outreaches and Health Action Days.

Contribution to health systems strengthening (Result area 1 & 2) Capacity building on facilitative supervision & Client Oriented Provider Efficient services (COPE) • The project team worked jointly with District Health Management Teams (MOMS and MOPHS) and level 2 to 5 facilities to generate specific work plans for activities to be supported by the project based on priorities in their AOP 7 documents. Needs assessments for human resource, training and equipments were also conducted jointly by project staff and DHMT members. • The process of finalizing facility-level MOUs took two months to complete. By the close of the quarter, the project had reviewed all work plans and sent back for revision. Two provincial level MOUs had been finalized and 9 DHMT MOUs, 244 facility MOUs received duly signed. Fifty MOUs were expected by first week of October. • A one day sensitization meeting was held with provincial managers from both MOPHS and MOMS on facilitative supervision and quality improvement. During the meeting, the provincial strategy on supervision was agreed upon. It was agreed that Client Oriented Provider Efficient services (COPE) would be revived as a quality improvement approach to be used to improve service quality at selected health facilities within the province. • District and provincial managers were taken through a 3-day orientation on facilitative supervision. The content was adapted from the MOH Facilitative Supervision Manual for Supervisors of RH services (2005) and training materials. The managers reviewed various supervision tools with the purpose of strengthening the integrated supervision tool especially for use in supervision of district and provincial health facilities.

Mentorship • A mentorship strategy was rolled out with a focus on providing coaching by master mentors to the district mentors in the central sites who would then cascade this mentorship to their satellite sites. • Five mentorship teams were established covering Mombasa, Kilifi, Malindi,Kilindini and Msambweni. Initial assessments were conducted at five level 4 facilities to be used as model sites for mentorship after which the mentorship teams were taken through a two day orientation using the national mentorship guidelines. • Coaching sessions were provided by the master mentors to 12 mentors on HTC, PMTCT and M&E. The mentorship teams managed to conduct mentorship on gaps identified during the facility assessments • 12 lower level facilities were also visited for purposes of mentorship. • Five sites were identified by the provincial team for development as skills laboratories where onsite mentorship can take place in future. Out the five districts, Malindi and Port Reitz in addition to providing mentorship to their satellite sites have established in house activities with weekly meetings involving their hospital management teams. They are also conducting CMEs to increase the knowledge base of all within their facilities including those who may not necessarily be directly involved in the CCC. This is vital for sustainability of the program in the event of attrition of established mentors by transfers, leave or even death. • Master mentors made courtesy calls to the provincial team including the Provincial Directors of Medical Services and Public Health and Sanitation, the PARTO and PASCO as well as ensuring

the goodwill of the DHMTs and hospital management prior to carrying out coaching sessions with the mentorship team. • The master mentors have provided interactive coaching sessions on topics such as; how to mentor; sensitization on new CCC tools; MOH guidelines on HTCs; enhancing PITC and DBS collection for EID; clinical approaches to the HIV infected adult and child and; recognition of common OIs and case scenarios on WHO clinical staging of HIV disease in both children and adults. • The master mentors responded to the DQA report with both HMIS and Pharmacy mentors addressing the issues that were raised.

Quarterly Performance monitoring matrix: • Forty five (45) PMST & PHMT members sensitized on Facilitative Supervision and Client Oriented Provider Efficient services (COPE). • Fifty eight (58) provincial and district mangers oriented on Facilitative Supervision. • Thirty five (35) MOH mentors oriented on mentorship. • Fourteen (14) DHMT/PHMT sensitized on mentorship. • Two (2) coaching sessions for the mentors. • Ten (10) sites have been visited in response to the DQA, ( Mewa DH, Coast provincial general hospital, Mariakani, KPA bandari clinic, Likoni DH, Kwale DH, Voi DH, Taveta DH, Wesu DH, Mwatate H/C). • Eighty four (84) mentorship visits (336 contact hours). • Seventeen (17) sites have ongoing mentorship carried out by MOH mentors. These are; Gede HC, Malindi DH, Malanga AIC Dispensary, Marikebuni Disp, Marafa HC, Garashi Disp, Gongoni HC, Chaani Disp, Magongo HC, Bokole CDF Disp, Likoni DH, Mambrui Disp, Mtangani Disp, Kilifi DH, Msambweni DH, Tudor, Port Reitz DH). • Two CMEs were carried out on Cardiovascular Disease Screening and PMTCT – initiation of treatment for paediatrics at Malindi DH and Port Reitz DH respectively. A total of 23 participants attended the CMEs.

Activities planned for the next quarter: • Support sensitization of DHMT/HMT and facility in-charges on facilitative supervision and COPE. • Support orientation of four more DHMTs on facilitative supervision - Kilifi, Malindi, Kaloleni and Lamu. • Support orientation of COPE facilitators from MOMS and MOPHS. • Support COPE Facilitators implement 1st COPE exercise for facility staff at selected sites. • Through the service delivery team continue to support implementation of supervision by DHMT, PMST & PHMT at facility and district level respectively. • The mentorship program will continue to orient and coach the district mentors on the following topics. • Clinical - Adult and paediatric ART with focus on rational use of ARVs, Monitoring and changing therapy, TB/HIV management, Revisiting OIs in adults and children. (Nutrition – IYCF and ongoing nutritional assessment of adults & children; Psychosocial support - counseling support and; new HMIS data tools).

• A move towards standardization of CMEs, encouragement of mentors to share case scenarios in order to facilitate this. • Mentorship forum for all the districts to allow for sharing of experiences, peer review among the teams and in order to determine the mentorship needs of the province as well as for peer review of the teams. • Identification of senior clinicians to provide on-going support of mentorship activities. • Better documentation of in house activities within the central sites including meetings held and CMEs.

Support Supervision The project supported the PHMT and DHMTs to conduct supportive supervision visits as one of the core functions in line with AOP. The PHMT MOMS visited 8 facilities and 2 district medical services teams while MOPHS visited 12 facilities and 2 DHMTs. All the supported 11 DHMTs supervised 178 facilities.

Linkages with National Mechanisms PDMS Coast with APHIAplus Team on a supervision visit to Hospital on Faza Island • The project continued to work with HFG to implement youth activities (already highlighted in Result 3.2). One staff was successfully co-located to the Mombasa office. • MSH –HCSM project also co-located one staff to the Mombasa office and he has been working in close collaboration with the service delivery team for more efficient support to the Ministry of Health. • The project responded to a recruitment request by Capacity Project to send a list of 15 staff for MOMS and MOPHS facilities.

Table 4: Human Resource Needs for Coast Province Cadre Number Facility to be Posted 1 Clinical Officers 1 Taveta D. Hospital 2 KRCHN 1 Likoni DH 3 HRIO 4 Mwatate SDH, DMOH office Taita, DMOH Office Mombasa, DMOH office Lamu 4 VCT Counselor 2 Port Reiz Hospital, Kilifi 5 Nutritionist 1 CPGH 6 Laboratory Technologist 2 Malindi DH,, Mtwapa Dispensary 7 Pharmacy Technicians 4 DIani HC, Gongoni HC, Witu HC, Vipingo HC

5.0 Integration of Gender-related Activities • During the quarter, the integration of GBV response services in outreaches, mobile camps and in ANC and PNC services had been planned. Capacity building activities for health workers had been planned specifically on SAFE and GBV response. The project also planned to screen BCC materials and ETL session guides for gender responsiveness, train drama groups on GBV awareness and undertake screenings on the Sita Kimya docudrama. GBV working groups were to be formed, teachers sensitized on GBV related topics and men’s forums on GBV held. While not all activities were undertaken, a good start in implementation was made with a firm relationship with the Ministry of Gender, Children and Social Development established. • The project participated in planning meetings for GBV related activities with the Ministry of Gender, Children and Social Development. • GBV coordination work is already taking root in Mombasa spearheaded by the Coast General Hospital and MOPHs through the Provincial RH Coordinator. In addition ICRH and the National Gender and Equality Commission have been active in the region. At the beginning of the quarter the project participated in the Coast GBV Working Group meeting hosted by Coast Provincial General Hospital. It was found that since there a province level GBV working group exists, there would be no need to duplicate this effort. Instead the project will focus on establishing GBV working groups at the district level. • The project supported two one day GBV stakeholder meetings for Government and non- Government actors in Mombasa and Malindi. These were key entry meetings in which diverse sectoral representatives participated including Government officials from ministries/ departments of gender, health, education, youth and children as well as the provincial administration. Several women’s organizations such as Sauti ya Wanawake, Coast Women in Development, Maendeleo ya Wanawake, Muslim Women in Leadership and Caucus for Women’s leadership also participated. NGOs represented include FIDA-K, World Vision, ActionAid, ICRH and Men for Gender Equality Now (MEGEN) as well as the USG supported YES Youth Can initiative. • Brief sensitization of GBV was undertaken followed by discussions on formation of the GBV working groups. Since there is a province level GBV working group in the Coast, it was agreed that district level working groups will be the main focus in Kisauni, Changamwe, Lango Baya and Malindi. Project supported CHWs from the GBV Committees in the CUs participated in the meetings and will continue to do so as part of the working groups to ensure that there is synchrony in activities at the community level. Of note is that the Department of Gender has welcomed the initiative and is taking a leading role in the planning of meetings, coordination and mobilization of participants. This is a good indicator for future sustainability of activities in this region. • Sita Kimya docudrama screenings were undertaken through the BCC component and are reported on in other sections of this report. The ETL session guides were screened for gender responsiveness to ensure that appropriate prevention messages were included and that any gender insensitive messaging was excluded. • Activities focusing on the health facility level were delayed but will be emphasized in the next quarter. In addition, a GBV facility preparedness assessment will guide the type of inputs by the project.

Challenges 1. August was the month of Ramadhan (Muslims are fasting) and hence it was difficult to mobilize community members and scale up implementation of many activities since some of the partners are Muslims.

Planned Activities 1. Recruitment of a Gender Coordinator for the Coast to scale up the implementation of gender integration activities at health facility and community levels. 2. Facilitate the participatory development of TORs for undertaking GBV health facility. preparedness assessments for Nairobi and Coast; MOMs/MOPHS and Ministry of Gender to be involved; The strategy for undertaking this exercise has been changed to embrace a more participatory and scientific approach that will provide a strong evidence base for interventions while enhancing capacity of Government HCWs. 3. Support GBV response integration activities at the health facility level through CMEs and sensitization sessions for health care workers. 4. Support training on GBV prevention, response and coordination for Mombasa and Malindi stakeholders. 5. Support monthly GBV working group meetings for Kisauni, Changamwe, Lango Baya and Malindi after the trainings. 6. Support community GBV prevention and response outreaches in Mombasa, Malindi and Taveta in partnership with local community groups. 7. Mark the 16 Days of Activism against Gender Based Violence in Mombasa, Malindi and Taveta; activities will integrate HIV and RH/FP. 8. Screen the Sita Kimya docudrama clips to community groups and facilitate discussions.

6.0 Monitoring and Evaluation • The project team, PASCO, PARTO and PHRIOs coordinated training of health workers on revised HMIS tools in all the 11 districts in Zone 2 Coast region. A total of 827health workers were trained from 235 health facilities (23 hospitals, 41 health centers, 138 dispensaries and 28 clinics).

Table 5: Number of health workers trained by district and module. District Number Trained HTC C&T PEP, HEI & Total PMTCT Target Actual Target Actual Target Actual Target Actual Mombasa/Kilindini 60 58 50 56 50 62 160 176 Kaloleni 25 20 20 19 28 34 73 73 Kwale 27 25 12 20 27 25 60 70 Taita 58 19 20 24 58 19 136 62 Kilifi 25 18 25 38 25 29 75 85 Taveta 25 24 25 24 25 24 75 72 Malindi 25 31 25 21 25 26 75 78 Kinango 28 25 12 24 25 12 65 61 Lamu 40 31 25 25 40 25 105 81 Msambweni 31 24 31 25 31 20 93 69 Total 344 275 245 276 334 276 917 827

• The PASCO and PHRIO were facilitated to distribute the revised HMIS tools from the provincial stores to the respective district stores. Logistical support was provided to the DASCOs and DHRIOs to provide OJT to health workers during the distribution of the tools to the health facilities. • Out of the targeted 344 health facilities in the province, 17 health facilities in Taita, Taveta, and Msambweni Districts had so far been provided with the tools and OJT given to the health workers. The exercise is ongoing and it is expected to end by end of October 2011. • Support has continued to districts to enter data into District Health Information Software (DHIS). The support comprised hiring 1data clerk per district for 5 days per month and, airtime to facilitate connectivity to internet during data entry. • The project supported PHMT/PMST to conduct Routine Data Quality Assessment (RDQA) in 11 districts. The exercise targeted 13 district hospitals, 10 sub-district hospitals and 11 high volume health centers in the province. The objective of the exercise was to verify the quality of data in the high volume health facilities and strengthen their data management and reporting systems. • To increase support to other health facilities in the province which were not assessed during the RDQA exercise, DHRIOs were supported to visit the facilities and provide facilitative supervision in data management. • 11 DHMTs were supported to convene monthly data review meetings with facility in-charges to review facilities data and develop action plans to address the identified data gaps from the respective facilities.

Challenges 1. Most clinics and dispensaries could not send representatives for the training on revised HMIS tools due to understaffing in the facilities. The situation is worse for private clinics managed by one health worker with intention of maximizing profits. The health workers miss opportunities to receive updates on new guidelines/tools. 2. Competing tasks for PHMT/PMST/DHMT members causes delay or postponing scheduled activities.

Recommendations • The DHMTs to enhance OJT on revised HMIS tools to reach health workers who missed the training. • The DASCOs and DHRIOs to identify competent health workers in data management within facilities (champions) and use them to mentor their peers in the district.

Planned activities for next quarter 1. Orient DHRIOs and HRIOS on DHIS/GIS. 2. Conduct Geographic Information System (GIS) mapping and update Master Facility List (MFL). 3. Support connectivity to DHIS and data entry. 4. Facilitate DHMT to conduct on-job-training on revised HMIS tools. 5. Facilitate the DHMT to provide technical assistance to health workers on data gaps identified during RDQA. 6. Facilitate the DHRIOs to hold monthly data review meeting with in-charges. 7. Facilitate the PHRIO to hold quarterly review and planning meeting with DHMTs. 8. Train TOT CHWs/CHEWs/CHCs on CBHMIS. 9. Facilitate TOTs to orient CHWS on CBHMIS. 10. Conduct quarterly data feedback sessions with sub-grantees. 11. Hold DTLC/DASCO/DHRIO quarterly meetings.

ANNEXES

ANNEX I: Performance Monitoring Matrix – Nairobi Province No. PEPFAR April‐ July‐ Oct‐ Indicator MOH, Yr 1 June Sept Dec Total % Indicator Baseline Targets March 2011 2011 2011 Achievement Achievement NAIROBI PROVINCE PERFORMANCE INDICATORS PEPFAR INDICATORS PREVENTION Prevention Sub Area 1: PMTCT Number of pregnant women with known HIV status (includes women who were tested for HIV & received P1.1.D their results) 21,666 21,991 2,505 7,482 6,644 16,631 76 Number of HIV positive pregnant women who received antiretrovirals to reduce risk of mother‐to‐child P1.2.D. MIN transmission 1,223 1,231 159 334 246 739 60 Prevention Sub Area 4: Injection and Non‐injection drug use

P4.1.D Number of injecting drug users (IDUs) on opioid PR substitution therapy 0 3 0 0 0 0 0 Prevention Sub Area 5: Male Circumcision

P5.1.D Number of males circumcised as part of the minimum 0 MIN package of MC for HIV prevention services, by age 52 0 0 0 0 0 <1 0 5 0 0 0 0 0 1 to 14 0 18 0 0 0 0 0 >15 0 29 0 0 0 0 0 Prevention Sub Area 6: Post Exposure Prophylaxis

P6.1.D Number of persons provided with post‐exposure MIN prophylaxis, by exposure type 0 100 310 906 573 1,789 1,789 Occupational TBD TBD 5 15 33 53 0 Rape/sexual assault victims TBD 100 295 852 415 1,562 1,562 Other non‐occupational TBD TBD 10 39 125 174 0

Prevention Sub Area 7: Prevention with People Living with HIV (PwP) Number of People living with HIV/AIDS (PLHIV) reached with a minimum package of Prevention with PLHIV (PwP) P7.1.D MIN interventions 32,001 35,488 15,653 24,962 36,954 36,954 104 Prevention Sub Area 8: Sexual and Other Risk Reduction Number of the targeted population reached with individual and/or small group level preventive P8.1.D interventions that are based on evidence and/or meet PR the minimum standards required, by sex and age 0 20,500 0 1,226 56,000 57,226 279 Male 0 376 15861 16,237 0 10‐14 0 0 0 214 5552 5,766 0 15‐19 0 3,500 0 162 6,073 6,235 178 20‐24 0 0 805 805 0 25+ 0 0 0 0 3,431 3,431 0 Female 0 17,000 0 850 40139 40,989 241 10‐14 0 316 6702 7,018 0 15‐19 1,700 0 534 5,999 534 31 20‐24 0 0 1,386 1,386 0 25+ 0 0 26,052 26,052 0 P8.2.D Number of targeted population reached with individual and/or small group level preventive interventions that are primarily focused on abstinence and/or being faithful, and are based on evidence and/or meet the minimum standards required 20,000 0 530 23,055 23,585 118 Male 10,000 0 214 10889 11,103 111 10‐14 5,000 0 214 5552 5,766 115 15‐19 5,000 0 0 5,337 5,337 107 20‐24 0 0 0 0 0 25+ 0 0 0 0 0 Female 10,000 0 316 12166 12,482 125 10‐14 5,000 0 316 6702 7,018 140 15‐19 5,000 0 0 5,464 5,464 109

20‐24 0 0 0 0 0 25+ 0 0 0 0 0 Number of targeted population reached with individual and/or small group level preventive interventions that P8.3.D are based on evidence and/or meet the minimum PR standards required, by MARP type and sex 0 6,250 0 220 1,392 1,612 26 SW 0 4,800 0 195 895 1,090 23 Male 0 100 0 0 0 0 0 Female 0 4,700 0 195 895 1,090 23 IDU TBD 0 0 0 0 0 0 Male 0 0 0 0 0 0 0 Female 0 0 0 0 0 0 0 MSM 0 700 0 25 125 150 21 Other vulnerable populations (Matatus) 0 750 0 0 372 372 50 Male 0 700 0 0 281 281 40 Female 0 50 0 0 91 91 182 P8.4.D Number of condom service outlets 200 230 290 290 0 Prevention Sub Area 11: Testing and Counseling Number of individuals who received Testing and Counseling (T&C) services for HIV and received their test P11.1.D MIN results, by sex and age 0 132,800 17,926 56,563 63,929 138,418 104 Male 0 54,448 9,778 25,847 27,168 62,793 115 <15 0 5312 791 2,594 3208 6,593 124 15+ 0 49,136 8,987 23,253 23,960 56,200 114 Female 0 78,352 8,148 30,716 36,761 75,625 97 <15 0 5,312 760 2242 3160 6,162 116 15+ 0 73,040 7,388 28,474 33,601 69,463 95 Prevention Sub Area 12: Gender Number of people reached by an individual, small‐group, or community‐level intervention or service that explicitly addresses norms about masculinity related to HIV/AIDS, P12.1.D by sex and age 0 4,000 0 40 1,379 1,419 35 Male 0 2000 0 586 586 29

0‐14 0 0 0 0 0 15‐24 0 1,000 0 217 217 22 25+ 0 1,000 0 10 369 379 38 Female 0 2,000 0 793 793 40 0‐15 0 0 0 0 0 15‐24 0 1,000 0 288 288 29 25+ 0 1,000 0 30 505 535 54 Number of people reached by an individual, small group or community‐level intervention or service that explicitly addresses gender‐based violence and coercion related to P12.2.D HIV/AIDS, by sex and age 0 4,000 0 205 3,529 3,734 93 Male 0 2000 0 0 1,428 1,428 71 0‐14 0 0 0 0 0 0 15‐24 0 1,000 0 0 217 217 22 25+ 0 1,000 0 97 1,211 1,308 131 Female 0 2,000 0 0 2,101 2,101 105 0‐15 0 0 0 0 0 0 15‐24 0 1,000 0 0 288 288 29 25+ 0 1,000 0 108 1,813 1,921 192 Number of people reached by a individual, small‐group, or community level intervention or service that explicitly addresses the legal rights and protection of women and P12.3.D girls impacted by HIV/AIDS, by sex and age 0 4,000 0 0 3,529 3,529 88 Male 0 2000 0 0 1,428 1,428 71 0‐14 0 0 0 0 0 0 15‐24 0 1,000 0 0 217 217 22 25+ 0 1,000 0 0 1,211 1,211 121 Female 0 2,000 0 0 2,101 2,101 105 0‐14 0 0 0 0 0 0 15‐24 0 1,000 0 0 288 288 29 25+ 0 1,000 0 0 1,813 1,813 181

Number of people reached by a individual, small‐group, or community level intervention or service that explicitly aims to increase access to income and productive resources of women and girls impacted by HIV/AIDS, by P12.4.D sex and age 0 122 0 0 0 0 0 Male 0 0 0 0 0 #DIV/0! 0‐14 0 0 0 0 0 0 #DIV/0! 15‐24 0 0 0 0 0 0 #DIV/0! 25+ 0 0 0 0 0 0 #DIV/0! Female 0 122 0 0 0 0 0 0‐14 0 0 0 0 0 0 #DIV/0! 15‐24 0 38 0 0 0 0 0 25+ 0 84 0 0 0 0 CARE Care Sub Area 1: 8.1 Number of OVC served by OVC programs 0 71,000 ###### 22,585 57,983 57,983 82 8.1.a Number served in 3 or more core areas 0 35,500 1,130 2,893 56,258 56,258 158 Male TBD 13,135 561 1,553 28,310 28,310 216 Female TBD 22,365 569 1,340 27,948 27,948 125 8.1.b Number served in 1 or 2 core areas 0 35,500 12,040 19,692 1,725 1,725 5 Male TBD 14,555 5,990 9,671 905 905 6 Female TBD 20,945 6,050 10,021 820 820 4 Care Sub Area 1: Clinical Care (Includes OVC)

C2.1.D Number of HIV positive adults and children receiving a MIN minimum of one clinical service, by sex and age 0 55,000 46,958 49,924 52,585 52,585 96 Male 0 19,500 16,105 17,223 18,075 18,075 93 <15 TBD 2750 1519 1573 1619 1,619 59 15+ TBD 16,750 14,586 15,650 16,456 16,456 98 Female 0 35,500 30,853 32,701 34,510 34,510 97 <15 TBD 2750 1,531 1586 1592 1,592 58 15+ TBD 32,750 29,322 31,115 32,918 32,918 101

C2.2.D Number of HIV positive persons receiving cotrimoxazole MIN prophylaxis, by sex and age 0 35,488 33,625 35,450 49,486 49,486 139 Male 0 14,550 11,609 12,805 16,945 16,945 116 <15 TBD 1420 951 955 1660 1,660 117 15+ TBD 13,130 10,658 11,850 15,285 15,285 116 Female 0 20,938 22,016 22,645 32,541 32,541 155 <15 TBD 1420 1096 900 1611 1,611 113 15+ TBD 19,518 20,920 21,745 30,930 30,930 158 C2.3.D Number of HIV positive clinically malnourished clients MIN & who received therapeutic or supplementary food PR TBD TBD 0 0 0 0 0

C2.4.D TB/HIV: Percent of HIV positive patients who were MIN screened for TB in HIV care or treatment setting TBD 70% 0% 0 0 TB/HIV: Percent of HIV positive patients who were screened for TB in HIV care or treatment (pre‐ART or C2.5.D MIN ART) who started TB treatment TBD 80% 0% 0 0 Care Sub Area 5: Support Care Number of eligible clients (OVC) who received food and/or other nutrition services (WILL ADD PROTECTION, C5.1.D MIN PSS, EDUCATION), by age TBD 9,350 327 9,053 8,411 17,791 190 <18 TBD 9,350 327 9,053 8,411 17,791 190 18+ 0 0 0 0 0 0 0 Number of HBC clients served, by sex PR 11,164 11,164 11,350 11,366 11,992 11,992 107 Male 2,688 2,688 2,729 2,759 2,863 2,863 107 Female 8,476 8,476 8,621 8,607 9,129 9,129 108 TREATMENT Treatment Sub Area 1: ARV Services Number of adults and children with advanced HIV T1.1.D infection newly enrolled on ART, by age & sex TBD 1396 337 1146 1331 2,814 202 Male TBD 558 106 437 504 1,047 188 <1 TBD 5 0 0 0 0 0 <15 TBD 51 6 36 42 84 165

15+ TBD 502 100 401 462 963 192 Female TBD 803 231 709 827 1,767 220 <1 TBD 5 0 0 0 0 0 <15 TBD 75 9 25 23 57 76 15+ TBD 723 222 684 804 1,710 237 Pregnant/lactating TBD 35 0 0 Number of adults and children with advanced HIV infection receiving antiretroviral therapy (ART) (Current), T1.2.D by sex and age 17,470 18,692 17,351 19,020 19,755 19,755 106 Male 6,988 7,477 6,700 7,499 7,546 7,546 101 <1 52 53 0 0 0 0 0 <15 648 695 615 689 736 736 106 15+ 6,288 6,729 6,085 6,810 6,810 6,810 101 Female 10,482 11,215 10,651 11,521 12,209 12,209 109 <1 53 53 0 0 0 0 0 <15 995 1069 512 583 597 597 56 15+ 9,084 9,738 10,139 10,938 11,612 11,612 119 Pregnant women 350 355 169 215 206 206 58 Percent of adults and children known to be alive and on treatment 12 months after initiation of antiretroviral T1.3D therapy 91% 93% 0 0 <15 TBD 90% 0 0 >15 TBD 95% 0 0 HEALTH SYSTEM STRENGTHENING Health System Strengthening Sub Area 1: Laboratory

H1.1.D Number of testing facilities (laboratories) with capacity MIN to perform clinical laboratory tests 7 7 0 0 PROGRAMMATIC INDICATORS MONITORING AND EVALUATION Number of quarterly RDQA in supported sites and PR implementing partners 0 12 0 5 12 17 142

SYSTEMS STRENGTHENING PR Number of DHMT/PHMT members trained on COPE 0 30 0 0 0 0 Number of Community Units trained on Community PR COPE 0 20 0 0 0 0 Number of DHMT members oriented on DDIU (Data PR Demand & Information Use) 0 24 0 27 6 27 113 RESULT 3: INCREASED USE OF QUALITY HEALTH SERVICES, PRODUCTS AND INFORMATION 3.1: Increased availability of an integrated package of quality high‐impact interventions at community and facility level PR Number of community workers trained 0 3,650 0 207 2,138 207 6 PR Number of facilities integrating MARP friendly services 0 5 0 2 2 40 HIV/TB MIN Number of Infants tested for HIV at 6 weeks TBD 526 41 134 81 256 49 MIN Number Infants tested for HIV at 12 weeks TBD 157 21 58 70 149 95 MIN Number of Infants provided with ARV prophylaxis 1,000 1,046 153 319 134 606 58 Number of TB patients who received HIV CT and test MIN results TBD 9,000 573 1,771 1,728 4,072 45 MNCH MIN & Number of children <5 years given Vit A (including OVC) PR 0 15,000 0 5,468 5,352 10,820 72 PR Number of couples counseled & tested for HIV 10,833 835 2488 2847 6,170 57 Counseled 10,833 1094 2506 2930 6,530 60 Tested 10,833 835 2488 2842 6,165 57 Both HIV positive 49 98 95 242 0 Discordant 44 181 167 392 0 RH/FP Couple Years of Protection (CYP) in USG‐supported PR program at project‐supported facilities 3.1.7‐4 0 48,000 20,370 36,664 57,034 119 No. of people trained in FP/RH with USG funds 90 0 100 326 426 473 Males 0 0 0 97 97 0 Females 0 0 0 229 229 0

No. of USG‐assisted service delivery points providing FP counseling or services 77 50 85 85 85 110 No. of service delivery points reporting stock‐outs of any contraceptive commodity offered by the SDP 0 0 Number of counseling visits for FP/RH as a result of USG 3.1.7‐6 assistance 7,000 7,537 15,131 19,987 42,655 609

3.1.7‐ Number of people that have seen or heard a specific 21 USG‐supported FP/RH message 25,000 0 0

3.1.7‐ Number of USG‐assisted service delivery points 32 experiencing stock‐outs of specific tracer drugs 0 0 Number of children less than 12 months of age who 3.1.6‐8 received DPT3 from USG‐supported programs 4,402 4,318 8,720 0

3.1.6‐ Percent of children under five years old with diarrhea 43 treated with Oral Rehydration Therapy (ORT) 0 0 3.1.6‐ Percent of births delivered by caesarean section 46 0% 12% 12% 14% 14% 0

3.1.6‐ Percent of children who have received measles vaccine 57 by 12 months of age 0% 0% 0% 0 0 Number of Pregnant women supplied with LLITNs 0 No. Of children under five years of age distributed with long lasting treated Nets(LLITNs) 0 0 # of Long Lasting Insecticides Treated Nets (LLITN) distributed 0 0 3.2: Increased demand for an integrated package of quality high‐impact interventions and community and facility levels Number of individuals reached through small group discussions on health excluding HIV (disaggregated by PR age and sex) 0 6,000 0 0 743 743 12 3.3: Increased adoption of healthy behaviors Number of community dialogue days held on health PR topics TBD 36 0 17 55 72 200 Number of pregnant women attending at least 4 ANC MIN visits 0 15,000 1,678 4,939 4,897 11,514 77 Number of deliveries with a skilled birth attendant (SBA) MIN MCH in USG‐assisted programs 3.1.6‐ 11 0 9,000 1,560 5,417 5,184 12,161 135

Number of improvements to laws, policies, regulations or MCH guidelines related to improved access to, and use of, 3.1.6‐ 14 health services drafted with USG support 0 3.4: Increased program effectiveness through innovative approaches Number of facilities with information corners for DUDM PR and QI 0 5 0 0 0 0 PR Number of IP/CU trained on OVC QI standards 0 3 0 3 3 6 200 Number of male champions trained for FP/RH, GBV, PR VMMC 0 90 0 0 0 0 0 RESULT 4: SOCIAL DETERMINANTS OF HEALTH ADDRESSED TO IMPROVE THE WELL‐BEING OF THE COMMUNITY, ESPECIALLY MARGINALIZED, POOR AND UNDERSERVED POPULATIONS 4.1: Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integration with economic strengthening programs Number of households linked to household economic PR strengthening initiatives 0 15 0 1290 93 1,383 24,153

PR Number of children trained on basic financial literacy 0 300 0 322 0 322 107 4.2: Improved food security and nutrition for marginizalized, poor and underserved populations Number of individuals receiving nutrition literacy PR education 3,000 0 0 1,500 1500 500 4.3: Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs Number of supported schools with children's health PR and/or rights clubs 0 20 0 16 0 16 80 4.4: Increased access to safe water, sanitation and improved hygiene

3.1.6‐3 Liters of drinking water disinfected with USG‐supported, 5,000 MCH point‐of‐use treatment products 5,000 0 364,000 15,632,700 15,996,700 319,934 4.5: Strengthened systems, structures and services for protection of marginalized, poor and underserved populations Number of district and provincial GBV working groups PR established 1 2 0 2 2 2 100 PR Number of teachers trained in: 30 0 0 90 90 300 PR Sexual Offences Act 0 30 0 0 90 90 300 PR Stigma reduction of GBV/HIV/AIDS 0 30 0 0 90 90 300

Number of chief's offices with Child Protection Desks PR established 0 20 0 0 0 0 0 PR Number of male champion networks established 1 2 0 0 0 0 0 4.6: Expanded social mobilization for health Number of adolescents/youth reached through drama PR outreaches in secondary schools on RH/FP, GBV, VMMC 0 20,000 0 0 9,987 9987 50 PR Male 0 10,000 0 0 5,039 5039 50 PR Female 0 10,000 0 0 4,948 4948 49

ANNEX II: Performance Monitoring Matrix – Coast Province No PEPFAR Year 1 Jan ‐ April ‐ Total % Indicator MOH, Indicator Baseline Targets March June July ‐ Aug Achievement Achievement PEPFAR INDICATORS PREVENTION

Prevention Sub Area 1: PMTCT Number of pregnant women with known HIV status (includes women who were tested for HIV & received their results P1.1.D 99,408 104,378 22,104 23,575 25,731 71,410 68% Number of HIV positive pregnant women who received antiretrovirals to reduce risk of mother-to-child transmission P1.2.D 4,482 5,562 778 1,196 933 2,907 52% Prevention Sub Area 4: Injection and Non‐injection drug use Number of injecting drug users (IDUs) on P4.1.D opioid substitution therapy PR 0 50 ‐ ‐ ‐ ‐ ‐ Prevention Sub Area 5: Male Circumcision Number of males circumcised as part of the P5.1.D minimum package of MC for HIV prevention MIN services, by age N/A N/A ‐ ‐ ‐ ‐ <1 year N/A N/A ‐ ‐ ‐ 1‐14 years N/A N/A ‐ ‐ ‐ 15+ N/A N/A ‐ ‐ ‐ Prevention Sub Area 6: Post Exposure Prophylaxis Number of persons provided with post- P6.1.D exposure prophylaxis, by exposure type MIN 350 368 131 243 244 618 168% Occupational 150 158 11 46 23 80 51% Rape/sexual assault victims 150 158 62 151 166 379 241%

Other non-occupational 50 53 58 46 55 159 303% Prevention Sub Area 7: Prevention with People Living with HIV (PwP) Number of People living with HIV/AIDS (PLHIV) reached with a minimum package of P7.1.D Prevention with PLHIV (PwP) interventions MIN 8,000 8,400 0 0 11,588 11,588 138% Prevention Sub Area 8: Sexual and Other Risk Reduction Number of the targeted population reached with individual and/or small group level preventive interventions that are based on P8.1.D evidence and/or meet the minimum standards PR required, by sex and age 0 35,000 0 8,762 41,351 50,113 143% Male 0 15,000 0 3,903 16,131 20,034 134% 10-14 0 0 0 0 0 0 15-24 0 8,000 0 9,881 9,881 25+ 0 7,000 3,903 6,250 10,153 Female 0 20,000 0 4,859 25,220 30,079 150% 10-14 0 0 0 0 0 0 15-24 0 10,500 0 0 10,833 10,833 25+ 0 9,500 0 4,859 14,387 19,246 P8.2.D Number of targeted population reached with individual and/or small group level preventive interventions that are primarily focused on abstinence and/or being faithful, and are based on evidence and/or meet the minimum standards required 0 7,000 0 0 10,521 24,521 350% Male 0 3,000 0 0 4,793 10,793 10‐14 0 3,000 0 0 3,257 9,257 15‐19 0 0 0 0 1,536 1,536 Female 0 4,000 0 0 5,728 13,728 10‐14 0 4,000 0 0 2,827 10,827 15‐19 0 0 0 0 2,901 2,901

Number of population reached with individual and/or small group level preventive interventions that are based on evidence and/or meet the minimum standards required, P8.3.D by MARP type and sex PR 0 13,450 0 3,030 2,074 5,104 38% SW 0 2,800 0 3,030 1,010 4,040 Male 280 1,929 268 2,197 Female 2,520 1,101 742 1,843 IDU 0 150 0 0 27 27 18% Male 135 23 23 Female 15 4 4 MSM 0 500 0 0 0 0% Other vulnerable populations (Matatus & Prisions) 0 10,000 0 0 1,037 1,037 10% Male 5,000 0 0 Female 5,000 1,037 1,037 Prevention Sub Area 11: Testing and Counseling Number of individuals who received Testing and Counseling (T&C) services for P11. HIV and received their test results, by sex 1.D and age MIN 463,916 536,628 63,160 71,642 85,239 220,041 41% Male 198,345 229,052 23,576 27,397 32,861 83,834 <15 39,668 45,618 7642 7,958 10,132 25,732 15+ 158,677 183,434 15,934 19,439 22,729 58,102 Female 265,571 307,577 39,584 44,245 52,378 136,207 <15 53,116 61,083 9,245 10,246 13,213 32,704 15+ 212,455 246,493 30,339 33,999 39,165 103,503 Prevention Sub Area 12: Gender

Number of people reached by an individual, small- group, or community-level intervention or service that explicitly addresses norms about masculinity related to HIV/AIDS, by sex and age PR 0 186,300 0 0 104 104 0.1% Male 0 24,300 0 0 55 55 0-15 0 7,290 0 0 0 0 15-24 0 4,860 0 0 0 0 25+ 0 12150 0 0 55 55 Female 0 162,000 0 0 49 49 0-15 0 50,220 0 0 0 0 15-24 0 43,740 0 0 0 0 25+ 0 68,040 0 0 49 49 Number of people reached by an individual, small group or community-level intervention or service that explicitly addresses gender-based violence and coercion related to HIV/AIDS PR 0 204,800 0 0 104 104 0.1% Male 0 41,600 0 0 55 55 0% 0-15 0 7,540 0 0 0 0 0% 15-24 0 14,060 0 0 0 0 0% 25+ 0 20000 0 0 55 55 0% Female 0 163,200 0 0 49 49 0% 0-15 0 50,520 0 0 0 0 0% 15-24 0 44,240 0 0 0 0 0% 25+ 0 68,440 0 0 49 49 0% Number of people reached by a individual, small- group, or community level intervention or service that explicitly addresses the legal rights and protection of women and girls impacted by PR HIV/AIDS 0 186,300 0 0 0 0 0% Male 0 24,300 0 0 0 0 0% 0-15 0 7,290 0 0 0 0

15-24 0 4,860 0 0 0 0 25+ 0 2,150 0 0 0 0 Female 0 162,000 0 0 0 0 0% 0-15 0 50,220 0 0 0 0 15-24 0 43,740 0 0 0 0 25+ 0 68,040 0 0 0 0 Number of people reached by a individual, small- group, or community level intervention or service that explicitly aims to increase access to income and productive resources of women and girls impacted by HIV/AIDS, by sex and age PR 0 40,000 0 1,581 30,754 32,335 81% Male 0 11,924 0 748 14,515 15,263 128% 0-15 0 980 0 0 0 0 15-24 0 5052 0 0 13,273 13,273 25+ 0 5892 0 748 1,242 1,990 Female 0 28,076 0 833 16,239 17,072 61% 0-15 0 1964 0 0 0 0 15-24 0 11508 0 0 14,652 14,652 25+ 0 14604 0 833 1,587 2,420 CARE Care Sub Area 1: "Umbrella" Care Indications (Includes OVC) C1.1. Number of eligible adults and children provided D with a minimum of one care service, by sex and MIN age 79,849 79,849 49,849 64,301 83,560 83,560 105% Male 39,471 39,471 25,131 32,639 37,700 37,700 96% <18 38682 38682 25131 32639 35905 35,905 18+ 789 789 0 0 1795 1,795 Female 40,378 40,378 24,718 31,662 45,860 45,860 114% <18 39570 39570 24718 31662 40186 40,186 18+ 808 808 0 0 5674 5,674

Care Sub Area 1: Clinical Care (Includes OVC) C2.1. Number of HIV positive adults and children D receiving a minimum of one clinical service, by MIN sex and age 66,000 69,300 60,134 68,894 71,071 71,071 103% Male 26,400 27,720 17,420 23,337 24,827 24,827 90% <15 5,280 5,544 2,557 3,662 4,246 4,246 15+ 21,120 22,176 14,863 19,675 20,581 20,581 Female 39,600 41,580 42,714 45,557 46,244 46,244 111% <15 7,920 8,316 3,323 3,711 4,058 4,058 15+ 31,680 33,264 39,391 41,846 42,186 42,186 C2.2. Number of HIV positive persons receiving D cotrimoxazole prophylaxis, by sex and age MIN 62,056 65,159 16,339 39,953 46,060 46,060 71% Male 24,822 26,063 5,101 13,880 17,030 17,030 65% <15 4,964 5,212 800 2,106 2,555 2,555 15+ 19,858 20,851 4,301 11,774 14,475 14,475 Female 37,234 39,096 11,238 26,073 29,015 29,015 74% <15 7,447 7,819 806 2,048 2,381 2,381 15+ 29,787 31,276 10,432 24,025 26,634 26,634 C2.3. Number of HIV positive clinically D malnourished clients who received therapeutic MIN or supplementary food & PR 7,000 7,350 - - - - - TB/HIV: Percent of HIV positive patients C2.4.D who were screened for TB in HIV care or MIN treatment setting TBD 40% 38% 41% 34% 34% 86% TB/HIV: Percent of HIV positive patients C2.5. who were screened for TB in HIV care or D treatment (pre-ART or ART) who started TB MIN treatment TBD 40% 88% 96% 94% 94% 235% Care Sub Area 5: Support Care

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Number of eligible clients who received food C5.1. and/or other nutrition services, by age D MIN 24,000 25,200 8,981 45,329 27,930 45,329 180% <18 2,000 2,100 8,981 45,329 27,930 45,329 18+ 21,000 22,050 0 0 0 0 Pregnant/lactating 1,000 1,050 0 0 0 0 TREATMENT Treatment Sub Area 1: ARV Services Number of adults and children with advanced T1.1. HIV infection newly enrolled on ART, by sex D and age 6,656 7,076 1,299 1,680 2,303 5,282 75% Male 2,662 2,793 272 517 692 1,481 53% <1 111 116 0 <15 421 440 53 96 115 264 15+ 2,130 2,237 219 421 577 1,217 Female 3,029 3,183 725 961 1,338 3,024 95% <1 126 135 0 <15 479 503 67 81 97 245 15+ 2,424 2,545 658 880 1,241 2,779 Pregnant/lactating 965 1,100 302 202 273 777 71% Number of adults and children with advanced HIV infection receiving antiretroviral therapy T1.2. (ART) (Current), by sex and age D 38,675 50,361 25,671 21,248 27,297 27,297 54% Male 17,404 24,892 9,147 7,553 9,277 9,277 37% <1 724 6,031 0 <15 2,752 4,846 1,171 1,151 1,402 1,402 15+ 13,928 14,015 7,976 6,402 7,875 7,875 Female 20,641 24,807 16,222 13,501 17,747 17,747 72% <1 885 2,562 0 <15 3,363 5,750 1,027 1,130 1,403 1,403

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15+ 16,393 16,494 15,195 12,371 16,344 16,344 Pregnant women 630 662 302 194 273 273 41% HEALTH SYSTEM STRENGTHENING Health System Strengthening Sub Area 1: Laboratory H1.1. Number of testing facilities (laboratories) with D capacity to perform clinical laboratory tests MIN 15 16 15 15 15 15 94% Number of community workers and members trained (CHWs, paralegals, youth, MARPs, PR PLHIV) 2,397 2,100 0 0 3,304 3304 157% PROGRAMMATIC INDICATORS MONITORING AND EVALUATION Number of quarterly RDQAs in supported PR sites, IPs and model Community Units 0 4 0 0 1 1 25% Number of quarterly data feedback sessions PR with IPs 0 1 0 0 1 1 100% SYSTEMS STRENGTHENING (SPECIFIC SYSTEM STRENGTHENING NOT ALREADY IN RESULTS 3 AND 4) ` PR Number of facilities applying COPE 06 00 0 0 0% Number of Community Units applying PR Community COPE 06 00 0 0 0% Number of facilities receiving at least one supportive supervision visit from P/DHMT PR during the quarter 90 90 362 324 198 198 219% Number of sites receiving mentoring visit(s) from provincial/district mentors during the PR quarter 0 15 0 0 17 17 113% Number of CHWs receiving monthly PR supervision visits by CHEWs 0 550 2,397 2,392 2,655 2,655 483% Number of facilities, IPs, CUs, CBOs holding quarterly meetings to discuss feedback on PR service quality 0 45 45 53 62 62 137% Percent of model Community Units accessing PR HSSF, CDF, or other community funds 0% 18% 0% 0% 0% 0% 0%

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RESULT 3: INCREASED USE OF QUALITY HEALTH SERVICES, PRODUCTS AND INFORMATION 3.1: Increased availability of an integrated package of quality high‐impact interventions at community and facility level Number of P/DHMTs and Community Units oriented on systems strengthening approaches (FS, COPE, OJT, CME) PR 0 20 0 0 15 15 75% Number of community workers and members trained (CHWs, paralegals, youth, MARPs, PR PLHIV) 2,397 2,100 0 0 3,304 3304 157% Number of outreaches (mobile services) PR conducted for VCT, TB, MNCH services 0 66 11 50 369 430 652% Number of stakeholder meetings conducted at community, district and provincial level PR 3 5 4 11 16 31 620%

Number of improvements to laws, policies, regulations or guidelines related to improve 3.1.6- access to and use of health services drafted 14 with USG support 0 1 - - - 0 HIV/T B Number of Infants tested for HIV at 6 weeks MIN 2,441 2,563 169 233 230 632 25% Number of infants tested for HIV at 12 weeks MIN 459 482 125 208 201 534 111% Number of individuals counseled and tested for HIV at MARP clinics or drop-in centers PR 8,000 8,400 0 0 1,167 1,167 14% PR Number of HBC ciients served, by sex 15,154 15,912 15,154 15,049 9,105 9,105 57% Male 4,052 4,255 4,052 4,043 2,721 2,721 64% Female 11,102 11,657 11,102 11,006 6,384 6,384 55% MNC H

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Number of children dewormed at least once in MIN a year 513,813 539,504 0 68,977 71,249 140,226 26% Number of LLITNs distributed to pregnant women and children <5 MIN 141,918 149,014 0 29,793 22,857 52,650 35% MIN Pregnant women receiving two doses of Intermittent Presumptive Therapy (IPT2) 80,892 115,445 27,254 23,535 22,503 73,292 63% Number of growth monitoring sessions PR conducted by CBOs and IPs 0 64 0 0 0 0 0% Number of immunization defaulters traced by MIN CHWs 0 6,000 0 0 0 0 0% 3.1.6- Number of cases of child diarrhea treated in 6 USG-assisted programs 7,632 18,454 0 - - - Number of children less than 12 months of 3.1.6- age who received DPT3 from USG-supported 8 programs 23,433 30,463 21,760 - 37,161 37,161 122% Number of people trained in 3.1.6- maternal/newborn health through USG- 26 supported programs TBD 2,860 0 0 0 - Percent of children under five years old with 3.1.6. diarrhea treated with Oral Rehydration 43 Therapy (ORT) 51% 66% - - - - 3.1.6- Percent of births delivered by caesarean 46 section 11% 11% 12% 12% 10% 10% 87% Percent of children who have received the 3.1.6- third dose of Pneumococcal conjugate vaccine 53 by 12 months of age 0% 30% 27% 35% 34% 34% 113% 3.1.6- Percent of children who have received measles 57 vaccine by 12 months of age 78% 82% 90% 87% 93% 93% 113% Number of children under 5 years of age who 3.1.6- received Vitamin A from USG-supported 10 programs” 360,244 386,710 58,466 94,154 79,452 232,072 60%

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Number of people trained in child health and 3.1.9- nutrition through USG-supported health area 1. programs 0 4,710 0 0 0 0 0% RH/FP Number of WRA receiving FP commodities MIN 451,287 488,851 60,245 68,652 81,933 210,830 43% 3.1.7‐ Couple years of protection (CYP) in USG- 4 supported programs 17,500 18,375 14,868.60 42,189 41,230 98,288 535% 3.1.7‐ Number of counseling visits for FP/RH as a 6 result of USG assistance 310,125 339,935 60,245 68,652 81,933 81,933 24% 3.1.7‐ Number of people that have seen or heard a 21 specific USG‐supported FP/RH message 274,608 749,443 81,131 87,864 105,485 105,485 14% 3.1.7‐ Number of people trained in FP/RH with USG 22 funds 220 3,000 0 0 0 0 0%

Number of policies or guidelines developed 3.1.7‐ or changed with USG assistance to improve 26 access to and use of FP/RH services 0 0 ‐ ‐

3.1.7‐ Number of USG‐assisted service delivery points 32 experiencing stock‐outs of specific tracer drugs 81 33 ‐ ‐ 0 0 0% Number of USG-assisted service delivery 3.1.7‐ points providing FP counseling or services 33 341 341 319 339 347 347 102% 3.2: Increased demand for an integrated package of quality high‐impact interventions and community and facility levels Number of community education sessions conducted (community dialogue days, ETL sessions, drama, etc.) PR 5,130 9,695 2,587 2,825 2,781 8,193 85% 3.3: Increased adoption of healthy behaviors Number of pregnant women attending at least MIN 4 ANC visits 48,771 65,106 7,170 9,706 9,416 26,292 40%

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Number of deliveries with skilled birth attendants (SBA) in USG - assisted programs 3.1.6- 11 51,062 73,604 7,080 14,764 10,391 32,235 44% Number of children <1 year fully immunised MIN 99,846 105,059 19,146 12,116 25,486 56,748 54% MIN Number of households using ITNs TBD 20,000 - 17,749 27,963 27,963 140% 3.4: Increased program effectiveness through innovative approaches Number of facilities with information corners PR for DUDM and QI 0 33 0 0 0 0 0% Number of IP/CU applying OVC QI PR standards 03000 0 0 0%

Number of Community Units supervised by PR P/DHMT using the CS compliance checklist 0 15 0 0 0 0 0% Number of exchange visits conducted to PR facilitate learning on best practices 0 44 0 0 0 0 0% Number of adolescent-parent and PCC groups PR holding monthly meetings 0 30 0 0 0 0 0% Number of support groups for vulnerable populations (MARPs, PLHIV, youth) formed/ PR strengthened 0 82 0 0 6 6 7% RESULT 4: SOCIAL DETERMINANTS OF HEALTH ADDRESSED TO IMPROVE THE WELL‐BEING OF THE COMMUNITY, ESPECIALLY MARGINALIZED, POOR AND UNDERSERVED POPULATIONS 4.1: Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integration with economic strengthening programs Number of community members trained on HH economic strengthening approaches (SPM/VSL, business, Aflatoun) PR 0 3,730 0 1,554 7,683 9,237 248% Number of CBOs and CUs selling socially PR marketed products 0 15 0 0 54 54 360% 4.2: Improved food security and nutrition for marginizalized, poor and underserved populations

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Number of quarterly exchange visits conducted PR by farmers groups 0 5 0 0 1 1 20% Number of nutrition education sessions PR conducted by CHEWs, CHWs, farmers' groups 0 1,500 0 11 0 11 1% 4.3: Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs Number of 'Keep Girls in school' campaigns PR conducted within Community Units 0 45 0 0 0 0 0% Number of model ECDs established in PR Community Units 0 2 0 0 0 0 0% 4.4: Increased access to safe water, sanitation and improved hygiene Number of children reached with theatre PR sessions on safe water and hand washing 0 27,000 0 0 5,596 5,596 21% MIN Number of households treating water TBD 6,000 ‐ ‐ 22,172 22,172 370% 3.1.6‐ Liters of drinking water disinfected with USG‐ 8 supported point‐of‐use treatment products TBD 120,000 ‐ ‐ 13,071,600 13,071,600 ‐ Number of households with functional pit MIN latrines TBD 20,000 18,232 30,149 48,381 242% 4.5: Strengthened systems, structures and services for protection of marginalized, poor and underserved populations Number of district and provincial GBV technical PR working groups established 0 4 0 0 0 0 0% Number of male champions identified and PR trained 0 120 0 0 0 0 0% 4.6: Expanded social mobilization for health Number of special events conducted (MOYA PR youth week, Malezi Bora/BF weeks, etc) 0 4 0 2 3 5 125% Number of Shuga, GATE and Gjue events held PR 0 4 0 0 5 5 125%

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Annex 3: APHIAplus Nairobi Office

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Annex 4: APHIA;lus Coast Office

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