USAID KENYA APHIAplus WESTERN KENYA

USAID KENYA (APHIAPLUS WESTERN KENYA) PROGRESS REPORT FOR Q2 FY 2017

USAID KENYA

APHIAplus WESTERN KENYA QUARTERLY PROGRESS REPORT

AUGUST 2017 This publication was produced for review by the United States Agency for International Development. It was prepared by staff of PATH’s country program in Kenya.

USAID KENYA (APHIAPLUS WESTERN KENYA) PROGRESS REPORT FOR Q2 FY 2017

USAID KENYA

APHIAplus WESTERN KENYA FISCAL YEAR 2017

QUARTER 2 PROGRESS REPORT

APRIL 1 through JUNE 30, 2017

Award No: AID-623-A-11-00002

Prepared for

Dr. Maurice Maina

United States Agency for International Development Kenya

c/o American Embassy

United Nations Avenue, Gigiri

PO Box 629, Village Market

Nairobi 00621

Kenya

Prepared by

PATH’s Country Office in Kenya

ACS Plaza, 4th Floor

Lenana and Galana Road PO Box 76634

Nairobi 00100

Kenya

DISCLAIMER

The authors’ views expressed in this report do not necessarily reflect the views of the United

States Agency for International Development or the United States Government.

USAID KENYA (APHIAPLUS WESTERN KENYA) PROGRESS REPORT FOR Q2 FY 2017 ii

TABLE OF CONTENTS

LIST OF TABLES ...................................................................................................................................... III

LIST OF FIGURES ..................................................................................................................................... V

ACRONYMS AND ABBREVIATIONS ................................................................................................... VI

EXECUTIVE SUMMARY ..................................................................................................................... VIII

I. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ............................................................................ 1

Subpurpose 1. Increased and expanded quality HIV services ................................................................. 1

HIV testing and counseling services .................................................................................................. 1

Elimination of mother-to-child transmission of HIV (eMTCT) ....................................................... 12

HIV care and treatment .................................................................................................................... 24

TB-HIV co-infection services .......................................................................................................... 36

HIV prevention services ................................................................................................................... 42

Services for orphans and vulnerable children ................................................................................... 57

Subpurpose 2. Increased access to and utilization of malaria prevention and treatment services ......... 65

Malaria prevention and treatment services ....................................................................................... 65

Subpurpose 3. Strengthened and functional county health systems ...................................................... 67

Human resources for health services ................................................................................................ 67

Health care financing ........................................................................................................................ 67

Commodity security ......................................................................................................................... 68

Strategic monitoring and evaluation ................................................................................................. 69

II. ACTIVITY PROGRESS (QUANTITATIVE IMPACT) ...................................................................... 69

III. CONSTRAINTS AND OPPORTUNITIES .......................................................................................... 69

IV. PERFORMANCE MONITORING ...................................................................................................... 69

V. PROGRESS ON GENDER STRATEGY .............................................................................................. 74

VI. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ................................... 74

VII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ............................................................. 75

VIII. PROGRESS ON LINKS WITH GOVERNMENT OF KENYA AGENCIES .................................. 76

IX. PROGRESS ON USAID FORWARD ................................................................................................. 79

X. SUSTAINABILITY AND EXIT STRATEGY ..................................................................................... 79

XI. GLOBAL DEVELOPMENT ALLIANCE (IF APPLICABLE) .......................................................... 80

XII. SUBSEQUENT QUARTER’S WORK PLAN ................................................................................... 80

XIII. FINANCIAL INFORMATION ......................................................................................................... 82

XIV. ACTIVITY ADMINISTRATION ..................................................................................................... 84

XV. INFORMATION FOR ANNUAL REPORTS ONLY ........................................................................ 84

XVI. GPS INFORMATION ....................................................................................................................... 84

XVII. SUCCESS STORIES ........................................................................................................................ 85

ANNEX A. SCHEDULE OF UPCOMING EVENTS ............................................................................... 90

ANNEX B. LIST OF DELIVERABLE PRODUCTS ................................................................................ 90

ANNEX C. ACTIVITY IMPLEMENTATION RESULTS TABLES ....................................................... 91

iii

LIST OF TABLES

Table 1. Overall project HIV testing and counseling performance, Y6Q4 to Y7Q2, compared with COP

2016 targets. 2

Table 2. County-level HIV testing and counseling and identification of HIV-positive individuals, Y6Q4 to

Y7Q2, compared with COP 2016 targets. 4

Table 3. County performance comparing positivity against achievement versus COP 2016 targets. 5

Table 4. County-level pediatric HIV testing and counseling and identification of HIV-positive individuals,

Y6Q4 to Y7Q2, compared with COP 2016 targets. 6

Table 5. Outcomes of the HIV positive yield from the referrals made to HTS from GMP, April

to June 2017 7

Table 6. Partner notification and family testing, April to June 2017. ........................................................... 8

Table 7. HIV testing services (HTS) modalities, Y6Q4 to Y7Q2................................................................. 8

Table 8. HTS performance by age and gender, Y6Q4 to Y7Q2. .................................................................. 9

Table 9. External quality assurance proficiency testing, round 16. ............................................................ 11

Table 10. Prevention of mother-to-child transmission of HIV (PMTCT) summary achievements,

October 2016 to June 2017, against COP 2016 .......................................................................................... 13

Table 11. Prevention of mother-to-child transmission of HIV (PMTCT) overall achievements,

April to June 2017 14

Table 12. Community PMTCT activities and their contribution (April-June 2017) .................................. 16

Table 13. Prevention of mother-to-child transmission (PMTCT) cohort analysis ...................................... 22

Table 14. Summary care and treatment achievements (Y6Q4 to Y7Q2).................................................... 25

Table 15. County antiretroviral therapy (ART) initiation against COP 2016 targets (Y7Q2). ................... 26

Table 16. Current antiretroviral therapy (ART) losses and retention during the April to June

2017 reporting period, by county. 28

Table 17. Current antiretroviral therapy (ART) achievement during Semi-Annual Program

Results (SAPR) and Y7Q2 period, by county. ............................................................................................ 29

Table 18. Pediatric antiretroviral therapy (ART) achievement, Y6Q4 to Y7Q2 period, by

county. 30

Table 19. Progress made in tracing of SAPR (Oct 2016 to Mar 2017) defaulters and those lost to

follow-up. 31

Table 20. Total number of CD4 done across the 32 project-supported nodal sites, Y7Q2. ........................ 32

Table 21. Viral load (VL) done and suppression in different age groups in Y7Q2. ................................... 32

Table 22. Differentiated drug delivery approaches at facility and community level, Y7Q2 ...................... 34

Table 23. Outcomes of adolescent services, Y7Q2..................................................................................... 35

Table 24. Key TB-HIV performance against COP 2016 target .................................................................. 37

Table 25. Tuberculosis (TB) screening among antiretroviral therapy (ART) clients, Y7Q2. .................... 40

Table 26. GeneXpert utilization rate per county, Y7Q1 to Y7Q2. ............................................................. 41

Table 27. Proportion of antiretroviral therapy (ART) patients who completed a standard course

of TB preventive therapy (isoniazid preventive therapy [IPT]) .................................................................. 41

iv

Table 28. Voluntary male medical circumcision (VMMC) performance by county, Y6Q4 to

Y7Q2. 43

Table 29. Fisher folk reached with HIV prevention services, October 2016 to June 2017. ....................... 45

Table 30. Fisher folk reached during splash inside out sessions and complete referrals provided,

April to June 2017 45

Table 31. Results of HIV testing of fisher folk in two counties, April to June 2017. ................................. 46

Table 32. Results of HIV testing of fisher folk in two counties, October 2016 to June 2017. ................... 46

Table 33. Post gender-based violence (GBV) care services, October 2016 to June 2017. ......................... 48

Table 34. Survivors of gender-based violence (GBV) reached with services, Y6Q4 to Y7Q2. ................. 49

Table 35. Enrollment status of adolescent girls and young women (AGYW), by county. ......................... 50

Table 36. Numbers of adolescent girls and young women receiving services. .......................................... 51

Table 37. Reasons for adolescent girls and young women (AGYW) to discontinue pre-exposure

prophylaxis. 53

Table 38. Number of adolescent girls and young women (AGYW) reached with education

subsidies. 56

Table 39. Orphans and vulnerable children (OVC) served per county in Y7Q2. ....................................... 58

Table 40. Trend in orphans and vulnerable children (OVC) served. .......................................................... 58

Table 41. HIV status of project supported orphans and vulnerable children. ............................................. 60

Table 42. Number of orphans and vulnerable children (OVC) accessing HIV testing services. ................ 60

Table 43. HRH establishment by county by end of Y7Q2 ......................................................................... 67

Table 44. Central and satellite ART commodity sites reporting rates, April to June 2017 ........................ 68

Table 45. Data quality audit comparisons for care and treatment, Y6Q4 to Y7Q2. ................................... 71

Table 46. Linkages between the Government of Kenya and the project. ................................................... 78

Table 47. Subsequent quarter’s work plan. ................................................................................................. 80

Table 48. Actual expenditure details 83

Table 49. Budget notes 83

Table 50. Schedule of upcoming events. .................................................................................................... 90

v

LIST OF FIGURES

Figure 1. HIV counseling and testing uptake by county, Y7Q2. ................................................................ 17

Figure 2. Maternal and infant prophylaxis uptake by county, Y7Q2. ......................................................... 18

Figure 3. Early infant diagnosis (EID) cascade, Y6Q4 to Y7Q2. ............................................................... 19

Figure 4. Linkage status of HIV positive infants, Y7Q2. ........................................................................... 20

Figure 5. Outcome of mother-to-child transmission of HIV (MTCT) audits, Y7Q2. ................................. 21

Figure 6. HIV-exposed infant (HEI) cohort analysis at 9 and 18 months. .................................................. 23

Figure 7. Viral suppression by age categories, in the nine project counties. .............................................. 33

Figure 8. TB/HIV cascade, Y6Q4 to Y7Q2. ............................................................................................... 39

Figure 9. Layering of services for adolescent girls and young women (AGYW) in three age

categories (10–14, 15–19, 20–24). 50

Figure 10. Orphans and vulnerable children (OVC) served, by type of service. ........................................ 59

Figure 11. Cash flow report and financial projections (pipeline burn-rate). ............................................... 82

vi

ACRONYMS AND ABBREVIATIONS

ACF active case finding

AGYW adolescent girls and young women

AIDS acquired immune deficiency syndrome

ANC antenatal care

APHIAplus AIDS, Population and Health Integrated Assistance Plus

ART antiretroviral therapy

ARV antiretroviral medication

CBO community-based organization

CCC comprehensive care clinic

CHMT County Health Management Team

CHV community health volunteer

CME continuing medical education

COP Country Operational Plan

CPT cotrimoxazole preventive therapy

DHIS district health information system

DQA data quality assessment

DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored and Safe

DR-TB drug-resistant tuberculosis

DSD direct service delivery

EBI evidence-based intervention

EID early infant diagnosis

eMTCT elimination of mother-to-child transmission of HIV

FBO faith-based organization

FP family planning

GBV gender-based violence

GIS geographic information system

HCW health care worker

HEI HIV-exposed infant

HES household economic strengthening

HIV human immunodeficiency virus

HMIS health management information system

HTC HIV testing and counseling

HTS HIV testing services

ICF intensified case finding

IEC information, education, and communication

IPC infection prevention and control

IPT isoniazid preventive treatment

KEMSA Kenya Medical Supply Agency

LCHV lead community home visitor

LIP local implementing partner

M&E monitoring and evaluation

MCH maternal and child health

MIP malaria implementing partner

MOH Ministry of Health

vii

MTCT mother-to-child transmission of HIV

NACS nutrition assessment, counseling, and support

NASCOP National AIDS & STI Control Programme

NGO nongovernmental organization

NHIF National Health Insurance Fund

NHRL National HIV Reference Laboratory

OLMIS OVC longitudinal management information system

OPD outpatient department

OVC orphans and vulnerable children

PCR polymerase chain reaction

PE peer educator

PEP post-exposure prophylaxis

PEPFAR US President’s Emergency Plan for AIDS Relief

PHDP Positive Health, Dignity, and Prevention

PITC provider-initiated testing and counseling

PLHIV people living with HIV

PMTCT prevention of mother-to-child transmission of HIV

PPE personal protective equipment

PrEP pre-exposure prophylaxis

PSSG psychosocial support group

RH reproductive health

RLSN rider-led sample network

RRI Rapid Results Initiative

SAPR Semi-Annual Program Results

SCHMT Sub-County Health Management Team

SGBV sexual and gender-based violence

SIMS Site Improvement through Monitoring System

SMS short message service

STI sexually transmitted infection

TB tuberculosis

TB/HIV tuberculosis and HIV co-infection

TWG technical working group

USAID US Agency for International Development

VL viral load

VMMC voluntary medical male circumcision

VSLA voluntary savings and loan association

USAID KENYA (APHIAPLUS WESTERN KENYA) PROGRESS REPORT FOR Q2 FY 2017 viii

EXECUTIVE SUMMARY

The AIDS, Population and Health Integrated Assistance Plus Western Kenya Project is a US

Agency for International Development-funded project that is being implemented from January

2011 through December 2017 by a consortium led by PATH and including World Vision.

Since 2011, the project has:

Contributed to improvements in key health indicators.

Built the capacity of community-level structures to respond to the needs of people.

Strengthened linkages between health facilities and communities to facilitate access to HIV

care and treatment.

Enhanced health service quality by building the capacity of health care workers and

improving infrastructure of health facilities.

Helped empower communities and promote sustainability through support for local

community-based organizations.

In Year 7 Quarter 2 (Y7Q2, April through June 2017), the period under review, the project

continued to align its activities with US President’s Emergency Plan for AIDS Relief county

prioritization based on the HIV burden and Joint United Nations Programme on HIV/AIDS 90-

90-90 goals.1 In line with this and as outlined in the project’s Year 7 work plan, Homa Bay,

Kisumu, Migori, Busia, Kakamega, and Kisii were categorized as scale up to saturation counties;

Nyamira and Bungoma as aggressive scale-up counties; and Vihiga as a sustained county.

During the reporting quarter, the project supported HIV testing and counseling of 404,910

clients. This brings the total number of clients counseled and tested in the Y6Q4 to Y7Q2 period

(October 2016 through June 2017) to 1,240,811 against the Country Operational Plan 2016 (COP

2016) target of 929,003 (134% achievement). This performance exceeded the 75% threshold for

the quarter.2 The number of clients who tested HIV positive for the reporting period was 5,722,

bringing the total number of HIV-positive clients in Y6Q4 to Y7Q2 period to 16,279, against a

COP 2016 target of 30,734, a 53% achievement.

During the reporting quarter, 26,812 pregnant women were counseled and tested for HIV, of

whom 1,434 (5%) tested positive. Maternal prophylaxis was provided to 1,408 women (98% of

those who tested positive), and 1,395 infants (97%) received prophylaxis. Within the Y6Q4 to

Y7Q2 period, 90,899 women accessed testing services for the prevention of mother-to-child

transmission of HIV, against a COP 2016 target of 163,919 (55% achievement). Among these,

4,690 women (5%) were diagnosed HIV positive. Maternal prophylaxis uptake for the Y6Q4 to

Y7Q2 period was 97% and infant prophylaxis uptake was also 97%. For the Y6Q4 to Y7Q2

period, maternal prophylaxis performance translates to a 50% achievement against the COP 2016

target.

1 An ambitious UNAIDS treatment target to help end the AIDS epidemic. By 2020, 90% of all people living with HIV will know their HIV

status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression. 2 The 75% threshold is the expected performance for all indicators as of the end of the quarter. Indicators whose results were greater than 75%

against the COP 2016 target performed well, while indicators whose results were less than 75% against the COP 2016 target did not meet the expected target.

USAID KENYA (APHIAPLUS WESTERN KENYA) PROGRESS REPORT FOR Q2 FY 2017 ix

During the reporting quarter, 5,349 clients were initiated on antiretroviral therapy, bringing the

total to 15,659 clients within the Y6Q4 to Y7Q2 period, a 41% achievement against the COP

2016 target. At the end of the reporting period, 107,916 clients were active on treatment, against

the COP 2016 target of 120,374 (90% achievement).

Through HIV prevention services implemented during the reporting period, a total of 11,794

clients accessed voluntary medical male circumcision services during the period, bringing the

total number reached in the Y6Q4 to Y7Q2 period to 32,707, against a COP 2016 target of

44,618 (73% achievement). Behavioral interventions reached 2,926 fisher folk with evidence-

based interventions during the period under review, bringing the total for the Y6Q4 to Y7Q2

period to 8,927, against a target of 13,738 (65% achievement).

Within the reporting period, a total of 230,936 orphans and vulnerable children (OVC) were

served. Performance for the quarter translates to an achievement of 86% against the COP 2016

target of 268,818. A total of 183,613 OVC (younger than 18 years) were HIV negative, 7,586

were positive, and the status of 4,364 was unknown. All the 7,586 HIV-positive OVC were

linked to antiretroviral treatment programs across the project zone.

The project continued to implement the DREAMS initiative in 34 wards during the reporting

period (29 in Homa Bay and 5 in Kisumu East sub-county). The project enrolled 32,476

adolescent girls and young women (AGYW), 97% of the project target of 34,264; all have been

entered into the DREAMS database.

USAID KENYA (APHIAPLUS WESTERN KENYA) PROGRESS REPORT FOR Q2 FY 2017 1

I. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

Subpurpose 1. Increased and expanded quality HIV services

HIV testing and counseling services

The project continued to provide direct service delivery (DSD) support to all the 537 project-

supported sites. The areas of focus included capacity-building through mentorship of HIV testing

and counseling (HTC) providers on the use of family and partner testing registers, understanding

the new HIV testing services (HTS) algorithm, and the testing and retesting guidelines for

selected HTS providers. Reorientation of the HTS providers on the use of the master health

facility register for tracking the HIV-positive persons, use of the index client family members

line-listing forms, use of client locator forms, understanding the medical waste segregation job

aid, use of screening tools to establish eligibility for HIV testing, and understanding the referral

process of HIV-positive clients featured most during these sessions. Supportive supervision and

facility-level issues-based continuing medical education (CME) addressed site-specific issues in

selected sites.

The project increased the number of HTS service providers from 441 in the previous quarter to

519 and deployed these teams across 380 sites as a task-shifting strategy to enhance provider-

initiated testing and counseling (PITC) services; this translates to 71% site coverage, which is an

improvement from 60% coverage in the previous quarter. The remaining 29% of sites comprise

private clinics and dispensaries where focal persons were identified and empowered to offer

HTS. The project identified roving HTS service providers from the existing teams to provide

linkage support in private clinics that are not offering HIV treatment services.

The project also supported printing and distribution of job aids and standard operating

procedures to guide service providers in screening children, adolescents, and adults for eligibility

in testing; supported purchase of tents for sites that lacked adequate testing space; and supported

purchase of testing timers meant to uphold quality and ensure standardized timing of test results.

During the reporting quarter of April to June 2017, a total of 404,910 clients were counseled and

tested, of whom 5,722 were identified as HIV positive. Cumulatively in the three quarters of the

Country Operational Plan 2016 (COP 2016), a total of 1,240,811 clients were counseled and

tested against the target of 929,003, translating to 134% achievement. A total of 16,279 clients

among those counseled and tested were identified as HIV positive as at end of Y7Q2 period

against COP 2016 target of 30,734 (53% achievement).

The project’s HTC performance for October 2016 through June 2017 period is shown in Table 1

below.


Table 1. Overall project HIV testing and counseling performance, Y6Q4 to Y7Q2,

compared with COP 2016 targets.

Indicator

COP

2016

target

Y6Q4 Y7Q1 Y7Q2 Total %

achieved

No. of clients counseled

and tested for HIV 929,003 407,378 428,523 404,910 1,240,811 134%

No. of clients testing HIV

positive 30,734 4,880 5,677 5,722 16,279 53%

Source: Ministry of Health 731 (reporting form).

The individuals counseled and tested slightly declined from 428,523 in the January to March

2017 period to 404,910 in the April to June 2017 period, with a slight improvement in the HIV

positive identified from 5,677 to 5,722, translating to a positivity rate of 1.4% from 1.3% the

previous quarter. At least three out of the nine months of COP 2016 period, one per quarter, have

been riddled with health care worker industrial action with significant negative effect on the

project’s performance in identification of HIV-positive individuals. April 2017 marked the

beginning of the quarter under review with 1,762 positives identified, a drop from 2,072 reported

in the previous month. The project realized this low performance in April despite the resumption

of functional services in the health facilities’ inpatient and outpatient departments. Noting the

low performance in April, the project accelerated HTS services for May and June to improve the

identification of HIV-positive clients. To this effect, the project increased the number of HTS

providers from 163 to 229 in the western counties of Kakamega, Vihiga, Bungoma, and Busia—

where significant HIV incidences had been observed—while maintaining the coverage of HTS

providers in the scale-up to saturation counties in Nyanza region at 100%. Under this super-

acceleration mode, the month of May 2017 realized 2,285 positives, an increase by 523 positives

from the previous month, with Kakamega County contributing 741 positives (32%). This

momentum could not be sustained beyond the month of May owing to the commencement of the

nurses’ strike, which affected client flow at all service delivery points in virtually all public

health facilities and and led to closure of most health centres and dispensaries.

To mitigate the nurses’ strike, the project redeployed HTS service providers from the non-

functional service delivery points in the high-volume sites to support testing services in private

and faith-based facilities, which had recorded an influx of patients in June 2017. In Migori

County, for instance, Rapcom nursing home reported 15 positives in June 2017 (up from 8

positives in May) and Jevros clinic identified 8 positives (up from 3 positives in May 2017). In

sites with more than one tester, HTS providers were dedicated to specifically support partner

notification and family testing; to support male-targeted outreach to the already mapped hot

spots; and to support weekend and extended-hours services at other selected facilities. These

interventions cumulatively realized 1,675 positives in the month of June: 52 positive clients were

identified from the weekend and extended-hours services, with 20 of these being men. Currently,

36 sites offer weekend coverage, which accounts for 81% of the 52 positives as compared to

extended-hours services, which has a 19% contribution. Extended-hours services have been

initiated in 10 of the project-supported sites; this will be scaled up to more sites in the next

quarter. Due to low patient flow in public health facilities, the project focused more on targeted

outreaches to mapped hotspots at the community setting. To further strengthen the targeted

testing approach, the project will continue to embrace PITC at the facility setting to capture over


50% of outpatient department (OPD) clients and 100% of inpatients with testing and will further

strengthen weekend coverage, offering extended-hours testing to progressively attain 50%

coverage of HTS sites. The project will continue with male-targeted outreach to mapped-out

hotspots within the supported sites catchment and finalize sexual partner notification and family

member testing in both the facility and community settings. The project will continue with the

snowballing approach to reach out to social networks of newly diagnosed positive clients.

The project is on track to achieve the counseling and testing targets in all six scale-up to

saturation counties—namely, Busia (86%), Kisumu (168%), Homa Bay (95%), Kakamega

(106%), Kisii (534%), and Migori (163%). All the other supported aggressive scale-up and

sustained counties equally met their counseling and testing targets against the expected target of

75%. The project will sustain this effort so as to achieve the counseling and testing COP 2016

targets, particularly in Busia and Homa Bay counties, which have not achieved their testing

target.

On the identification of HIV-positive individuals, only Busia (85%) and Kisii (331%) among the

six scale up to saturation counties met the expected targets. Migori (59%), Kisumu (54%), and

Kakamega (46%) were all below the 75% target. Homa Bay recorded a 26% achievement, up

from 17% the previous quarter. Homa Bay County registers an average of 157 positives monthly

with a positivity rate of below 1% in almost all strategies employed. In this reporting quarter, the

county reported 466 positives, down from 477 positives the previous quarter. The number of

individuals tested had a corresponding drop from 41,642 to 36,199, leading to a modest rise in

positivity rate from 1.2% to 1.3%, respectively. Partner notification and index contacts testing

yielded 54 positives among 6,832 contacts tested, while the male-targeted outreaches yielded 10

positives among a total of 962 tests conducted, translating to a positivity rate of 0.8% and 1%,

respectively.

Kisumu is the only county that demonstrated an upward trend this reporting quarter by

identifying 189 positives in April, 208 in May, and 227 in June 2017, with an improved

positivity rate from 1.3% in May to 1.7% in June. This was attributed to the acceleration of the

activities that target the use of nonstigmatizing platforms, in this case hypertension screening, to

offer HTS services in a county with multiple “location and find” opportunities as compared to

Homa Bay. A total of 21 diversified outreaches were conducted in June 2017, reaching out to

2,864 individuals, with 46 positives identified, a positivity rate of 1.6%. Index contacts testing

was biased toward sexual partners’ notification and testing since most of the enlisted children

below 15 years had been reached with HTC services. The index contacts testing realized a total

of 66 positives among 1,043 contacts tested, a 6.3% positivity rate. Migosi health center, one of

our high-volume project-supported sites, consistently offered daily extended-hours services

targeting men between 6 pm and 10 pm. This facility had a significant number of male clients

who were identified as HIV positive in this implementation period. Within 14 days of adding

extended-hours services, Migosi reached a total of 419 individuals with testing and identified 9

(7 males, 2 females) positives, a positivity rate of 2.1%. In June 2017, the site reported 35

positives up from 29 positives in May 2017. The project data for HIV incidences within Kisumu

further guided a mop-up around three key facilities in the densely populated rural urban slums,

namely Airport dispensary, Star Hospital, and K’owino. Airport reported 23 positives in June (up

from 20 in May), Star reported 21 positives in June (up from 10 in May), and K’owino reported

20 positives in June (up from 12 positives in May).


Among the two aggressive scale-up counties, Bungoma (661%) met the set HIV-positive

identification target while Nyamira (31%) did not meet the target. Nyamira is a predominantly

low-HIV-prevalence county with a constant positivity rate of below 1%. To realize the positive

identification target in Nyamira, the project will continue support for focused testing among new

testers, priority populations, and family and partner testing particularly sexual partners and the

snowballing approach to achieve the APR 2017 targets for HIV-positive identification. Vihiga

(137%) met the expected HIV-positive targets. Table 2 summarizes the HTC achievements

against COP 2016 targets in the project counties.

Table 2. County-level HIV testing and counseling and identification of HIV-positive

individuals, Y6Q4 to Y7Q2, compared with COP 2016 targets.

County HIV testing and counseling HIV-positive

COP

2016

target

Y6Q4 Y7Q1 Y7Q2 Total % COP

2016

target


Scale up to saturation counties

Homa

Bay

142,026 56,799 41,642 36,199 134,640 95% 5,572 478 477 466 1421 26%

Migori 85,964 43,782 48,688 48,002 140,472 163% 3,257 718 537 677 1,932 59%

Kisumu 63,004 29,128 35,568 41,095 105,791 168% 3,485 706 544 624 1,874 54%

Kisii 7,646 14,582 14,873 11,377 40,832 534% 108 148 105 105 358 331%

Kakamega 296,897 101,523 101,191 112,696 315,410 106% 10,764 1,622 1,424 1,852 4,898 46%

Busia 61,441 16,407 20,496 16,230 53,133 86% 878 270 219 258 747 85%

Subtotal 656,978 262,221 262,458 265,599 790,278 120% 24,064 3,942 3,306 3,982 11,230 47%

Aggressive scale-up counties

Nyamira 216,652 82,757 96,256 75,555 254,568 118% 5,337 541 607 522 1,670 31%

Bungoma 29,551 36,762 37,369 34,298 108,429 367% 297 604 652 706 1,962 661%

Subtotal 246,203 119,519 133,625 109,853 362,997 147% 5,634 1,145 1,259 1,228 3,632 64%

Sustained county

Vihiga 25,822 25,638 32,440 29,458 87,536 340% 1,036 429 476 512 1417 137%

Grand

total

929,003 407,378 428,523 404,910 1,240,811 134% 30,734 4,880 5,677 5,722 16,279 53%


The achievement of COP16 targets on HIV-positive clients is a priority of the project in this

year. This is despite the high positivity rate used in deducing these targets.

Table 3 below compares the achieved positivity rate from HTS in all the project counties versus

the positivity rate that was used in computing the COP 2016 HIV positive targets. Busia has the

two parameters tying, but in most of the other counties (apart from Bungoma), the COP 2016

target positivity rate is almost twice that being realized in the three quarters of COP 2016 period.


Table 3. County performance comparing positivity against achievement versus COP 2016

targets.

County Y6Q4–Y7Q2

testing achievement

Y6Q4–Y7Q2

positives achieved

Positivity against

achievement

COP 2016 target

positivity rate

Homa Bay 134,640 1421 1.06% 3.90%

Kisii 40,832 358 0.88% 1.40%

Kisumu 105,791 1,874 1.77% 5.50%

Migori 140,472 1,932 1.38% 3.80%

Nyamira 254,568 1,670 0.66% 2.50%

Bungoma 108,429 1,962 1.81% 1.00%

Busia 53,133 747 1.41% 1.40%

Kakamega 315,410 4,898 1.55% 3.60%

Vihiga 87,536 1417 1.61% 4.00%

Total 1,240,811 16,279 1.31% 3.30%


Pediatric HIV testing

A total of 75,238 children were counseled and tested, with 473 among those tested turning out

HIV positive for the reporting period between April and June 2017 (see Table 4). Cumulatively,

the project recorded a total of 224,327 (189%) pediatric tests, exceeding the target of 75%. The

overall number of HIV-positive children identified was 1,363, which is a 31% achievement of

target with a proportionate yield of <1%. All nine project-supported counties met the expected

pediatric counseling and testing targets of 75%. For HIV positives identified, only four counties

were on track with the expected 75%—namely, Bungoma (312%), Busia (158%), Kisii (86%),

and Kakamega (80%). The other five counties—Homa Bay (10%), Kisumu (11%), Migori

(26%), Nyamira (34%), and Vihiga (74%)—did not meet the 75% threshold. In June, deliberate

efforts were made to improve pediatric yield, given that the maternal and child health (MCH)

and the inpatient departments as the main pediatric testing points were affected by the nurses’

strike. The project intensified contacts testing and specifically leveraged psychosocial support

groups, in that the contacts of index clients were invited to such groups and tested if eligible;

some children were also reached with testing services at the household level over the weekends

as opposed to the male partners, who opted for such services outside the family settings. The

project realized a total of 151 positives in June, a slight drop from May, when 182 positives were

recorded. Most of the counties reported slight drops in absolute positive numbers, with Homa

Bay County reporting 10, 14, and 10 positive children for the months of April, May, and June

respectively. Kisumu dropped from 12 to 10 while Migori dropped from 23 to 20 in the May and

June performances. The project will strengthen index contacts testing and optimize testing in

pediatric inpatient departments and testing of eligible OVC, as well as continue to offer targeted

testing in settings with high yield including tuberculosis (TB) and malnutrition clinics.


Table 4. County-level pediatric HIV testing and counseling and identification of HIV-

positive individuals, Y6Q4 to Y7Q2, compared with COP 2016 targets.

County` HIV testing and counseling HIV positive

COP

2016

target

Y6Q4 Y7Q1 Y7Q2 Total % COP

2016

target


Scale up to saturation counties

Homa Bay 30,592 11,360 7,888 6,696 25,944 85% 1,507 58 55 34 147 10%

Migori 18,647 7,022 6,940 6,823 20,785 111% 819 58 82 69 209 26%

Kisumu 13,353 4,777 6,291 6,990 18,058 135% 1,017 24 58 33 115 11%

Kisii 1,798 2,325 3,394 2,604 8,323 463% 29 11 7 7 25 86%

Kakamega 10,292 16,083 19,612 21,912 57,607 560% 450 96 132 133 361 80%

Busia 7,344 2,300 3,212 2,502 8,014 109% 38 21 18 21 60 158%

Subtotal 82,026 43,867 47,337 47,527 138,731 169% 3,860 268 352 297 917 24%


Nyamira 19,874 15,821 20,311 15,874 52,006 262% 356 42 40 41 123 35%

Bungoma 13,279 4,376 7,178 6,603 18,157 137% 59 48 57 79 184 312%

Subtotal 33,153 20,197 27,489 22,477 70,163 212% 415 90 97 120 307 74%

Sustained county

Vihiga 3,607 4,593 5,606 5,234 15,433 428% 188 44 39 56 139 74%

Grand

total

118,786 68,657 80,432 75,238 224,327 189% 4,463 402 488 473 1363 31%

Source: Ministry of Health 731 (reporting form). Growth Momitoring and Promotion (GMP)-HTS linkage

HIV case finding for the pediatric population at the MCH was complementarily supported

through screening either anthropometrically or clinically and then referral for testing. Those

enrolled in nutrition clinics with malnutrition and those who have had readmissions or relapses

were also referred for testing as shown in Table 5 below. Male testing was also supported

through organizing for noncommunicable disease outreaches, where comprehensive nutrition

services were given alongside other services.


Table 5. Outcomes of the HIV positive yield from the referrals made to HTS from GMP,

April to June 2017

County No. referred for

testing

Positives % Positives

Kakamega 624 12 2

Bungoma 247 8 3

Busia 55 0 0

Vihiga 97 0 0

Homa Bay 142 1 1

Migori 310 7 2

Kisumu 239 4 2

Kisii 25 1 4

Nyamira 189 0 0

Total 1,928 33 2

Kisii and Bungoma recorded the highest proportion of the malnourished children testing HIV

positive at 4% and 3%, respectively, with none in Nyamira, Vihiga, and Busia.

Partner and family index client testing

In the reporting period, the program intensified partner and index contact testing as a strategy to

identify more HIV-positive clients across all counties (see Table 6). The project devised a

partner notification and family testing summary register to capture all the contacts per site and

establish the site coverage. The project continued line-listing all family members and sexual

partners of index client contacts at the comprehensive care clinic (CCC), prioritizing PMTCT

(prevention of mother-to-child transmission of HIV) mothers and making deliberate efforts to

offer HTS at both the facility and community settings. During the line-listing exercise, new

family members and spouses were updated and discordant couples were enlisted for retesting as

per the national guidelines.

Overall, partner notification and family testing yielded improved results in the quarter, with

31,530 contacts reached and a yield of 537 positives realized, an increase from last quarter’s

23,126 contacts tested and yield of 434 positives. The positivity rate, however, reduced from 2%

to 1.7% in this reporting quarter (April to June 2017).


Table 6. Partner notification and family testing, April to June 2017.

County Contacts tested Contacts

HIV positive

Contacts enrolled

in HIV care

Positivity rate

Homa Bay 6,832 54 50 0.8%

Kisumu 1,043 66 64 6.3%

Migori 8,981 161 125 1.8%

Busia 1,108 30 26 2.7%

Kakamega 6,398 102 87 1.6%

Kisii 490 2 2 0.4%

Nyamira 1,979 28 28 1.4%

Bungoma 2,021 51 50 2.5%

Vihiga 2,678 43 43 1.6%

Total 31,530 537 475 1.7% Source: Project data.

.

Kisumu (6.3%) reported a high positivity rate, followed by Busia (2.7%) and Bungoma (2.5%).

Migori (1.8%), Vihiga (1.6%), and Kakamega (1.6%) reported a lower than 2% positivity,

resulting from the high number of contacts reached, specifically the high number of children.

Nyamira (1.4%) improved from below 0.4%, and Homa Bay (0.8%) maintained the same trend.

The low rates in Nyamira and Kisii are in keeping with facility positivity rate. The HIV

incidence in Western region counties is higher than in counties in Nyanza region.

The project has continued to employ different testing modalities, with each giving different

results. Table 7 shows the testing modalities and the yield for the period of October 2016 to June

2017.

Table 7. HIV testing services (HTS) modalities, Y6Q4 to Y7Q2.

HTS modality Clients tested Clients HIV positive Positivity rate

PITC – TB clinic 4024 932 23.16%

Key population 1,734 64 3.69%

PITC- PMTCT (ANC only) 87,678 1,788 2.04%

Index client contact testing 56,570 1071 1.89%

PITC inpatient services 56,530 947 1.68%

VCT 256,109 3,752 1.47%

PITC- outpatient services 852,730 9,454 1.11%

PITC - VMMC 13,341 26 0.19%

Note: ANC, antenatal care; PITC, provider-initiated testing and counseling; PMTCT, prevention of mother-to-child transmission of HIV;

TB, tuberculosis; VCT, voluntary testing and counseling; VMMC, voluntary medical male circumcision. Source: Ministry of Health 731 (reporting form), project data.

As shown in Table 7 above, the TB clinic had the highest positivity rate, whereas PITC in the

OPD generated the highest number of positive clients. Thus, optimizing the TB clinic testing and

the OPD testing will be part of the project’s strategies in the coming quarters. Index client

contact testing is a promising modality for the project, with an overall positivity of 1.9%. The

project will endeavor to have 100% uptake for the existing clients as well as the new ones.


Table 8 below further provides the age and gender disaggregations in HTS for the three quarters

of COP 2016 period. It shows that children (<15 years), adolescents and young persons aged 15–

24 years old, and men have the lowest achievements in the number of clients testing HIV

positive.

Table 8. HTS performance by age and gender, Y6Q4 to Y7Q2.

Indicator Age/Gender COP 2016

Target

Y6Q4 Y7Q1 Y7Q2 % achieved

HTS_TST <15 136,526 85,953 80,431 75,238 177%

15-24 286,973 110,511 176,973 164,655 158%

>25 687,450 237,174 206,999 190,782 92%

Male 457,898 147,483 157,897 146429 99%

Female 666,407 286,155 306,506 284,246 132%

HTS_Pos <15 4,920 401 485 473 28%

15-24 9,249 1,005 1,213 1,122 36%

>25 21,867 3,996 4,707 4,632 61%

Male 11,892 1,677 1,988 1,334 42%

Female 24,144 3,725 4,417 4,893 54% Source: Ministry of Health 731 (reporting form).

The project will continue employing strategies that have evidently produced results in

identification of more HIV-positive clients. Such strategies include the use of focus group

discussions that actively involve men as part of the process to improve HTS uptake among men,

as well as the use of “unlinked anonymity” (that is, providing call-back hotlines for adolescents,

where they can be directed to youth-friendly HTS services); these activities will continue in the

coming quarter. Other county-specific strategies that have produced high positivity rates will

also be employed. These include testing at the boda boda bases, testing of fisher folk, testing in

formal and informal workplaces, and the integration of HTS in the nonstigmatizing platform for

noncommunicable disease servicesunder the Healthy Heart Africa (HHA) project.

HTC outreaches to key populations and other mapped community groups

Between April and June 2017, local implementing partners conducted 12 outreaches (9 in

Kisumu and 3 in Busia) where 1,592 fisher folk were tested for HIV, out of which 38 tested new

HIV positive, translating to a 2.4% positivity rate. Only two clients were unlinked to treatment

and the project will make follow ups to ensure they are linked to treatment in the subsequent

reporting quarter.

Cumulatively, between October 2016 and June 2017, a total of 3,940 of the 8,927 fisher folk

reached were effectively referred for and received essential packages of biomedical and

structural services. Specifically, 3,686 out of the 8,927 fisher folk reached in that period were

newly tested/referred for HTS. Eighty-five (85) of them tested HIV positive, translating to a

2.3% positivity rate, and nearly all of those (83 of 85) were successfully linked to treatment,

translating to 98% linkage. Follow up of the 2 unlinked clients will be made to ensure they are

linked to treatment in the subsequent reporting quarter.


The project continued with the focus on the “location and population” strategy by mapping out

all hotspots to help target resources to areas with the greatest need. A total of 114 hotspots were

elicited across the project-supported sites. From these mapped hot spots, a total of 7,467

individuals (5,116 M, 2,351 F) were reached with testing services of which 136 (78 M, 58 F)

turned out HIV positive, a positivity rate of 1.8%. The hotspots reached comprised boda boda

sheds; brick, ballast, and gold mines; bars and pubs; tea factories; sugar cane cutters; and matatu

touts, among others. Focus group discussions (FGDs) conducted at the respective work places

were used as an entry point for most of the outreaches that targeted men. The uniformed police in

Oyugis, Homa Bay County, were among the formal work places that consented to HTS

following a consensus meeting with the base commander. The male-targeted FGDs also sought

to elicit some of the reasons why this subpopulation was reluctant to seek health care services.

The cited reasons included: long hospital queues, sitting alongside mothers and children, the

direct and indirect costs charged by the health facilities, lack of essential drugs in the facilities,

and the health care workers’ attitudes toward men. The majority therefore opted for over-the-

counter medicines and use of herbs, resorting to seeking health services as the last option.

Linkage to care and treatment services

Given the additional benefit of same-day enrollment into care, the project has strengthened the

adoption of a team approach that includes the involvement of peer educators (PEs) and

community health volunteers (CHVs) at the point of HIV diagnosis. The project has further

strengthened referral mechanisms through facility-level biweekly linkage meetings. Each HTC

provider is able to follow, over time, HIV-positive clients who are not enrolled, and this is

captured using a project-designed linkage template. All HIV-positive clients are escorted to the

CCC for enrollment into care by the HTS provider, a peer educator, or clinician. HIV-positive

clients are then captured in the Master Facility Linkage Register at the link facility, and the HIV-

Positive Client Referral Forms are signed by the receiving officer, including the locator form for

tracking purposes. The project has further supported each testing site with standard operating

procedures for referrals based on the HTS guidelines and index contacts line-listing forms for the

contacts of the newly diagnosed as part of the information captured upon diagnosis.

Quality assurance

The project continued to support County and Sub-County Health Management Teams (CHMTs

and SCHMTs) for quality assurance in HTC services through supportive supervision and

capacity-building interventions, including mentorship and individual observed sessions for HTC

providers. The project also provided onsite mentorships, focusing more on high-volume and

high-yield sites so as to ensure that HCWs upheld quality standards at all levels of service

provision.

The project supported the distribution of 3,661 proficiency test panels for round 16 across the

nine supported counties (see Table 9). A total of 3,581 proficiency tests were processed and sent

back to the national HIV reference laboratory, a response rate of 98%. So far the project has

received 3,501 results, of which 3,175 (91%) are satisfactory and 326 (9%) are unsatisfactory.

Among the 326 HTC service providers with unsatisfactory responses, 202 (62%) were nurses

under the PMTCT program, 59 (18%) were laboratory technologists, 30 (9%) were clinical

officers, 26 (8%) were HTS counselors, and 9 (3%) were from a pool of nutritionists,


pharmacists, and social workers trained to support counseling and testing at the county’s request.

The majority (80%) of the providers that received unsatisfactory responses were due to incorrect

test results, with some reporting both incorrect results and use of wrong algorithm; 5% were due

to incomplete data kit. Most of the providers who reported unsatisfactory responses were

participating in proficiency tests for the first time, given that the project supported enrollment of

all the testers as an external quality assurance measure in HTS.

Table 9. External quality assurance proficiency testing, round 16.

County Received

from

NHRL

Sent back

to NHRL

Results

received

Satisfactory Not

satisfactory

Performance Response

Homa Bay 189 188 137 136 1 99% 99%

Kisumu 77 77 77 60 17 78% 100%

Migori 158 157 157 153 4 97% 99%

Busia 247 218 194 168 26 87% 88%

Nyamira 694 686 686 623 63 91% 99%

Kakamega 1,155 1,143 1,139 1,057 82 93% 99%

Kisii 101 101 101 96 5 95% 100%

Bungoma 721 696 695 615 80 88% 97%

Vihiga 319 315 315 267 48 85% 99%

Total 3,661 3,581 3,501 3,175 326 91% 98% Note: NHRL, national HIV reference laboratory.

Source: Project data.

The institution of corrective action is going on for each of the affected providers with a plan for

completion once the affected nurses resume duty. The project will ensure that all clients with

HIV-positive test results are retested by a second tester before they are initiated on treatment as

per the current national guidelines. The project will separately enroll more testers who joined the

project sites for round 17.

Challenges

1. Nurses Strike

The nation wide nurses strike was the main challenge to HTS in the reporting period. It began in

the last week of May through June 2017. It led to the closure of 181 public health facilities

supported by the project (mainly dispensaries and health centres manned by nurses). MCH and

inpatient services were also paralyzed in majority of the open public health facilities. Client flow

in key HTS areas was significantly reduced in public facilities. On the contrary, client flow to

private and faith based organizations (FBO) health facilities increased significantly sometimes

leading to a strain on available resources. Effects of the strike on testing and HIV positive yield

for June in comparison to April and May 2017 in selected health facilities facilities in shown in

Annex C.

To mitigate the effects of the strike on HTS, the project liaised with CHMTs/ SCHMTs and put

in place the following measures:


Re-deployment of project supported HTS providers from closed public facilities to

support privates /FBOs to address increased workload. The redeployment was reviewed

weekly and the providers moved to needy sites as appropriate.

Focus on community HTS strategies due to the low numbers of clients in public facilities.

The strategies included testing of partners and family members of index clients; and

outreaches to mapped hotspots based on project data e.g in the rural –urban slums in

Kisumu and shop to shop/ garage to garage testing in Isebania (Migori county)

Allocated a team to support extended and weekend coverage in sites that were

operational including private/FBO facilities.

Optimizing community HTS and Hypertension screening to reach out to Men in

Homabay and Kisumu counties (Healthy Heart Africa )

Deliberate efforts to reach out to formal workplaces including the uniformed police in

Rachuonyo and Busia

2. Delays in relaying back Round 16 Proficiency Testing results

This was mainly, in counties with multiple implementing partners. The National HIV

Reference Laboratory (NHRL) works through one identified implementing partner in each

county to collect the proficiency tests on behalf of others for processing and to collect hard

copies of the processed tests. A few samples for Round 16 had no diluents in the package as

witnessed in Round 15 and the pending corrective action for the nursing cadre that is still on

strike. The project will continue networking with other implementing partners through

identified focal persons so as to reduce the turnaround time.

Elimination of mother-to-child transmission of HIV (eMTCT)

During the reporting quarter, the project continued support for PMTCT services in 346 health

facilities (Nyanza 128; Western 218). The comprehensive support focused on improving

antenatal care (ANC) coverage, strengthening identification of HIV-infected women, providing

highly active antiretroviral therapy (ART) and infant prophylaxis, improving early infant

diagnosis services, and analyzing retention among maternal and HIV-exposed infant cohorts.

The project supported health care workers to carry out targeted ANC outreaches, pregnancy

mapping, and strengthened referrals from community levels. Site-level capacity-building was

done via supporting supervision and mentorship, monthly zonal eMTCT meetings, focused

onsite and offsite mentorships, CMEs, and on-the-job trainings to promote uptake of counseling

and testing among pregnant and breastfeeding women; orientations on commodity management

and rapid-test-kit forecasting and allocation meetings at county level; data documentation,

review, and reporting; and county stock-taking forums. The project also supported the county

level eMTCT technical working group (TWG)/business planning meetings. Human resource

support was also given to the private and faith-based organization (FBO) sites to enable them to

cope with the service need during the nurses’ strike that affected the Ministry of Health (MOH)

sites.

During the reporting quarter, 26,812 pregnant women had known HIV status at ANC only,

including 924 known positives. Of the pregnant women counseled and tested, 1,434 (5%) tested

HIV positive while 1,408 women (98% of those who tested positive) and 1,395 infants (97% of


those who tested positive) received antiretroviral (ARV) prophylaxis, respectively. Overall, for

the October 2016 to June 2017 period, the project reached 90,899 women with known status, of

whom 4,690 were positive. Table 10 below shows the achievement for the three quarters in

comparison to COP 2016 targets.

Table 10. Prevention of mother-to-child transmission of HIV (PMTCT) summary

achievements, October 2016 to June 2017, against COP 2016

Indicator COP

2016

Target


Achievement

Number of sites 346 346 346 346 346 100%

Number of pregnant women

with known status

163,919 27,002 37,085 26,812 90,899 55%

Number of pregnant women that

are HIV positive

9,145 1,337 1,919 1,434 4,690 51%


known to be HIV positive

792 1,195 924 2,911


new positive

545 724 510 1,779


issued with prophylaxis

9,145 1,272 1,866 1,408 4,546 50%

Number of infants issued with

prophylaxis

9,145 1,273 1,859 1,395 4,527 51%

Note: COP, Country Operational Plan. Source: Ministry of Health (MOH) 731.

The project therefore achieved 90,899 clients (55% of target) with known status at the end of the

third quarter of COP 2016 period, against a target of 163,919 pregnant women. Of the targeted

9,145 HIV-positive clients, the project identified 1,434 in the quarter, bringing the total to 4,690

clients (51% of target). A total of 1,408 pregnant women and 1,395 infants were issued

prophylaxis during the April to June 2017 period.

The overall project PMTCT performance during the reporting period (April to June 2017) was

much lower than in the last quarter (January to March 2017). This was mainly due to the nurses’

strike that started in June and is still going on, hence paralyzing ANC services in all government

health facilities. The performance dropped by about 75% from May to June 2017 due to the

nurses’ strike. Table 11 below shows the overall performance for the quarter.


Table 11. Prevention of mother-to-child transmission of HIV (PMTCT) overall

achievements, April to June 2017

Indicator April May June Total


with known status

10,698 12,549 3,565 26,812


that are new HIV positives

211 235 64 510


known to be HIV positive

367 420 137 924

Total HIV positive pregnant

women

578 655 201 1,434

Source: Ministry of Health (MOH) 731

To mitigate the nurses’ strike on PMTCT services, the project undertook the following measures;

Redirected PMTCT clients on treatment to CCCs for provision of ARVs through sending

SMS/ calling using peer educators/ mentor mothers;

Making local arrangements with nurses that live inside or near closed health facilities to

attend to PMTCT mothers when called upon. This has worked in some dispensaries and

health centres;

Engaged locum (temporary) nurses in private facilities that continue to receive an influx

of pregnant women seeking ANC services;

The project has agreed with some private facilities to waive user fees for ANC clients in

exchange for the project providing locum nurses there;

ANC community outreaches to mapped sites guided by project data;

Community PMTCT activities such as pregnancy mapping and referrals to operational

sites.

The high COP target for Nyamira County above its expected pregnancies still remains a

challenge for the project toward achievement of its expected quarterly performance against COP

2016 targets. However, the county is on track with achieving its coverage with a 61% against the

expected pregnancy.

The project continues to record an increase in known HIV-positive clients in the quarter, as has

been seen in the previous reporting periods, reporting 64% (924 out of 1,434), which is attributed

to older clients desiring to have children due to the success of the PMTCT program and the

ability of project-supported clinicians to provide services to known HIV positive pregnant

women at the first ANC visit during the ongoing strike. Support for family planning (FP)/HIV

integration through mentorship and use of reproductive health (RH) coordinators has continued

with a view to reducing unmet need for family planning. The project will focus on Migori, Homa

Bay, Vihiga, Busia, and Bungoma counties that reported known positives of 60% and above

during the quarter.


Performance of the known HIV-status indicator against the COP 2016 target at county level was

as follows: Busia 109%, Kisumu 91%, Homa Bay 79%, Kisii 65%, Kakamega 58%, Migori

57%, Vihiga 53%, Bungoma 52%, and Nyamira 33%. Busia, Kisumu, and Homa Bay counties

achieved above the expected performance of 75%, while the remaining counties are below 75%

and if the nurses strike continues, they may not achieve their targets. Nyamira County has the

lowest performance for known status (33% of the COP 2016 target) but the PMTCT coverage is

61% of target (8,362 out of 13,645). Nyamira County has a higher COP 2016 target as compared

to the expected pregnancies, and this could affect achieving the set targets. The project supported

human resource for health in the private and FBO health facilities across the counties and this

contributed to 940/3,582 (26%) ANC attendance during the month of June.

Improving coverage of PMTCT services through community interventions

During the reporting period, the project supported several community PMTCT activities which

contributed to more women reached with testing in 1st ANC as illustrated in Table 12 below.

The project continued to utilize facility level data in making decisions on where to focus the

interventions so as to maximize on resources to achieve the set targets. Working with existing

community structures such as community health volunteers (CHVs), traditional birth attendants

(TBAs) and village elders, the facilities conducted household mapping to identify pregnant

women early in pregnancy, escorted referrals for those who delay starting ANC as well as

community targeted ANC outreaches to reach pregnant women from hard to reach areas.

Community Health Volunteers were facilitated to conduct household level mapping exercise in

Bungoma County in the month of June with the objective of identifying pregnant women in their

pregnancy to start attending ante natal care (ANC) clinic early, a precursor for receiving the

standard ANC package which includes PMTCT. The exercise was conducted in 48 project

supported PMTCT sites that have not met their ANC coverage targets and as a result 1,431

pregnant women were identified as having not started ANC and referrals were referred to link

health facilities. Out of this, 629 pregnant women were effectively referred and accessed

PMTCT services as shown in Table 12. Four pregnant women were identified as HIV positive

translating to a 1% HIV positivity rate and all the 4 were enrolled on treatment and received both

maternal and infant prohylaxis.


Table 12. Community PMTCT activities and their contribution (April-June 2017)

Activity Counties undertaking

activity

Sites

undertaking

activity

Pregnant women 1st ANC

reached and documented in

facility

Mapping and

referral of pregnant

women at

household level

Bungoma 48 629

Escorted referrals of

previously

identified women

by CHVs

Nyamira, Homabay,

Kisumu, Migori, Kisii,

Bungoma, Busia,

Kakamega, Vihiga

226 5,825

ANC-

focused/targeted

community

outreaches

Kakamega , Bungoma,

Vihiga, Kisii and Nyamira

83 791

Total 7,245

Community health volunteers were facilitated with incentives to make follow up visits at

household level to ascertain referral compliance among the pregnant women who had been

mapped and referred. Those women who had not complied with the referral on follow up were

then escorted by the CHVs in person to the facility to ensure they receive the services. In some

instances, TBA were incentivized the same way as CHVs for them to be able to physically escort

any pregnant woman who goes for ANC at her home to the facility to receive PMTCT services.

Use of data at facility level in household mapping of pregnant women enabled the project to

support focused ANC outreaches to reach out to pregnant women in hard to reach areas. This

was done in 3 counties the rest being hampered by the on going nurses’ strike. A total of 83

outreach sites were conducted reaching 791 pregnant women out of which 713 accessed HIV

testing resulting in 3 HIV positive pregnant women. Only one pregnant woman accepted

maternal and infant prophylaxis, the other 2 are still under follow up to ensure they are

convinced on the benefits of ART treatment.

The project also supported the community mentor mother initiative in Homa Bay County as a

retention strategy for the mother and baby pairs in PMTCT for HIV positive mothers and HIV

Exposed Infants. For the period under review, 14 mentor mothers covered up to 329 Villages,

taking care of 727 clients, 64 of these having been referred from the facilities to the mentor

mothers for further support in the community. A total of 226 of the clients were facilitated to

attend community PMTCT PSSGs. A total of 131 of clients were visited at home for support on

various issues that affect their adherence as well as for defaulter tracing purposes. As a result of

messages passed during the PSSG meetings and home visits, 15 referrals were made for partner

testing, 12 for children testing; 34 clients assisted on status disclosure to family members while

22 mothers were referred for community HIV services including nutrition demonstration on

kitchen gardening and income generation activity groups.


The project will continue with mapping of pregnant women and supported targeted ANC

outreaches to reach pregnant women in identified sites in all the counties. The project will work

with the sites that missed opportunities to reach these women with counseling and testing and

link those identified to health care as appropriate.

PMTCT cascade

In the reporting quarter, counseling and testing uptake for first ANC visit was 102%, and this was

because mothers who missed testing in the last quarter were also tested; maternal prophylaxis was

98%, and infant prophylaxis was 97%. Figure 1 below shows the PMTCT cascade on uptake of

counseling and testing by county for the quarter.

Figure 1. HIV counseling and testing uptake by county, Y7Q2.

Source: Ministry of Health (MOH) 711/MOH 731.

Note: ANC, antenatal care.

Access to counseling and testing among women attending ANC services remained high in all

counties during the reporting period, with a few missed opportunities. The project has listed the

mothers who missed counseling and testing for follow up to ensure that they are tested and

documented.

Homa Bay Kisumu Migori Busia Nyamira Kisii Kakamega Bungoma Vihiga

1st ANC 1,410 1,247 2,167 1,668 2,211 402 7,645 6,140 2,364

ANC tested 1,248 1,154 2,019 1,649 2,299 395 8,855 6,014 2,263

% tested 89% 93% 93% 99% 104% 98% 116% 98% 96%

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

1st ANC ANC tested % tested


Figure 2. Maternal and infant prophylaxis uptake by county, Y7Q2.

Source: Ministry of Health (MOH) 731.

All counties continued to report high uptake for both maternal and infant prophylaxis as shown

in Figure 2 above. Peer educators conducting home visits to trace and bring back the mothers and

their infants supported health care workers (HCWs) to continuously account for missed

opportunities. The project supported County Health Management Teams (CHMTs) to enable

successfully traced clients on prophylaxis to be reflected in the district health information system

(DHIS). Hence, they were able to account for all missed opportunities. All sites continued to

conduct mentorship; offer PMTCT support groups; provide ARV commodities in integrated

MCH settings; and offer support for commodity consumption, forecasting, and reporting.

Early infant diagnosis

During the reporting quarter, 2,616 polymerase chain reaction (PCR) tests were processed. This

was 182% of the estimated 1,434 HIV-exposed infants (proxy from HIV-positive pregnant

mothers) in the quarter. This percent achievement is higher than that attained in the previous

quarter (132%) and the project continued with mentorship to the dormant early infant diagnosis

(EID) sites with an aim of scaling up the uptake of EID services. Of the 2,616 PCR tests taken in

the quarter, 44% (1,152) were drawn within 2 months of the child’s birth. This was attributed to

inclusion of repeat PCR test as per the revised EID algorithm. To improve on this indicator, the

project will continue to sensitize HCWs on the importance of performing the first PCR at 6 to 8

weeks of age. Figure 3 below shows the EID cascade for the reporting period, compared to the

previous two quarters.

HomaBay

Kisumu Migori Busia Nyamira KisiiKakame

gaBungom

aVihiga

HIV +ve 227 168 175 76 87 19 408 178 96

Maternal prophylaxis 224 166 171 75 85 19 396 181 98

Infant prophylaxis 221 164 164 75 85 19 389 180 98

0

50

100

150

200

250

300

350

400

450


Figure 3. Early infant diagnosis (EID) cascade, Y6Q4 to Y7Q2.

Note: ART, antiretroviral treatment; DBS, dry blood spot.

Source: Early infant diagnosis (EID) database.

Compared to Y6Q4 and Y7Q1, in the Y7Q2 period more tests were conducted (2,616 compared

to 1,909 and 2,528, respectively). This increase was a result of mentorship to the dormant EID

sites to scale up EID services. Of all the tests processed, 1,152 (44%) were done at the

recommended period (when the infant is younger than 2 months of age). The overall HIV-

positivity rate at 18 months in the quarter was 5.3% (139 of 2,616), with a 3.8% (44/1,152)

positivity rate at 2 months. The project will continue to strengthen early identification of infants.

Linkage of HIV-positive infants

The project reported a gross number of 139 infants who were identified as HIV-positive in the

quarter, according to the EID website (see Figure 4). Further validation of these results showed

that the initial PCR positive results were 105 infants. This translates to an adjusted “true”

positive figure of 105, which is lower than the 113 of the last quarter. Of these, 96 have been

enrolled on treatment, 3 infants died before enrollment, 2 were lost to follow-up, 1 was an adult

sample, and 3 with other reasons such as decline. The re-tests and viral loads were captured

under other reasons.

1,337

1,909

1,181

120 96

1,919

2,528

1,238

136 98

1,434

2,616

1,152

139 96

0

500

1,000

1,500

2,000

2,500

3,000

# of Positive Women # of DBS taken Taken < 2months # Positive # Initiated on ART

Y6Q4 Y7Q1 Y7Q2


Figure 4. Linkage status of HIV positive infants, Y7Q2.

Note: ART, antiretroviral treatment; HEI, HIV-exposed infant; LTFU, lost to follow-up.

Source: National AIDS & STI Control Programme (NASCOP)/Early infant diagnosis (EID) website.

The project supported the facilities to conduct mortality audits for the three infants who died and

identified the following causes of death: late identification of the infants after 2 months, missed

opportunity for testing during ANC visit, and home delivery. The project will strengthen early

identification and referral of HIV-exposed infants from the community using CHVs.

139

105

96

3 2

2115

0

20

40

60

80

100

120

140

160

# Positive # TruePositive

# Enrolled # Dead # LTFU # Others #pending


Figure 5. Outcome of mother-to-child transmission of HIV (MTCT) audits, Y7Q2.

Note: #, number; ANC, antenatal care; HAART, highly active antiretroviral therapy; HEI, HIV-exposed infant; MAT, maternity;

OPD, outpatient department; PCR, polymerase chain reaction; PNC, postnatal care.

As shown in Figure 5, mother-to-child transmission of HIV (MTCT) audits show that reasons for

such transmission were mainly: late PCR tests (after 2 months, for 61 out of 105 cases), missed

prophylaxis (21 out of 105), lack of skilled deliveries (54 out of 105), and lack of ANC

attendance by the mothers (39 out of 105). There were also missed opportunities in early testing

of mothers, and some of the mothers seroconverted in the periods beyond ANC attendance.

PMTCT cohort analysis

A PMTCT cohort analysis was conducted in all PMTCT-supported sites to establish client

retention at 3 months, 6 months, and 12 months after enrollment. Viral uptake and suppression

levels were also determined. Retention at 3-, 6-, and 12-month cohorts was 93%, 89%, and 83%,

respectively, within the project-supported sites and generally higher among known HIV-positive

clients (93%) compared to the newly positive (85%). Viral load uptake was low due to lack of

proper documentation in a few sites. This is being strengthened through on-the-job training,

mentorship on the registers, and real-time dispatch of results in all supported sites. Suppression

levels were recorded at 84% and 89% in 6- and 12-month cohorts, respectively. Table 13 below

illustrates the quarter’s PMTCT performance.

105

96

44

61

6

39

21

54

0

33

0

20

40

60

80

100

120

# ofHEIs

audited.

#enrolled.

# tested<2/12

#tested >

2/12

# +veafter 1st

PCR

# ofmums

missed ANC

# ofmumsmissedHAART

#missedSkilled

delivery

# +ve atMAT

# +ve atPNC/OPD


Table 13. Prevention of mother-to-child transmission (PMTCT) cohort analysis

Cohort months 3-month cohort 6-month cohort 12-month cohort

Dec-16 Sep-16 March-15

Indicator KP NP Total KP NP Total KP NP Total

A Enrolled into cohort 346 360 706 400 340 740 456 310 766

B Transfer in (TI) 23 4 27 50 6 56 42 16 48

C Transfer out (TO) 16 12 28 23 11 34 16 22 38

D Net cohort (A+B-C) 307 344 651 327 323 650 393 282 675

E Defaulters 10 35 45 7 8 15 13 9 22

F Lost to follow-up

(LTFU)

0 0 0 15 32 47 10 33 43

G Reported dead 0 0 0 1 1 2 0 3 3

H Stopped 2 1 3 2 1 3 0 1 1

I Alive and active on

treatment

295 308 603 302 281 583 370 236 606

J Viral load (VL) collected 0 0 0 250 260 510 345 204 549

K Virally suppressed

(VL<1,000)

0 0 0 220 208 428 300 186 486

L % Retained (I/D*100) 96% 89% 93% 92% 86% 89% 94% 83% 89%

M Viral suppression NA NA NA 88% 78% 84% 87% 91% 89%

Note: KP, known positive; NP, new positive.

Source: Antiretroviral therapy (ART) register.

HIV-exposed infant cohort analysis

HIV-exposed infant (HEI) cohort analysis was conducted during the reporting period for both the

9- and 18-month cohort clients in all supported PMTCT sites. The primary goal was to establish

MTCT rates and the percent retained/active in follow-up as shown in Figure 6 below.


Figure 6. HIV-exposed infant (HEI) cohort analysis at 9 and 18 months.

Source: HIV-exposed infants (HEI) register; AB: antibody

Overall, the project’s retention rate among the 9-month cohort was 84% with a 4% MTCT rate,

while the same indicators for the 18-month cohort were 72% and 5%, respectively. Retention and

650, 84%

30, 4%40, 5%

45, 6%8, 1%

Nine-month HIV-exposed infant cohort outcomes April to June 2016 cohort, n=773

% Active in follow-up

% Identified as positive between 0 and9 months

% Transferred out between 0 and 9months

% Missing 9 month follow-up visit

% Died between 0 and 9 months

426, 72%

14, 2%

26, 5%

58, 10%

60, 10%6, 1%

Eighteen-month HIV-exposed infant cohort outcomesApril to June 2016 cohort, n=590

% AB negative at 18 months

% Active at 18 months but no AB testdone

% Identified as positive between 0 and18 months

% Transferred out between 0 and 18months

% Lost to Follow-Up between 0 and 18months

% Died between 0 and 18 months


MTCT rates across the 9-month and 18-month cohorts generally improved. This improvement

can be attributed to the project’s continued focus to promote retention of mother-baby pairs by

strengthening appointment and defaulter tracing systems; PMTCT postnatal-specific

psychosocial support groups (PSSGs); quality improvement team meetings with clinicians, PEs,

and mentor mothers; and, capacity-building of HCWs and PEs/mentor mothers on maternal,

infant, and young child feeding. In addition, routine MTCT/mortality audits created opportunity

for corrective actions on gaps identified. HEI graduation held in the supported facilities also

made a difference. Moving forward, the project will continue to embrace the strategies that made

the facilities perform well.

HEI Graduation Ceremonies in the counties

Three health facilities (Kokwanyo, Nyawango and Tala) in Homa Bay county and the

sorounding communities were supported to organize and conduct HEI graduations in the

community after successful follow up of HIV positive mothers by CHVs and community mentor

mothers. The lay persons ensured that all the ANC and PNC mothers and HEIs received the

required PMTCT services including imminizations for the chidren and as a result 62 chidren

were successfully confirmed to be HIV negative at 18 months and released from the facility into

the community to join clubs.

Another graduation in Bungoma County saw 73 children born of HIV positive mothers graduate

with negative HIV results. Upendo PSSG showcased the importance of disclosure, partner and

child testing for PMTCT. Mothers shared their joy of having children free from HIV infection

and recognition of their role and commitment by the healthcare team.

HEI Graduation ceremony in Bungoma County

HIV care and treatment

Overall across the project, 5,349 clients were initiated on treatment in the reporting period of

April to June 2017, bringing the total number of clients on ART to 15,659 from Oct 2016 to June

2017, a 41% achievement against a COP target of 38,511, as shown in Table 14. In regard to

pediatric performance, the momentum created last quarter was sustained, with initiation of 475

pediatric clients on treatment; a total of 1,339 children have been initiated on treatment against a

COP 2016 target of 3,160 (an achievement of 42% against of target).


Table 14. Summary care and treatment achievements (Y6Q4 to Y7Q2).

Indicator COP

2016

target

Achievement %

achievement

Y6Q4 Y7Q1 Y7Q2 Total

New

ART

Overall 38,511 4,764 5,546 5,349 15,659 41%

Pediatric 3,160 391 473 475 1,339 42%

Current

ART

Overall 120,374 101,557 105,601 107,916 107,916 90%

Pediatric 13,240 9,466 9,971 10,196 10,196 77% Note: ART, antiretroviral therapy.

ART uptake among the identified and enrolled on care has progressively been excellent in the

three quarters: a total of 15,659 clients were initiated on treatment compared to 15,322 clients

that were enrolled in care with the surplus (337) being clients who were on cotrimoxazole only

and had not been initiated on ART in the previous periods. To achieve these, the supported sites

continued to embrace the new test-and-treat guidelines; facility performance tracking was used to

assess the gaps and opportunities that existed in the facilities; contracted staff were retained

through the counties’ departments of health while also engaging more clinical locum staff in

some of the sites that were targeted as potentially high-yielding. Performance-based incentives

were used to motivate the health providers to work toward target achievement. In the reporting

period (April to June 2017), there was deliberate efforts to ensure that the project is on track to

achieve its targets, with the entire project adopting a super-accelerated performance mode with

tangible outputs being realized in the yield and subsequently initiation on treatment. However,

the industrial action by the nurses that commenced in the last week of May 2017 impacted

negatively on the momentum that had been created, bringing service delivery to a standstill,

especially in the Tier 1 and 2 facilities, which were mainly supported by nurses. The project

undertook the following measures to mitigate the effects of the strike on treatment services;

Redeploying project supported clinicians to open CCCs to beef up the staff due to an

increased number of treatment clients from closed facilities

Using peer educators attached to closed facilities to send bulk SMS and call clients

scheduled for clinic appointments and direct them to the nearest open CCC for services. The

project developed a tool that is used to track clients directed to other health facilities

Making local arrangements with nurses that live inside or near closed health facilities to

attend to treatment clients when called upon. This has worked in some dispensaries and

health centres.

Using roving project supported clinicians to see clients in closed facilities. This has not been

easy especially in facilities where the nurse in charge is not willing to open the facility.

As shown in Table 15, a total of 5,349 clients were initiated on treatment in this quarter

compared to 5,546 in the previous quarter. The month of May contributed 41% (2,179 of 5,349)

to the quarter’s performance; had this been sustained in June, more than 6,000 individuals would

have been reported in this quarter.


Table 15. County antiretroviral therapy (ART) initiation against COP 2016 targets (Y7Q2).

County COP16

target

New ART

Y6Q4 Y7Q1 Y7Q2 Total % achieved

Scale-up to saturation counties

Homa Bay 5,568 448 464 438 1,350 24%

Kisumu 4,203 371 590 530 1,491 35%

Migori 4,415 476 621 553 1,650 37%

Kakamega 11,561 1,389 1,680 1,740 4,809 42%

Kisii 254 101 155 111 367 144%

Busia 2,365 225 287 273 785 33%

Subtotal 28,366 3,010 3,797 3,645 10,452 37%


Bungoma 1,935 642 664 700 2,006 104%

Nyamira 6,609 681 663 528 1,872 28%

Subtotal 8,544 1,323 1,327 1,228 3,878 45%

Sustained category

Vihiga 1,601 431 422 476 1,329 83%

Grand total 38,511 4,764 5,546 5,349 15,659 41%

Source: MOH 731

Homa Bay, Kisumu, Migori, Busia, Kakamega, and Kisii counties are the six scale up to

saturation counties the project supports, and they have the bulk of targets allocated; these

counties initiated 3,645 clients within the quarter and cumulatively 10,452—a 67% contribution

of the total COP 2016 achievement (15,659) from Oct 2016 to June 2017. Among the six

counties, Kisii County surpassed its COP 2016 targets of 254, by initiating 111 clients within the

quarter and cumulatively 367 clients, translating to an overall achievement of 144% against the

COP 2016 target. The other five counties of Kakamega, Migori, Kisumu, Busia, and Homa Bay

had an overall achievement of 42%, 37%, 35%, 33%, and 24%, respectively, against their COP

2016 targets. Among the aggressive scale up counties, Bungoma County surpassed its COP 2016

target, having initiated 700 clients in Quarter 2 with an overall achievement of 104% (2,006 of

1,935), while Nyamira County is at 28% (1,872 of 6,609). Vihiga, the only sustained county the

project supports, is on track having initiated 476 clients in the quarter and 1,329 from Oct 2016

to June 2017 against a COP 2016 target of 1,601 translating to 83%.

Homa Bay is the lowest performing county in ART initiation across the nine project-supported

counties. With a COP 2016 target of 5,568, the county has managed to initiate 1,350 on

treatment, resulting in the 24% performance. The county has good linkage to treatment, such that

of the 1,607 positives identified in the last nine months (1,421 through HTS, 186 through

PMTCT), 84% have been put on treatment. This low performance is a derivative of and follows

on the identification of the HIV-positive individuals in this county. Against an expected 3.9%

used in deriving the positive test target, the county’s yield was 1.1% translating to a 26% target

achievement in the three quarters for positive clients and a similar one (24%) for ART initiations.

There has been improvement in pediatric performance, and the counties of Kakamega, Kisii, and

Busia are on track within the three quarters, having achieved 107% (386), 92% (24), and 77%

(75), respectively, against their COP 2016 targets. The other counties’ overall achievement was

as follows: Vihiga 68%, Bungoma 56%, Nyamira 47%, Migori 26%, Homa Bay 20%, and


Kisumu 19%. The project will continue to employ winning strategies to identify more children

and link them to care and treatment with focus in counties that are still lagging.

On the current ART indicator, during the reporting period, the project achieved 107,916 against a

COP 2016 target of 120,374, translating to 90% achievement. During the same period, the

performance against target among the males was 84% (33,042 of 39,046) and among females

was 92% (74,874 of 81,330).

During the reporting period (April to June 2017), the project started from a baseline of 105,601

(current ART in March 2017) and reported 5,349 new ART enrollments, giving an expected

current ART of 110,950 (see Table 16 below). Against this, a current ART of 107,916 was

realized in June 2017, indicating an overall net loss of 3,034. Overall achievement as at the

Y7Q2 reporting period beginning with a September 2016 baseline of 102,261, plus a total of

15,659 new ART clients who were initiated on ART in the last nine months, giving an expected

current ART of 117,920, against a reported figure of 107,916 at the end of the Y7Q2 period. This

translates to a 91% crude retention in the 9-month period (107,916 of 117,920).

During the reporting period (April to June 2017), the project lost an overall 3,034 current-ART

clients, of whom 42% were contributed in June (1,266 of 3,034); April and May reported 1,243

and 525 losses, respectively. The majority of the losses in June were defaulters who missed their

appointments in the month as a result of the nurses’ strike, which affected 51 facilities (Nyamira-

30, Bungoma-10, Kisii-7, Kakamega-2, and Migori-2) that are run by MOH nurses. These

facilities are low-volume sites, with a range of 50 to 300 clients active on ART. The project

made efforts to ensure that those affected received their refills from neighboring facilities as

transit clients and redirected some staff to support these sites during the ongoing strike.

The project undertook an audit of the 3,034 current-ART clients reported to have been lost

during the reporting period and sampled the facilities that reported a high margin of losses;

nearly half of the losses were contributed by defaulters (largely, clients who missed

appointments during the last week of the month during the reporting period and even when

traced back were captured in the subsequent month, thus missed to be captured in the daily

activity register of the reporting month). An example is in Rachuonyo District Hospital in Homa

Bay County; this hospital has a high volume of clients, with a current-ART cohort of 3,851. It

reports that an average of 15 clients miss appointments every day, which translates to nearly 105

clients who miss appointments during the last week of the month and thus are unlikely to be

captured in the daily activity register at the close of the month. The project to this effect has

sensitized the facility health workers to reduce and ultimately minimize appointments given to

clients toward the end of the month and ensure a rapid defaulter tracing mechanism is in place to

track defaulters as soon as they miss appointments.


Table 16. Current antiretroviral therapy (ART) losses and retention during the April to

June 2017 reporting period, by county.

County Current ART

Y7Q1

New ART

Y7Q2

Expected

Current ART

Current ART

Y7Q2

Losses Crude

retention

Bungoma 12,927 700 13,627 13,348 279 98%

Busia 7,061 273 7,334 7,171 163 98%

Homa Bay 13,238 438 13,676 13,314 362 97%

Kakamega 28,824 1,740 30,564 29,638 926 97%

Kisii 1,874 111 1,985 1,850 135 93%

Kisumu 6,545 530 7,075 6,809 266 96%

Migori 12,344 553 12,897 12,638 259 98%

Nyamira 12,613 528 13,141 12,835 306 98%

Vihiga 10,175 476 10,651 10,313 338 97%

Total 105,601 5,349 110,950 107,916 3,034 97%

Source: MOH 731

In the category of scale up to saturation (Homa Bay, Kisumu, Migori, Kisii, Kakamega, and

Busia counties), the overall achievement for current ART was 88% (71,420 of 80,924) against

the cumulative target in this category (see Table 17). This category contributes to 67% of the

overall target; during the reporting period four out of the six counties were on track, with two

counties (Migori and Busia) achieving above 100%. Kakamega and Homa Bay are in progress

with an achievement of 86% and 71%, respectively. These two counties have a deficit of 4,657

and 5,522 clients, respectively, needed to achieve overall targets by Annual Program Results

(APR) 2017. Kakamega was allocated increased targets for new ART initiation (11,561 clients

up from 5,373 in the COP 2015 period), thus an expected monthly new ART target of 963 while

currently achieving an average enrollment is 500 monthly. Homa Bay was allocated a COP 2016

target of 5,568 clients for new enrollment, thus a monthly target of 464 while currently achieving

an average of 150 monthly. Homa Bay has experienced lower enrollments against target, as

evident from the overall positivity in the county being 1% against an expected 4% (used in

deducing the COP 2016 targets).


Table 17. Current antiretroviral therapy (ART) achievement during Semi-Annual

Program Results (SAPR) and Y7Q2 period, by county.

County COP16 target Current ART



Homa Bay 18,836 13,182 13,238 13,314 71%

Kisumu 6,936 6,049 6,545 6,809 98%

Migori 11,981 11,766 12,344 12,638 105%

Kakamega 34,295 27,182 28,824 29,638 86%

Kisii 1,905 1,730 1,874 1,850 97%

Busia 6,971 6,792 7,061 7,171 103%

Subtotal 80,924 66,701 69,886 71,420 88%


Nyamira 17,804 12,444 12,613 12,835 72%

Bungoma 11,886 12,558 12,927 13,348 112%

Subtotal 29,690 25,002 25,540 26,183 88%

Sustained county

Vihiga 9,760 9,854 10,175 10,313 106%

Grand total 120,374 101,557 105,601 107,916 90%

Source: MOH 731

In the category of aggressive scale up, the overall achievement is 88% (26,183 of 29,690) against

the cumulative target in this category. This category contributes to 25% of the cumulative target.

Of the two counties in this category, Bungoma is on track with an achievement of 112%, while

Nyamira is in progress with an achievement of 72% (12,835 of 17,804). Nyamira has a deficit of

4,969 to meet the overall COP 2016 targets. The only county in the sustained category, Vihiga,

achieved 106% (10,313 of 9,760) against expected target.

In regard to the pediatric performance, during the reporting period, the project achieved 10,196

clients on ART against a COP 2016 target of 13,240 translating to 77% achievement (see Table

18). Within the quarter, the project began with a baseline of 9,971 clients on ART in March 2017

and added 475 new on ART, giving an expected June current ART of 10,446. However, the

reported figure as at June 2017 was 10,196. Beginning with an APR September 2016 baseline of

9,707, a total of 1,339 new ART clients were initiated on ART in 9 months, giving an expected

current ART of 11,046, against a reported figure of 10,196 at the end of the Y7Q2 period. This

translates to a 92% crude retention in the 9-month period (10,196 of 11,046).


Table 18. Pediatric antiretroviral therapy (ART) achievement, Y6Q4 to Y7Q2 period, by

county.

County COP16

target

Current ART



Homa Bay 2,127 1,193 1,240 1,244 58%

Kisumu 790 437 485 500 63%

Migori 1,379 1,090 1,136 1,246 90%

Kakamega 4,005 2,604 2,832 2,832 71%

Kisii 264 167 185 185 70%

Busia 768 566 579 571 74%

Subtotal 9,333 6,057 6,457 6,578 70%


Nyamira 1,453 1,187 1,195 1,204 83%

Bungoma 1,296 1,198 1,216 1,307 101%

Subtotal 2,749 2,385 2,411 2,511 91%

Sustained county

Vihiga 1,158 1,024 1,103 1,107 96%

Grand total 13,240 9,466 9,971 10,196 77%

Source: MOH 731

As shown in Table 18, in the category of scale up to saturation counties, the overall achievement

was 70% (6,578 of 9,333) against the cumulative target in this category. The counties that are on

track are Migori and Busia, with 90% and 74%, respectively. Kisii and Kakamega are also on

track with 70% and 71%, respectively, while the lowest are Kisumu and Homa Bay at 63% and

58%, respectively. These two counties have a deficit of 290 and 866 clients, respectively, to

achieve the overall current target. The average achievement month on month in these counties

was 10 and 15 clients, respectively.

In the category of aggressive scale up, the overall achievement is 91% (2,511 of 2,749) against

the cumulative target in this category. Bungoma is on track with an achievement of 101%, while

Nyamira achieved 83%.

The only county in the sustained category, Vihiga, achieved 96% (1,107 of 1,158) against its

expected target.

Retention of clients on ART

To strengthen retention of clients at facility level, the project continued to work with existing

community mechanisms i.e. CHVs, expert clients and community peer educators to trace clients

who had defaulted from treatment and become lost to follow up. During the previous reporting

period, there were reported losses of 6,973 clients in SAPR 2017 period, of whom 4,226 clients

were defaulters, and the project embarked on a defaulter tracing exercise during the reporting

period. Facilities were supported during the RRI period to line list all clients who had been

identified as missed appointments in the period of October 2016 to March 2017 and did not have

a tracing outcome as at April 2017. The tracers used the client physical locator information to


trace the clients and about 86% of the 4,226 clients who were defaulters and loss to follow ups

were traced and accounted for during this quarter, with the findings shown as in Table 19.

Table 19. Progress made in tracing of SAPR (Oct 2016 to Mar 2017) defaulters and those

lost to follow-up.

Note: ART, antiretroviral therapy; CCC, comprehensive care clinic; LTFU, lost to follow-up; SAPR, Semi-Annual Program

Results.

To further enhance retention of clients, the project worked with the sub-county MOH teams to

urge facilities to limit client appointments. The project implemented the strategy of booking most

clients in the first 3 weeks of the month so that the last week of the month is set aside for tracing

clients who missed their appointments to come for ART refills and reviews before the month

ends. This is because the project observed that for most clients who miss their appointments in

the last week of the month and are reported as defaulters, a good number of them come back in

the first week of the following month. This strategy will enable the facilities to retain their client

base over time with minimal losses. The project will continue strengthening the appointment

reminders, daily evaluation of retention and the weekly tracing efforts while also strengthening

documentation at facility level to ensure all clients are captured in the daily activity register and

reported at the end of the month by having the clinicians, data clerks and peer educators review

their work daily to synchronize their data. The project will provide more focus to the pivot

counties of Kakamega, Homa Bay, and Nyamira, which contribute a great proportion to the

overall number of defaulters and those lost to follow up.

Similarly, efforts will be directed at achieving the first 90 positives through identification and

testing of partners and eligible children of index clients—optimally linking them to care and

treatment and retaining them.

Laboratory support

The project continued to provide support to 32 CD4 nodal sites in the quarter. It also maintained

linkages for viral load processing with Kenya Medical Research Institute (KEMRI) Alupe-


(Busia), KEMRI/US Centers for Disease Control and Prevention (CDC) (Kisian), and the Walter

Reed Program (Kericho).

CD4 and viral load uptake and networks

The summary of the CD4 baseline uptake over the quarter is shown in Table 20. A total of 32

CD4 nodal sites supported the network of the CD4 samples from the sites in the 9 counties. They

processed samples as baseline tests. During the quarter, the nodal sites with CD4 FACSCount

(15), PIMA point-of-care (13), and FACSCalibur machines (2) had sufficient reagents. A total of

4,977 CD4 samples were networked and processed in the quarter as baseline and/or for

diagnostic purposes. For diagnostic purposes, clients with CD4 counts below 100 cells/mm were

tested for serum cryptococcal antigen (CrAG).

Table 20. Total number of CD4 done across the 32 project-supported nodal sites, Y7Q2.

County CD4 done

Homa Bay 750

Kisii 925

Nyamira

Kisumu 502

Migori 648

Bungoma 284

Busia 432

Kakamega 1,093

Vihiga 343

Total 4,977

The project supported the viral load (VL) sample networks to the testing labs from all the sites. It

also maintained linkages for VL processing with KEMRI (Alupe-Busia); KEMRI/CDC (Kisian);

and the Walter Reed Program (Kericho). During the quarter, 29,881 first VL samples from the

project sites were processed and results availed to the clients. Of these, 77% (23,013/29,881)

were virally suppressed. The suppression rate varied by different age groups, with children (0–14

years) having the lowest suppression rate of 54% as shown in Table 21.

Table 21. Viral load (VL) done and suppression in different age groups in Y7Q2.

VL done and

suppression

Children 0-

14 yrs

Adolescents

15-19 yrs

Adults 20+

yrs

Total

First VL

done

2,929 822 26,130 29,881

Virally

suppressed

1,584 462 20,967 23,013

% virally

suppressed

54% 56% 80% 77%

However, there is still a backlog of samples at the testing labs of 2,819 VL samples across the

three testing hubs. When adjusted for the unprocessed/pending samples, the total number of VL

samples collected during the quarter increases to 32,700.


The suppression rate varied by different age groups, with adults across all the counties having

better suppression rates than the children and adolescents, as shown in Figure 7.

Figure 7. Viral suppression by age categories, in the nine project counties.

Note: BGM, Bungoma; BSA, Busia; HB, Homa Bay; KISII, Kisii; KK, Kakamega; KSM, Kisumu; MIG, Migori; NYM, Nyamira;

TOT, total; VHG, Vihiga.

To improve the uptake of viral load as well as the quality of the data that eventually is

transmitted to the VL website, the project undertook an exercise to create sub hubs where remote

log-in commenced in the last COP period in 7 sites and a scale-up undertaken in this reporting

period to reach 91 sites in total. These sites have received project support in human resources,

capacity-building, and modems as well as data bundles for internet use. The project has also

provided capacity-building for health care workers in accessing results for the viral load and

DBS using the SMS platforms, facility log-in to the website, and the mLab mobile application.

A scale-up of the rider-led sample network (RLSN) also took place in this quarter, with each

project-supported facility receiving a visit at least twice a week for the collection of all

networked samples and delivery of results of processed specimens from the central labs. This has

not only helped to create/re-create demand of services by the facilities, but also drastically

reduced batching of samples at the facilities and subsequently reduced the turn around time

(TAT) for samples sent to the testing hubs.

Differentiated Model of Care

In the reporting quarter, the project continued to implement the differentiated model of care at

the facility and community levels. The line listed clients continued to be sensitized and enrolled

onto this client-centred model, leading to an increase from 2,393 enrolled in the last quarter to a

cumulative of 7,252 clients on fast track in 204 facilities in the reporting period. In the

community model, clients in community ART refill groups (CARGs) increased ten-fold from

0

20

40

60

80

100

HB KISII KSM MIG NYM BGM BSA KK VHG TOT

Paeds 0-14 yrs 50 45 53 50 53 56 56 56 58 54

Adole 15-19 yrs 71 43 63 69 52 58 59 49 45 56

Adults 20+ yrs 80 78 83 80 76 80 83 80 83 80

VS

in p

erc

en

t


282 reported in the last quarter to 2,295 in the reporting quarter with 388 link facilities. Table 22

shows the project’s cumulative performance in the two models at county level.

Table 22. Differentiated drug delivery approaches at facility and community level, Y7Q2

County Current on

ART (Sep.

2016)

Eligible for

differentiated care

# clients on

facility fast track

# clients on

CARGs

Total

Homa Bay 12,974 3,760 1,514 429 1,943

Kisii 1,827 414 184 19 203

Kisumu 6,021 2,201 716 52 767

Migori 11,790 4,546 568 182 750

Nyamira 12,257 2,909 979 198 1,177

Bungoma 12,844 2,621 774 510 1,284

Busia 6,831 1,649 162 118 280

Kakamega 27,531 7,719 1,023 476 1,306

Vihiga 10,073 3,235 1,332 311 1,643

Total 102,148 29,054 7,252 2,295 9,665

Working with a target of 29,054 that was deduced by assessing the most stringent of the eligibity

criteria, that of IPT completion, the project will work towards enrolling the remaining 20,000

clients onto the differentiated model of care. The project will also focus on assessing the patient-

and health system level outcomes of these models.

PHDP interventions targeting PLHIV

The project continued to work towards empowering PLHIV to make effective decisions to

adhere to treatment and lead healthy life styles through provision of health and HIV education to

all PLHIV attending clinics. This was done through peer educators in both facility and

community PSSGs. In the quarter under review, a total of 1,340 newly enrolled clients received

one on one adherence counselling sessions to enable them to begin life-long treatment, know the

benefits of ART and the disadvantages of not adhering to treatment. Another 3,030 PLHIV who

defaulted on their appointment dates and were traced back to care and 5,680 suspected treatment

failures received one on one enhanced adherence sessions as booster sessions to strengthen their

adherence while dealing with barriers affecting their treatment. The project also supported

facility PSSGs with 3,230 PLHIV newly enrolled on care received key messages on PHDP that

included disclosure, family planning, condom promotion and use while making referrals for

1,997 of these clients to join community PSSGs in order to continue receiving psychosocial

support at community level.

At community level, the project supported establishment of additional 82 PSSGs bringing the

total to 858 community PSSGs from 776 in the previous quarter. The community PSSG

membership grew from 14,121 to 14,401 during the reporting period. The groups provide a

forum for PLHIV to meet and discuss key messages on PHDP while referring those in need of

services for service provision. During the reporting period, a total of 13,663 PLHIV attended

sessions with all receiving key messages on adherence and condom promotion messages, out of

which 9,903 completed all the 5 PHDP sessions. Out of these, 5,550 received condoms and


referrals were made for different services including 1,581 for family planning, 385 for GBV

screening, 867 for STI screening and 848 for nutrition assessment at facility level.

The following strategies were undertaken in the quarter to improve the pediatric and adolescent

viral suppression across the project zone:

Deployment of 76 adolescent Peer educators to support CCCs

Support for the partial disclosure of HIV status to children above 5 years was undertaken;

Directly observed therapy (DOT) by caregivers of both pediatrics and adolescents

Linkage of adolescents to teachers in boarding schools for support & observation

Special clinics i.e. weekend & holiday clinics to minimize missed appointments due to

school days and avoid tiring children

Leveraging on activities & collaboration with adolescent projects in the region

(EJAF/ELMA) in Kisumu county

Use of social media to discuss on adherence and follow up on appointment keeping

Table 23 below shows outcomes of adolescent services provided in the reporting quarter.

Table 23. Outcomes of adolescent services, Y7Q2

County Total # of on

Treatment

# Receiving

Weekend

Services

#in boarding school

linked to Teachers

# on DOTs

by Case

Managers

# Virally

suppressed

Kisumu 338 317 54 33 260

Migori 477 156 18 66 219

Kisii 74 74 12 45 53

Nyamira 311 311 112 65 164

Homabay 668 342 71 90 487

Bungoma 772 637 91 114 234

Busia 580 332 45 191 318

Kakamega 2,415 361 233 372 1273

Vihiga 1410 439 69 241 810

Total 7,045 2,969 705 1217 3,818

In the quarter, the project also undertook activities aimed at enhancing adherence among the

clients that were failing treatment so as to ensure resuppression occurred. These included:

DOTs at home through home visits by peer educators

2 weekly STF clinics with intensive adherence sessions

Home visits to strengthen adherence at home

STF PSSGs and buddies

Nutrition assessment, counseling, and support

In the reporting period, 55,747 (52%) people living with HIV (PLHIV) from most of the ART

sites were reached with nutrition assessment, counseling, and support (NACS). However, this

was a drop compared to the previous quarter. This drop was caused by the nurses’ strike—

especially in sites where we have trained them to carry out nutrition services and prepare reports.

The project has also been engaging nutrition volunteers to help carry out NACS in high-volume


facilities, but this time the volunteers were engaged in June only, hence missed opportunities in

the preceding two months. However, the project aims at reaching more PLHIV now that the

volunteers are on board again.

During this period, 8,929 PLHIV were given food supplementation, which included fortified

blended flours and ready-to-use therapeutic food (RUTF). There was shortage of Food By

Prescription (FBP) during the period in many sites, and many clients got RUTF instead. The

supplies are expected to resume at the end of July, and priority will be given to Kakamega and

Homa Bay, where we have more FBP sites, and then the rest of the counties. Peer educators and

adherence counselors were supported to continue establishing nutrition demonstration centres to

provide sessions to newly enrolled clients and suspected treatment failures to enable them learn

how to grow nutritious food crops and replicate the same in their households, hence improve their

nutrition status.

Health informatics: Electronic Medical Records (EMR) and ART dispensing tool

The project has continued to support 119 facilities that were furnished with Kenya OpenMRS

platform of EMR. Ninety (90) facilities, out of one hundred and nineteen, (119); (75%) have

achieved Point of Care usage of the system. Refresher trainings on Data use to support EMR

clinical decision making at facility level, technical support and mentorship have been done and

will continue to be offered to the clinical team and health records staff.

A total of 62 health facilities (29 in Kakamega, 13 in Vihiga, 6 in Bungoma, 4 in Busia, 3 in

Nyamira, 3 in Migori and 1 in Kisumu) have already achieved the required Data Quality

threshold and are awaiting launch by the department of health in the respective counties. The

project has set a goal of achieving paperless operations in at least 63 sites by September 2017.

The project also has continued to support 42 health facilities that host the ART dispensing tool

through hardware and software upgrading to the new tool with core features to manage

commodities. Reporting and direct transmission of viral load results from NASCOP website

where the results are synchronized with patient data in the system. More so, the project

conducted off-site trainings and on-site mentorships at the facility levels. Given the shift to the

Electronic Dispensing and Inventory Tracking Tool, the project upgraded 32 facilities to the new

Web ADT. Support to the other sites will continue in the coming quarter even as the project

addresses challenges with the internet access to synchronize viral load results as well as

migration to the new platform continue to be supported by the Clinton health access team.

TB-HIV co-infection services

During the reporting period, a total of 508 sites were supported while implementing the TB/HIV

co-infection services, with focus on improved TB/HIV integration through three different models

of care. Out of the 511 supported sites, 218 (43%) provided a complete integration model, 181

(35%) provided a partial integration model, and 112 (22%) provided a cross-referral model. All

the sites provided active case finding (ACF), intensified case finding (ICF), immediate ART for

all TB/HIV co-infected clients, and isoniazid preventive therapy (IPT) initiation for eligible

asymptomatic clients with an aim of improved IPT completion rate. The complete integration


model was noted to be the best, in that patient management was good and the defaulter rate and

patient waiting time at the facility were noted to be low.

The project also supported provision of a minimum package of infection prevention and control

(IPC) to reduce TB transmission among health care workers and other patients. To improve on

the TB case finding and GeneXpert utilization, the project supported implementation of the

sample networking system through introduction of the RLSN approach, where one motorcycle

rider per sub-county (41 sub-counties and 41 riders) was engaged to transport samples (CD4,

GeneXpert, viral load, and EID) from peripheral sites to central sites with the diagnostic

equipment (CD4/GeneXpert samples) or for onward transmission to other labs (viral load

samples). Other activities during the reporting quarter included capacity-building initiatives, joint

supportive supervision, performance review meetings, and school health talks.

TB/HIV performance

As shown in Table 24 and Figure 8, in Y7Q2, 1,400 TB patients were registered in project-

supported sites, leading to a total of 3,363 TB registered patients in these sites. Of the total

registered patients, 3,249 (97%) were counseled and tested for HIV and 1,178 of these 3,249

(36%) were identified as TB/HIV co-infected; 1,165 of these 1,178 (99%) were initiated on

cotrimoxazole preventive therapy (CPT) and 1,120 of the 1,178 (95%) were put on ART.

Table 24. Key TB-HIV performance against COP 2016 target

TB/HIV performance indicators COP 2016

Targets


Number of TB cases registered 1,269 694 1,400 3,363

Number of TB patients who were

counseled, tested for HIV, and received

results

7,309 1,238 674 1,337 3,249

Proportion counseled and tested for HIV

and received results against COP 2016

target

44%

Number of HIV-infected TB patients 473 264 441 1,178

Proportion of TB-HIV co-infection 36%

Number of HIV-infected TB patients on

cotrimoxazole

469 258 438 1,165

Number of HIV-infected TB patients on

ARVs

2,564 454 246 420 1,120

Proportion of HIV-infected TB patients on

ARVs against COP 2016 target

44%

Number of HIV-positive clients screened

for TB

120,374 91,539 101,305 102,648 102,648

Proportion of PLHIV clients screened for

TB against COP 2016 target

(105%) 85%

Note: ARV, antiretroviral; COP, Country Operational Plan; PLHIV, people living with HIV; TB, tuberculosis.

Source: TIBU System data/MOH 711.


Further analysis against the COP 2016 target of 7,309 clients indicated that 3,249 TB patients

were counseled and tested for HIV; this translates to 44% (3,249 of 7,309) project achievement

against the expected 75% at the end of the reporting period. Despite the increase of registered

patients by 706 patients as compared to Y7Q1 report, the overall low performance of 44% could

be attributed to the low number of registered TB patients in the Y7Q1 period coupled with the

health care workers’ strike.

To further improve and sustain the TB case finding and other key indicators, the project will

work closely with the facility and sub-county team members with a focus on improved case

finding. This will be achieved through utilization of the new RLSN system by ensuring that ACF

is conducted in all reporting sites and all identified patients are registered in the TB4 registers.

The project has recruited 324 ‘cough monitors’ who will be tasked in the ACF activities with

timely referrals; this cough monitors system will be a key deliverable in subsequent quarters.

ART initiation among TB/HIV co-infected clients

During the reporting period, 1,120 TB/HIV co-infected clients were initiated on ART, out of

1,178 co-infected clients, translating to a 95% ART uptake. When compared to the COP 2016

target, an achievement of 44% (1,120 of 2,564) was realized (see Table 24). The low COP target

performance (below the expected 75%) can be attributed mainly to the low case finding

witnessed in the Y7Q1 period. To further improve on ART uptake among co-infected TB

patients, the project has continued to focus on ACF through the cough monitors program,

mentioned above, to ensure that more clients are diagnosed earlier and started on treatment. The

project will also continue with dissemination of ART guidelines and capacity-building for health

providers and will support regular performance review meetings to ensure proper documentation

and reporting.


Figure 8. TB/HIV cascade, Y6Q4 to Y7Q2.

Note: ART, antiretroviral treatment; CPT, cotrimoxazole preventive therapy, CT, counseled and tested [for HIV]; TB,

tuberculosis.

Source: TIBU System data/Ministry of Health (MOH) 711.

Childhood TB/HIV

In Y6Q1 and Y7Q2, the proportion of children diagnosed with TB was 9% (198 of 2,094), of

which 98% (194 of 198) were tested for HIV, and 31% (61 of 198) were co-infected with

TB/HIV. All 61 children co-infected with TB/HIV were on CPT and 93% (56 of 61) were

initiated on ART. In subsequent quarters, the project will continue to support capacity-building

initiatives and the cough monitors approach to ensure that there is no missed opportunity of TB

diagnosis among children. This will be done through utilization of pediatric ICF cards at all

levels of care, with keen focus on the outpatient department (OPD), inpatient department (IPD),

CCC, and MCH clinics. Sensitization of HCWs on GeneXpert use for all symptomatic children

based on the GX algorithm will be supported to scale up the diagnosis of TB among children to

the set target of 12%. The project will also strengthen the sample networking approach through

the RLSN system. On ART initiation among the co-infected children, the project focus will be to

improve the uptake from the current 93% to 98% through facility-based CME and mentorship of

HCWs on ART guidelines for eligibility among the co-infected children.

1,269 1,238

473 469 454

694 674

264 258 246

1,400 1,331

441 438 420

3,3633,249

1,178 1,165 1,120

NUMBER OF TB CASES REGISTERED

NUMBER OF REGISTERED TB PATIENTS WHO

RECEIVED HIV CT AND RESULTS

NUMBER OF TB PATIENTS HIV POSITIVE

NUMBER OF TB PATIENTS ON CPT

NO OF HIV POSITIVE TB PATIENTS ON ART

Y6Q4 Y7Q1 Y7Q2 TOTAL


Intensified case finding—TB screening

During the reporting period, a total of 102,648 clients were screened for TB, translating to 95%

achievement (102,648 of 107,916), as shown in Table 25. To further improve and sustain the TB

screening achievements, the project will focus on counties with less than 90% TB screening

(Kisii and Nyamira) to ensure that above 95% screening among PLHIV is achieved. The project

will also provide targeted mentorship and facility CMEs across all the supported CCCs. Cough

monitors will also be tasked to ensure that proper screening for all the PLHIV is conducted

during every clinic visit with regular use of ICF cards and ICF files.

Table 25. Tuberculosis (TB) screening among antiretroviral therapy (ART) clients, Y7Q2.

County No of ART

Clients Y7Q2

No Screened for

TB Y7Q2

% ART Clients screened for

TB Y7Q2

Busia 7,171 6,922 97%

Homa Bay 13,314 12,475 94%

Kisumu 6,809 6,630 97%

Migori 12,638 12,342 98%

Kakamega 29,638 28,566 96%

Kisii 1,850 1,761 95%

Nyamira 12,835 11,980 93%

Bungoma 13,348 12,159 91%

Vihiga 10,313 9,813 95%

Total 107,916 102,648 95%

Note: COP, Country Operational Plan; TB, tuberculosis.

Source: Ministry of Health (MOH) 731.

GeneXpert diagnostic system utilization

In Y7Q2, GeneXpert utilization rates across all the supported counties were on the increase, with

an error rate below 3.5% as shown in Table 26. The increase may be attributed to the new RLSN

approach. During the reporting quarter, the project introduced the cough monitors program,

which is expected to increase the utilization rate in all 41 supported sub-counties. During the

reporting period, stockouts of falcon tubes and cartridges were noted to be a major challenge; in

subsequent quarters, the project will purchase buffer stock to support the sites in instances of

stockouts.


Table 26. GeneXpert utilization rate per county, Y7Q1 to Y7Q2.

Source: NTLD-P – Online GX Alert.

TB preventive therapy

The project continued to support implementation of IPT initiatives through various capacity-

building activities. During the reporting period, a total of 7,218 asymptomatic PLHIV were

started on IPT. Analysis of clients who were initiated on IPT 6 months earlier showed that

87% of the clients completed the course of therapy (see Table 27). In subsequent quarters,

the project will focus on counties that achieved less than 85% completion rates. The project

will also support quarterly meetings for SCTLCs and SC-Pharmacists to ensure availability

of IPT commodities. The project will also support capacity-building initiatives to ensure

that there is timely follow-up with regular updates and reviews of facility IPT registers.

Table 27. Proportion of antiretroviral therapy (ART) patients who completed a standard

course of TB preventive therapy (isoniazid preventive therapy [IPT])

County Number starting IPT

(Y7Q2)

Number started IPT

6 months ago

Number completed

IPT (Started 6

months ago)

% Completing IPT

Busia 538 892 799 90%

Bungoma 1,123 423 299 71%

Kakamega 2,396 2,220 2,099 95%

Vihiga 680 997 671 67%

Migori 831 1,722 1,585 92%

Homabay 514 304 285 94%

Kisumu 275 136 136 100%

Nyamira 674 510 498 98%

Kisii 187 314 147 47%

Total 7,218 7,518 6,519 87%

Source: Ministry of Health (MOH) district health information system (DHIS).

TB/HIV cohort analysis

The cohort analysis for 1,297 TB clients registered one year earlier (Y6Q2) showed that 88% of

the reported clients (1,142 of 1,297) completed their TB course treatment; 2% (25) were lost to

follow-up; 4% (49) were transferred to other facilities before completion of treatment; 1% (14)

County % GeneXpert

utilization

Y7Q1

% GeneXpert

error rate

Y7Q1

% GeneXpert

utilization

Y7Q2

% GeneXpert

error rate

Y7Q2

Kisumu 94% 2% 98% 1.2%

Homa Bay 75% 2.9% 86% 3%

Migori 72% 3% 83% 2%

Busia 81% 2.6% 89% 3%

Kakamega 63% 2.4% 91% 2.5%

Nyamira 75% 3% 82% 3%

Kisii 68% 3% 72% 2%

Bungoma 89% 2% 93% 2%

Vihiga 36% 3% 54% 3.5%


were reported as failed and were subjected to GeneXpert testing, drug-susceptibility testing, and

culture; and 5% (67) of the clients died while on treatment. The project will focus on improved

TB outcomes with reduced death rates through early detection of TB by cough monitors and

timely treatment initiation.

Drug-resistant TB management

In Y7Q2, 5 new drug-resistant (DR) patients were reported in project-supported sub-counties,

bringing the total number of DR-TB patients on treatment at project-supported sites to 56. All 5

DR-TB patients were diagnosed through the GeneXpert machine. Contact tracing for all 5 new

clients was conducted at household level, and a total of 17 contacts were screened; none was

found to be MTB positive. Cohort analysis of the seven DR-TB patients who were started on

treatment 2 years ago indicated that 72% (5 of 7) were cured, 14% (1 of 7) transferred to other

site, and 14% (1 of 7) died while on treatment. The project will continue with support for DR-TB

management through regular clinical review meetings and DR-TB surveillance through contact

tracing and transport of samples for GeneXpert through the RLSN approach.

Infection prevention and control

During the reporting quarter, 87% (441 of 508) of all the project-supported sites were able to

provide a minimum infection prevention and control (IPC) package (i.e., well-ventilated waiting

bays, triaging of clients, and opening of windows). All 441 sites developed an IPC plan and used

information, education, and communication (IEC) materials. In subsequent quarters, the project

will support regular health talks by cough monitors at facility and community levels to ensure

that there is minimal transmission of TB among HCWs, other patients, and visitors to the facility.

Community TB care

In Y7Q2, the project supported outreaches and school health talks in 24 schools that had reported

TB cases. A total of 1,245 pupils and students were screened for TB; 2 new children were

diagnosed and initiated on treatment. Household contacts of 5 multidrug-resistant (MDR)–TB

patients was conducted and all the GeneXpert samples for 12 presumptive cases were MTB

negative. In subsequent quarters, the project will focus on all contacts of smear-positive clients

through the cough monitors program.

HIV prevention services

Voluntary medical male circumcision services

During the reporting period (April to June 2017), the project continued to provide direct service

delivery (DSD) support to 39 project-supported voluntary medical male circumcision (VMMC)

sites through the provision of consumables, equipment, and reporting tools; supportive

supervision; and mentorship on VMMC service provision. All 39 VMMC sites are in scale up to

saturation counties (Homa Bay, Migori, Kisumu, and Busia). As shown in Table 28, during the

period, 11,794 men accessed VMMC services across the 39 sites in the four counties. Nearly all

(11,588 men, or 98%) were counseled and tested for HIV as part of the VMMC minimum

package of services; of these, 8 men turned positive and were referred and linked for HIV care,

treatment, and support. There was no adverse event reported. The project and MOH teams


continue to ensure that young adolescents with immature penile anatomy receive the service

using the recommended dorsal slit technique.

Table 28. Voluntary male medical circumcision (VMMC) performance by county, Y6Q4 to

Y7Q2.

County COP 2016

targets

Medical circumcisions done


Homa Bay 28,282 8,495 2,723 6,726 17,944 63%

Migori 8,278 4,132 473 2,404 7,009 85%

Kisumu 5,830 1,825 401 1,191 3,417 59%

Busia 2,228 2,627 237 1,473 4,337 195%

Total 44,618 17,079 3,834 11,794 32,707 73%

At the end of the quarter ending June 2017, a total of 32,707 clients had accessed VMMC services

against a COP 16 target of 44,618, a 73% achievement.

At the county level, Busia and Migori achieved greater than the expected 75% performance

(195% and 85%, respectively). Homa Bay managed to conduct 17,944 circumcisions against a

COP target of 28,282 (63% achievement) and Kisumu managed 3,417 against a COP target of

5,830 (59% achievement). This achievement is attributed to the project support for six weeks of

a rapid results initiative and four weeks of an accelerated VMMC campaign coinciding with a

school holiday in April 2017 across all 39 fixed and outreach sites. Busia County’s set target was

way below the demand for services in the county. In Migori County, the project sites were about

the only ones providing VMMC services in Quarter 1, a period when there was a slow transition

between the other VMMC implementing partners in the county; this resulted in a huge influx of

clients seeking VMMC services in the project-supported sites. This influx catapulted the

project’s county performance to 50% of its annual target by end of that quarter. Kisumu’s and

Homa Bay’s relatively huge targets called for more outreach and mobile VMMC services. These

outreaches, however, have been affected by the intermittent health care workers’ strikes that

have led to the closure of most of these outreach sites. To mitigate effects of the ongoing nurses’

strike, the project plans to engage (on a locum basis) qualified and competent VMMC surgeons

(RCOs and nurses) and deploy them in the affected outreach sites. Although the project plans to

conduct VMMC mobile and outreaches based on demand, the project will ferry clients from

affected sites to the non-affected sites for services.

The project used multifaceted strategies to mobilize clients for services. For example, to increase

demand for VMMC services, the project continued to engage with community structures for

social mobilization during VMMC rapid results initiatives (RRIs) and outreaches targeting males

aged 10 to 29 years in the community and in educational institutions. Door-to-door community

mobilization by the CHVs also ensured that there was a steady stream of clients at facility level.

The project also continued to sensitize women on the benefits of VMMC, enabling them to make

referrals, accompany partners for VMMC, and offer support during the healing period. Targeted

partner testing was also carried out during the VMMC service at all supported sites, and

appropriate linkages to care, treatment, and support made for all clients testing HIV positive. The


project also continued to support and participate in the national, county, and sub-county VMMC

task force activities for the purposes of coordinating VMMC services in the region.

The project continued with the process of computerizing management of VMMC data, a system

that enables the project to generate VMMC data electronically and to enable specific VMMC

data disaggregation for reporting and decision-making purposes.

During this period, 100 health care providers were trained on male circumcision under local

anesthesia; across the 39 project-supported sites, these providers continued to practice male

circumcision under the supervision of county VMMC trainer of trainers (ToTs), who ensured

that they attained the required skill set to offer male circumcision to both clients with mature and

immature penile anatomy. The project has continued to support quality assurance initiatives by

supporting the MOH teams to conduct continuous supportive supervision and mentorship, and by

supporting monthly data review meetings, conducting data quality assessment (DQA) and Site

Improvement through Monitoring System (SIMS).

Priority population

The project continued supporting KRCS and WRCCS to implement a combination HIV-

prevention approach targeting fisher folk through evidence-based interventions (EBIs) in 17

beach management units in Kisumu (12) and Busia (5) counties. The EBIs implemented were

Splash Inside Out (SIO) and Positive Health Dignity and Prevention (PHDP). The combination

prevention approach was implemented within the 90:90:90 concept for sustained service uptake

and was underpinned by the following activities.

Behavioral interventions included conducting peer education at individual and group levels and

outreaches, risk assessment, risk-reduction counseling and skills-building promotion,

demonstration and distribution of male and female condoms, and implementing PHDP as well as

screening for sexually transmitted infections (STIs), TB, and drug and alcohol abuse. The

behavioral interventions implemented resulted in the increased uptake of biomedical and

structural services by the fisher folk reached under the prevention, care, and treatment

continuum.

Through biomedical interventions, the fisher folk were linked to referral facilities for the uptake

of the health service package. Some were also reached through integrated outreaches. The

package included HTS, STI treatment, HIV and TB care and treatment, VMMC, RH/FP

(including emergency contraception), post-exposure prophylaxis (PEP) and tracking of effective

referrals. To ensure uptake of care and treatment services, the project used a linkage register to

track completed referrals.

Structural interventions were also implemented and entailed the following: promoting 100%

condom use, legal aid, mitigating sexual and gender-based violence, promoting alcohol and drug

reduction, and mounting condom dispensers at strategic locations in the beaches. Alternative

sources of income including linkage to microfinance and other devolved funds such as Uwezo

and Women Enterprise Fund was done. Through networking and collaboration, one fisher folk


PSSG from Nduru Beach in Kisumu was linked to Kenya Commercial Bank, which trained the

group on financial management with a view toward improving their economic status.

Within the period of October 2016 to June 2017, the project supported direct service delivery and

technical assistance to two LIPs through data validation and verification, supportive supervision,

mentorship, performance review and reporting, commodity consumption and forecasting, and

financial management including budgeting. This support resulted in 85 peer educators from the

two LIPs reaching 8,927 fisher folk, translating to 65% COP target achievement (Busia-75% and

Kisumu-51%). Though not on track toward achievement of the COP 2016 target, there was

tremendous improvement in Kisumu, particularly in June 2017, due to motivation of the peer

educators through timely payment of stipends and close monitoring and supervision by the

project staff. In addition, 3 peer educators who had been dropped due to lack of funding

voluntarily assisted in conducting one-on-one sessions to fisher folk, boosting the number

reached. Table 29 below illustrates the number of fisher folk reached between October 2016 and

June 2017.

Table 29. Fisher folk reached with HIV prevention services, October 2016 to June 2017.

County COP

2016

target

# reached

Oct–Dec

2016

# reached

Jan–Mar

2017

# reached

Apr–Jun

2017

# reached

Oct 2016–

Jun 2017

% of target

achievement

Busia 7,848 2,136 2,222 1,559 5,917 75%

Kisumu 5,890 1,028 615 1367 3,010 51%

Total 13,738 3,164 2,837 2,926 8,927 65%

Biomedical interventions

Between April and June 2017, 2,132 of the 2,926 fisher folk reached during Splash Inside Out

sessions were effectively referred for and received at least one essential package of services as

shown in Table 30. Specifically, 1,592 of them were newly tested/referred for HTS, of which 38

were HIV positive, translating to a 2.3% positivity rate.

Table 30. Fisher folk reached during splash inside out sessions and complete referrals

provided, April to June 2017

Month County Reached Complete referrals for biomedical services Complete referrals for

structural services HTS STI VMMC TB CaCx EC/FP GBV A&D PSS FSS LA

Apr Busia 586 153 0 1 6 21 5 0 0 0 0 1

Kisumu 155 69 29 22 6 42 43 8 7 16 10 9

May Busia 617 174 1 0 3 5 3 0 0 0 0 0

Kisumu 201 175 41 34 26 32 76 29 19 18 9 15

Jun Busia 356 148 0 0 0 1 1 0 0 0 1 0

Kisumu 1,011 382 47 41 64 102 138 24 18 22 16 19

Total 2,926 1,101 118 98 105 203 266 61 44 56 36 44 Note: A&D, [Alcohol & Drugs; CaCx, [Cancer of Cervix]; EC, emergency contraception; FP, family planning; FSS, [family

support services]; GBV, gender-based violence; HTS, HIV testing services; LA, [legal aid]; PSS, psychosocial support; STI,

sexually transmitted infection; TB, tuberculosis; VMMC, voluntary medical male circumcision.


Cumulatively, between October 2016 and June 2017, a total of 3,940 of the 8,927 fisher folk

reached were effectively referred for and received essential packages of biomedical and

structural services. Specifically, 3,686 out of the 8,927 fisher folk reached in that period were

newly tested/referred for HTS. Eighty-five (85) of them tested HIV positive, translating to a

2.3% positivity rate, and nearly all of those (83 of 85) were successfully linked to treatment,

translating to 98% linkage. Follow up of the 2 unlinked clients will be made to ensure they are

linked to treatment in the subsequent reporting quarter.

Tables 31 and 32 illustrate use of HIV testing services by fisher folk between October 2016 and

June 2017.

Table 31. Results of HIV testing of fisher folk in two counties, April to June 2017.

County Number

reached

Newly tested/

referred

Newly testing

positive

Known

positives

Missed

opportunities

including those

declining referrals

Busia 1,559 966 4 26 567

Kisumu 1,367 626 34 112 629

Total 2,926 1,592 38 138 1,196

Table 32. Results of HIV testing of fisher folk in two counties, October 2016 to June 2017.

County Number

reached

Newly tested/

referred

Newly testing

positive

Known

positives

Missed

opportunities

including those

declining referrals

Busia 5,917 2,254 14 73 3,590

Kisumu 3,010 1,432 71 169 1,409

Total 8,927 3,686 85 242 4,999

All 242 known positives are on treatment in linked health facilities within the 8 wards where the

LIPs operate (6 in Kisumu, 2 in Busia).

As shown in Table 32, between October 2016 and June 2017, there were 4,999 missed

opportunities for HTS and 242 known positives amongst the fisher folk reached. The LIPs

organized for 40 outreaches (29 in Kisumu, 11 in Busia) where peer educators mobilized their

peers to access HIV testing for those who had missed the opportunity. At these outreach

sessions, 3,192 fisher folk (1,544 M, 1,648 F) were reached and tested for HIV, including the

missed opportunities. Of these, 48 fisher folk (28 M, 20 F) tested HIV positive, and 46 (27 M,

19 F) were successfully linked to care. More outreaches will be conducted in the following

quarter to reach the pending missed opportunities.

Cumulatively, between October 2016 and June 2017, a total of 79,343 condoms were distributed

to 7,310 fisher folk (3,512 M, 3,798 F) through 804 outlets in Kisumu and Busia counties (see

Annex C).


Structural Interventions

During the quarter, two legal aid clinics were done in collaboration with Children’s Legal Action

Network in Busia County, reaching 82 fisher folk (32 M, 50 F) with information on gender-

based violence (GBV) and property rights, among other concerns. Consequently, 8 people were

supported by a lawyer who participated in the clinic to handle cases of land, child protection, and

gender-based issues on a subsidized fee. On linkage to microfinance to fisher folk, 2 more

groups accessed devolved funds from Uwezo and Women Enterprise Fund, bringing to a total of

15 groups accessing devolved funds to expand and/or diversify individual businesses. The

groups also continued with table banking, which continued to improve the member’s economic

safety nets. In Kisumu County, one group from Nduru Beach was linked to financial institutions

such as Kenya Commercial Bank, which trained members on financial management, hence

building their capacity in record keeping and business diversification. The LIPs continued to

collaborate with other partners such as the Ministry of Health, Kenya Commercial Bank, and

microfinance institutions to provide services to the fisher folk.

The LIPs continued to collaborate with other partners such as the Ministry of Health, Kenya

Commercial Bank, and microfinance institutions to provide services to the fisher folk.

Gender mainstreaming and integration

The project continued to strengthen gender integration activities in service delivery to facilitate

access to and utilization of health care services by both men and women through community-

level norm change interventions and community- and facility-level GBV response services. The

key activities implemented in the reporting quarter were community-level education to empower

both male and female genders on gender-based violence (GBV) prevention and response,

orientation of police on gender to strengthen operations of gender desks in police stations and

GBV response, marking of the Day of the African Child, and protection and legal services to

GBV survivors. The project also continued supporting CMEs for HCWs to strengthen post

violence care service provision and reporting.

Addressing male norms and behaviors

The project continued to implement community-level activities to explore and reduce negative

gender norms that impact access to and use of services. In addition, these activities aimed at

preventing GBV and creating demand for clinical services. The activities carried out to address

norms change were orientation of local administration and police officers on gender and GBV

service provision, community-level dialogue sessions on gender and GBV, conducted gender

analysis using the gender marker method in Ntimaru (Migori County) to understand the

prevailing circumstances surrounding persistent physical gender violence recorded in the

community. The project also supported gender TWG monthly meetings to strengthen GBV

response, branding of the project-supported paralegals with t-shirts, and marking of the Day of

the African Child. Using the SASA! community mobilization approach

(http://raisingvoices.org/sasa/), 3,105 people were reached with norms and behavior changing

information and education in Y7Q2.


Post gender-based violence (GBV) services

The project continued to support integrated post GBV care services both at the community and

facility levels leading to an achievement of 2,673 in Y7Q2 period and a total of 6,363 clients

reached by end of June 2017, an achievement of 92% against COP 2016 target of 6,889 (see

Table 33 below).

Table 33. Post gender-based violence (GBV) care services, October 2016 to June 2017.

COP 2016

targets


reached

% achievement

6,889 1,385 2,305 2,673 6,363 92%

Community-level GBV services

The project continued to conduct active GBV case identification through screening during

community outreaches and at the safe spaces. Targeted community-level sensitizations on GBV

were also held in Lurambi and Ikolomani (Kakamega County), Ntimaru and Kegonga (Migori

County), Ekerenyo (Nyamira County), and Rachuonyo (Homa Bay County), which had recorded

high cases of GBV.

In addition, the project supported gender TWGs to coordinate marking of the Day of the African

Child. In Kisumu, Bungoma, Kakamega, Nyamira, and Migori, the gender TWGs continued to

engage communities and administrations to understand the policy and legal contexts in relation

to violence against women and girls and how to collaborate with other actors in offering

response services. In Busia, Kisumu, Homa Bay, and Migori, the project continued to engage

women as essential partners in promoting voluntary male medical circumcision (VMMC) and

HIV testing among men, providing key messages on the benefits of VMMC and male-partner

testing to the females.

Facility-level post GBV services

During the reporting quarter, the project supported CMEs and supportive supervision for health

care workers to improve GBV screening, understanding and use of GBV reporting tools and

standard operating procedures, complete documentation of physical violence cases in the OPD

registers, and use of the black books to capture other forms of GBV (non-sexual) that receive

clinical services. The project-supported, facility-based peer educators and paralegals were

assisted to follow up clients to ensure that PEP medication is completed. To strengthen reporting

of non-sexual GBV, the project supported meetings involving data officers and health care

providers at the OPD to identify the existing gaps and how to improve on them. In Kisumu and

Nyamira counties, the project supported meetings between police officers and HCWs from two

major police stations and sub-county hospitals to facilitate collaboration and linkage for legal

redress of cases. As a result, a total of 352 survivors of sexual violence (350 F, 2 M) were

reached with services in Y7Q2, compared to 388 in Y7Q1, giving an achievement of 6,363 as at

end of June 2017 (92% against COP 2016 target) as shown in Table 34 below.


Table 34. Survivors of gender-based violence (GBV) reached with services, Y6Q4 to Y7Q2.

County COP

2016

targets

Y6Q4 (GBV–

sexual and

other)

Y7Q1

(GBV–

sexual and

other)

Y7Q2

(GBV–

sexual)

Y7Q1

GBV–

other)

Total %

achievement

Bungoma 860 192 261 65 165 683 79%

Busia 803 136 89 30 87 342 43%

Homa Bay 690 106 156 5 129 396 57%

Kakamega 986 211 627 87 509 1,434 145%

Kisii 302 60 112 7 179 358 119%

Kisumu 677 146 122 12 245 525 78%

Migori 800 188 352 37 331 908 114%

Nyamira 788 227 403 10 458 1,098 139%

Vihiga 983 130 183 99 218 630 64%

Total 6,889 1,385 2,305 352 2,321 6,363 92%

A total of 256 survivors of sexual violence were tested for HIV, 213 received PEP, 114 received

STI treatment, and 52 were linked to legal, police, psychosocial, and protection services. In

Kakamega County, the project facilitated the rescue of 11 female survivors of sexual violence, 4

of them children. The project supported the survivors with daily dignity packs and food through

Dwele shelter home in Kakamega for a period of two weeks, after which they were re-integrated

with their families and caregivers. In Naitiri, Bungoma County, project-supported paralegals

facilitated the formation of a support group for GBV survivors to create a forum for experience

sharing and psychosocial support, while in Vihiga and Migori counties, 2 cases were transferred

to Eldoret and Kisumu, respectively, to protect the witnesses. A total of 26 cases proceeded to

court, 3 were concluded, and 23 are ongoing.

DREAMS interventions

In this reporting quarter, the project continued to implement the interventions in the two

Counties of Kisumu and Homa Bay. Focusing on the four categories of interventions in the

DREAMS initiative. A major focus was placed on ensuring that enrolled adolescent girls and

young women (AGYW) receive services. In the previous quarter, some AGYW were indicated

as having received zero services. The project therefore put efforts to find the AGYW and

determine the reasons for this. Additionally, the project, in view of the coming elections and in

anticipation of program disruptions, put in place mechanisms to accelerate achievements and

also to keep the AGYW safe.

AGYW enrollment into DREAMS

In the reporting quarter, significant progress was made in AGYW enrollment. Current enrollment

is at 32,476 AGYW against the project target of 34,264; this is a slight decrease from last

quarter’s enrollment level of 33,392. The decrease was attributed to a project-instituted measure

of de-enrolling 182 AGYW ages 10–14, 187 AGYW ages 15–19, and 557 AGYW ages 20–24 as

a result of over enrollment of these cohorts in Quarter 1, especially in Homa Bay County. Self-

requested exits, lost to follow up, request by the caregiver, and death also contributed to


reduction in the numbers. To achieve the overall target, the project will continue to enroll

AGYW aged 20–24 years whose target has not been achieved.

Table 35 below shows the enrollment status at the end of the quarter.

Table 35. Enrollment status of adolescent girls and young women (AGYW), by county.

County COP

2016

target

Enrolled

, ages

10–14

COP

2016

target

Enrolled,

ages 15–

19

COP

2016

target

Enrolled,

ages

20–24

COP

2016

target

Total

AGYW

enrolled

% of

target

Kisumu 3,971 2,650 7,823 6,441 7,823 5,409 19,617 14,500 74%

Homa Bay 2,373 4,357 6,137 7,728 6,137 5,891 14,647 17,976 123%

Total 6,344 7,007 13,960 14,169 13,960 11,300 34,264 32,476 95%

Services layering

Layering in DREAMS refers to the extent to which inidividual AGYW have received the

maximum number of services for their age cohort as contained in the DREAMS package of

interventions. Six services are considered the minimum required for ages 15-24 and four services

for ages 10-14. As at the end of the reporting period, the project had reached 20,066 (62% of

target) of the enrolled AGYW with at least six services (See services section below). The cohort

ages 15–19 has the best service layering in the project, as seen in Figure 9.

Figure 9. Layering of services for adolescent girls and young women (AGYW) in three age

categories (10–14, 15–19, 20–24).


Table 36 below shows the actual numbers of AGYW receiving packages of interventions.

Table 36. Numbers of adolescent girls and young women receiving services.

# of services 0 1 2–3 4–5 6

# of AGYW receiving

services

199

955

3,905

7,337

20,066

Percent 1% 3% 12% 23% 62%

In general, the project is on course to providing comprehensive services access to all the AGYW.

The 199 AGYW receiving 0 services represents the number of AGYW who the project no longer

has access to or contact with and are eligible for exiting.

Provision of services

DREAMS services are packaged in four different components:

1. Empowering girls and young women.

2. Mobilizing communities.

3. Strengthening families.

4. Reducing risk among sexual partners.

Details of each service component and

achievement in the reporting period is

outlined in the narrative sections below;

1. Empowering Adolescent Girls and

Young Women

Interventions in this section include HIV

abstinence activities, other HIV-

prevention activities, condom promotion

and prevention, HIV testing services, pre-

exposure prophylaxis, post-violence care,

expanded and improved contraceptive

method mix, and social asset building.

The project supported the training of

facilitators of evidence-based

interventions including for My Health My Choice (MHMC), Healthy Choices for a Better Future

(HCBF), Families Matter Program (FMP), and SHUGA. We also supported the sensitization of

71 CHVs on contraceptive method mix.

Post violence care: The project continued to strengthen the provision of post violence care

services to AGYW both at the community and facility levels. At the community level, project-

supported paralegals, girl mentors, and the project team sensitized communities on GBV

prevention and response through churches and chiefs’ barazas. The paralegals also held

Local chief engages AGYW at the safe space


education sessions with the AGYW at the safe spaces to enhance their understanding and

reporting of GBV. Relevant service providers such as the police, local administrators, and health

care workers were involved in the safe space education sessions to give the AGYW information

on how to use their offices as well as to increase the girls’ confidence in using services from

these departments/offices. In addition, the project supported 900 AGYW from each county

(Homa Bay and Kisumu) to participate in marking the Day of the African Child. Two meetings

were held between the police, local administrators, and DREAMS project implementers to

strengthen GBV responses through an understanding of roles and responsibilities. Through these

meetings, it came up that it was important to have a police officer accompany GBV survivors to

the health facility because it reduced the waiting time and also the medical report fees demanded

by some health care providers.

At the facility level, the project supported CMEs and supportive supervision targeting health care

workers to offer quality sexual and gender-based violence (SGBV) services, including GBV

screening specific to AGYW. The project also continued to conduct GBV screening for AGYW

in all the wards. As a result, a total of 517 AGYW received post-GBV services. Of these cases,

176 received trauma counseling in health facilities, 264 received psychosocial services, and 21

reported to the police for legal services.

Pre-exposure prophylaxis: The project has so far enrolled a total of 770 AGYW on pre-

exposure prophylaxis (PrEP)—436 in Kisumu and 334 in Homa Bay. Of the 770 AGYW, 203

are ages 15–19 and 567 are ages 20–24. In the reporting period, DREAMS enrolled 358 AGYW

on oral PrEP (158 in Kisumu and 200 in Homa Bay); 88 are ages 15–19 and 270 are ages 20–24.

The most common risks factors/behaviors that made AGYW eligible for PrEP were engagement

in transactional sex, history of sex under influence of alcohol or drugs, concurrent multiple

sexual partners, sex with partner (s) of unknown HIV status, and inconsistent or no condom use.

In the same period, 48 AGYW (21 in Kisumu and 27 in Homa Bay) have been discontinued on

PrEP, which represents 5% and 9% against the total number newly initiated on PrEP, as shown

in Table 37 below.


Table 37. Reasons for adolescent girls and young women (AGYW) to discontinue pre-

exposure prophylaxis.

Reasons for discontinuations Kisumu Homa Bay

Experiencing side effects 5 5

Non-adherence 1 8

AGYW relocated 1 2

Reduction of risk 5 1

Client choice 3 8

Intimate partner violence/rejection 5 2

Compelled by parent 1 0

Pregnancy ‘fears’ 0 1

Total 21 27

Adherence is integral to success of PrEP, and the number discontinued for nonadherence is

higher in Homa Bay (8) compared to Kisumu (1). Using this information, the project has

involved PrEP ‘ambassadors’ along with adherence counselors in small group sessions to

improve and sustain adherence, as well as support group meetings as a buffer against stigma and

negative social norms. The number opting out as a result of reduced risk is higher in Kisumu (5)

compared to Homa Bay (1). This is significant as it shows that the reasons for eligibility for PrEP

are being addressed to either lower or eliminate the high risk and wean off the AGYW on PrEP

to continue with other combination prevention services. For those discontinued due to low risk or

for clients who by choice took PrEP for the next 28 days from the last exposure, none has sero-

converted to HIV positive. We are also mitigating other reasons for discontinuations through

continuous sensitization of AGYW on PrEP, capacity-building of service providers, and

engagement of other key stakeholders to achieve better outcomes for PrEP. Also, 147 test results

for both serum creatine and hepatitis B surface antigen have been received, which were all

normal. A low creatinine clearance indicates an underlying renal disease, which is

contraindicated for PrEP, while a positive Hepatitis B SAg test requires prolonged use of PrEP

since abrupt discontinuation of PrEP may cause a flare-up of the Hepatitis B infection hence a

repeat(follow-up) Hepatis B SAg test will be a pre-requisite test to stopping PrEP.

In partnership with the Ministry of Health, we identified 7 central sites for PrEP commodity

management (1 in Kisumu and 6 in Homa Bay). We have also worked closely with these link

health facilities to quantify, forecast, report, and order drugs through Kenya Medical Supply

Agency (KEMSA). Following our support, these health facilities had a total of 1,550 PrEP packs

(1,068 in Kisumu and 482 in Homa Bay) as their ending stock balance by the end of June 2017.

The current stock is sufficient to cover refills and new initiations for the next two months.

HIV testing services: DREAMS continues to work with HTS providers from link health

facilities to offer these services to AGYW in safe spaces either in isolation or integration with

other interventions such as evidence-based interventions, condom promotion and provision,

contraceptive method mix, PrEP, and social asset-building sessions. In FY2 (Year 2 of

DREAMS implementation), DREAMS reached 27,926 AGYW (15,561 in Kisumu and 12,365

in Homa Bay) against the project target of 30,458, which represents coverage of 92%. However,

in FY2Q3, the project reached 9,755 AGYW (6,507 in Kisumu and 3,248 in Homa Bay) with


HTS; this includes 1,466 AGYW ages 10–14 years, 4,545 ages 15–19 years, and 3,744 ages 20–

24 years. Of those tested in this quarter, 49 AGYW (28 in Kisumu and 21 in Homa Bay) were

new HIV positives and a total of 16 enrolled into treatment with unique patient numbers. In

addition, the project is working closely with AGYW, mentors, HTS providers and other health

care workers to complete linkage to care and treatment.

Condom promotion and provision (CPP): The DREAMS project rides on several interventions

and opportunities to provide comprehensive condom education and access to AGYW. These

include EBIs, HTS, PrEP, STI screening, and condom promotion and distribution sessions only

at safe spaces. In FY2, the project facilitated 14,782 AGYW (8,052 in Kisumu and 6,730 in

Homa Bay) with condom promotion and provision. However, in FY2Q3, 8,453 AGYW (5,292 in

Kisumu and 3,161 in Homa Bay) were reached with the same services; this includes 126 AGYW

ages 10–14 years, 4,134 ages 15–19 years, and 4,193 ages 20–24 years. For those who opt to

take up contraceptives (ages 15–24 years), referrals are done to link health facilities for

individual counseling and provision of contraceptives. The project continues to help AGYW

appreciate the value of condoms in both HIV and STI prevention.

Contraceptive method mix (CMM): In FY2, 12,606 AGYW (7,633 in Kisumu and 4,973 in

Homa Bay) were reached with contraceptive method mix education. For FY2Q3, 7,881 AGYW

(4,547 in Kisumu and 3,334 in Homa Bay) have been reached with the same intervention; this

includes 138 ages 10–14 years, 3,817 ages 15–19 years, and 3,926 ages 20–24 years. The project

continues to work with sexual and reproductive health officers from MOH and other partners in

the same sector to provide individual counseling and contraceptives for AGYW ages 15–24

years who request them either at safe spaces or through referrals to link health facilities.

However, it has been observed that AGYW generally find safe spaces to be a friendlier venue in

which to interact with HCWs and receive contraceptives compared to health facilities.

2. Mobilizing Communities and Norms Change

This category of interventions seeks to educate girls and young women and men, as well as to

mobilize communities, and includes norms change and school-based HIV and violence

prevention.

The interventions aim to ensure that AGYW have access to community resources and persons,

and also that gender education is facilitated amongst the population to make girls live in a safe

and respectful environment.

Evidence-based interventions: The project continued to implement EBIs including My Health

My Choice (MHMC) and Healthy Choices for a Better Future (HCBF). SHUGA 2 was generally

implemented at the safe spaces. Working under the auspices of the Ministry of Education, the

project worked with schools to reach 3,451 AGYW in Kisumu and 13,178 in Homa Bay.

A total of 2,996 individuals were reached through SASA! for violence and HIV prevention.


3. Strengthening Families

The social protection approach adopted by the project seeks to continuously offer a

comprehensive package of services to the AGYW and their households. Interventions in this

component aim at providing social protection for AGYW and include cash transfers, education

subsidies and school fees, learner’s packages and/or dignity packs, and combined socioeconomic

approaches, which also include parenting skills for caregivers.

A total of 17,996 AGYW (3,056 ages 10–14, 9,476 ages 15–19, and 5,455 ages 20–24) have

been reached with social protection services including cash transfers, education subsidies, and

parental caregiver programs with the aim of reducing their vulnerability and mitigating risks

while enhancing their coping strategies.

Strengthened parenting/caregiver programs for AGYW age 10–24: The project continued to

support improved parenting skills and intergenerational communication using the FMP I

curriculum to train caregivers of AGYW ages 10–14. In the reporting period, 360 caregivers

were reached, bringing the total to 529 caregivers reached in FY2. The trained caregivers have

demonstrated improved communication with and inclusion of the AGYW in decision-making,

especially regarding their education choices. Strategies have been instituted to increase the reach

to the targeted caregivers while supporting the formation of dialogue groups for both caregivers

and AGYW for the purpose of feedback and further support.

Increased access to cash transfers by AGYW ages 15–24: The focus at the beginning of the

quarter was to complete the identification of eligible AGYW to benefit from cash transfers. To

this end, the project enrolled 1,551 new AGYW (602 in Homa Bay and 949 in Kisumu) and their

households into the DREAMS cash transfer program. Another 321 AGYW (212 ages 15–19 and

109 ages 20–24) received their second cash disbursement, while 29 others received their third

disbursement. In total, the project has supported 1,901 AGYW/households (804 in Homa Bay

and 1,097 in Kisumu) with cash transfers to support their households to meet some of the needs

they consider important.

Increased access to education subsidies for AGYW ages 10–24: Retention of girls in school

remains the key education strategy employed by the project in the reporting period. This period

saw 4,228 AGYW (2,211 in Homa Bay and 2,016 in Kisumu) benefit from the DREAMS

education subsidies, bringing the total to 12,591 AGYW (6,203 in Homa Bay and 6,388 in

Kisumu) who have received education subsidies, as shown in Table 38. This quarter saw 912

AGYW (826 in Homa Bay and 86 in Kisumu) supported with school fees. Also provided was a

learner’s package comprising sanitary items in addition to mathematical sets; the learner’s

package is aimed at reducing the likelihood of AGYW engaging in sex in exchange for basic

sanitary items.


Table 38. Number of adolescent girls and young women (AGYW) reached with education

subsidies.

County COP

2016

target

#

reached,

ages

10–14

COP

2016

target

#

reached,

ages

15–19

COP

2016

target

# reached,

ages

20–24

COP

2016

target

Total

Achieved

Kisumu 882 944 5,650 4,053 869 1,391 7,401 6,388

Homa Bay 528 758 4,432 3,803 682 1,642 5,642 6,203

Total 1,410 1,702 10,082 7,856 1,551 3,033 13,043 12,591

Increased access to combination socioeconomic approaches for AGYW ages 10–24: The

project continued to provide a comprehensive package of economic-strengthening services

including linking AGYW to employment, microfinance, internship, vocational skills training,

and income-generating activities, in addition to training on financial capability and

entrepreneurship. In the quarter under review, 356 AGYW (188 in Homa Bay and 168 in

Kisumu) were reached with economic-strengthening services. A total of 90 AGYW were linked

to employment, while 217 others were supported to acquire vocational skills. In view of earning

income and creating employment, 23 AGYW were supported to establish income-generating

activities. In readiness for jobs, the project further linked 26 AGYW to internship opportunities.

The project paid the annual National Health Insurance Fund (NHIF) premium contribution for 40

AGYW ages 15–19 and half the year for 158 AGYW ages 20–24, with the aim of supporting

them and their families to plan for risk. Four AGYW reported they used the NHIF cards to cover

inpatient charges that they considered huge. AGYW who are chronically ill or have chronically

ill caregivers who require immediate medical attention will continue to be prioritized for this

service, including young mothers with no source of income. For sustainability, the project is

working with the AGYW ages 20–24 to enable them to start income-generating initiatives to

support continuous contributions for the period beyond the expiration of the semi-annual

contribution, which runs from April to September 2017. Cumulatively, a total of 250 AGYW

ages 15–19 and 1,162 ages 20–24 have been reached with this initiative.

4. Reducing Risk among Sexual Partners

This intervention aims at characterizing the typical sex partners of adolescent girls and young

women, and linking them to HTS, ART, and VMMC. In the reporting period, 3,430 male sexual

partners of AGYW (1,850 in Kisumu and 1,580 in Homa Bay) were reached with these

interventions: 1,457 male partners linked HTS, of which 12 were HIV positive and 11 (92%)

enrolled into treatment, 375 male partners referred for VMMC, and 2,585 with CPP.


Services for orphans and vulnerable children The project continued to implement activities at county, community, household, and child level

to support child outcomes. The areas of focus included HIV testing, counseling, and linkage;

nutrition; education; protection; psychosocial support; and household economic strengthening

(HES). The capacity of the 76 implementing community-based organizations (CBOs) was

strengthened for quality services and data management. At the county level, the project

continued to work with Department of Child Services to strengthen the social service system for

care of orphans and vulnerable children (OVC) within the 10 project counties and expanded the

project’s engagement with other line ministries to include the Ministry of Education and the

Ministry of Agriculture. The project conducted transition meetings with various partners

including the incoming OVC partner. A handing-over report with key project products including

OVC data was shared with them to facilitate smooth transition and continued service provision

for OVC.

1. Increased access to health and social services for OVC and their families

The project has a COP target of 268,818 OVC, against which 230,936 OVC (85.9%) were served

in the reporting period, as shown in Table 39. Prioritized services included HIV testing,

nutritional support for children under 5, food supplementation for malnourished OVC in all age

cohorts, protection, psychosocial support, shelter, care, and household economic strengthening.

Of the 8,187 OVC who left the program in this quarter, 3,833 graduated,3 4,226 were

transferred,4 and 128 exited without graduation.5 Migori, Kisumu and Homa Bay were at 66%,

87%, and 69% achievement of OVC served against COP 2016 target, respectively, and

enrollment plans to recruit additional OVC were shared with the incoming partner to improve on

the number of OVC served.

3 Children and caregivers are deemed to be stable and no longer in urgent need of externally supported services.

4 Children and families have transitioned to other forms of support programs other than PEPFAR-funded OVC programs (could include other

donor-funded programs). 5 Children lost to follow up, aged out without a graduation plan from PEPFAR OVC program, re-located, or died.


Table 39. Orphans and vulnerable children (OVC) served per county in Y7Q2.

County COP 2016

target

Y7Q2 active

OVC

Graduated Transferred Exit without

graduation

OVC

served

% served (vs.

COP target)

Bungoma 20,761 20,758 506 709 16 21,989 105.9%

Busia 15,800 20,279 307 366 9 20,961 132.7%

Homa Bay 80,681 54,386 494 623 38 55,541 68.8%

Kakamega 32,742 32,165 945 1,132 24 34,266 104.7%

Kisii 5,270 4,704 48 32 1 4,785 90.8%

Kisumu 38,544 32,444 629 530 11 33,614 87.2%

Migori 40,780 26,050 419 263 14 26,746 65.6%

Nyamira 3,506 3,501 71 90 4 3,666 104.6%

Siaya 23,165 20,920 124 307 7 21,358 92.2%

Vihiga 7,569 7,542 290 174 4 8,010 105.8%

Overall 268,818 222,749 3,833 4,226 128 230,936 85.9%

Source: OVC longitudinal management information system (OLMIS) June 2017.

Table 40. Trend in orphans and vulnerable children (OVC) served.

OVC services Y6Q1 Y6Q2 Y6Q3 Y6Q4 Y7Q1 Y7Q2

Number of OVC active

within period

195,854 189,681 181,991 177,435 220,536 222,749

Number of OVC served 192,162 185,065 165,253 163,254 227,883 230,936

Percent served 98% 98% 91% 92%


In the first two quarters of Year 7, the project notably served 100% of the OVC enrolled in the

program, as shown in Table 40 above. This was made possible as the project embraced case

management planning that extended caregiver involvement, contributions, and enabled effective

delivery of prioritized OVC needs.

Figure 10 shows the types of services provided to the OVC. Details of the specific services are

explained under the subsequent sections of the report.


Figure 10. Orphans and vulnerable children (OVC) served, by type of service.

Source: OLMIS, June 2017

Accessing health services

The project had 195,563 OVC below 18 years old, of which 183,613 had negative HIV status

and 7,586 were HIV positive; all HIV-positive OVC are linked to ARV treatment programs

across the project zone as indicated in Table 41 below. The 4,364 OVC with unknown status are

drawn mostly from the ineligible group for testing based on the risk assessment. For those at risk,

the project has continued to support their HIV testing services and to expand this service to their

siblings. The project has improved the service by adding weekend and school holiday campaigns

and testing and escorted referrals to health facilities. Capacity-building on treatment literacy,

disclosure, and adherence counseling for caregivers of HIV-positive OVC and older OVC was

also conducted in the reporting period. This has increased enrollment rates.

29,221

190,543

111

155,492

216,601

81,139

Education Health &Nutrition HES Protection PSS Shelter &Care


Table 41. HIV status of project supported orphans and vulnerable children.

County Active OVC < 18 HIV positive On ARV

treatment

Not on ARV

treatment

HIV negative Unknown

HIV status

Bungoma 17,990 1,035 1,035 - 16,854 101

Busia 16,542 1,028 1,028 - 15,512 2

Homa Bay 47,985 1,212 1,212

46,519 254

Kakamega 27,319 1,263 1,263 - 25,796 260

Kisii 4,460 198 198 - 2,539 1,723

Kisumu 30,346 880 880 - 28,687 779

Migori 22,459 740 740 - 21,644 75

Nyamira 3,090 146 146 - 2,821 123

Siaya 19,443 610 610 - 17,786 1,047

Vihiga 5,929 474 474 - 5,455 -

Overall 195,563 7,586 7,586 - 183,613 4,364

Note: ARV, antiretroviral; OVC, orphans and vulnerable children.


Of the 222,749 active OVC (all ages), 218,432 have been tested, 8,117 are positive, and all HIV-

positive OVC are linked to treatment as indicated in Table 42 below.

Table 42. Number of orphans and vulnerable children (OVC) accessing HIV testing

services.

HIV testing

and linkage

Y6Q1 Y6Q2 Y6Q3 Y6Q4 Y7Q1 Y7Q2

Active OVCs

177,435 220,536 222,749

Number tested

for HIV

175,394 183,808 181,599 176,987 215,451 218,432

Number

positive

6,466 5,970 5,742 6,266 7,685 8,117

Number linked

to treatment

6,264 5,943 5,742 6,251 7,645 8,117

% linked to

treatment

96.9% 99.5% 100.0% 99.8% 99.5% 100.0%


Nutrition

Nutrition assessment was conducted for 50,947 OVC; of these, 6,231 OVC were malnourished

(5,224 moderately and 1,007 severely) and were provided with supplementary food. In addition,

516 HIV-positive caregivers (294 M, 618 F) who were also malnourished were provided with the

therapeutic food. A total of 11,986 cartons of First Food and 1,632 cartons of Foundation Plus

were procured in Quarter 1 and distribution was done in both Quarter 1 and Quarter 2 periods.

Details of the food are provided in Annex C. The CBO representatives are trained to carry out


continued assessment as well as the food distribution with support of health workers in their sub-

counties.

Education

The project’s education strategy aims at enhancing access to school and completion of school by

providing an enabling environment. The project collaborates with the Ministry of Education in

addressing the OVC educational needs in the following areas: school fees subsidies, scholastic

materials, mentorship, and county coordinating working group.

During the reporting period, 2,272 OVC received school fees in addition to the 5,397 OVC who

benefited in Quarter 1. Almost half (1,007 OVC) were paid for from the project and the rest

(1,265 OVC) through referral and linkage to other partners, including presidential bursaries

under the Department of Children’s Services. Also, 2,164 girls were supported with sanitary

pads, 138,787 OVC received Toms shoes, and 2,431 OVC received school uniforms.

In Migori County, 7 OVC who had completed vocational training were supported with business

startup kits. The OVC had earlier received vocational training in various trade areas, ranging

from carpentry, mechanics and welding for the males, and hairdressing and sewing for the

females. All the identified beneficiaries had lacked startup kits to enable them to start their own

businesses. They were encouraged to give back to their communities by taking in a deserving

apprentice.

Distribution of food supplements (left) and nutrition assessment (right) at Heart Nyakach community-based

organization


Child protection services

A total of 14,938 households have active NHIF subscriptions supported by the project, with an

annual subscription fee paid directly to NHIF. This was achieved in Y7Q1; the focus in Y7Q2

was to ensure that the households are managing the economic strengthening initiatives set up

through case management to enable them to take up the subscription for subsequent years. The

project has facilitated linkage of 14,464 households to cash transfer (OVC and elderly). Of the

active 222,749 OVC, 59.7% (132,972 individuals) have been supported with birth registration.

An additional 312 OVC received mattresses, 32,306 OVC received blankets and 9 OVC had

their shelter repaired during the reporting period.

2. Capacity of households and communities strengthened to protect and care for OVC

Promotion of savings groups

Village savings and loaning associations (VSLAs) continue to be a key household economic

strengthening (HES) intervention in the project. Within the quarter, 52 new VSLA groups were

formed across the 10 counties, bringing the total number of active VSLAs to 926. The increase

was driven by concerted efforts the project placed on training community-based trainers (CBTs),

supporting their monitoring of VSLA activities at community level, holding regular joint review

meetings to report achievements and challenges, and sharing lessons learned by peers in other

CBOs. Through the VSLAs, a total of KSh. 38.7 million was in circulation out of which 18.5

million were in loans benefiting 24,675 caregivers supporting 63,764 OVC. Two VSLA groups

had a share-out of 1.19 million in Kisumu and Siaya, which caregivers utilized to grow their

assets, expand their businesses, and meet basic needs including shelter, education, and health

care.

Orphans and vulnerable children (OVC) receiving business startup kits.


Productive assets

To strengthen the resilience of highly vulnerable households, the project refreshed the trained

CBO management staff on the HES strategy to enable them to prepare households for transition

by increasing their participation in

HES activities. Small livestock was

also purchased for highly

vulnerable HHs: 1,361 HHs

benefited from goats, sheep,

poultry, piglets, and tissue-

culture banana.

Transition and sustainability

The project continued to ensure that sustainability remained at the core of OVC services

interventions, with the focus continuing to be institutional sustainability and household and

community resilience.

The 76 implementing CBOs received institutional and governance support in additional to

technical skills to manage and ensure sustainable child outcomes. All 76 organizations received

opportunities to apply for small PEPFAR grants, with the project team providing technical

insights in developing their proposals. The CBOs were trained on compliance to donor standards,

governance, and financial management.

To promote sustainability at household level, caregivers continued to engage in small business

enterprises supported by funding from the VLSAs, income-generating activities, and

microfinance institutions. In Migori County, for example, caregivers are engaged in a ‘one egg

per child’ initiative.

The one egg per child per month simply means every OVC has a responsibility to bring

an egg every month. With a mutual understanding among the OVC and their

caregivers, they all wait for generational offspring for cost-effective chickens to be

distributed to all. Systematically, a child receives a chick, rears it to egg laying age,

and submits to the CBO office for recording. Mirrored on a value-chain, the child is

groomed to understand and practice the basics of animal husbandry and get income to

take care of their basic needs.

The project also supported older OVC with vocational training skills and provided them with

business startup kits to promote self-employment.

Caregivers receiving productive assets.


In addition, all the CBOs were introduced to the incoming partner and a transition plan was

shared with them for OVC needing program support to be sure that the support is continued.

A total of 1,234 households supporting 3,833 OVC transitioned from project support through

graduation.

Linkage to microfinance institutions

Within the quarter, 502 households were reported as linked to microfinance institutions (MFIs)

with a direct purpose of enabling them acquire capital to build their asset base for their business.

MFIs like One Acre Fund, Nuru, and Development in Gardening (DiG) have over the years

come in handy to train caregiver support groups on business skills, after which they offer group-

guaranteed loans to enable loanees start their own small businesses. The MFIs are instrumental

in monitoring and supporting the caregivers to make progress in their business ventures.

3. Strengthened child welfare and protection systems at county level, and improved

structures and services for effective responses in targeted counties

Partnership with the Department of Children Services, Ministry of Education, Civil Registrar,

and the Ministry of Agriculture continued in the quarter in support of birth registration, linkage

to cash transfer, and Constituency Development Fund bursaries for school fees across the

counties. Groups of 500 caregivers who received small livestock and those carrying out small-

scale farming have been linked to the Ministry of Agriculture, Livestock and Fisheries for

continued advice and technical support. The project continued to build social capital in the

community, which is critical for sustainability.

Strengthening use of OLMIS

To support data quality at the CBO level and continuous mentorship of CBOs on the use of the

OVC longitudinal management information system (OLMIS), 47 data clerks recruited in 2016

were supported to conduct quarterly data quality assessments to ensure consistency of data from

household level to the OLMIS. The data clerks also conducted continuous capacity-building to

OVC desk people, lead community home visitors, and community health volunteers in the 76

CBOs.


Subpurpose 2. Increased access to and utilization of malaria prevention and treatment services

Malaria prevention and treatment services

Linkage and coordination

In Y7Q2, the project continued to arrange for joint partner planning meetings. Three malaria

implementing partner (MIP) linkage and coordination meetings were successfully held, bringing

together A+, PSK, URC, MEASURE Evaluation PIMA, MalariaCare, Kenya Civil Society

Strengthening Program (KCSSP), Palladium (Tupime Kaunti).

During this quarter, the main milestone for the linkage was the review of the supportive

supervision (SS) tool, and bringing the CMCCs on board for the review of activities and joint

planning aimed at strengthening advocacy for the malaria work supported by USAID in the

region.

In collaboration with the other MIPs in the area, activities planned by the project, such as

supportive supervision, SHFs, and TWG meetings, continued to be jointly attended by other

USAID MIPs at county and sub-county levels.

During the meetings, it has been noted that the joint approach has many advantages, including

cost cutting, show of partnership, and reduced waste of time and duplication of service.

Malaria supportive supervision

The project supported all 10 counties (6 in Nyanza, 4 in Western), reaching a total of 75 sub-

counties (41 N, 34 W) and 430 RHFs (221 N, 209 W). As a result of this support, 1,970 HCWs

(1,069 N, 901 W) were provided on-the-job training and/or mentorship in malaria case

management, based on identified gaps in knowledge and skills.

Based on the supportive supervision tool being reviewed, the findings still indicate challenges

including high malaria positivity rates; irregularity in artemether-lumefantrine dosage schedule;

inadequate advocacy, communication, and social mobilization (ACSM) materials in a number of

facilities; and inconsistent availability of the outpatient tally sheets (MOH 705A and B). This

was strengthened through mentorship and on-the-job training during the review. Other corrective

measures put in place included holding feedback sessions with all staff so that individuals were

assigned the responsibility of making desired changes. The role of data in decision-making at the

local level was emphasized, as well as the need for HCWs to tabulate summary data at facility

levels to indicate trends. These findings have remained a challenge to the malaria programme for

some time now. The nurses’ strike during the quarter worsened the situation, making this support

incomplete.

The project made an effort to distribute the IEC materials as well as the current malaria

guidelines to most of the facilities.

The HCWs were urged to continue monitoring malaria trends in their respective areas by

charting findings and periodically alerting the sub-county malaria control coordinators on the

levels reached.


To address the challenges, the project in consultation with Tupime Kaunti will work to support

data review meetings. The focus will be on gaps identified during supportive supervision visits

and recommendations for strengthening clinical skills through practice as recommended by the

technical working groups and the national malaria guidelines.

Malaria stakeholder forums at county and sub-county level

The project continued to support county and sub-county malaria stakeholder forums in 9 counties

(5 in Nyanza, 4 in Western) reaching a total of 29 sub-counties (9 Nyanza, 20 Western). The

forum, comprising representatives from the national malaria control program, KEMSA, and

other MIPs to contribute toward improving malaria performance indicators in the region. During

the meetings, each MIP is usually given time to present the project role, activities undertaken,

areas of operation, and planned activities for the next quarter.

The issues, gaps, and challenges that were identified were discussed and recommendations made

on how to solve them locally first. The project continued to follow up and address the identified

gaps with the respective partners in each region.

These meetings were well attended with the participation of 1,033 (310 Nyanza, 723 Western)

people in the region. Action plans were drawn and roles and responsibilities were outlined and

reviewed in subsequent meetings.

Malaria technical working group meetings

Malaria TWG meetings were held in 38 sub-counties (20 in Nyanza, 18 in Western) with 416

members (114 N, 302 W). The gaps identified during the supportive supervsion and stakeholders

forum were followed up by the TWGs, supported by the project.

Among other issues, the respective TWGs recommended that data collecting tools be made

available and improved, that KEMSA should always be attending the SHF to handle the

commodity component, and that KCSSP should look into this.

Malaria performance data review meetings

Performance data review meetings should be taken up as a serious component of the deliverables

after the exit of PIMA by its successor; A+ will be following this keenly as one of the key

linkage areas.

During the data review meetings in Q1, concerns were raised, including inadequate tools for data

collection, inaccurate or incomplete data, commodity stockouts, inadequate advocacy,

communication, and social mobilization (ACSM) materials, and utilization of the same data

source, among others. As a result of the identfied gaps, discussions/proposals have been made

for Palladium and/or the successor to PIMA to take over the support for this important

component of malaria management.


Subpurpose 3. Strengthened and functional county health systems

Human resources for health services

The project retained 684 county contracted HRH supporting HIV services delivery in supported

sites in the 9 counties as shown in Table 43. There was also additional short term locum staff

engaged to enhance the implementation of 90-90-90 strategy and to bridge the gap in COP 16

target achievements.

Table 43. HRH establishment by county by end of Y7Q2

Cadre Scale-up to saturation counties Aggressive

scale-up

counties

Sustaine

d

County

Total

Ho

ma

Ba

y

Kis

um

u

Bu

sia

Mig

ori

Kis

ii

Ka

ka

meg

a

Bu

ng

om

a

Ny

am

ira

Vih

iga

HRIOs 11 4 11 14 5 47 5 17 11 125

Nurses 3 3 4 1 1 28 1 9 50

MLTs 1 2 5 9 3 5 21 46

HTC Counsellors 54 15 18 58 18 22 34 100 319

Nutritionists 2 2 3 1 3 2 3 1 17

Clinical Officers 8 10 14 4 39 25 5 19 124

Pham Tech 2 1 3

Social Workers

Total 79 32 53 81 29 149 70 139 52 684

Source. Project records

We were actively involved in planning and attending two regional Inter-County HRH

consultative forums in which we directly supported Vihiga and Nyamira county teams to

participate.

The main challenge relating to HRH in the quarter was the nursing industrial action that placed

additional burden on the HRH staff to extend services beyond the HIV care and treatment, often

with limited resources at their disposal as most amenities were not readily accessible.

Health care financing

The project continued to support, on a monthly basis, performance based incentives to health

facilities based on their performance on the following service areas: Linkage to care, ART

initiation, PCR 6-8 weeks; PCR positive put on ART, and net gain for current on ART. Most

health facilities continue to make use of these incentives to support HIV service infrastructure

and health care worker motivation.


Commodity security

Support to improved supply chain logistics and commodity management

The project supported all 52 ART reporting sites (45 central and 7 standalone) to submit monthly

reports to KEMSA LMIS system, achieving 94% reporting rate in the quarter. Table 44 below

shows the reporting rates per county.

Table 44. Central and satellite ART commodity sites reporting rates, April to June 2017

County Central ART sites Satellites

supported

Satellites reporting Average reporting

rate

Busia 4 32 28 88%

Homa Bay 3 34 34 100%

Kisumu 2 24 24 100%

Migori 4 47 42 89%

Kakamega 15 171 164 96%

Kisii 1 14 14 100%

Nyamira 5 104 92 88%

Bungoma 7 85 79 93%

Vihiga 4 43 43 100%

Standalone sites - 7 7 100%

Total 45 561 527 94%

A few satellite facilities manned by nurses have had challenges reporting during the strike hence

not obtaining the optimal reporting rate in some counties. Facilities in Vihiga, Homa Bay,

Kisumu and Kisii counties as well as all the 7 standalone sites (4 in Kakamega, 1 each in Vihiga,

Kisumu and Migori) obtained 100% reporting rate.

To support the quantification, ordering, storage and inventory management, the project supported

all the 52 ART ordering sites through continuous off-site mentorship and on job training on good

commodity management practices. The project working with NASCOP managed to upgrade 3

satellites to ordering sites (Migosi, Manyala and Bukaya) hence improving access of HIV

commodities to nearby satellite sites, thus ease the burden of overstocking and improve quality

of reporting. The project jointly with NASCOP has also supported training of pharmacists from

all the 9 counties on New KEMSA LMIS reporting system.

The project has also supported procurement of ART reporting tools (DAR for ARVs and OIs,

FCDRR and FMAPS) across all supported sites, to improve on documentation and reporting for

ARV drugs.

Support to county technical oversight and coordination for commodity management and

patient safety

In the quarter, the project continued to support all the nine counties to hold monthly commodity

technical working group meetings to coordinate commodity management and reporting in the

nine counties. Under this auspices, the redistribution of off schedule drugs like plain Zidovudine

tablets, Dolutegravir, Amphotericin B and PrEP commodities as well as short-expiry drugs was

undertaken in various counties including Kisumu, Kakamega, Migori and Homa Bay counties.


The project provided support in carrying out of supportive supervisions at county and subcounty

levels to help in monitoring commodity management challenges at the health facilities. Identified

gaps were addressed through mentorship and on-job training, also aimed at strengthening

pharmacovigilance reporting among the healthcare workers.

The project continued to strengthen multi-disciplinary teams at facility levels to discuss

suspected treatment failures and continuous monitoring of adverse drug reactions in patients.

The project, working with CHAI conducted training on introduction of web-based ADT in all

reporting health facilities and supported the installation. The tool besides managing drug

inventory, patients’ records and dispensing, also has capability of generating current patients’

viral load from the NASCOP website.

Strategic monitoring and evaluation

During the reporting period, monitoring and evaluation (M&E) activities helped to strengthen

data management and reporting systems. M&E activities included mentorship to enhance the

capacities of project collaborators and MOH systems, including rollout of the revised HIV data

collection and reporting tools; data quality improvement; reporting at county, sub-county,

facility, and community levels; and strengthening of the OVC reporting process and use of the

OLMIS and DREAMS databases. The activities undertaken were in line with the M&E strategic

areas of implementation. Details on the strategic M&E activities are included in the performance

monitoring section.

II. ACTIVITY PROGRESS (QUANTITATIVE IMPACT)

Please refer to the performance data tables in the attachment.

III. CONSTRAINTS AND OPPORTUNITIES

The health care workers’ strike that continued into the reporting period affected service delivery

in project-supported health facilities and contributed to low performance in various indicators,

especially in the June 2017 period. The project will continue to take advantage of HRH staff

supported through the project to strengthen service delivery in health facilities.

IV. PERFORMANCE MONITORING

During the reporting period, the project continued to collaborate with the MOH at the county and

sub-county levels to provide support in addressing MOH reporting tools shortages in the nine

project-supported counties. The project supported photocopying and distribution of the blue

cards, daily activity registers, intensified case-finding cards, and appointment cards during the

reporting period. The support contributed to the availability of the reporting tools and to

improved updates of patient records and data quality at the facility level.


Capacity-building of MOH systems, structures, and personnel on data collection and use

Strengthening health care worker capacity on reporting tools, indicators, and data use

The project continued to strengthen its support for onsite mentorship on health management

information system (HMIS) reporting tools across the nine supported counties. A total of 344

HCWs (40 in Vihiga, 12 in Kakamega, 12 in Homa Bay, 11 in Kisumu, 12 in Busia, 123 in

Bungoma, 103 in Nyamira, and 21 in Kisii) were mentored in the reporting period. This brings

the total to 1,550 HCWs mentored in the Y6Q4 through Y7Q2 period. The support targeted gaps

that were identified during SIMS visits, monthly data review meetings at project level, quarterly

data review meetings at the sub-county level, and routine DQA at site level. The focus was on

addressing reporting challenges in use of MOH 731, MOH 711, the daily activity register, the

ART register, the SGBV register, ANC register, and HEI cohort analysis.

Under the DREAMS initiative, the project continued to provide onsite mentorship on use of the

web-based system for all 34 supported administrative wards. The mentorship targeted mentors

and ward staff who engage with girls at the ward level on updating the service uptake forms.

Improving data quality

Facility data quality audit

In the reporting period, the project, in liaison with data clerks at the health facility level,

conducted DQAs in 121 project-supported high-volume health facilities during the months of

April to June 2017. The DQA built on previous similar audits that have been carried out by the

project since April 2014. These audits focus on comparison of data from source registers—

monthly reporting on MOH 731 and DHIS2 by facilities.

Generally, the results showed continued improvements in data consistency in the follow-up

period of April to June 2017 (see Table 45 below). These results were due to the project’s

continued onsite mentorship on the use of MOH 731 and to the support from data clerks assigned

to the high-volume health facilities. The project will continue to carry out DQAs to identify gaps

in data quality and to develop data quality improvement plans to address gaps.


Table 45. Data quality audit comparisons for care and treatment, Y6Q4 to Y7Q2.

Indicator Month Verification status (between source registers and MOH 731) No. of facilities

No variation

Over-reported

MOH 731

Under-reported

MOH 731

No. of

individuals

currently on

ART

Jan-16 91% 7% 2% 60

Feb-16 94% 4% 2% 62

Mar-16 94% 4% 2% 61

Apr-16 86% 11% 3% 63

May-16 87% 11% 2% 63

Jun-16 92% 8% 0% 63

Jul-16 86% 8% 6% 87

Aug-16 88% 8% 3% 86

Sept-16 97% 0% 3% 34

Oct-16 89% 4% 7% 104

Nov-16 92% 2% 6% 102

Jan-17 99% 1% 0% 85

Feb-17 99% 0% 1% 85

Mar-17 98% 0% 2% 86

Apr-17 93% 3% 4% 117

May-17 94% 4% 2% 121

Jun-17 94% 4% 2% 112

Jan-16 89% 3% 8% No. of

individuals

currently on

care

59

Feb-16 92% 6% 2% 60

Mar-16 92% 5% 3% 61

Apr-16 86% 11% 3% 64

May-16 87% 10% 3% 62

Jun-16 89% 9% 2% 63

Jul-16 79% 13% 8% 87

Aug-16 88% 8% 4% 84

Sept-16 97% 0% 3% 34

Oct-16 91% 3% 6% 104

Nov-16 92% 3% 5% 102

Jan-17 93% 6% 1% 86

Feb-17 93% 5% 2% 85

Mar-17 98% 2% 0% 86

Apr-17 92% 4% 4% 115

May-17 92% 6% 2% 119

Jun-17 94% 4% 2% 111

No. of

individuals

currently on

cotrimoxazole

Jan-16 88% 6% 6% 58

Feb-16 91% 5% 4% 58

Mar-16 91% 5% 4% 60

Apr-16 87% 11% 2% 62

May-16 86% 11% 3% 62

Jun-16 87% 11% 2% 64

Jul-16 79% 10% 10% 87

Aug-16 85% 9% 6% 87

Sept-16 94% 6% 0% 34

Oct-16 89% 6% 5% 104

Nov-16 92% 4% 4% 102

Jan-17 95% 4% 1% 82

Feb-17 90% 7% 3% 82

Mar-17 95% 1% 4% 85

Apr-17 93% 4% 3% 116

May-17 94% 4% 2% 120

Jun-17 95% 4% 1% 112 Note: ART, antiretroviral therapy; MOH, Ministry of Health. Source: Data Cross-Check Summary Report, 2016–2017.


DREAMS data quality audit

Data verification and quality assessments were conducted during visits to the safe spaces. The

exercise included checking for availability of standard tools and consistency, accuracy, and

completeness of information documented on the DREAMS enrollment form, service uptake,

referrals tool, male sexual partners planning and monitoring tools, and EBI registers. Chart

abstraction was done during these visits to monitor quality of services offered to the AGYW and

layering of services for individual girls.

The DQA also assessed proper utilization of the tools and use of the DREAMS database to

generate project reports. Facility-based data verification was conducted for PMTCT DREAMS

indicators, with the support of Ministry of Health staff, along with mentorship of staff working in

PMTCT-supported sites on the tally sheets and summary tools that capture PMTCT data for the

DREAMS project. Onsite data verification was done for facilities visited and desk review to

ensure consistency of data in DHIS2. PrEP has been rolled out and records for AGYWs started

on PrEP are being reviewed to check on completeness of information. Monthly reports on PrEP

for each ward and commodity reports from facilities were submitted.

All 34 wards are supported by a data clerk, who weekly updated information in the DREAMS

system, with bimonthly data review meetings conducted by the M&E staff at the ward to review

performance. The M&E staff continued with management of the DREAMS database, generation

of monthly reports, and completion of the performance monitoring plan and project dashboards.

Review of monthly reports was done with the aim of identifying gaps in reporting and

understand the DREAMS reportable indicators by the implementers, frequency of reporting, and

data flow.

Quarterly data review meetings at the sub-county level

The project continued to support quarterly data review meetings in all project-supported sub-

counties. A total of 170 HCWs (29 in Vihiga, 57 in Homa Bay, 60 in Bungoma, and 22 in

Kakamega) were reached during the data review meetings. The project was not able to reach

HCWs in the other counties due to the HCWs’ strike that took place during the reporting period.

This brings the total to 964 HCWs reached in the Y6Q4 through Y7Q2 period. HCWs included

clinical and data management staff. During the meetings, facility-level data for HTC, care and

treatment, PMTCT, and VMMC were reviewed. Key gaps in performance and data quality,

including missed opportunities in service provision, were discussed and strategies formulated for

data quality improvement at the facility level.

The project continued to support 92 health records and information officers (8 in Migori, 5 in

Kisumu, 10 in Nyamira, 7 in Siaya, 5 in Homa Bay, 2 in Kisii, 13 in Bungoma, 7 in Busia, 25 in

Kakamega, and 10 in Vihiga) with monthly airtime to ensure timely, complete, and accurate

entry of health service delivery data into DHIS2.

Under DREAMS, the project supported ward-level data review meetings to ensure that source

documents are properly completed and service uptake forms completed. The project also

supported monthly review of reports at the county level to identify gaps in reporting and assess

performance of DREAMS reportable indicators against COP 2016 targets.


Quarterly county M&E TWG meetings

To improve coordination of M&E activities in the counties, the project supported quarterly

county M&E TWG meetings. A total of 63 HCWs (16 in Busia, 17 in Nyamira, and 30 in

Migori) attended the county TWG meetings during the reporting period.

Bimonthly meetings to review DHIS2 data

During the reporting quarter, the project supported bimonthly meetings to review consistency of

data reported in DHIS2 against facility summary reports (MOH 731 and MOH 711A) and project

data. The indicators reviewed were for HTC, PMTCT, and care and treatment programs. A total

of 73 HCWs (30 in Bungoma, 38 in Nyamira, and 5 in Kisii) participated in the bimonthly

meetings, for a total of 162 HCWs reached through bimonthly meetings to review data

consistency in the Y6Q4 through Y7Q2 period. Through the process, data entry inconsistencies

in DHIS2 were identified and corrected by sub-county health records and information officers.

This contributed to improvement in the quality of data in DHIS2.

Strengthening the use of the OVC longitudinal management information system (OLMIS)

During the reporting period, the project continued to provide targeted onsite mentorship to CBO

staff on use of OLMIS, including the OVC reporting tools. The onsite mentorships were

provided based on identified CBO-specific issues. The 47 data clerks assigned to the 76 project-

supported CBOs provided support in the filing of OVC records and in entry and validation of

OVC data in OLMIS at the CBO level.

The project also provided system maintenance support to the CBOs, especially to CBOs that had

technical system challenges in computers that they use for data management and reporting

through the OLMIS. The project also handed over the OLMIS database to the incoming partner,

Catholics Relief Services (CRS), who will continue to implement the OVC program from July

2017 onward. The hand-over process went well, and the project has continued to provide

relevant information and data to CRS.

Strengthening use of the VMMC M&E system

The project continued to strengthen use of the VMMC M&E system. Twelve data clerks

assigned to Busia, Kisumu, Homa Bay, and Migori counties continued to support entry of

VMMC data into the M&E system at the site level.

Meaningful use of ICT infrastructure

To enhance meaningful use of ICT infrastructure for data management and reporting at facility,

sub-county, and county levels, the project, during the previous quarter, delivered a set of

computers, printers, uninterrupted power supply (UPS), Cisco routers, access points, and dongles

to ten supported sites and respective CHMT and SCHMT offices in four scale up to saturation

counties: Homa Bay, Kisumu, Migori, and Busia. During the reporting period, the project

installed the computers, printers, UPS, Cisco routers, access points, and dongles in the respective

sites. The project will monitor use of this information and communication technology (ICT)

infrastructure with an aim of establishing them as model ICT sites and centers of excellence in


the provision of service delivery, data management, and use of electronic medical records at

points of care.

Use of the open data kit platform in weekly collection of data

The project rolled out use of the open data kit (ODK) tool for weekly collection of data on early

warning indicators for all nine supported counties. The ODK application enables offline data

entry through a pre-designed form in a mobile phone, then loaded to a central server database,

which is then downloaded and analyzed in any required format. A total of 122 data clerks/health

records and information officers and 184 clinical staff (a total of 306 HCWs) were trained on use

of the ODK tool.

Progress on Site Improvement through Monitoring System (SIMS)

During the reporting period, the project worked with International Business and Technical

Consultants Inc (IBTCI) to conduct SIMS in six CBOs—five in Homa Bay County and one in

Migori County. The areas of concern that require immediate action are included in Annex C.

V. PROGRESS ON GENDER STRATEGY

The project continued to respond to the existing gender inequality gaps through facility- and

community-level interventions. At the facility, the project supported capacity-building of HCWs

on SGBV reporting to improve through CMEs and on-the-job training. The project also

supported HCWs to conduct GBV screening exercises to help in identifying cases of SGBV. At

the community level, the project supported community-awareness creation activities to enhance

demand creation for GBV services as well as to address power relations and imbalances that

prevent people from seeking care and treatment services. The project supported orientations of

local administration and police officers on gender and GBV to strengthen their response services,

community-level dialogue sessions on GBV, gender analysis in Ntimaru (Migori County), and

monthly gender technical working group (GTWG) meetings to strengthen the coordination of

gender activities in all the counties. In addition, the project supported marking of the Day of the

African Child.

VI. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING

Improved disposal of health care waste formed the core of environmental mitigation activities

during this reporting period. This was complemented by training and mentorship through

integrated supportive supervision and technical advice to project supported facilities. A total of

11 health facilities in 7 counties (Kakamega, Bungoma, Busia, Vihiga, Siaya, Migori, and Homa

Bay) were visited during the quarter.

Medical waste incinerators recently renovated with support from the project were commissioned

and launched at Sio Port, Cheptais, and Lumakanda sub-county hospitals in Busia, Bungoma,


and Kakamega counties, respectively. Renovation at Kabondo in Homa Bay and Awendo in

Migori was finalized and these are pending commissioning. All five incinerators are now fully

operational with adequate and secure holding space for waste. In additional, Ipali health center

was supported to revive and begin using the incinerator installed by the county government of

Vihiga. Incinerator operators at all the above facilities were trained on operation and

maintenance, record keeping, and health and safety measures. They were also equipped with

personal protective equipment (PPE), operating tools, and firefighting equipment. This was done

to optimize incineration so as to ensure proper destruction of biohazardous waste as well

minimize emissions. Use of PPE is expected to minimize occupational hazards such as exposure

to contaminated waste and risk of needlestick injuries. Next steps will involve support to these

facilities to treat and dispose of safety boxes from other health facilities within the respective

sub-counties that do not have incinerators.

Training and mentorship sessions were conducted in 11 health facilities for a total of 71 health

workers. Participants included members of the health management teams at county and facility

levels, health care service providers, and waste handling staff (casual workers). The following

facilities were supported: Sio Port, Cheptais, and Lumakanda sub-county hospital in Busia,

Bungoma, and Kakamega; Ipali health center in Vihiga; Kabondo sub-county hospital and

Othoro and Ober health centers in Homa Bay. Others were Awendo and Uriri sub-county

hospitals and Mariwa health center in Migori and Siaya county referral hospital. Training and

mentorship focused on refreshing best practices on waste handling, especially segregation

according to national guidelines, safe handling, storage, treatment, and disposal. Emphasis was

given to integration of waste management and infection prevention and control. Due to the

ongoing strike by nurses, it was not possible to roll out health care waste management trainings

as planned. Training for other cadres will continued as we wait for the nurses’ strike to be

resolved.

VII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS

Applying Science to Strengthen and Improve Systems project

Collaboration with the Applying Science to Strengthen and Improve Systems (ASSIST) project

continued in this quarter, in line with the 2017 work plan activities that related to quality

improvement. The project continued and scaled up support in quality improvement by supporting

quality improvement team meetings in the region. County TWGs on quality improvement were

supported across the zone. Quality and work improvement team meetings were supported jointly

at the facility-management and departmental levels. In the high- and medium-volume facilities,

the projects supported coaching sessions, during which the periodic review was done of the

Standards of Care according to the Kenya HIV Quality Improvement Framework.

Kenya Agricultural Value Chains Enterprises project

APHIAplus Western Kenya partnered with the Kenya Agricultural Value Chains Enterprises

(KAVES) project and Agricultural Sector Development Support Programme (ASDSP) in

building the capacity of caregivers on value chains, focusing on horticulture, dairy, and poultry

farming.


During the reporting period, a farmers’ field day exercise was conducted to promote dairy

farming, poultry, and maize value chains in Butere presided over by the Kakamega County

governor; 678 caregiver farmers from 14 CBOs in Kakamega and Vihiga counties participated.

One Acre Fund

APHIAplus Western Kenya partnered with One Acre Fund in supporting caregivers with farm

inputs and solar lamps on soft credit across the project area. During the reporting period, 245

caregivers from Khwisero Dorcas CBO, Bushesma CBO and Bushe CBO (trained and supported

with farm inputs in Q1) were monitored to ensure they achieve the highest yield to ensure they

are able to repay the loans provided for inputs and accrue profit from the sale of the extra yields

after storing the grains for home consumption.

During the reporting period, the project also partnered with other USAID-funded partners

Academic Model Providing Access to Healthcare (AMPATH), Centre for Health Solutions

(CHS) Kenya, Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), and University of

Maryland in providing HIV testing and counseling and linkages to care and treatment.

MEASURE Evaluation PIMA

During the reporting period, the project continued work with the MEASURE Evaluation PIMA

team to address OLMIS-related issues and transition of OLMIS to the incoming OVC

implementing partner, Catholic Relief Services. The PIMA team also provided remote

backstopping support to the project, based on identified needs.

VIII. PROGRESS ON LINKS WITH GOVERNMENT OF KENYA AGENCIES

The project has strengthened partnerships with national and county government agencies on the

areas of food security, health, education, and protection for OVC. During the reporting quarter,

partnerships with county health departments enabled the project to continue supporting HIV

testing services for OVC and health access as shown in Table 46.

The project’s education strategy aims at enhancing access to school and completion by providing

an enabling environment. The project collaborates with the Ministry of Education in addressing

OVC educational needs in the following areas: school fees subsidies, scholastic materials,

mentorship, and county coordinating working groups. The project also collaborated with the

Ministry of Education to provide safe spaces in selected schools. The project also supported

quarterly gender TWG meetings in the two counties and supported two county governments to

develop gender strategic plans, among other activities.

During the reporting period, 2,272 OVC received school fees in addition to the 5,397 OVC who

benefited in Q1; of these, 1,007 were paid for from the project and 1,265 through referral and

linkage to other partners. In addition, area advisory councils at the local and county levels were

supported to strengthen child protection initiatives. OVC households were linked to the


departments of children, civil registration, and vital statistics, as well as the National Health

Insurance Fund for the acquisition of cash transfers, birth registration certificates, and medical

insurance coverage.

During the reporting quarter, the project collaborated with the Ministry of Education to

strengthen OVC’s and AGYW’s access to, and retention in, schools. This was done through

school fees support and the promotion of adult education through consultative meetings and

supportive supervision.

To further strengthen the OVC households economically, households in different levels of

vulnerability (high, moderate, and low vulnerability) were linked to various forms of support.

During the period, 8,129 highly vulnerable OVC households were linked to respective county

governments’ cash transfer assistance programs to boost their economic resilience. This has

increased these households’ economic resilience level and helped them move out of highly

vulnerable status.


Table 46. Linkages between the Government of Kenya and the project.

GOK agency Component Area of linkage

Ministry of Health Nutrition

HIV testing and

counseling

WASH, bio medical

services

Growth monitoring for children under five

HIV testing and counseling

Referrals for OVC treatment

Care and treatment for HIV-positive OVC

Safe water

WASH HIV integration

NHIF enrollment for OVC households

Facilitating trainings on DREAMS initiative

Provision of biomedical outreach and referral

services for AGYW

Ministry of Education Education OVC school fees support through bursaries

School fees vetting

Monitoring and capacity-building of school

boards of management

Supervision of adult learning centers

Biannual forums for county education boards

Support to DREAMS safe spaces

Payment of DREAMS AGYW school fees

Ministry of Labour,

Social Security and

Services (Children’s

Department)

OVC and child

protection,

education, social

protection

AAC support and addressing crucial agendas

during meetings

Supervision and periodic accreditation of

CBOs

Capacity-building of CBOs

Cash transfer to OVC households

Linkages for economic strengthening for

PLHIV and CHVs

Department of Youth

and Gender, Children

Services

Social asset building Safe spaces for girls

TWGs for gender

Cash transfer

Ministry of Internal

Security (Kenya Police)

Security and

Accountability

Post GBV care for AGYW/Accountability-

legal support

Ministry of Agriculture,

Livestock and Fisheries

Food security and

nutrition, and

household economic

strengthening

Capacity-building of caregivers of OVC

Promotion and monitoring of 4K clubs

Technical support to greenhouse operators

Technical support in nutritional demonstration

centers for PLHIV

Ministry of Interior and

Coordination of

National Government

(Kenya Police)

Education, OVC, and

child protection

Follow up on disaster preparedness in schools

Membership on AACs

Constituency

Development Fund

Education School fees support for OVC

Note: AAC, area advisory council; AGYW; adolescent girls and young women; CBO, community-based organization; CHV,

community health volunteer; GBV, gender-based violence; GOK, Government of Kenya; HIV, human immunodeficiency

virus; OVC, orphans and vulnerable children; PLHIV, people living with HIV; WASH, water, sanitation, and hygiene.


IX. PROGRESS ON USAID FORWARD

The project continued to ensure that sustainability remained at the core of OVC services. The

focus was on institutional sustainability and household and community resilience. The project

continued to work with the 76 CBOs, building their institutional and technical capacity to

manage and ensure sustainable child outcomes. All 76 CBOs received opportunities to apply for

small PEPFAR grants, with the project team providing technical insights in developing their

proposals. The CBOs were trained on compliance to donor standards, governance, and financial

management.

The project continued to build the capacity of 15 CBOs that provide services to DREAMS

beneficiaries/AGYW through trainings, mentorship, and supportive supervision. The project

continued to work with 6 local implementing partners as a strategy of building local capacity to

implement interventions targeting AGYW. The support provided to the local implementing

partners was both financial and technical to enable them to deliver targeted interventions to girls

with high vulnerability. Project-trained mentors and facilitators regularly reach out to AGYW

with repeat prevention and risk-reduction messages, condom promotion, and referrals for

biomedical services including social protection services in the two counties of Homa Bay and

Kisumu.

X. SUSTAINABILITY AND EXIT STRATEGY

The project continued to ensure that sustainability remained at the core of OVC services. The

focus continues to be within three key areas: institutional sustainability, household and

community resilience, and environmentally sustainable production systems.

Institutional sustainability seeks to transition services and responsibility at the household and

CBO levels. At the CBO level, capacity-building through exchange visits, twinning of CSO,

quarterly review meetings, and supportive supervision was carried out, which has resulted in

strengthened networks, stronger linkages for resource mobilization, and enhanced governance

and management of these organizations. In Y7Q2, Village savings and loan associations

(VSLAs) continued to be a key household economic strengthening intervention in the project.

Community-based trainers (CBTs) trained by the project continued to promote village savings

and loan (VSL) methodology among the OVC caregivers. A total of 52 new VSLA groups were

trained during the reporting period, bringing the number of active VSLA groups to 926.

During the reporting period, KSh. 38.7 million was in circulation and 18.5 million in loans

benefiting 24,675 caregivers supporting 63,764 OVC. Two groups had a share-out of 1.19

million in Kisumu and Siaya, which caregivers utilized to grow their assets, expand their

businesses, and meet basic needs including shelter, education, and health care.


XI. GLOBAL DEVELOPMENT ALLIANCE (IF APPLICABLE)

Not applicable.

XII. SUBSEQUENT QUARTER’S WORK PLAN

Progress against planned activities during the reporting period is outlined in Table 47 below.

Table 47. Subsequent quarter’s work plan.

Planned activities from previous quarter Actual status this quarter Explanations for deviations

Increased and expanded high-quality HIV services

Support facility mentorship activities by the

mentoring teams for ART, PMTCT, HTC, lab,

and pharmacy.

Was not fully accomplished in

this quarter.

Health Care Workers strike that

was witnessed in June 2017

hindered full implementation

especially in high volume sites

TRAIN HEALTH CARE WORKERS ON

THE REVISED ART GUIDELINES


this quarter.





SUPPORT FACILITY-BASED CME FOR

ART AND PMTCT ON A QUARTERLY

BASIS.


this quarter.





SUPPORT THE LABORATORY-

NETWORKING MODEL (CD4, EID,

BIOCHEMISTRIES, HEMATOLOGY, AND

VIRAL LOAD).


this quarter.





SUPPORT ART PMTCT REPORTING TO

MEET APR TARGETS.


this quarter. Quarter’s target were

not met.





SUPPORT ACCELERATED ART

ENROLLMENT AND RETENTION

ACTIVITIES


this quarter. Targets not met





SUPPORT KQMH QI BASELINE

ASSESSMENTS AND REASSESSMENTS

IN SITES, AS WELL AS LEARNING

SESSIONS AND COACHING.


this quarter.





SUPPORT FACILITY ART/PMTCT

DEFAULTER TRACING MECHANISMS

(DIARIES, PEER EDUCATORS, AIRTIME,

AND SMS REMINDERS).


this quarter. Some of the clients

missed their appointments.





SUPPORT FACILITY PLHIV SUPPORT

GROUP MONTHLY MEETINGS

(INCLUDING PEDIATRIC, MALE,

ADOLESCENT, PMTCT, GENERAL CCC).



missed their appointments and

PSSG visits in the facilities.





SUPPORT HIV COUNSELING AND

TESTING AT ANC AND MCH CLINICS OF






Planned activities from previous quarter Actual status this quarter Explanations for deviations

PREGNANT MOTHERS AND MOTHER-

BABY PAIRS.

missed on being attended to at the

clinics.



PROVIDE HCW MENTORSHIP ON

EMTCT.


this quarter.





SUPPORT NONCLINICAL COUNSELORS.

Completed planned activities for

the quarter

Not applicable

SUPPORT DR-TB PATIENTS TO ACCESS

TREATMENT.

Completed planned activities for

the quarter.

Not applicable

DREAMS

Pre-exposure prophylaxis (PrEP) rollout Ongoing Identified adolescent girls and

young women (AGYW) put on

PrEP as required

Cash transfer rollout Ongoing A continuous process.

Increasing the numbers

School fees payment Completed N/A

Financial capabilities and entrepreneurship

training

Completed N/A

Vocational training Completed N/A

National Health Insurance Fund (NHIF)

registration

Completed N/A

Village savings and loan association

(VSLA) training

Ongoing Not a one of activity

Parental skills training Ongoing Not a one of activity; also

awaiting Families Matter!

Program curricula

Services for orphans and vulnerable children (OVC)

Enroll OVC with direct 12-month

subscription for NHIF

Completed Not applicable

Sensitize link facility volunteers for

defaulter tracing, treatment retention, and

escorted referrals.


Build the capacity of community-based

organizations (CBOs) on revised

household economic-strengthening (HES)

strategy


Mobilize, train, provide, and follow up of

productive assets within the Wakumi

groups of highly vulnerable households


Facilitate community-based trainers to

build the capacity of savings groups and

monitor and conduct review meetings



Twin up CBOs to strengthen their

capacities (in governance, resource

mobilization, and quality improvement)


Conduct county stakeholder meetings to

develop transition plans, support core team

to implementation the plan, and review on

a monthly basis (for 3 months)


Support OVC to register and acquire birth

certificates

Complete Not applicable

Support CBOs to identify, enroll, and

monitor newly enrolled OVC


Identify and train additional community

health volunteers and lead community

home visitors


XIII. FINANCIAL INFORMATION

Project cash flow and financial projections

Project cash flow and financial projections are highlighted in Figure 11 below.

Figure 11. Cash flow report and financial projections (pipeline burn-rate).

0

50000000

100000000

150000000

200000000

250000000

Expenditure Pipeline Obligation

Obligation

2017 Quarter 4 ProjectedExpenditure




Budget details

T.E.C: $216,065,090

Cumulative Obligation: $200,575,061.41

Cumulative expenditure

Actual $187,139,883.14

Accrual $ 1,054,380.95

Total $188,194,264.09

Table 48. Actual expenditure details

Obligation 2017 Quarter II

cumulative

expenditures

2017 Quarter III

projected

expenditures

2017 Quarter IV projected

expenditures

$200,575,061.41 $187,139,883.41 $9,269,923.00 $7,073,932.00

Personnel $18,346,892.28 $1,218,210.00 $1,218,210.00

Fringe benefits $5,557,059.38 $363,720.00 $363,720.00

Travel $13,291,046.42 $407,441.00 $205,014.00

Equipment $873,469.74 $0.00 $0.00

Supplies $16,062,870.56 $656,097.00 $393,658.00

Contractual $533,591.37 $238,192.00 $257,248.00

Other direct Costs $107,083,882.33 $4,952,675.00 $3,252,675.00

Overhead $25,391,071.33 $1,433,588.00 $1,383,407.00

Source: Project financial records, June 2017

Budget notes

Table 49. Budget notes

Salary and wages This has stabilized and should remain the same in the next quarter

Fringe benefits Fringe benefits are a constant ratio against all salaries and wages

(payments of provident fund; social security; medical premiums are

included in the fringe pool)

Travel, transport, per diem This is expected to come down in the next quarter as the project

heads towards closure

Equipment No purchase of equipment anticipated in the next quarter.

Contractual The project will continue to implement Performance Based

Incentives up to the end of Quarter II

Supplies This has consistently stabilized.

Other direct costs Other direct costs are anticipated to stabilize from quarter II.

Subgrants OVC sub grants came ended on 30th June 2017.

Overhead Calculated as per Award conditions

G&A Calculated as per Award conditions

Material overhead Calculated as per Award conditions


New subaward details

None

XIV. ACTIVITY ADMINISTRATION

Personnel

There were no changes in the project key personnel within the reporting period.

Contract, award, or cooperative agreement modifications and amendments

The project received an incremental obligation of $ 14,320,407 on May 2, 2017. The OVC sub grants

ended on June 30, 2017.

XV. INFORMATION FOR ANNUAL REPORTS ONLY

N/A.

XVI. GPS INFORMATION

Please see the GPS information sheet in the attachment.


XVII. SUCCESS STORIES

Success story 1 - DREAMS initiative Makes girls dream again

Doreen Auma is only 14 years old, but she is already a mother. In 2016, Doreen braved the

stigma often directed toward young girls who get pregnant while in school to continue with her

studies and attain a better life for herself and her siblings. She hopes to become a nurse and care

for young mothers like herself and children. Doreen is among more than 500 girls supported

under the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS)

initiative supported by the US President’s Emergency Plan for AIDS Relief targeting adolescent

girls and young women.

Doreen comes from a polygamous family in Homa Bay County where poverty and cultural

practices, including polygamy, continue to fuel the spread of HIV. Doreen’s problems started

when her father married a second wife and abandoned her mother, who is the first wife. Doreen’s

mother has to care for the five siblings by casual jobs just to make enough for the family,

sometimes having to take Doreen with her. As a result, in the struggle to make ends meet,

Doreen started either attending classes for only half a day or missing out completely to take up

casual work to earn a living.

The dire situation at home made Doreen suffer trauma, psychological issues, confusion, and

withdrawal from her peers, making her lose her self-esteem and self-confidence. She could not

concentrate in school and thought of running away to get married, just like her elder sister.

During this time, a man she met at a funeral vigil (locally referred to as disco matanga) took

advantage of her and impregnated her, forcing Doreen, who was in class seven, to drop out of

school completely. The man fled when he received the news, leaving the young girl to face

motherhood alone. This came with not only a lot of stigma and judgment from her neighbors but

also verbal abuse from her own father.

In June 2016, Doreen was enrolled in the DREAMS project after meeting all the eligibility

criteria requirements. She was attached to Otange ‘Safe Space, where she is receiving services.

She was immediately referred for biomedical services and linked to Otange dispensary, where

she was enrolled in antenatal care.

“Joining the DREAMS could not have come at a better time. I have learned and benefited a lot,”

Doreen says.

Doreen also underwent behavioral interventions such as Life Skills Education and My Health

My Choice, regular mentorship sessions, and SASA intervention. Another structural intervention

that Doreen received at the safe space was a learner’s package that contained sanitary towels,

toothpaste and toothbrush, and body lotion. She singles out the mentorship sessions, which she

says have empowered her to better deal with life.

“I have learned how to take care of myself. If I had joined the safe space earlier, I would not

have become pregnant because I would have known how to protect myself,” she said.

At Minyere Primary School, Doreen is an obedient, hard-working pupil. She is able to focus on

her studies because her mother has agreed to take care of her one-year-old baby boy while

Doreen is at school. In the evening, she breastfeeds her son and takes a few hours to do her


homework and read for her exams. The DREAMS initiative has also provided her with a solar

lamp to aid her during her studies, and she was also enrolled in the cash transfer program of

4000/=, which her mother receives on her behalf as she takes care of her baby.

DREAMS aims to give adolescent girls and young women an opportunity to live Determined,

Resilient, Empowered, AIDS-free, Mentored, and Safe lives. The objective of DREAMS is to

reduce by 40% the HIV incidence among females between the ages of 10 and 24 in two years.

DREAMS in Kenya is implemented in Homa Bay, Siaya, Kisumu, and Nairobi counties, which

have an HIV prevalence of 26%, 24.8%, 19%, and 6%, respectively (KAIS, 2012).

Success story 2 - I am living testimony of the success of prevention of mother-to-child

transmission of HIV

Losing a child is, definitely, one of the most traumatic moments in a mother’s life. As if one was

not enough, Martha Kwamboka lost three in a row. She was devastated and even wondered if she

had been bewitched. Nearly ten years after she lost her third baby, Martha decided to turn the

pain into a passion to help HIV-positive mothers deliver HIV-free children. She is one of the

mentor mothers working with the AIDS, Population, and Health Integrated Assistance

(APHIAplus Western) project to support prevention of mother-to-child transmission (PMTCT)

of HIV in Bungoma County.

“I delivered my first child, a baby boy, in 2000 and I was very happy. The baby was fine but at

about four months he stopped growing and complications set in. He developed swellings around

the lymph nodes and died at six months,” said Martha, narrating her ordeal. Martha got pregnant

again in 2002 and gave birth to a baby boy who looked healthy; six months later he developed a

strange skin rash and died a few weeks later. The same thing occurred to her third-born child,

also a baby boy.

“I was so angry and disillusioned. I knew I had been bewitched or my marriage had been cursed,

so I left my husband. A few years later, I started getting sickly and came to the hospital

[Bungoma County Referral Hospital] where I was tested and told that I was HIV positive. I was

encouraged to join a support group where I started to learn a lot about how to live positively,”

she said.

It was in this support group of people living with HIV that Martha met her new husband in 2010.

Seven years on, Martha is an ecstatic mother to six-year-old Joy and two-year-old Joshua. Both

children went through the PMTCT process and graduated after being confirmed HIV free at 18

months.

“I was hesitant at first because I feared that what happened earlier would happen again. The

clinician, however, assured us through counseling that it was possible to have a healthy baby. We

had to ensure that we were adhering to our medication, [that we] maintained a low viral load, and

that we were healthy before we tried to have the baby. When my daughter was born, I named her

Joy after our support group name. I brought her in regularly for PMTCT and when at 18 months

she was tested negative for HIV, I became emboldened. The second child was easy,” she

explains.


Martha’s husband, Emmanuel Nyumba, also went through similar tribulations and says PMTCT

has enabled him to experience the joy of being a father. He too was previously married and lost

three children and a wife before discovering that he was HIV positive.

“It is not easy to lose three children and a wife. In my Luo community there is something called

chira [loosely translated, this means a curse] and this is what we all thought was the reason

behind the death of my first three children. But when I fell sick in 2000, a test was taken and that

is when I discovered that my children were dying of HIV-related complications,” said

Emmanuel.

Martha says she is now content with her two children and wants to spend her time helping other

women deliver and raise HIV-negative children. She spends her day at the Bungoma County

Referral Hospital, where she is known as a mentor mother who helps counsel and encourage

women at the PMTCT clinic on the benefits of treatment adherence and its resultant impact of

healthy HIV-negative babies.

“Women lose hope once they test positive for HIV. Some women used to abort their babies out

of fear that they will give birth to HIV-positive children. Others even deliver but abandon their

newborns at the hospital because they do not want to take home an HIV-positive baby,” she said.

Martha is proud of the work that she and other mentor mothers are doing to reduce HIV

infections in the county. Bungoma has an HIV prevalence rate of 2.8%, with women and young

people of reproductive age being the most affected. The rollout of aggressive PMTCT programs

such as the mentor mother initiative have helped reduce the rate of mother-to-child transmission

from 5.2% in 2015 to the current 4%.

Success story 3 - Improving adherence through treatment buddies at Butere County

Hospital

Ask Livingstone Okune how he contracted HIV and he will point to his alcoholism. Alcoholism

and HIV would also have sent him to the grave if it were not for Christabel Bukachi, an

adherence counselor with the USAID-funded APHIAplus Western project. Christabel convinced

Livingstone to reduce his drinking and adhere to treatment.

Livingstone was in a group of 130 HIV-positive people on treatment who a year ago were not

responding to antiretroviral therapy, largely due to poor adherence to treatment. He is now

responding well to treatment and regained his health thanks to the treatment buddies initiative, an

aggressive Butere County Hospital program initiated to support patients with adherence

difficulties.

In February 2015, Livingstone was brought to the hospital very sick. His CD4 cell count, the

measure of the level of immunity in the body, was barely above 30. He was in dire straits: this

was well below 500, which is indicative of good health. He was counseled and immediately

enrolled on ARVs. Six months later, a viral load was taken to assess how he was responding to

treatment. His clinician was shocked to find that his viral load was more than 20,000 copies. A

second viral load test was conducted after another six months and it was more than 40,000.

When a third test was done in August 2016, it had shot to more than 200,000 copies! The

clinician concluded that Livingstone was not taking his medicine properly. Six months later and


after close monitoring by his treatment buddy, his viral load dropped to low detectable levels,

and Livingstone looked and felt healthier.

The treatment buddies initiative involves assigning specific peer counselors to clients who are

struggling to adhere to treatment. The peer counselor befriends the client and in the process is

able to understand the unique challenges his/her client may face.

Christabel, who was assigned to handle Livingstone, says, “Livingstone was one of the most

difficult clients I have ever dealt with. . . . He would come here drunk, incoherent, and disorderly

and would shout at us.” This is contrary to how I found him at the Facility Comprehensive Care

Center on the day of this interview. Livingstone was sober, composed, and coherent.

“I was drinking too much and this was affecting my health. I would drink all day and when I got

home I would just sleep without taking any food or my medication,” he admitted.

The treatment buddies initiative was mooted at a meeting convened by Butere Sub-County AIDS

and Sexually Transmitted Infections Coordinator Christine Odhiambo. The initiative aimed to

address the low viral load suppression at the facility and support clients with adherence

challenges, especially the alcoholics.

“Poor adherence was clouding our efforts in other areas and we had to do something,” Odhiambo

said.

“Our linkage to treatment for clients testing [HIV] positive was above 80% but due to poor

adherence, the viral load suppression was low,” she added.

Butere County Hospital is the second largest health facility in Kakamega County providing care

nearly 1,500 people living with HIV (PLHIV) on antiretroviral therapy. Because of poor

adherence, the number of suspected treatment failures was rising and affecting suppression of the

viral load, a key target in the UNAIDS 90-90-90 HIV treatment strategy. The 90-90-90 treatment

strategy seeks to ensure that 90% of people living with HIV know their status, 90% of people

living with HIV are put on treatment, and 90% of PLHIV on treatment attain viral load

suppression. Following the implementation of the treatment buddies initiative and other

adherence support strategies, the number of patients not adhering to treatment dropped by almost

two-thirds, from 130 in April 2016 to just 48 in May 2017.

To deal with patients with alcoholic challenges like Livingstone, the hospital also started a

special alcoholics’ clinic where counselors would discuss their challenges. Other strategies

adopted by the peer counselors included reducing the intervals for clinic visits and involving the

alcoholics’ partners or close relatives for increased support. For Livingstone, it is a double win.

“No one had really spent time to educate me on the dangers of alcohol. Now I can plan my life

and support a family, something that I was not doing earlier,” he said.

Christabel, who has lived with HIV for more than 20 years, says, “I see no reason why someone

should die of HIV, especially now when treatment is widely available.”


With initiatives like the treatment buddies at Butere County Hospital, people living with HIV

like Livingstone can enjoy the full benefits of antiretroviral therapy and contribute to ending new

infections.


ANNEX A. SCHEDULE OF UPCOMING EVENTS

The scheduled activities for Quarter 3, 2017, are included in Table 50 below.

Table 50. Schedule of upcoming events.

Date Location Activity

July to September 2017 Kisumu and Homa Bay Pre-exposure prophylaxis (PrEP): Identify

more beneficiaries

July to September 2017 Kisumu and Homa Bay Cash transfer: Continue payments

July to September 2017 Kisumu and Homa Bay School fees payment: Verification of

beneficiaries

July to September 2017 Kisumu and Homa Bay Financial capabilities and entrepreneurship

training

July to September 2017 Kisumu and Homa Bay Vocational training

July to September 2017 Kisumu and Homa Bay National Health Insurance Fund (NHIF)

registration: Monitor usage and payments

July to September 2017 Kisumu and Homa Bay Village savings and loan association (VSLA)

training

July to September 2017 Kisumu and Homa Bay Parental skills training

ANNEX B. LIST OF DELIVERABLE PRODUCTS

None.


ANNEX C. ACTIVITY IMPLEMENTATION RESULTS TABLES

1. Busia county site level HTS results, April to June 2017


2. Kisumu county site level HTS results, April to June 2017


3. Condoms distributed to fisher folk in two counties, April to June 2017.

County Number of

condom outlets

Number of condoms

distributed

Number of individuals receiving condoms

Male Female Total

Busia 135 11,408 570 857 1,427

Kisumu 182 18,841 661 714 1,375

Total 317 30,249 1,231 1571 2,802

4. Orphans and vulnerable children (OVC) served per county, as of Y7Q2.

County Served

Y7Q2

Served

Y7Q1

Served

Y7Q1

Served

Y6Q4

Served

Y6Q3

Served

Y6Q2

Served

Y6Q1

Bungoma 22,658 20,289 100.0% 86.2% 91.5% 104.9% 108.2%

Busia 21,294 19,124 99.7% 95.0% 83.8% 94.4% 97.5%

Homa Bay 55,207 54,077 99.7% 89.4% 91.8% 99.2% 97.3%

Kakamega 34,096 31,398 98.1% 96.6% 92.4% 99.2% 104.3%

Kisii 4,830 5,819 98.2% 85.8% 95.9% 90.6% 91.4%

Kisumu 33,621 32,067 100.0% 97.9% 82.1% 95.0% 89.2%

Migori 26,250 24,912 99.9% 85.7% 89.3% 93.7% 98.9%

Nyamira 3,667 3,507 100.0% 96.7% 94.4% 101.7% 104.7%

Siaya 21,369 20,760 99.8% 90.9% 71.3% 89.6% 99.6%

Vihiga 8,006 7,381 99.7% 98.7% 99.5% 92.8% 101.2%

Total 230,998 219,334 99.5% 92.0% 85.6% 96.8% 99.2%

Source: OVC longitudinal management information system (OLMIS) 2017.

5. Orphans and vulnerable children (OVC) services, by domain.

Service by domain Education Health and

nutrition

HES Protection PSS Shelter and care

Bungoma 6,325 15,922 63 10,652 19,670 8,939

Busia 2,203 17,725 6 15,817 20,357 4,443

Homa Bay 9,391 48,686 4 41,310 51,076 26,951

Kakamega 2,153 25,796 20 25,669 30,962 9,084

Kisii 4 4,013 - 4,588 4,692 252

Kisumu 2,348 31,757 5 24,049 32,547 10,181

Migori 3,792 20,946 6 11,913 25,293 16,133

Nyamira 11 2,437 1 2,819 3,474 394

Siaya 2,669 16,073 5 12,060 20,978 1,520

Vihiga 325 7,188 1 6,615 7,552 3,242

Total 29,221 190,543 111 155,492 216,601 81,139

Note: HES, household economic strengthening; PSS, psychosocial support.

Source: OVC longitudinal management information system (OLMIS) 2017.


6. Food supplementation status, as of June 10, 2017.

Counties First Food

received

First Food

distributed

Amount

remaining

Foundation Food

received

Foundation

distributed

Amount

remaining

Bungoma 1,303 1,222 81 180 178 2

Busia 1,353 1,206 147 125 124 1

Kakamega 2,023 1,849 174 388 387 1

Vihiga 498 432 66 80 80 0

Siaya 976 929 47 158 157 2

Kisumu 1,761 1,615 146 248 246 2

Kisii and

Nyamira

517 517 0 76 76 0

Homa Bay 1,801 1,573 228 230 225 5

Migori 1,754 1,550 204 147 147 0

Total 11,986 10,793 1,193 1,632 1,628 4


7. Progress on Site Improvement through Monitoring Systems (SIMS)

Domain Element

assessed CBOs USAID

ratings (May/

June 2017)

Project

re score Immediate

action Long-term

action

OVC Beneficiary/ Client rights

and stigma

discrimination

policies

Kafhag Yellow N/A CBO to

customize its

own stigma and

discrimination

policy based on

the national

guidelines.

System

strengthening

for protection

services.

Assessment

and utilization

of performance

data in quality

improvement

(QI) activities

Mirogi Yellow Yellow

N/A CBO to

constitute a QI

team complete

with work

plans and

monitoring

plans.

QI teams are

active and

supported to

perform.

Data quality

assurance Jola to Ajoli Yellow

Yellow

N/A Schedules for

quarterly data

quality

assessment

(DQA) done.

Tools for DQA

developed.

Conduct

quarterly

DQA.

Child safe

guarding Weckma Yellow N/A Develop and

disseminate

CSO specific

child protection

strategy.

Child

protection

strategy

guiding

protection

standards in the CBO.


8. PHDP support at facility and community level in project supported counties.

Ind

ica

tor

Bu

ng

om

a

Bu

sia

Ka

ka

meg

a

Vih

iga

Kis

um

u

Ho

ma

ba

y

Mig

ori

Ny

am

ira

Kis

ii

Pro

ject

To

tals

No. of PLHIV (15

years and above)

enrolled in PHDP

Sessions

1,530 1,353 3,517 1,367 140 1,326 2,841 1,335 254 13,663

No. of PLHIV (15

years and above)

completing all

sessions

835 1,332 1,564 1,167 120 1,326 2,622 821 116 9,903

No. of PLHIV (15

years and above)

provided with

information on

adherence

1,530 1,353 3,517 1,367 140 1,326 2,841 1,335 254 13,663

No. of PLHIV (15

years and above)

provided with

condom

1,428 666 2,110 161 70 0 225 747 143 5,550

Completed Effective Referrals for Various Services

No. of PLHIV (15

years and above)

referred for FP

192 0 324 20 46 0 25 861 113 1,581

No. of PLHIV (15

years and above)

Referred for GBV

0 0 383 2 0 0 0 0 0 385

No. of PLHIV (15

years and above)

Referred for STI

14 0 159 25 0 0 17 434 218 867

No. of PLHIV (15

years and above)

Reffered for

Nutrition

305 0 482 61 0 0 0 0 0 848

Documents

USAID KENYA APHIAplus WESTERN KENYA