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Afya Ziwani

SEMIANNUAL PROGRESS REPORT

(JANUARY–MARCH 2020)

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

Adolescent girls and young women attending a sensitization session on COVID-19 at a safe space hosted in a local

administration’s compound in Kisumu County on April 5,2020. Photo: PATH.

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Afya Ziwani

SEMIANNUAL PROGRESS REPORT

(JANUARY–MARCH 2020) Prepared for Dr. Stanley Bii US 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 US Agency for International Development or the US Government.

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Contents

Abbreviations ................................................................................................................................................ v

List of tables ................................................................................................................................................. vii List of figures ................................................................................................................................................. x Executive summary ....................................................................................................................................... 1

Overview ................................................................................................................................................... 1 Prevention ................................................................................................................................................. 1

HIV testing services................................................................................................................................... 3 Antiretroviral therapy ................................................................................................................................. 4

Viral load services ..................................................................................................................................... 4 TB/HIV ....................................................................................................................................................... 5 Prevention of mother-to-child transmission of HIV .................................................................................... 5 Early infant diagnosis ................................................................................................................................ 5

Key achievements ......................................................................................................................................... 7 1. High-priority population intervention: Adolescent girls and young women ........................................... 7 2. High-priority population intervention: Fisherfolk .................................................................................. 13

3. Voluntary medical male circumcision .................................................................................................. 15 4. Pre-exposure prophylaxis ................................................................................................................... 17

5. HIV testing services ............................................................................................................................ 18 6. HIV care and treatment ....................................................................................................................... 24 7. Laboratory support .............................................................................................................................. 33

8. TB/HIV ................................................................................................................................................. 34

9. Elimination of mother-to-child transmission of HIV ............................................................................. 37 10. Commodity security ........................................................................................................................... 45 11. Health systems strengthening ........................................................................................................... 48

12. Strategic monitoring and evaluation .................................................................................................. 50 Performance monitoring: Data tables ......................................................................................................... 54

Constraints and opportunities ..................................................................................................................... 55 Progress on gender strategy ....................................................................................................................... 56

Number of people receiving post-gender-based violence clinical care minimum package .................... 56 Adolescent girls and young women/adolescent boys and young men ................................................... 56

Provision of activities to prevent and respond to gender-based violence ............................................... 56 Progress on environmental mitigation and monitoring ................................................................................ 58 Progress on links to other USAID and Centers for Disease Control and Prevention programs ................. 59

Progress on links with Government of Kenya agencies ............................................................................. 60 Global development alliance (if applicable) ................................................................................................ 61 Subsequent quarter’s work plan ................................................................................................................. 62

Budget and expenditure details ............................................................................................................... 64

Actual expenditure and future projections details ................................................................................... 65 Expenditure notes ................................................................................................................................... 65

Activity administration ................................................................................................................................. 66 Personnel ................................................................................................................................................ 66 Contract amendments ............................................................................................................................. 66

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Subcontractors ........................................................................................................................................ 66 Other significant approval(s) from USAID ............................................................................................... 66

GPS information .......................................................................................................................................... 67 Success story: Viral resuppression in a child and an adolescent in Nyamira County ................................ 68

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Abbreviations

AGYW adolescent girls and young women

AIDS acquired immune deficiency syndrome

ANC antenatal care

ART antiretroviral therapy

ARV antiretroviral

C&T care and treatment

CALHIV children and adolescents living with HIV

CME continuing medical education

DATIM Data for Accountability, Transparency and Impact Monitoring

DCM differentiated care model

DHIS2 District Health Information Software 2

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

EBI evidence-based intervention

ECHO Extension for Community Healthcare Outcomes

EID early infant diagnosis

EMR electronic medical record

FF fisherfolk

FMATT facility missed appointment tracking tool

FY fiscal year

GBV gender-based violence

HCW health care worker

HEI HIV-exposed infant

HF health facility

HIV human immunodeficiency virus

HIVST HIV self-testing

HTS HIV testing services

iHRIS integrated human resources information system

IPT isoniazid preventive therapy

KEMSA Kenya Medical Supplies Authority

LIP local implementing partner

MER Monitoring, Evaluation, and Reporting

MOH Ministry of Health

MSP male sex partner

MTCT mother-to-child transmission of HIV

MWENDO Making Well-informed Efforts to Nurture Disadvantaged Orphans and Vulnerable Children

NASCOP National AIDS & STIs Control Programme

OTZ Operation Triple Zero

OVC orphans and vulnerable children

PCR polymerase chain reaction

PEPFAR US President’s Emergency Plan for AIDS Relief

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PLHIV people living with HIV

PMTCT prevention of mother-to-child transmission of HIV

PMTCT_ART HIV-positive pregnant women on antiretroviral therapy

PMTCT_STAT women attending their first ANC visit who knew their HIV status

PMTCT_STAT_POS HIV-positive pregnant women with known status

PNS partner notification services

PrEP pre-exposure prophylaxis

PrEP_NEW newly on PrEP treatment

PrEP_NEW_AGYW newly on PrEP treatment among the AGYW

PSSG psychosocial support group

Q quarter

SAPR semiannual progress report

SASA start, awareness, support, and action

STF suspected treatment failure

TB tuberculosis

TX_CURR number of individuals currently enrolled in treatment

TX_NEW number of individuals newly enrolled in treatment

USAID US Agency for International Development

VL viral load

VLS viral load suppression

VMMC voluntary medical male circumcision

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List of tables

Table 1. AGYW who accessed services (FY20 SAPR). ............................................................................... 2

Table 2. FF who accessed services (FY20 SAPR). ...................................................................................... 2

Table 3. VMMCs conducted (FY20 SAPR). .................................................................................................. 3

Table 4. PrEP_NEW services (FY20 SAPR). ............................................................................................... 3

Table 5. HIV testing services (FY20 SAPR). ................................................................................................ 3

Table 6. ART services (FY20 SAPR). ........................................................................................................... 4

Table 7. Viral load services (FY20 SAPR). ................................................................................................... 4

Table 8. TB/HIV services (FY20 SAPR). ...................................................................................................... 5

Table 9. PMTCT services (FY20 SAPR). ...................................................................................................... 5

Table 10. EID services (FY20 SAPR). .......................................................................................................... 6

Table 11. Number of AGYW reached by county and against targets (FY20 SAPR). ................................... 8

Table 12. Key behavioral evidence-based interventions. ............................................................................. 8

Table 13. AGYW who received behavioral interventions by county (FY20 SAPR). ..................................... 8

Table 14. Number of AGYW who knew their HIV status through HTS, by age and county (FY20 SAPR). . 9

Table 15. Number of AGYW who received financial capability training (FY20 SAPR). .............................. 10

Table 16. AGYW with complete primary layering (FY20 SAPR). ............................................................... 10

Table 17. PrEP_NEW_AGYW (FY20 SAPR). ............................................................................................ 11

Table 18. Number of MSPs of 15- to 24-year-old AGYW reached with services, by county (FY20 SAPR).

.................................................................................................................................................................... 12

Table 19. Enrollment of eligible OVC in DREAMS, by county and age cohort (FY20 SAPR). ................... 13

Table 20. AGYW co-enrolled in OVC program, with complete primary layering (FY20 SAPR). ................ 13

Table 21. FF currently supported (FY20 SAPR). ........................................................................................ 14

Table 22. FF HTS results (FY20 SAPR). .................................................................................................... 14

Table 23. FF services, per Kisumu County area (FY20 SAPR). ................................................................. 14

Table 24. VMMC performance by county (FY20 SAPR). ........................................................................... 15

Table 25. VMMC performance by age bands (FY20 SAPR). ..................................................................... 15

Table 26. PrEP_NEW performance by county (FY20 SAPR). .................................................................... 17

Table 27. PrEP_CURR performance by county (FY20 SAPR). .................................................................. 17

Table 28. Project-supported HTS results, by county (FY20 SAPR). .......................................................... 18

Table 29. Pediatric HTS results by county (FY20 SAPR). .......................................................................... 19

Table 30. HTS_TST_POS results by county (FY20 SAPR). ...................................................................... 19

Table 31. HTS_TST_POS yield by county (FY20 SAPR). .......................................................................... 19

Table 32. HTS linkage results against proxy indicator HTS_TST_POS (FY20 SAPR). ............................. 20

Table 33. HTS linkage results (FY20 SAPR). ............................................................................................. 20

Table 34. PNS cascade of services, overall, by quarter (FY20 SAPR). ..................................................... 21

Table 35. PNS contribution to HIV positives and positive yield (FY20 SAPR). .......................................... 22

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Table 36. PNS summary of cascade by sex (FY20 SAPR). ....................................................................... 22

Table 37. PNS cascade per tested population (FY20 SAPR). .................................................................... 22

Table 38. PNS cascade of services by county, ≥ 15 years old (FY20 SAPR). ........................................... 23

Table 38. HIVST kits distributed (FY20 SAPR)........................................................................................... 24

Table 39. New clients on ART, by county (FY20 SAPR). ........................................................................... 25

Table 40. New pediatric clients on ART, by county (FY20 SAPR). ............................................................ 25

Table 41. Twelve-month cohort retention (FY20 SAPR). ........................................................................... 25

Table 42. Total current clients on ART, by county (FY20 SAPR). .............................................................. 26

Table 43. Current pediatric clients on ART, by county (FY20 SAPR). ....................................................... 26

Table 44. Current ART net gain by county (FY20 SAPR). .......................................................................... 27

Figure 1. Overall net ART retention (March 2020). ..................................................................................... 27

Table 45. Monthly changes in current on ART by county and overall (FY20 Q2). ..................................... 28

Table 46. Overall performance of 39 sites in Operation Triple Zero (FY20 Q2). ........................................ 29

Table 47. CALHIV enrolled/virally suppressed in MWENDO/OVC program (FY20 SAPR) ....................... 29

Table 48. PLHIV enrollment in PSSGs (FY20 Q2). .................................................................................... 30

Figure 2. Differentiated care cascade (FY20 Q2). ...................................................................................... 31

Table 49. VL uptake by county—routine and targeted testing against current on treatment (FY20 Q2). .. 32

Table 50. VLS by county, routine and targeted VL testing (FY19 Q3 to FY20 Q2). ................................... 32

Table 51. VLS by age group for routine VL testing (FY20 Q1 and Q2). ..................................................... 32

Table 52. VLS by cadre for routine VL testing (FY20 Q1 and Q2). ............................................................ 32

Table 53. Key TB/HIV performance indicators (FY20 SAPR). .................................................................... 35

Table 54. TB cascade (FY20 SAPR). ......................................................................................................... 35

Table 55. TB screening by county (FY20 SAPR). ...................................................................................... 36

Table 56. IPT for TB (FY20 SAPR). ............................................................................................................ 37

Table 57. PMTCT uptake by county (FY20 SAPR). ................................................................................... 37

Table 58. PMTCT_STAT summary achievements (ANC1) by county (FY20 SAPR). ................................ 38

Table 59. PMTCT_ART summary achievements by county (FY20 SAPR). ............................................... 38

Table 60. Average VLS among PMTCT clients (FY20 Q2). ....................................................................... 38

Table 61. PMTCT cohort analysis (FY20 Q2). ............................................................................................ 39

Table 62. Overall EID tests between 0 and 12 months old (FY20 SAPR). ................................................. 40

Table 63. EID test performance by monthly periods (FY20 SAPR).* ......................................................... 40

Table 64. Early infant diagnosis cascade—initial tests only (FY20 SAPR). ............................................... 41

Table 65. Outcome of HEI positivity audits (FY20 Q2). .............................................................................. 43

Table 66. HEI analysis of 12-month cohort (FY20 Q2). .............................................................................. 44

Table 67. HEI analysis of 18-month cohort at 24 months (FY20 Q2). ........................................................ 44

Figure 3. Central and satellite ART commodity sites’ reporting rates into KHIS (FY20 Q2). ..................... 47

Table 68. HF staff participation in CME by topics covered (FY20 Q2). ...................................................... 49

Table 69. Health care professionals contracted (FY20 Q2). ....................................................................... 50

Table 70. Health care lay workers contracted (FY20 Q2). .......................................................................... 50

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Table 71. Non-health-care lay workers contracted (FY20 Q2). .................................................................. 50

Table 72. EMR distribution at service delivery points, by county (FY20 Q2). ............................................. 52

Table 73. Provision of post-GBV clinical services (FY20 SAPR). ............................................................... 57

Table 74. Government ministries and departments that Afya Ziwani collaborated with (FY20 Q2). .......... 60

Table 75. Work plan activities and statuses for increased and expanded high-quality HIV services (FY20

Q2). ............................................................................................................................................................. 62

Figure 4. Expenditure status and financial projections (pipeline) in US dollars (FY20 Q2). ....................... 64

Table 76. Actual expenditure details, in US dollars (FY20 Q2). ................................................................. 65

Table 77. Expenditure notes. ...................................................................................................................... 65

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List of figures

Figure 1. Overall net ART retention (March 2020). ..................................................................................... 27

Figure 2. Differentiated care cascade (FY20 Q2). ...................................................................................... 31

Figure 3. Central and satellite ART commodity sites’ reporting rates into KHIS (FY20 Q2). ..................... 47

Figure 4. Expenditure status and financial projections (pipeline) in US dollars (FY20 Q2). ....................... 64

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Executive summary

Overview

Afya Ziwani is a US Agency for International Development (USAID) project funded by the US President’s

Emergency Plan for AIDS Relief (PEPFAR). It is implemented by a PATH-led consortium of Kenyan

nongovernmental organizations. The project is a five-year project from October 1, 2017, to September 30,

2022. Afya Ziwani aligns its activities with PEPFAR’s 95-95-95 goals and the Kenyan Ministry of Health’s

guidelines and directives. The project builds the institutional capacity of communities, health facilities

(HFs), and counties to effectively conduct and sustainably manage their responses to the HIV epidemic.

In its first two project years, Afya Ziwani supported four high-burden and one moderate-burden

HIV/tuberculosis (TB) counties of western Kenya. In Quarter 2 (Q2) of fiscal year 2020 (FY20), the project

continued its support to the counties of Kisumu (in the three designated subcounties of Kisumu East,

West, and Central) and Nyamira (all its five subcounties) under the HIV service delivery arm. As well, the

project continued to support the adolescent girls and young women (AGYW) in Homa Bay, Kisumu, and

Migori through the AGYW/DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe)

services. The AGYW work was implemented under the auspices of orphans and vulnerable

children/DREAMS, as per the PEPFAR directions for country operational plan 2019.

In FY20 (project Year 3), the project supported a total of 115 HFs, each of which had at least one

PEPFAR-assigned target, in the two counties of Kisumu and Nyamira. All HFs had HIV testing services

(HTS) targets; 111 had PEPFAR targets for antiretroviral therapy (ART); 26 had targets for TB; and 84

had targets for prevention of mother-to-child transmission of HIV (PMTCT). For prevention services, the

project prioritized four intervention areas in the reporting quarter: AGYW, fisherfolk (FF), voluntary

medical male circumcision (VMMC), and pre-exposure prophylaxis (PrEP). Only two HFs had PEPFAR-

assigned VMMC targets, but the project supported seven other satellite HFs. The project received a

contract modification to include key population interventions within the its scope of work.

Prevention

Adolescent girls and young women

AGYW services were provided through four local implementing partners that worked in 260 safe spaces,

49 wards, and 16 subcounties in the three counties of Homa Bay, Kisumu, and Migori. Table 1

summarizes the numbers of AGYW that accessed services during the reporting quarter and the

semiannual program review period.

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Table 1. AGYW who accessed services (FY20 SAPR).

Cohort Q1 Q2 SAPR Annual Target

Achievement

9–17 years old 703 27,486 28,189 38,154 74%

18–24 years old 16,965 13,571 30,536 39,727 77%

9–24 years old 17,668 41,057 58,725 77,881 75%

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; Q quarter; SAPR, semimanual progress report.

At the semimanual progress report (SAPR) period, the project surpassed the expected achievement for

the overall annual target for the 9- to 24-year-old cohort (75%) as well as that for the 9- to 17-year-old and

the overall 18- to 24-year-old cohorts; the respective performances in these cohorts were 74% and 77%.

This was a remarkable improvement from the 23% attained at Q1. A total of 58,725 vulnerable AGYW

received services in the last six months—at least one of the behavioral, biomedical, or structural

interventions under the comprehensive package of services for primary HIV prevention.

In the SAPR period, 23% (13,785 of 58,725) of active AGYW were fully layered (received all required

services). Age-specific results were as follows: 24% for the 9- to 17-year-old cohort and 23% for 18- to

24-year-old cohort. This performance is satisfactory, given that the AGYW have only been in the program

for less than 6 months against a desired 9 to 12 months. Secondary interventions were provided on an

as-needed basis.

Fisherfolk

Another key prevention area was the provision of services to FF located at the Lake Victoria landing sites

of Kisumu County. Afya Ziwani provided services through one local implementing partner, in collaboration

with 12 government-registered beach management units, to reach both male and female FF with a

comprehensive package of HIV prevention, care, and treatment services. Table 2 summarizes the

number of FF that accessed services in the reporting quarter. Afya Ziwani achieved 46% of its annual

target of FF accessing services by this quarter. There are no gender disaggregated targets.

Table 2. FF who accessed services (FY20 SAPR).

Q1 Q2 SAPR

Annual Target

Achievement

Male 1,244 922 2,222

Female 1,871 1,275 3,196

Total 3,115 2,197 5,418 11,868 46%

Abbreviations: FF, fisherfolk; FY, fiscal year; Q, quarter; SAPR, semiannual progress report.

Voluntary medical male circumcision

A third key prevention service supported by the project was VMMC. Afya Ziwani provided support to nine

VMMC-providing HFs in Muhoroni subcounty of Kisumu County. Of the supported HFs, two had targets

specified by PEPFAR and the remaining seven were their satellite HFs. Table 3 summarizes the number

of VMMCs conducted in the two quarters of the year.

Afya Ziwani provided VMMC services to 433 clients this quarter—69% of its annual target as at the

SAPR. For the quarter, 64% of clients were 15 years old or older; the PEPFAR target for this age group is

60%. This improvement was in line with PEPFAR direction to scale back services for those younger than

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15 years old. As well, the project partnered with Population Services Kenya to create demand for services

for the older cohorts. There was no form of adverse event, including tetanus, reported in Q2.

Table 3. VMMCs conducted (FY20 SAPR).

Q1 Q2 SAPR Annual Target Achievement

1,554 433 1,987 2,862 69%

Abbreviations: FY, fiscal year; Q1, quarter; SAPR, semiannual progress report; VMMC, voluntary medical male circumcision.

Pre-exposure prophylaxis

The project supported HFs to provide PrEP to new and continuing clients. This quarter, the project is

reporting on the PrEP_NEW indicator (newly on PrEP treatment), as well as the semiannual indicator,

PrEP_CURR (continuing on PrEP treatment in each period). The project targeted AGYW between 18 and

24 years old for PrEP, including having HF staff visit the AGYW safe spaces to educate them on PrEP

and provide services. Table 4 summarizes the number of new clients, both among AGYW and all clients,

who received PrEP services in the quarters, as well as those currently on PrEP as at the end of Q2.

Table 4. PrEP_NEW services (FY20 SAPR).

PrEP_NEW Q1 Q2 SAPR Annual Target

Achievement

AGYW 176 988 1,164 2,477 47%

All Clients 139 409 548 589 93%

PrEP_CURR

SAPR Annual Target

Achievement

AGYW

All Clients 1,281 742 172%

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; PrEP_CURR, continuing on PrEP treatment in each period; PrEP_NEW, newly on PrEP treatment; PrEP, pre-exposure prophylaxis; Q, quarter; SAPR, semiannual progress report.

Safe spaces have been crucial in AGYW accepting and forming positive attitudes about PrEP. Thus, each

safe space has a dedicated link health facility to provide biomedical services (e.g., PrEP). The safe

spaces use the link health facility health care workers (who provide high-quality services), tools (to record

services in the overall Kenya Health Information System, as the safe spaces do not have a master facility

linkage code), and commodities (the link facility forecasts and procures commodities from the Kenya

Medical Supplies Authority).

HIV testing services

The project supported HTS at 115 HFs with PEPFAR targets (113 provided ART services). Partner

notification services continued to be a key component. Table 5 summarizes FY20 SAPR HTS results.

Table 5. HIV testing services (FY20 SAPR).

Indicator Q1 Q2 SAPR Annual Target

Achievement

HTS 37,629 33,307 70, 936 118,132 60%

HTS_POS 902 1,190 2,092 4,160 50%

Linked to C&T

808 1,090 1,898 4,018 47%

Abbreviations: C&T, care and treatment; FY, fiscal year; HTS, HIV testing services; HTS_POS, HTS showing positive result; Q, quarter; SAPR, semiannual progress report.

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Using the proxy numerator of TX_NEW (newly on treatment), 92% of positives in Q2 were linked to the

testing HF for HIV care and treatment (C&T) services. When referrals to other HFs are included (actual

linkage), the linkage rate for the quarter is 94%. For the SAPR, the proxy linkage is 92%.

In Q2, the project’s HIV-positive yield at 3.6% is higher than the 3.5% target, representing a 102%

performance. This is a marked improvement from the 2.4% reported in Q1. For the SAPR, the positivity is

2.9%, which is 83% against the annual target.

During Q2, a total of 2,303 index clients were screened, of which 2,242 (97%) were offered partner

notification services; 5,108 (average of 2.3 each) contacts were elicited from these clients. Of these

contacts, 3,154 were tested and 838 (27%) were newly diagnosed to be HIV positive.

Antiretroviral therapy

The project supported 113 HFs with PEPFAR targets to provide HIV C&T, including ART. Table 6

summarizes ART services for the reporting quarter. Performance in the SAPR period on TX_NEW shows

that the project reached 47% of the annual target.

Table 6. ART services (FY20 SAPR).

ART Services Q1 Q2 SAPR Annual Target

Achievement

TX_NEW 808 1,090 1,898 4,018 47%

TX_CURR 22,367 23,234 23,234 26,235 89%

Change in TX_CURR

267 867

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; Q, quarter; SAPR, semiannual progress report; TX_CURR, currently on treatment; TX_NEW, newly on treatment.

The project achieved 89% of its annual target for the number of adults and children currently receiving

ART. There was a gain in the numbers on treatment in Q2, as well as the change in those currently on

treatment. To improve retention in care, the project continued to support differentiated care service

delivery. The project assisted 89 HFs (79% of ART sites) in providing the service. Overall, 11,708 ART

clients were enrolled, representing 86% of the 13,575 eligible, stable ART clients.

Viral load services

The project supported 113 HFs with PEPFAR ART targets to provide viral load (VL) testing. Table 7

summarizes the number of VL tests completed in the reporting quarter. Performance shows that the

project achieved its annual target for VL testing (the current measure of those who received a VL test

within the last year). Viral load suppression (VLS) was at 92%, which is within the targeted range of 90%

to 95% suppression rate. Of note, the project achieved 94% VLS for routine testing. Among clients who

received “targeted” VL testing (i.e., those who had initially failed on treatment and who received a

confirmatory VL test after enhanced adherence counseling), 83% were re-suppressed.

Table 7. Viral load services (FY20 SAPR).

VL Q2 Annual Target

Achievement

VL Testing 19,619 24, 331 81%

VLS 92% 95% 97%

Abbreviations: FY, fiscal year; Q, quarter; SAPR, semiannual progress report; VL, viral load; VLS, viral load suppression.

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In the quarter, the pediatric and adolescent VLS were at 79% and 85%, respectively. It is expected that

the project-supported transition of the pediatric and adolescent ART regimens to

tenofovir/lamivudine/dolutegravir and other efficacious regimens will further improve VLS in these age

groups, which have continued to report the lowest suppression.

TB/HIV

Performance in Q2 shows that the project is on track to achieve its annual targets for the TB/HIV

indicators (see Table 8). In the FY20 SAPR period, 99% (503 of 509) of TB patients were tested for HIV

and received their results, with 37% (187) found to be coinfected with HIV, of whom 95% (178) were on

ART. At their last visit, 22,663 (98%) comprehensive care center clients were screened for TB and 506 of

536 (94%) completed their isoniazid preventive therapy.

Table 8. TB/HIV services (FY20 SAPR).

TB/HIV Services Q1 Q2 SAPR Annual Target

Achievement

TB patients tested for HIV (TB_STAT) 259 244 503 1,003 50%

TB patients coinfected 95 92 187 367 51%

TB/HIV coinfected patients on ART (TB_ART) 92 86 178 375 47%

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; HTS, HIV testing services; Q, quarter; SAPR, semiannual progress report; TB, tuberculosis.

Prevention of mother-to-child transmission of HIV

The project supported 113 HFs to provide PMTCT services. Table 9 summarizes the numbers of women

that received these services in the quarter.

Table 9. PMTCT services (FY20 SAPR).

PMTCT Services Q1 Q2 SAPR Annual Target

Achievement

Pregnant women with known HIV status (PMTCT_STAT)

5,218 6,137 11,355 18,574 61%

HIV-positive pregnant women (PMTCT_STAT_POS)

294 317 611 1,492 41%

HIV-positive pregnant women on ART (PMTCT_ART)

292 315 607 1,420 43%

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; PMTCT, prevention of mother-to-child transmission of HIV; Q, quarter; SAPR, semiannual progress report.

Performance in Q2 shows that the project was mostly on track to achieve its annual targets, having

achieved more than 40% toward the annual targets. Overall, 100% (11,355 of 11,355) of women who had

antenatal care (ANC) visits knew their HIV status, of which 5.4% (611) were HIV positive. Of these, 74%

(450) were known to be HIV positive at entry, which indicates that women of childbearing age who live

with HIV feel confident that they can have HIV-negative children. Overall, 99% (607) of the HIV-positive

clients were on ART.

Early infant diagnosis

The project supported HFs to provide early infant diagnosis (EID) to HIV-exposed infants (HEIs), with

emphasis on testing by 8 weeks old. Table 10 summarizes the number of EID services provided in the

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reporting quarter. The 38% performance at SAPR shows that the project is not on track to reach its

annual target for EID testing by 12 months old. Against a target of 1,268 for EID at less than 2 months

old, the project achieved 34% (425) of tests. The coverage for EID, as measured against the number of

HIV-positive pregnant mothers at ANC and post-ANC, is at about 85% (537 of 633). Against the proxy

indicator of PMTCT_STAT_POS (HIV-positive pregnant women with known status) at ANC and post-

ANC, 67% of HEIs were tested by 8 weeks old in Q2.

Overall, for Q2, 14 (5.0%) of 282 HEIs tested HIV positive. For the 215 tested by 8 weeks old, 6 (2.8%)

were found to be HIV positive. Of the 67 HEIs tested between 2 and 12 months old in Q2, 8 were positive,

representing 12.0%. To improve on the EID indicators, the project has embarked on revitalizing the

expected date of delivery/EID-polymerase chain reaction log tool that was initiated in FY19 to track all

HIV-positive women from ANC through delivery and the postnatal period to ensure that the polymerase

chain reaction tests are done on time.

Table 10. EID services (FY20 SAPR).

EID Indicator Q1 Q2 SAPR Annual Target

Achievement

Percentage of infants, born to HIV-positive women, who received a first virologic HIV test (sample collected) by 12 months of age

POST-ANC + PMTCT POS

294 329 633

< 2 Months 207 218 425 1,268 34%

2–12 Months

58 54 112 139 81%

Total EID 265 272 537 1,407 38%

Abbreviations: ANC, antenatal care; EID, early infant diagnosis; FY, fiscal year; PMTCT, prevention of mother-to-child transmission of HIV; POS, HIV positive; Q, quarter; SAPR, semiannual progress report.

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Key achievements

1. High-priority population intervention: Adolescent girls and young

women

Through implementation of services for adolescent girls and young women (AGYW), the project seeks to

reduce new HIV infections among vulnerable AGYW between 9 and 24 years old.1 The project used a

strategy of providing layered services, including primary individual interventions to all enrolled AGYW as

per their age cohort, as well as secondary individual interventions based on each unique individual’s

circumstances.

Primary individual interventions include evidence-based interventions (EBIs); education on pre-exposure

prophylaxis (PrEP), condoms, and contraception; HIV testing services (HTS); social asset building; and

financial capability training. Secondary individual interventions include, among others, PrEP, education

support, and vocational training.

To be fully layered, an age cohort must receive the required primary services plus one secondary service.

Age-specific requirements include the following: 9 to 14-year-olds should receive three services, 15 to 17-

year-olds should receive six services, 18 to 19-year-olds should receive seven services, and 20 to 24-

year-olds should receive seven services.

The project continued to work with the orphans and vulnerable children (OVC) partner Catholic Relief

Services/MWENDO (Making Well-informed Efforts to Nurture Disadvantaged Orphans and Vulnerable

Children) to co-enroll girls aged 9 to 17 years old; those aged 18 to 24 years old were solely enrolled by

Afya Ziwani. The project graduated 73,839 and carried over 6,017. Of those carried over, only 2,719 are

ACTIVE, meaning they have received at least one service since October 1, 2019, to date. RETAINED

refers to AGYW who were receiving secondary services, such as PrEP, school fees, and vocational

training.

1.1 Primary individual interventions

Social asset building

The project tracks the number of AGYW who come to the 260 project-supported safe spaces in 49 wards

and receive social asset building interventions. These are denoted as “active AGYW.” In the second

quarter (Q2) of fiscal year 2020 (FY20), the project engaged with 13,571 AGYW aged 18 to 24 years, for

a total of 30,536 in the semiannual progress report (SAPR) 2020 period, which is 77% of the annual

target; it also engaged with 27,486 AGYW aged 9 to 17 years who received services over the last six

months in the safe spaces, for a total of 28,189 (74% of the annual target). These totals are reported

under the social asset building indicator. These active AGYW are broken down by county in Table 11. Q2

FY20 saw a tremendous increase in the enrollment of the age group 9 to 17 years from a low of 703. The

project continued to work with the OVC partner, MWENDO, to prioritize the OVC girls aged 9 to 17 years

old; in areas where the co-enrollment was not possible, then non-OVC girls were enrolled. The project

1 In fiscal year 2020, the project will target directly AGYW between 18 and 24 years old. The project will co-enroll the AGYW between 9 and 17 years old with the orphans and vulnerable children project MWENDO.

8

also worked on providing services not ordinarily offered by the OVC partner, such as education on

contraceptives and PrEP.

The project also continued to partner with the national government to have AGYW receive important

government documents such as birth certificates and national IDs, which are critical for receiving services

such as school fees and vocational training.

Table 11. Number of AGYW reached by county and against targets (FY20 SAPR).

County

Q1 Q2 SAPR Annual

Achievement Achieved Target

9–17 years

18–24 years

9–17 years

18–24 years

9–17 years

18–24 years

9–17 years

18–24 years

9–17 years

18–24 years

Homa Bay 277 8,064 10,824 4,448 11,101 12,512 12,304 13,875 90% 90%

Kisumu 388 6,139 12,235 6,792 12,623 12,931 18,855 18856 67% 69%

Migori 38 2,762 4,427 2,331 4,465 5,093 6,995 6,996 64% 73%

Total 703 16,965 27,486 13,571 28,189 30,536 38,154 39,727 74% 77%

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; Q, quarter, SAPR, semiannual progress report.

Behavioral evidence-based interventions

Table 12 shows the behavioral EBIs that were implemented by the project, per age group. The associated

indicator is the number of AGYW reached with standardized EBIs that are designed to promote the

adoption of HIV-prevention behaviors and service uptake.

Table 12. Key behavioral evidence-based interventions.

Behavioral (evidence-

based interventions)

Healthy Choices for a Better Future, 10 to 14 years old

My Health My Choice, 15 to 17 years old

Shuga 2, 18 to 24 years old

Afya Ziwani used certified facilitators to provide the above EBIs to AGYW. Due advantage was taken of

the weekends and the half-term holidays in the quarter to conduct sessions for the groups. Education on

biomedical HIV-prevention services—including HTS, PrEP, condoms, and contraception—continued to be

mainstreamed into these EBI sessions. During the sessions, PrEP, condoms, and contraception were

also provided by linkage health facilities (HFs) to AGYW between 18 and 24 years old.

Key results

Table 13 summarizes the key results for AGYW under the EBI indicator.

Table 13. AGYW who received behavioral interventions by county (FY20 SAPR).

County Q1 Q2 SAPR Achieved

AGYW Achievement

Homa Bay 1,932 9,486 11,418 26,179 44%

Kisumu 1,422 8,790 10,212 37,711 27%

Migori 370 2,937 3,307 13,991 24%

Total 3,724 21,213 24,937 77,881 32%

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; Q, quarter, SAPR, semiannual progress

report.

9

Discussion

Afya Ziwani prioritized uptake of EBIs by all enrolled AGYW. The project ensured that enrollment was

accompanied with a service—for examples, group-based interventions such as EBIs or individual

biomedical interventions such as HTS. It provided eligible AGYW with the EBIs, reaching 24,937 AGYW

in the SAPR period out of the targeted 77,881 (32% achievement against target).

The project printed and distributed EBI materials (manuals and posters) to the safe spaces across the

three counties. EBI sessions continued to be conducted with requisite fidelity as guided by the US Agency

for International Development (USAID). Strategies used included working with the schools that AGYW

attend to provide sessions in the afternoon breaks. The cost-cutting measure of mainstreaming education

on PrEP, condoms, and contraceptives into the EBIs will continue.

A large improvement in service provision was seen in Q2 compared to Q1. This improvement is likely to

be blunted in Q3 due to the restrictions brought on by COVID-19. However, the project plans to

restrategize on this and introduce use of virtual spaces, especially in urban and peri-urban settings where

smartphones are owned by the AGYW; reduce the number of girls in session to 12 to adhere to the cap of

15 people meeting; and involve the police and local administration to mainstream COVID-19 messages in

the sessions.

HIV testing services

The project provides HTS as a primary intervention for AGYW between 15 and 24 years old. The project

supports AGYW to be voluntarily retested once a year, in line with the national retesting guidelines. HTS

results are summarized in Table 14.

Key results

Table 14. Number of AGYW who knew their HIV status through HTS, by age and county (FY20 SAPR).

County 15–17 years old 18–19 years old 20–24 years old Total

Homa Bay 991 2,026 2,268 5,285

Kisumu 427 1,059 2,050 3,536

Migori 555 822 1,102 2,479

Total 1,973 3,907 5,420 11,300

Target 17,072 14,707 31,779

Achievement 23% 37% 36%

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; HTS, HIV testing services; Q, quarter, SAPR, semiannual progress report.

Discussion

The project achieved 36% for testing among the overall AGYW cohort as at the end of Q2. For the 18 to

19-year-olds, the project reached 23% (3,907) of the targeted 17,072 girls with an HIV test. The

performance was better for the 20 to 24-year-olds, compared to their younger counterparts, at 37% of the

targeted 14,707. No targets have been provided for the 15 to 17-year-olds as yet, with this service being

provided as a secondary intervention for the eligible girls.

The project held discussions with service delivery partners and the county health management teams to

ensure that HTS commodities, including HIV self-testing (HIVST) kits, were available for AGYW who use

HTS as an entry to prevention. The project prioritized participation in the allocation meetings that guide

need-based distribution of HTS commodities.

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Financial capability training

All AGYW need to receive financial capability training as a primary intervention to build their financial

skills. The trainings are conducted in groups for both in-school and out-of-school groups to serve as a

foundation for the girls and assist in determining the kind of money management decisions they will make

in life.

Key results

In Q2, an additional 21,088 AGYW received financial capability training; thus, the project reached 32% of

the annual target of 77,881. As Table 15 below shows, the project’s overall target as well as targets for

the age cohorts were not met in the reporting quarter.

Table 15. Number of AGYW who received financial capability training (FY20 SAPR).

County 9–14 years old 15–17

years old 18–19

years old 20–24

years old Total

Homa Bay 2,407 1,272 3,230 3,259 10,168

Kisumu 2,998 1,246 2,762 4,299 11,305

Migori 663 363 1,029 1,215 3,270

Total 6,068 2,881 7,021 8,773 24,743

Targets 15,295 22,860 21,343 18,383 77,881

Achievements 40% 13% 33% 48% 32%

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; Q. quarter, SAPR, semiannual progress report.

Discussion

The overall 32% performance against target is appreciable given that most of the enrolled girls have been

in the program for less than six months. This performance is a tremendous improvement from the 5% in

Q1. Better performance was witnessed among the 9- to 14-year-old and the 18- to 24-year-old cohorts

compared to the 15- to 17-year-old cohort. The project’s prioritization for enrollment of the 15- to 17-year-

old OVC and a paucity of this age group in the OVC project’s line list led to late enrollments of this cohort

and hence incomplete service provision. The optimal performance in this indicator may be threatened in

Q3 and possibly Q4, given the restrictions on congregating brought on by COVID-19. The project has

restrategized on this, as explained above under the EBI subsection.

Adolescent girls and young women with complete primary layering

In Q2, 13,333 girls received all of their primary individual interventions, bringing the total of AGYW that

have completed primary interventions to 13,785. This is a 23% performance against the active AGYW in

the program, as at the SAPR. Table 16 below shows the age group distribution of the number of AGYW

with complete primary layering against those active in the program.

Table 16. AGYW with complete primary layering (FY20 SAPR).

Age Group Q1 Q2 SAPR AGYW Served Achievement

9–14 years 0 4,974 4,974 15,754 32%

15–17 years 0 1,768 1,768 12,435 14%

18–19 years 162 2,729 2,891 14,423 20%

20–24 years 290 3,862 4,152 16,113 26%

Total 452 13,333 13,785 58,725 23%

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Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; Q, quarter, SAPR, semiannual progress report.

1.2 Secondary individual interventions

AGYW secondary services are provided to the recipients based on their circumstances and risks. These

services include PrEP, combination socioeconomic approaches, education support, among others.

Pre-exposure prophylaxis uptake

PrEP was provided to eligible AGYW between 18 and 24 years old. Afya Ziwani supported health care

workers (HCWs) from link HFs to visit the safe spaces to educate the AGYW about PrEP and to

determine eligibility, using a PrEP rapid assessment screening tool (see Table 17 for results). The AGYW

also received PrEP education in the Shuga 2 EBI. The PrEP_CURR_AGYW (individuals continuing on

PrEP from the AGYW cohort) achievement at the SAPR period was 2,068 (no target).

Key results

Table 17. PrEP_NEW_AGYW (FY20 SAPR).

Age Group Q1 Q2 SAPR Annual Target Achievement

18–19 years 68 297 365 137 266%

20–24 years 108 691 799 2,340 34%

Total 176 988 1,164 2,477 47%

Abbreviation: AGYW, adolescent girls and young women; FY, fiscal year; PrEP, pre-exposure prophylaxis; PrEP_NEW_AGYW, new individuals on PrEP from the AGYW cohort; Q, quarter, SAPR, semiannual progress report.

Discussion

PrEP_NEW_AGYW, new individuals accessing PrEP in the AGYW cohort, is not a US President’s

Emergency Plan for AIDS Relief (PEPFAR) Monitoring, Evaluation, and Reporting (MER) indicator. The

data source was the PrEP register in the AGYW safe spaces, and the data were inputted into the national

DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe) database. As such, the

project reported on all the AGYW that initiated PrEP, whether with Afya Ziwani or another HF supported

by local implementing partners (LIPs).

As shown in Table 17, the project achieved 47% of its annual target for PrEP_NEW_AGYW in the SAPR

period. The project will reactivate some of the successful strategies used last year under the PrEP surge,

such as PrEP support groups and PrEP Champs to achieve the annual target. In addition, due to COVID-

19 restrictions, the project will use virtual platforms, home delivery, and multimonth dispensing for PrEP.

Education support

The project developed and rolled out a revised criterion for the identification of eligible AGYW to be

provided school fees in the quarter. The aim was to support AGYW to remain in school (which impacts on

HIV prevention), by paying school fees and providing sanitary commodities. The Kenyan school year has

three terms: January to March, May to July, and September to November. In Q2, the project paid school

fees for 1,568 of a targeted 1,500 AGYW, reaching 105%. As well, the project provided 21,768 sanitary

commodities to 7,256 AGYW, and MWENDO supplemented for the cohort that they supported.

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1.3 Contextual interventions

Reducing risk in male sex partners

Afya Ziwani acknowledges that men have a role in reducing AGYW’s risk of HIV infection. As such, the

project supported the LIPs to conduct outreach activities that target typical male sex partners (MSPs) of

AGYW. Using the male characterization tool, Afya Ziwani worked with AGYW between 15 and 24 years

old to characterize their MSPs, ranking them by geographical area and occupation to identify the most

common partners. The project then worked with link HFs to conduct planned outreaches at the MSPs’

meeting points to facilitate male uptake of key HIV prevention services: HTS with treatment enrollment,

voluntary medical male circumcision (VMMC) referral, and condom distribution.

Key results

Table 18. Number of MSPs of 15- to 24-year-old AGYW reached with services, by county (FY20 SAPR).

County # of MSP

Outreaches # of MSPs Reached

# of MSPs Tested

# of MSPs Positive

# of MSPs Linked to

Care

# VMMCs Conducted

# of Condoms

Distributed to MSPs

Kisumu 14 597 67 0 0 0 7,720

Homa Bay 51 2,877 226 1 1 0 55,923

Migori 8 210 110 3 3 0 1,325

Total 73 3,684 403 4 4 0 64,968

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; MSP, male sex partner; SAPR, semiannual progress report; VMMC, voluntary medical male circumcision.

Discussion

After conducting characterization of MSPs of AGYW to identify the typical males AGYW have sex with,

the project conducted outreaches at identified MSP spots to facilitate MSPs’ access to HTS, VMMC, and

condoms, as well as linkage to antiretroviral therapy (ART).

More MSP outreaches were conducted in Homa Bay, where the project works in 33 wards, than in other

counties; thus, there was higher reach in the HTS and condom distribution in Homa Bay. The outreaches

not only provided males with an opportunity to access highly effective prevention services, they also

provided the project opportunity to work with males to mobilize their eligible partners for DREAMS.

SASA! for violence prevention

SASA!2 is an EBI that helps participants understand various types of power to better prevent gender-

based violence (GBV). SASA! comprises individual- and group-level sessions with AGYW, as well as

community-level sessions that are organized in venues like churches, chiefs’ meetings, etc. All community

members are invited, and meetings are usually attended by MSPs, boda-boda taxi cyclists, community

leaders, parents and guardians, and students and teachers.

In FY20 Q2, the project reached 23,956 community members with SASA!, including AGYW. This brings to

a total of 37,211 members reached with this intervention as at the SAPR. Of major import, SASA!

2 Sasa is a Kiswahili word that means now. SASA is also the abbreviation for start, awareness, support, and action.

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presented the project an opportunity to reach AGYW’s MSPs among the male participants in the EBI.

Thus, the project could discuss with them how the abuse of power leads to GBV and how they can use

their power to prevent GBV.

1.4 OVC/DREAMS co-enrollment

The project, under directive from USAID, worked with the OVC partner in the region, Catholic Relief

Services/MWENDO, to foster the co-enrollment of AGYW who were enrolled in the OVC program focused

on 9- to 17-year-old OVC. Tables 19 and 20 provide a status of the co-enrolled girls and service provision

as at the FY20 SAPR.

Table 19. Enrollment of eligible OVC in DREAMS, by county and age cohort (FY20 SAPR).

County 9–14 years old 15–17 years old Total

Homa Bay 2,458 1,452 3,910

Kisumu 1,919 764 2,683

Migori 136 91 227

Total 4,513 2,307 6,820

Enrolled in cohort 15,370 11,373 26,743

Achievement 29% 20% 26%

Abbreviations: DREAMS, Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe; FY, fiscal year; OVC, orphans and vulnerable children; SAPR, semiannual progress report.

Table 20. AGYW co-enrolled in OVC program, with complete primary layering (FY20 SAPR).

Age Group SAPR AGYW Served Achievement

9–14 years 2,061 4,513 46%

15–17 years 407 2,307 18%

Total 2,468 6,820 36%

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; OVC, orphans and vulnerable children; SAPR, semiannual progress report.

The reach for co-enrollment against the total enrolled AGYW is 26%, with the reach higher among the 9-

to 14-year-old cohort compared to their older counterparts. This is due to the paucity of eligible individuals

in the 15- to 17-year-old age group in the OVC program. The project has prioritized enrolling OVC girls

and would only enroll the others if the OVC were ineligible. The enrolled girls were provided with services

from both projects as applicable. The 9- to 14-year-old cohort had a higher achievement in primary

layering (46%) compared to the 15- to 17-year-old cohort. This is also because there are more OVC of

the former age compared to the latter; thus, they were easily and earlier enrolled and provided services.

2. High-priority population intervention: Fisherfolk

The project works in collaboration with 12 beach management units (Dunga, Kichinjio, Nyandiwa, Paga,

Usare, Rota, Ngege, Usoma, Mawembe, Ogal, Nyamware, and Nduru) in Kisumu County to reach

fisherfolk (FF), which includes those engaged in fishing (mostly male) and those engaged in trading

(mostly female), with a comprehensive package of prevention services. Behavioral interventions include

Splash Inside Out and Shuga 2; biomedical interventions include HTS, VMMC, and condom use

promotion; and structural interventions include SASA!

Key results

In the FY20 SAPR, a total of 5,418 FF received services through the project’s partnership with the Kenya

Red Cross Society; this was 46% of the annual target (see Table 21). Of the total of 5,418 FF, 41%

(2,222) were male and 59% (3,196) were female. All completed the Splash Inside Out and Shuga 2 EBI

14

sessions, and 3,752 were referred for HTS. Table 22 presents the cascade of HIV testing–related

services provided to the FF through FY20 Q1 and Q2.

Table 21. FF currently supported (FY20 SAPR).

FF Q1 Q2 SAPR Annual

Achievement Target

Male 1,300 922 2,222

Female 1,921 1,275 3,196

Total 3,221 2,197 5,418 11,868 46% Abbreviations: FF, fisherfolk; FY, fiscal year; Q, quarter, SAPR, semiannual progress report.

Table 22. FF HTS results (FY20 SAPR).

FF Q1 Q2 SAPR Target Achievement

Known positive (on treatment)

185 43 228

Offered testing 2,925 2,154 5,079

Newly tested 2,083 1,669 3,752 11,868 32%

HIV positive 48 37 85 475 18%

Linked to care & treatment

48 37 85 475 18%

Abbreviations: FF, fisherfolk; FY, fiscal year; HTS, HIV testing services; Q, quarter, SAPR, semiannual progress report.

As can be seen above, all of the 85 identified HIV positives in the quarter were linked to C&T. Table 23

breaks down the numbers on FF HTS, per area of Kisumu County.

Table 23. FF services, per Kisumu County area (FY20 SAPR).

Kisumu Areas

Known Positive Newly Tested Declined

Testing/Referred Total

Tested Positive and Started on Treatment

M F Total M F Total M F Total Total M F Total

Central Kisumu Ward

9 11 20 143 187 330 75 70 145 495 1 1 2

South West Kisumu Ward

38 57 95 645

1,154

1,799 214 260 474

2,368

7 14 21

Nyalenda B 21 30 51 239 305 544 182 237 419

1,014 9 11 20

Kobura Ward 20 18 38 187 279 466 122 172 294 798 16 23 39

Kabonyo Kanyagwal

9 15 24 272 341 613 46 60 106 743 2 1 3

Total 97 131 228

1,486

2,266

3,752 639 799

1,438

5,418

35 50 85

Abbreviations: F, female; FF, fisherfolk; FY, fiscal year; M, male; SAPR, semiannual progress report.

15

Discussion

The project conducted some moonlight and mostly daylight HTS activities to cater to the availability of the

FF. During the outreaches, 3,196 FF were offered HTS, of whom 2,266 (71%) were tested. Of those

tested, 50 tested HIV positive, reflecting a positivity rate of 2.2%, which is three times the 0.8% HIV

positivity reported in the FY19 period. With 228 FF known positives and another 50 newly tested as

positive, the overall HIV prevalence was 7% among those tested, excluding the declines. All (100%) were

linked to C&T. FF were referred to their link HFs for PrEP, VMMC, sexually transmitted infection (STI)

treatment, family planning, post-GBV care, and counseling on drug and alcohol abuse.

In the next quarter, the project will directly work with the department of fisheries in Kisumu County and the

beach management units. We plan to engage HTS providers and a program assistant to run the FF

program. The project will continue working with link facilities for referrals of other biomedical services

such as STI treatment.

3. Voluntary medical male circumcision

In FY20, Afya Ziwani is targeting VMMC service provision in Muhoroni subcounty of Kisumu County—in

particular, 2,862 clients for VMMC—through its support to nine VMMC-providing HFs. Of these HFs, two

have PEPFAR targets; the remaining seven sites are satellite HFs of the targeted sites. Project support

includes provision of consumables, equipment, reporting tools, support supervision, mentorship, and

technical support. During the reporting quarter, Afya Ziwani continued to support the Government of

Kenya and recommended the dorsal slit technique.

Key results

Overall performance in VMMC by quarter for the FY20 SAPR period is presented in Table 24. The age

band performance per quarter is presented in Table 25.

Table 24. VMMC performance by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 1,554 433 1,987 2,862 69%

Abbreviations: FY, fiscal year; Q, quarter; SAPR, semiannual progress report; VMMC, voluntary medical male circumcision.

Table 25. VMMC performance by age bands (FY20 SAPR).

Reporting period

Total MCs MCs among those < 15 years old

MCs among those > 15 years old

Achievement among those

> 15 years old to total

FY20 Q1 1,557 1,119 435 28%

FY20 Q2 433 157 276 64%

SAPR 1,987 1,276 711 36%

Abbreviations: FY, fiscal year; MC, male circumcision; Q, quarter; SAPR, semiannual progress report; VMMC, voluntary medical male circumcision.

Further details of the results are as follows:

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• All nine project-supported facilities provided VMMC in Q2 by use of their resident surgeons. The

project worked with the subcounty health management to activate Nyangori dispensary, which

had not provided these services in Q1 because of lack of skilled staff.

• 64% (276) of the 433 circumcised in Q2 were 15 years of age or older. This is above the

PEPFAR target of 60%. However, for the SAPR period, only 36% (711) of the 2,034 circumcised

met this PEPFAR target.

• 139 (32%) of the total 433 circumcised clients in Q2 returned for follow-up within the

recommended 14 days of circumcision. For the SAPR, 1,293 of the 1,987 (65%) had the 14-day

follow-up. These are markedly below the 80% threshold.

• No adverse event and tetanus cases were reported in Q1 and Q2.

• 624 (88%) of the 711 eligible circumcised males in Q1 and Q2 were tested for HIV, with none

(0%) testing positive.

Discussion

In this second quarter of the project Year 3, the project managed to reach 476 males with VMMC

services, for a total of 2,030 male circumcisions in the six months of implementation against the annual

target of 2,862. This translates to an achievement of 71% against an expected performance of 50% in the

SAPR period.

To achieve this result, the project worked to ensure optimal functioning of all the nine sites in Muhoroni

subcounty. Trained and skilled HCWs were maintained in all nine sites. In Q2, the project undertook a

mini rapid results initiative targeting the older cohort—those aged 15 years and older. Working with the

community mobilizers, the project used youth mobilizers, women mobilizers, informational materials in

youth video dens, and rewards such as branded T-shirts and reflector jackets to attract this older cohort

for VMMC. This led to a remarkable improvement of age pivoting, with 65% (309) of those circumcised

aged 15 years and older.

For the SAPR period, about 63% (1,290) of clients were 14 years old or younger. Thus, they were

ineligible for an HIV test as per the National AIDS & STIs Control Programme (NASCOP), which de-

emphasizes testing for clients aged 10 to 14 years. The testing uptake of 84% for those eligible (624),

therefore, is commendable; no client tested positive in the SAPR period.

A markedly low (29%) of the 477 VMMC clients returned for follow-up within 14 days of circumcision in

Q2. This is way below the recommended 80%. It is notable that 430 of the 477 male circumcisions (90%)

were done in the month of March. The poor follow-up rate is attributed to the restrictions of movement

during the COVID-19 period, which impacted clients visiting HFs, as well as home visits by the mobilizers.

The facility teams have been primed to undertake a phone follow-up of these clients and update the

outcome of these in the missed-appointment log.

During the period under review, there was no adverse event reported. The project and Ministry of Health

(MOH) service provision teams continued to ensure that all clients received the recommended dorsal slit

technique and ensure compliance with World Health Organization guidelines on tetanus immunization prior

to circumcision.

The project also continued to sensitize women on the benefits of VMMC, which enabled them to make

referrals, accompany partners for VMMC, and offer support during the healing period. In addition, the

project continued to strengthen intra-facility referral by referring clients for VMMC services, referring eligible

men who test HIV-negative from the different facility testing points. The project supported and participated

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in the national, county, and subcounty VMMC technical working group activities for the purposes of

coordinating VMMC services in the region.

4. Pre-exposure prophylaxis

PrEP targets seven major population groups, most of whom are either high-priority AGYW or key

populations (female and male sex workers). The Afya Ziwani project mainly targets and reports on PrEP

offered to AGYW and discordant couples of the general population. According to NASCOP data, HIV

treatment clinics are the main service delivery points for PrEP and the main safe spaces that target

AGYW. Afya Ziwani’s mandate is to provide technical support, avail where possible the reporting tools for

PrEP, assist in timely reporting, and build capacity for county- and HF-based activities. Afya Ziwani

reports on two indicators, PrEP_NEW and PrEP_CURR (which is only reported semiannually). The

former refers to the number of individuals who have been newly enrolled on PrEP, and the latter refers to

those, including the newly enrolled, who are continuing with PrEP in each period.

Key results

Tables 26 and 27, respectively, break down the number of individuals newly enrolled and currently on

PrEP by county.

Table 26. PrEP_NEW performance by county (FY20 SAPR).

County Q1 Q2 SAPR Annual

Target Achievement

Kisumu 98 374 471 528 89%

Nyamira 41 35 75 61 123%

Total 139 409 548 589 93%

Abbreviations: FY, fiscal year; PrEP_NEW, newly enrolled on PrEP treatment; Q, quarter, SAPR, semiannual progress report.

Table 27. PrEP_CURR performance by county (FY20 SAPR).

County SAPR Annual Target Achievement

Kisumu 1,111 660 168%

Nyamira 170 82 207%

Total 1,281 742 172%

Abbreviations: FY, fiscal year; PrEP_CURR, continuing on PrEP treatment; SAPR, semiannual progress report.

Discussion

Overall, the project achieved 93% of its annual target in the FY20 SAPR for the PrEP_NEW indicator and

172% for the PrEP_CURR indicator. For PrEP_NEW, the performance was better for Q2 (409) compared

to Q1 (139). A county-level analysis showed that in Kisumu County, 71% of the PrEP was offered to

persons aged 20 to 34 years and 76% of the initiated clients were females, alluding to the contribution of

the DREAMS/AGYW program. For Nyamira, the performance on these two disaggregates stood at 59%

and 57% respectively. There were no commodity shortages reported in the quarter. With Nyamira having

18

surpassed its target, accelerated efforts will be made to attain and surpass the target in Kisumu in the

next two quarters, while maintaining the numbers currently on PrEP.

For the PrEP_CURR, the project has surpassed the annual target in both counties. Focus will be put on

ensuring that the clients on PrEP receive a multi-month supply in line with the guidance provided during

the COVID-19 period.

5. HIV testing services

5.1 Health facility–based HIV testing services

Afya Ziwani set a target of 118,132 individuals for HIV testing in FY20, with 4,160 (3.5%) expected to be

HIV positive. To achieve this, during the reporting quarter, the project supported 115 HFs with PEPFAR

targets to conduct HTS, including through deployment of HTS providers, capacity-building, provision of

data-collection tools, mentorship, and supportive supervision. The project also provided HFs with direct

service delivery support, including deployment of 97 nonclinical HTS providers (including volunteers) at

95 sites (82% coverage).

During the reporting quarter, the project continued to enhance the working strategies initiated in the

previous year. Among these was optimization of an eligibility screening tool for all clients in the outpatient

department, along with testing of those that met the criteria. HTS at the HF level were restructured,

including shifting staff to meet the need and address technical challenges. The project maintained the 52

volunteer HTS providers recruited in the previous quarter to cover sites that had shown a potential to

identify HIV-positive clients. Partner notification services (PNS) continued to be the mainstay of

identification.

Key results

Project-supported HIV testing services

In the FY20 SAPR period, the following key project-supported HTS results were achieved, as presented

in Table 28. For overall HTS, the project surpassed its PEPFAR target for number of people tested, with a

60% achievement. At county level, Kisumu achieved 44% and Nyamira achieved 71%. The number of

tests were more than expected in Nyamira because there was more than double the average monthly

testing in the month of November 2019 due to a community testing exercise initiated by The Global Fund

to Fight AIDS, Tuberculosis and Malaria. In Q2, the average monthly tests were 7,000 with a total of

21,590 tests done, a 30% performance against the annual target, compared to 41% in Q1. Kisumu

County resumed outpatient services in the public HFs, with an average of 4,000 tests per month in Q2.

Table 28. Project-supported HTS results, by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 8,394 11,810 20,204 46,396 44%

Nyamira 29,235 21,497 50,732 71,736 71%

Total 37,629 33,307 70,936 118,132 60%

Abbreviations: FY, fiscal year; HTS, HIV testing services; Q, quarter, SAPR, semiannual progress report.

19

Pediatric clients

A total of 891 pediatric clients (15 years old or younger) were counseled and tested in Q2, representing

3% of the total tested (891/33,418). This was a significant reduction compared to the 3,314 tests done in

Q1. For the SAPR period, a total of 4,205 pediatric tests have been done; this is 31% against the annual

target (see Table 29). Both counties had a reduction in the tests, Nyamira by 79% (2,260) and Kisumu by

37% (163).

Table 29. Pediatric HTS results by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 438 275 713 4,454 16%

Nyamira 2,876 616 3,492 8,806 40%

Total 3,314 891 4,205 13,460 31%

Abbreviations: FY, fiscal year; HTS, HIV testing services; Q, quarter, SAPR, semiannual progress report.

People living with HIV identified and linked to care and treatment

As Table 30 presents, 1,190 clients among those who received HTS were found to be HIV positive. This

and the 902 in Q1 reflects 50% of the annual target of 4,160.

Table 30. HTS_TST_POS results by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 303 458 761 1,760 43%

Nyamira 599 732 1,331 2,400 56%

Total 902 1,190 2,092 4,160 50%

Abbreviations: FY, fiscal year; HTS_TST_POS, number of individuals who received HTS and received positive test results; Q, quarter; SAPR, semiannual progress report.

As can be seen in Table 31 below, the project achieved an overall yield of 3.6% in Q2, which is higher

than the 2.4% in Q1 and is helping the project make progress toward the 3.5% annual target.

Table 31. HTS_TST_POS yield by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 3.6% 3.8% 3.7% 3.8% 99%

Nyamira 2.1% 3.4% 2.6% 3.3% 80%

Total 2.4% 3.6% 2.9% 3.5% 83%

Abbreviations: FY, fiscal year; HTS_TST_POS, number of individuals who received HTS and received positive test results; Q, quarter, SAPR, semiannual progress report.

Table 32 presents performance in the SAPR period for people living with HIV (PLHIV) linked to C&T by

county, using the proxy indicator of newly initiated on ART. This results in a linkage rate of 91%.

20

Table 32. HTS linkage results against proxy indicator HTS_TST_POS (FY20 SAPR).

County HTS_TST_POS TX_NEW % Linked

Kisumu 761 683 90%

Nyamira 1,331 1,215 91%

Total 2,092 1,898 91%

Abbreviations: FY, fiscal year; HTS, HIV testing services; HTS_TST_POS, number of individuals who received HTS and received positive test results; SAPR, semiannual progress report; TX_NEW, number of individuals newly enrolled in antiretroviral therapy treatment.

Table 33 below presents the SAPR performance for PLHIV linked to C&T by county, using the Master

Facility Linkage Register. It is exactly aligned with the reported 2,093 positives in DATIM (Data for

Accountability, Transparency, and Impact). This is because these data are now collected from all the

sites. This results in a linkage rate of 93%.

All identified HIV positives, including those who were linked to the testing HF and those referred to

another HF, provide a more accurate linkage rate than the proxy TX_NEW indicator, which does not

consider those referred. Of the total 2,042 positives in the Master Facility Linkage Register, 1,779 (87%)

were directly linked to services at the testing HF and 143 (7%) were referred to another HF, resulting in

an actual linkage rate of 94%.

Table 33. HTS linkage results (FY20 SAPR).

County Total New

Positive

Known Positive in Care

Linked to AZ

Facility

Linked to a

Non-AZ Facility

Linked Within

the Same

Facility

Still on Follow-Up for

Linkage

Total Accounted

For

Total Linked

% Linkage

Kisumu 761 1 6 38 612 54 711 656 92%

Nyamira 1,331 1 48 51 1,167 64 1,331 1,266 95%

Total 2,092 2 54 89 1,779 118 2,042 1,922 94%

Abbreviations: AZ, Afya Ziwani; FY, fiscal year; HTS, HIV testing services; SAPR, semiannual progress report.

Discussion

In the FY20 SAPR period, the project reached 50% of its targeted positives, as presented in Table 30.

The highest performance was by Nyamira (56%). Kisumu recorded a low performance of 43%. The 458

positives identified in Kisumu in Q2 was 26% of the target (1,760), compared to the 17% in Q1. As had

been reported in the Q1 report, the low performance in Kisumu occurred during a protracted HCWs’ strike

in the public HFs, which reduced the volume of clients visiting the facilities who could have been

screened and tested. In January, the project engaged additional volunteer counselors, who revamped the

identification to 148 and a high of 170 in February.

The pediatric testing performance was 31% against target, and the positive identified was at 22% (73) of

the targeted 329. This performance improved in Q2 compared to Q1 at 41 and 32, respectively.

The project’s yield in Q2, presented in Table 31, surpassed the annual target, which was attributable to

the high positivity and contribution to positives of PNS. Nyamira County improved from 2.1% in Q1 to

3.4% in Q2, against a targeted 3.3%. The overall testing efficiency of the project was at 120%

(60%/50%).

The project’s proxy linkage for the SAPR period, as determined by the proportion of HIV-positive

individuals who were initiated on treatment (the TX_NEW indicator), was at 91% in the reporting quarter.

21

A total of 194 clients were not initiated on treatment using this indicator. However, the actual linkage

indicates that this improves to 93%.

To meet the overall HIV identification gap, the project continued to implement the HTS surge strategies in

all the HTS facilities that optimized case identification by using high-yield approaches in high HIV

prevalence HFs and service delivery points; offering full-scale PNS at the HF and community levels;

performing targeted provider-initiated testing and counseling, following the MOH eligibility criteria through

stringent use of the screening tools, with a focus on tuberculosis (TB), STIs, and HIV exposures; using

intensified social-network testing; strengthening self-testing for men; and screening children for eligibility.

5.2 Partner notification services

To increase the uptake of PNS, Afya Ziwani continued to expand the range of providers who can provide

PNS by supporting sensitization training of HCWs, including nurses, clinicians, adherence-support

counselors, nonclinical and volunteer HTS providers, lab officers, and supervisors. The project also

worked with HF-based and roving PNS champions to mentor these providers on PNS. All project-

supported HTS sites have capacity to provide PNS. Tables 34 through 38 summarize the PNS cascades

for the quarters, contribution to HIV positives and yield, as well as breakdowns by sex, tested population,

and county.

Key results

Table 34. PNS cascade of services, overall, by quarter (FY20 SAPR).

Cascade Q1 Q2 SAPR

Total index clients offered PNS 1,813 2,303 4,116

Index clients screened/accepted PNS 1,687 2,242 3,929

PNS acceptance rate 93% 97% 95%

Contacts identified 3,668 5,108 8,776

Ratio of contacts identified 2.2 2.3 2.2

Known positives 660 1,064 1,724

Known positives (%) 18% 21% 20%

Eligible 3,008 4,044 7,052

Tested 2,339 3,154 5,493

Uptake of testing 78% 78% 78%

Newly tested positive 615 838 1,453

Newly tested positive (%) 26% 27% 26%

Linked 573 798 1,371

Linked (%) 93% 95% 94%

Abbreviations: FY, fiscal year; PNS, partner notification services; Q, quarter; SAPR, semiannual progress report.

22

Table 35. PNS contribution to HIV positives and positive yield (FY20 SAPR).

Category Q1 Q2 SAPR

Total tested 37,629 33,408 71,037

Total positive 902 1,194 2,096

Total positive yield 2.4% 3.6% 3.0%

PNS tested 2,339 3,154 5,493

PNS positives 615 838 1,453

PNS positive yield 26% 27% 26%

PNS contribution 68% 70% 69%

Abbreviations: FY, fiscal year; PNS, partner notification services; Q, quarter; SAPR, semiannual progress report.

Table 36. PNS summary of cascade by sex (FY20 SAPR).

Indicator FY20 Q1 FY20 Q2 SAPR

Male Female Male Female Male Female

Male/female ratio to total eligible tested 0.7 0.8 0.7 0.8 0.7 0.8

Contacts elicitation ratio 2.7 1.8 2.7 1.8 2.7 1.9

Percent eligible tested 75% 80% 76% 80% 76% 80%

HIV positivity 20% 32% 22% 31% 21% 32%

Percent linkage 91% 95% 95% 96% 93% 95%

Abbreviations: FY, fiscal year; PNS, partner notification services; Q, quarter; SAPR, semiannual progress report.

Table 37. PNS cascade per tested population (FY20 SAPR).

Indicator

General Population

PMTCT STF

Percent index clients screened 97% 100% 99%

Contacts elicitation ratio 2.26 2.25% 2.44

Percent eligible tested 77% 76% 77%

HIV positivity 27% 19% 34%

Percent linkage 95% 92% 98%

Abbreviations: FY, fiscal year; PMTCT, prevention of mother-to-child transmission of HIV; PNS, partner notification services; Q, quarter; SAPR, semiannual progress report; STF, suspected treatment failure.

23

Table 38. PNS cascade of services by county, ≥ 15 years old (FY20 SAPR).

Indicator Kisumu Nyamira Total

Total index clients offered PNS 1,462 2,654 4,116

Index clients screened/accepted PNS 1,398 2,531 3,929

PNS acceptance rate 96% 95% 95%

Contacts identified 3,716 4,311 8,027

Ratio of contacts identified 2.7 1.7 2.0

Known positives 853 852 1,705

Known positives (%) 23% 20% 21%

Eligible 2,863 3,459 6,322

Tested 2,123 2,728 4,851

Uptake of testing 74% 79% 77%

Newly tested positive 504 905 1,409

Newly tested positive (%) 24% 33% 29%

Linked 470 858 1,328

Linked (%) 93% 95% 94%

Abbreviations: FY, fiscal year; PNS, partner notification services; SAPR, semiannual progress report.

Discussion

The above results indicate that PNS continued to be the most effective intervention for identifying

significant numbers of PLHIV. The overall yield for PNS in the SAPR period was 26%. PNS contributed to

69% of the total of newly identified PLHIV in the SAPR period, with a slight increase in Q2 compared to

Q1. Approximately 70% of the contacts elicited were tested at the community setting using the provider

referral approach. Blind testing was occasionally used to reach the elicited contacts. The testing uptake

improved in Q2 to 78%, with the linkage of clients identified through PNS remaining high. In this reporting

quarter, it was 93%, which was above the project’s proxy linkage of 90%.

The contact elicitation ratio for the male index clients was close to the recommended 1:3, whereas for the

female index, it was low. The positivity among the female contacts was higher than among male contacts.

Among the three groups elicited through PNS [i.e., the general population, prevention of mother-to-child

transmission of HIV (PMTCT), and suspected treatment failure (STF) contacts], the performances were

comparable across all the indicators, as shown in Table 37, though the STF had a higher positivity and

linkage. The high positivity of 34% among the STF contacts was not unexpected given that the indexes

have high transmissible viral copies. The elicitation rate, now a prime factor for consideration by PEPFAR,

was 1:3 in Kisumu, which met the PEPFAR threshold, and 1:2 in Nyamira.

The challenges that continued to affect PNS testing included stigma and disclosure issues, coupled with

the lack of clear, explicit policies and guidance in such situations at the implementation level; tracing of

elicited contacts beyond the facility catchment area; and the cost incurred for community PNS, where

several home visits are required to reach out to elicited sexual partners.

5.3 HIV self-testing

In FY20 Q2, a total of 46 project-supported sites reported that the distribution of the HIVST kits reached

1,628 tests. While the target was 480 HIVST kits in the year, 5,820 have been distributed as at the SAPR

24

(see Table 38), representing 1,213%. The project continued to use the two-pronged model/strategy for

HIVST: HF- and community-based models.

For the HF-based strategy, the key focus of self-testing was to improve uptake among men by reducing

missed opportunities—especially among partners of mothers attending antenatal care (ANC) services

and partners of HIV-positive clients who are unwilling to be tested by the HCW. This was done by

providing them the option of self-testing at the HF or at home.

For the community-based model, the aim was to serve as a complementary approach to the existing HTS

by targeting men during integrated outreaches; the goal was to reach a testing ratio of over 70% men to

women. Information on HIVST was offered during outreach mobilization. HIVST kits were provided to

clients who were eligible for testing (through a screening tool) but declined to be tested; there was

secondary distribution to partners of the men who tested positive.

Key results

Table 38. HIVST kits distributed (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 1,078 631 1,709 52 3,287%

Nyamira 3,114 997 4,111 428 961%

Total 4,192 1,628 5,820 480 1213%

Abbreviations: FY, fiscal year; HIVST, HIV self-testing; Q, quarter; SAPR, semiannual progress report.

Discussion

The project easily surpassed the conservative target of 480 that was set for the two counties by 5,820 tests

(1,213%). This target is about one-third that for FY19 (1,457). Self-test kits were distributed at community

settings, to men in formal and informal workplaces, as well as to HCWs, partners of ANC mothers, FF, and

AGYW. The performance in Q2 was lower because the big boost that had been there in Q1, from community

distribution in the two counties that was supported by Population Services Kenya, was no longer there.

Of the 5,820 HIVST kits distributed, 4,041 (69%) were done through the directly assisted approach and

1,779 (31%) were done through the unassisted approach.

Continuing challenges with HIVST included a lack of standardized documentation tools for distributed

HIVST kits, insufficient follow-up mechanisms to verify use of the HIVST kits that had been distributed for

use away from the HF, and delays in confirmatory positive testing that would lead to linkage to C&T.

6. HIV care and treatment

6.1 New on treatment

In FY20 Q2, Afya Ziwani supported 89 HFs with PEPFAR targets to provide ART. All these HFs had

TX_CURR targets; 84 had TX_NEW targets; and only 26 had TB/HIV targets. The target for PLHIV newly

initiated on ART was 4,018, which was 97% of the newly tested PLHIV target of 4,160. Tables 39 and 40

show the number of new and pediatric clients initiated on ART in Q1 and Q2 against the annual targets,

25

by county. For the 12-month cohort of newly enrolled ART patients, the project reported 80% retention,

with 3,437 of the total cohort of 4,283 still active at 12 months at the end of FY20 Q2 (Table 41).

Key results

Table 39. New clients on ART, by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 267 416 683 1,667 41%

Nyamira 541 674 1,215 2,351 52%

Total 808 1,090 1,898 4,018 47%

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; Q, quarter; SAPR, semiannual progress report.

Table 40. New pediatric clients on ART, by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 11 23 34 129 27%

Nyamira 24 31 55 184 30%

Total 35 54 89 313 29%

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; Q, quarter; SAPR, semiannual progress report.

Table 41. Twelve-month cohort retention (FY20 SAPR).

County

FY20 SAPR

Net cohort On ART 12

months %

retention

Kisumu 2,227 1,763 79%

Nyamira 2,056 1,674 81%

Total 4,283 3,437 80%

Source: Ministry of Health (MOH) 731 health facility report. Abbreviations: ART, antiretroviral therapy; FY, fiscal year; SAPR, semiannual progress report.

Discussion

In Q2, 1,090 clients were initiated on treatment, for a total of 1,898 in the SAPR period, which translates

to a 47% achievement against the country operational plan 2019 target of 4,018. This is 91% of the 2,092

clients identified as HIV positive in the SAPR period. The moderately below-target performance was

contributed by Kisumu County, which achieved 41% of the target. This was directly correlated with its

below-average yield from HTS, which resulted from the HCW strikes witnessed in Q1 and January of Q2,

as well as the reduction in workload in March due to the COVID-19 restrictions. However, the Kisumu

County performance in Q2 improved by 57% compared to Q1. Nyamira performed better against the

annual target, at 52% with a proxy linkage of 95%, nearing the project’s target of 97%.

The project’s performance in the SAPR period of 91% proxy linkage is a slight improvement compared to

the Q1 achievement of 90%. This is attributable to initiated strategies, such as the nonlinked clients’

tracker that was developed to improve this linkage to over 95% (TX_NEW target is 97% of the HIV-

positive target as proxy linkage).

26

For new pediatric clients on ART, the project achieved 54 in Q2 compared to 35 in Q1. This brings the

SAPR performance to 29% (89/313). Both counties are below the 50% threshold, with Kisumu being

lowest at 27%, despite having more than doubled the Q2 initiations (23) compared to Q1 (11). This

performance is in line with that of the HTS_TST_POS (number of individuals who received HTS and

received positive test results) for pediatrics, in which the project attained 22% (73/329) against the target.

However, the proxy linkage for pediatrics was optimal at 125% (91/73).

The project continued to refine the ART enrollment strategies, including HF performance tracking to

assess gaps and opportunities. The aims are to ensure that the proxy linkage is improved to greater than

95% and that the clients are initiated on ART immediately. The reduction in the number of project-

supported staff at facility level this year is a threat to this ambitious performance. The project is using the

novel roving clinician model to circumvent this. The project also continues to engage the county

departments of health to support HIV service provision.

6.2 Currently on treatment

The project’s FY20 target for those currently on ART is 26,235. Of these, the target for pediatrics

(15 years old or younger) is 2,048 (8% of total).

Key results

At the end of Q2, the total number of HIV clients currently on ART was 23,234, which is 89% against the

annual target of 26,235. Performance through Q2 by county and target is presented in Table 42.

Table 42. Total current clients on ART, by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 8,877 9,154 9,154 9,338 98%

Nyamira 13,490 14,080 14,080 16,897 83%

Total 22,367 23,234 23,234 26,235 89%

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; Q, quarter; SAPR, semiannual progress report.

Table 43 presents the total number of current pediatric clients (15 years old or younger) who were on

ART in Q2 against the annual target, by county. Of the total number of clients currently on ART, 1,530

(7%) were children 15 years old or younger; the project thus reached 75% of this age group’s annual

target (2,048).

Table 43. Current pediatric clients on ART, by county (FY20 SAPR).

County Q1 Q2 SAPR Annual Target

Achievement

Kisumu 552 535 535 674 79%

Nyamira 963 995 995 1,374 72%

Total 1,516 1,530 1,530 2,048 75%

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; Q, quarter; SAPR, semiannual progress report.

Discussion

At SAPR, the project achieved a current ART cohort of 23,232 against a country operational plan 2019

target of 26,235. Across the counties, Kisumu performed above its annual target of current clients on ART

27

at 98%, and Nyamira attained the lower at 83% against its overall target and 72% against its pediatric

target. Nyamira, a low-prevalence county, has tended to achieve on its noncurrent indicators, but it is

struggling with the retention of the identified and linked clients; though, as detailed in Section 6.3, this

improved in Q2. To reach the annual target of current clients on ART, the proxy linkage in Nyamira

County must continue to improve from the 92% in Q2 to the targeted 97%, while maintaining a retention

of over 90% month by month.

6.3 Retention

Key results

Table 44 below presents a picture of the project’s current retention as at the SAPR.

Table 44. Current ART net gain by county (FY20 SAPR).

County

Current on ART (FY19 Q4)

New on ART

(FY20 SAPR)

Transfers In (FY20 SAPR)

Defaulters/LTFU brought back (FY20 SAPR)

Expected Gain (FY20 SAPR)

Expected Current on ART (FY20

SAPR)

Actual Current on ART (FY20 SAPR)

Gain/Loss (FY20 SAPR)

Kisumu 8,720 683 80 62 825 9,545 9,154 -391

Nyamira 13,400 1,215 133 319 1,667 15,067 14,080 -987

Total 22,120 1,898 213 381 2,492 24,612 23,234 -1,378

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; LTFU, lost to follow-up; Q, quarter; SAPR, semiannual progress report.

Figure 1 presents the project’s retention performance on expected and net gain.

Figure 1. Overall net ART retention (March 2020).

Abbreviations: ART, antiretroviral therapy; TX_CURR, currently on treatment; TX_NEW, newly on treatment.

Table 45 presents the monthly changes in the current on treatment at county level and at the overall

project level during the reporting period.

1,090

867 , 80%

-223

-400

-200

0

200

400

600

800

1000

1200

Net ART Retention (Jan-Mar20, Q2)

TX_New

Change in TX_Curr

Difference betweenexpected and actualchange TX_Curr

28

Table 45. Monthly changes in current on ART by county and overall (FY20 Q2).

County Current on ART

(December 2019)

Monthly change in TX_CURR

January 2020

February 2020

March 2020

Kisumu 8,877 8,961 9,059 9,154

Nyamira 13,490 13,654 13,854 14,080

Total 22,367 22,615 22,913 23,234 Abbreviations: ART, antiretroviral therapy; FY, fiscal year; Q, quarter; TX_CURR, currently on treatment.

Discussion

As can be seen in Figure 1, retention performance in Q2 improved, with an increase of only 867 in the

current on treatment against a new on treatment of 1,090—a loss of 223 compared to 561 reported in Q1.

Nyamira County improved in its performance by increasing, month on month, the client currently on

treatment from 164 in January, to 200 in February and 226 in March; the county finally crossed the

14,000 mark in March. The improved performance in Nyamira is attributed to the increase in the number

of peer educators from 50 to 64. Peer educators, a lay cadre of staff, are instrumental in appointment

management at facility level. Peer educators will continue to receive the appointment management

airtime and prompt the clinicians to populate the client-level tools.

The project will scale up electronic medical records (EMR) in high- and medium-volume facilities. Working

with the Ushauri system, the project will send automated SMS reminders to clients who opt in to ensure

they are adhere to their appointments, and thus minimize the defaulter rates further.

6.4 Additional retention and adherence interventions

Care for HIV-infected children and adolescents

The project supported dedicated pediatric and adolescent clinic days and psychosocial support groups

(PSSGs) for children, adolescents, and their caregivers. The project also provided support for and scaled

up the Operation Triple Zero (OTZ) intervention, which focuses on adolescents and youth between 10

and 24 years old and emphasizes the commitment to zero missed appointments, zero missed drugs, and

zero (undetectable) viral load (VL). The project further supported pediatric and adolescent adherence

through a peer-to-peer buddy support system, adolescent literacy sessions on HIV self-management, a

case-management approach for clients with adherence issues that included directly witnessed ART

intake, and harmonization of appointments with school calendars to minimize missed appointments. The

project worked with the OVC partner Catholic Relief Services/MWENDO toward optimal enrollment of

eligible pediatrics and adolescents up to 17 years of age in the OVC program.

Key results

Overall, 896 (34%) of the 2,656 adolescents and youth currently on ART were active in OTZ clubs at 42

implementing HFs, as presented in Table 46. Table 46 also presents viral load suppression (VLS) rates

by age and sex.

29

Table 46. Overall performance of 39 sites in Operation Triple Zero (FY20 Q2).

Indicator Female 10–14 years

Male Female Male Female Male

Total 10–14 years

15–19 years

15–19 years

20–24 years

20–24 years

Adolescents current on ART

391 361 420 303 973 208 2,656

Active in OTZ 198 191 223 62 164 58 896

% of active in OTZ 51% 53% 53% 20% 17% 29% 34%

On OTZ with VL 99 84 96 32 80 14 405

Suppressed 85 79 87 31 77 13 371

VLS rate 86% 94% 91% 97% 96% 93% 92%

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; OTZ, Operation Triple Zero; Q, quarter; VL, viral load; VLS, viral load suppression.

Table 47 presents the cascade for enrollment of children and adolescents living with HIV (CALHIV)/OVC

by county.

Table 47. CALHIV enrolled/virally suppressed in MWENDO/OVC program (FY20 SAPR)

County CALHIV

Active on ART

Enrolled in MWENDO/

OVC

Virally Suppressed

% Enrolled in

MWENDO/ OVC

% of Enrolled Virally

Suppressed

Kisumu 685 511 419 75% 84%

Nyamira 1,379 702 588 51% 84%

Total 2,064 1,213 1,007 59% 84%

Abbreviations: ART, antiretroviral therapy; CALHIV, children and adolescents living with HIV; FY, fiscal year; MWENDO, Making Well-informed Efforts to Nurture Disadvantaged Orphans and Vulnerable Children; OVC, orphans and vulnerable children; SAPR, semiannual progress report.

Discussion

As Table 46 shows, the cascade of outcomes for adolescents who participated in OTZ includes an overall

VLS of 96%, indicating good adherence. Females in the 10- to 14-year-old and 15- to 19-year-old age

groups still posed a challenge in attaining the group average VLS levels, with males having higher rates

compared to their female counterparts. A challenge still exists in optimizing the enrollment to OTZ across

all age groups and sex, with enrollment averaging 34% and lowest among the females aged 20 to 24

years old. The lower enrollment of pediatrics and adolescents in the OVC program in Nyamira is a result

of late start-up. The overall suppression of the enrolled is 84%.

Positive health, dignity, and prevention interventions

Key strategies/interventions

The project supported HFs to form and/or strengthen PSSGs at both community and facility levels. The

HCWs and peer educators use the PSSGs as vehicles to disseminate key positive health, dignity, and

prevention messages, which aim to enhance members’ adherence to appointments and ART and help

them cope with chronic HIV infection. This quarter, the project provided very limited logistical support to

the HCWs, peer educators, and the attendees for their engagement with PSSGs due to the reduction in

funding for this year. The enrollment of PLHIV in the PSSGs during Q2 is shown in Table 48, which

depicts suppression per cohort.

30

Key results

Table 48. PLHIV enrollment in PSSGs (FY20 Q2).

PSSG Type No. of PSSGs

No. Enrolled in PSSGs

No. Suppressed

Percent Suppression

Total general adult PSSGs 37 1,822 1,693 93%

Total PMTCT PSSGs 91 1,379 1,280 93%

Total STF PSSGs 63 637 125 20%

Total pediatric PSSGs 78 789 611 77%

Total adolescent PSSGs 88 1,972 1,543 78%

Total men only PSSGs 12 246 223 91%

Total discordant couples’ PSSGs 10 275 257 93%

Total 379 7,120 5,732 81%

Source: Facility records, including peer educator logs. Abbreviations: FY, fiscal year; PLHIV, people living with HIV; PMTCT, prevention of mother-to-child transmission of HIV; PSSG, psychosocial support group; Q, quarter; STF, suspected treatment failure; VL, viral load.

Discussion

As shown in Table 48 above, the VLS in the PSSGs is good, at 81% and, if adjusted with removal of the

STF clients who expectedly are a non-suppressed cohort, at 86%. This is indicative of the role that these

groups play in improving and maintaining good suppression, considering that they focus on high-risk

clients. The project focused support in the quarter to the pediatric and adolescent groups.

PSSGs have been found to be effective in increasing retention and defaulter tracing. They also have

facilitated the formation and running of community antiretroviral refill groups. They have been effective in

adherence and disclosure counseling. They provide important psychosocial support, including mental

health counseling, education, spiritual support, and a forum for PLHIV to express themselves freely and

share experiences and challenges. A key to the success of PSSGs is that they are run by peers in

collaboration with HCWs. The peer educators identify clients’ needs per group and develop various

educational topics for discussion during every support group meeting.

The overall VLS of the project at 92% (Table 50) is an indicator of the role played by the PSSG

intervention, among others, in addressing psychosocial factors that deter optimal VLS.

Differentiated models of care

The project supported HFs to implement differentiated care for eligible clients on ART. In differentiated

care models (DCMs), clients are given longer intervals between clinic appointments, either through HF-

based fast-tracking or through community antiretroviral refill groups. These are interventions that are

intended to better meet client needs, while decongesting overburdened ART sites.

Key results

By Q2, 89 (79%) project-supported HFs were implementing differentiated care. Figure 2 presents the

differentiated care cascade at Q2.

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Figure 2. Differentiated care cascade (FY20 Q2).

Abbreviations: ART, antiretroviral therapy; CARGS, community antiretroviral refill groups; DCM, differentiated care model; FY, fiscal

year; Q, quarter.

Discussion

Afya Ziwani’s support for DCMs during the reporting period included mentorship and supportive

supervision, which entailed filling out the differentiated care register and monitoring outcomes. The

number of clients on DCMs in the two counties stood at 11,708, which represented 54% of the number of

current clients on ART (21,511) in the reporting sites. However, 86% of the stable clients (13,575) were

on DCMs, with the majority opting for the facility fast-track model as opposed to the community

antiretroviral refill groups. The project continued to assess, at site level, the uptake of DCMs based on the

number of current clients on ART and those stable. The project ensured that facilities continually

reviewed the stable status of their clients to improve these uptakes to greater than 60% and 90%,

respectively. Higher enrollment to DCMs has been associated with a better performance on the retention

of clients on treatment.

6.5 Viral load testing and suppression

Strategies to improve VLS include using the clinical teams to follow up on clients with high-VL by holding

specific clinic days for unsuppressed clients, providing PSSGs services, and encouraging HF and

subcounty multidisciplinary teams to meet to discuss with them.

Key results

For VL uptake, Table 49 presents the number of clients who had a valid VL test done within the past

12 months (April 2019 to March 2020) versus those eligible for the test (i.e., current on ART) in

September 2019. Table 50 presents the VLS trends over the four quarters from FY19 Q3 through FY20

Q2 for routine and targeted VL testing, against the tests done.

21,511

2,898

13,575

5,094

11,708 11,550

158

Current on ART Newly enrolled Stable Unstable Number on DCM

Number on Fast Track

Number in CARGS

0

5,000

10,000

15,000

20,000

25,000

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Table 49. VL uptake by county—routine and targeted testing against current on treatment (FY20 Q2).

County Q2 TX_CURR FY19

Q4 Achievement

Kisumu 8,208 8,720 94%

Nyamira 11,411 13,400 85%

Total 19,619 22,120 89 %

Abbreviations: FY, fiscal year; Q, quarter; TX_CURR, number of individuals currently enrolled in treatment; VL, viral load.

Table 50. VLS by county, routine and targeted VL testing (FY19 Q3 to FY20 Q2).

County FY19 Q3 FY19 Q4 FY20 Q1 FY20 Q2

Kisumu 91% 92% 93% 93%

Nyamira 87% 89% 91% 92%

Total 89% 91% 92% 92%

Abbreviations: FY, fiscal year; Q, quarter; VL, viral load; VLS, viral load suppression.

Table 50 shows a steady improvement in VLS each quarter, leading to an overall suppression rate of

92% for FY20 Q2. Of the total VL samples analyzed, 69% (14,277) were from female clients and 31%

(6,540) from male clients. In addition, 88% were from adults, 4% from pediatric clients, and 7% from

adolescents. Table 51 presents suppression results by age group. A further breakdown of VLS by cadre

is presented in Table 52.

Table 51. VLS by age group for routine VL testing (FY20 Q1 and Q2).

Age group Q1 Q2

< 2 years 65% 69%

2–9 years 79% 81%

10–14 years 76% 78%

15–19 years 84% 85%

20–24 years 91% 90%

25+ years 94% 94%

Total 92% 92%

Abbreviations: FY, fiscal year; Q, quarter; VL, viral load; VLS, viral load suppression.

Table 52. VLS by cadre for routine VL testing (FY20 Q1 and Q2).

Cadre Q1 Q2

All VL tests 92% 92%

Routine 94% 94%

Targeted 83% 83%

Male 91% 92%

Female 92% 93%

Pediatric 77% 79%

Adolescent 85% 85%

OTZ 80% 96%

PMTCT 93% 92%

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Abbreviations: FY, fiscal year; OTZ, Operation Triple Zone; PMTCT, prevention of mother-to-child transmission of HIV; Q, quarter; VL viral load; VLS, viral load suppression.

At Q1, a total of 20,817 clients had a VL test done over the previous 12-month period, against the

expected proxy target of 21,672 for the period, giving a coverage of 96%. An overall suppression rate of

92% was realized among clients who had a VL test. Against the VLS indicator target of 24,331, the

project achieved 19,165 (79%).

The project in the past has reported performances of over 100% for the VL coverage indicator because of

duplicates in VL tests from the MOH VL database. In this quarter, these data were abstracted from the

EMRs and facility registers and reconciled with those from the VL testing laboratories. This resulted in an

overall uptake of 96%, though the Kisumu uptake was higher at 101%. This performance comprised

clients who received a routine VL test, with a suppression rate of 94%, and those who received a targeted

VL test, with a suppression rate of 83%. By sex, females achieved an overall VLS of 92%, and males

achieved 91%. In addition, 93% VLS was achieved among women enrolled in PMTCT, and 80% was

achieved among adolescents. Data were extracted from the facility records, including the EMRs, VL

tracking logs, or client files.

Discussion

The VL uptake for the reporting period of 19,619 against a targeted 22,120, which represented 89%

coverage, was optimal. The client-level collection of these data that was mooted in FY20 helped to

mitigate the greater than 100% coverage that had been reported in the previous reporting periods. The

numerator for this indicator on coverage, as espoused in the MER 2.4, was the number of tests done in

the last one year. The denominator was the TX_CURR numbers six months ago.

There was continued improvement in VLS from previous quarters to this reporting period, from the 89%

achievement in FY19 Q3 to 92% achievement by FY20 Q2, which are within the PEPFAR target of 90%

to 95% range. Nyamira County showed the greatest improvement, from a low of 87% in the third quarter

of FY19 to 92% in this reporting period.

The project continued the pediatric ART optimization initiative to improve viral suppression among

pediatric and adolescent clients. Through this, the proportion of clients that were on a nevirapine-based

regimen dropped from 2.5% in October 2019 to 0.0% in March 2020, while the proportion of those on

dolutegravir improved from 6.5% to 12.0% over the same period.

7. Laboratory support

In FY20 Q2, the project supported several activities to ensure there was continuous quality improvement

processes related to a laboratory quality management system. The project supported quarterly technical

working group meetings for commodities in both counties, as well as other related meetings, such as

laboratory clinical interface, external quality assessment, and GeneXpert® (GeneXpert is a registered

trademark of Cepheid) utilization meetings. The project enabled an effective and robust sample

networking system to serve the project’s 115 ART/EID sites.

7.1 Key results

The transition from dried blood spot to blood plasma for VL testing remained at 100% coverage, with

115 of 115 networked facilities transitioned to blood plasma for VL testing. Remote log-in for the 113

facilities also reached 100%. The commodity reporting rate in both the District Health Information

Software 2 (DHIS2) and Health Commodities Management Platform for the eight project-supported

34

subcounties reached 100%. The commodity technical working group meetings helped in mitigating low

stock levels, overstocking, and stockouts of laboratory-related commodities.

Laboratory monitoring

In FY20 Q2, Afya Ziwani continued to support 113 HFs with ART and TB/HIV targets. The project’s

annual target was 26,235 current clients on ART (and who require access to VL and other testing, as per

the national guidelines). The national system requires that HF VL samples be sent for remote log-in at a

hub lab (typically located in a HF) before being sent on to a testing lab. The hub lab sends the VL

samples to their identified central testing lab, which includes the Kenya Medical Research

Institute/Centers for Disease Control and Prevention in Kisian and the Walter Reed Project in Kericho.

The project provided support to seven hub labs for the project’s eight supported subcounties.

7.2 Discussion

Four sites in Nyamira County continued to offer GeneXpert testing, with three of these sites (Nyamira

county referral hospital, Ekerenyo subcounty hospital, and Masaba subcounty hospital) working

continuously online. Frequent power outages in Manga subcounty hospital remained a challenge for

GeneXpert testing, resulting in an increase in number of errors reported.

Afya Ziwani continued to support sample networking of EID and VL samples from satellite sites to central

facilities remote log-in before the samples’ transportation to testing labs in Kericho and Kisumu. The

project also continued to support bundles for the hubs to enable remote log-in of samples. The project

provided airtime for subcounty medical laboratory coordinators to support reporting of lab commodities in

the DHIS2 and Health Commodities Management Platform.

7.3 HIV testing services recency testing study

The project continued to support four pilot study sites in Kisumu County that were initiated in March

2019—namely, St. Mark’s Lela, Migosi Health Centre, Nyalenda Health Centre, and Simba Opepo Health

Centre. The pilot study came to an end in February of this quarter. In January and February, six samples

were processed for recency in these sites. Migosi had three samples, with one returned and two pending;

St. Mark’s Lela had two samples both pending results; and Nyalenda had one sample whose results are

still pending. The result from the Migosi sample indicated a long-term infection.

8. TB/HIV

Afya Ziwani implemented TB/HIV services in all 26 project-supported HFs with TB/HIV targets with focus

on various capacity-building and direct service delivery initiatives, including secondment and sensitization

of HCWs, mentorship, HF continuing medical education (CME), joint supportive supervision, and

performance-review meetings to improve testing of TB patients for HIV.

8.1 TB/HIV coinfection services

The project team collected TB data from the facilities’ TB4 registers using an age-disaggregating tool.

The team uploaded data into the project’s data management system, the Program Reporting Information

System Management.

35

Key results

Results on key TB/HIV performance indicators for FY20 are shown in Table 53. Table 54 summarizes

performance on the TB cascade, by county.

Table 53. Key TB/HIV performance indicators (FY20 SAPR).

TB/HIV Performance Indicators Q1 Q2 SAPR Annual Targets

Achievement

Number of TB patients registered 262 247 509 1,003 51%

Number who knew their HIV status 259 244 503 1,003 50%

Proportion who knew their HIV status

99% 99% 99%

Number of HIV-infected TB patients 95 92 187 367 51%

Proportion of TB/HIV coinfection 37% 39% 38%

Number known HIV positive at TB diagnosis

84 82 166 240 70%

Number of TB patients counseled and tested for HIV, and received their results

175 106 281 763 37%

Number newly tested positive 11 10 21 127 17%

Number of HIV-infected TB patients on ARVs

92 86 178 375 48%

Proportion of HIV-infected TB patients on ARVs

97% 94% 95%

Source: Program Reporting Information System Management. Abbreviations: ARV, antiretroviral; FY, fiscal year; Q, quarter; SAPR, semi-annual progress report; TB, tuberculosis. Table 54. TB cascade (FY20 SAPR).

County TB

Registered Patients

TB Patient with Known HIV

Status

TB/HIV Coinfection

TB/HIV on ART

SAPR Target SAPR Target SAPR Target

Kisumu 107 105 235 49 124 48 124

Nyamira 400 398 768 138 243 130 251

Total 507 503 1,003 187 367 178 375

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; SAPR, semiannual progress review; TB, tuberculosis.

Discussion

The project reached the expected 50% FY20 SAPR TB performance on all but two of the key indicators.

The number of HIV-infected TB patients on antiretrovirals (ARVs) was at 48% against the annual target,

and a 37% performance was recorded for those tested and received HIV results. In the SAPR, 99% of

newly registered and relapsed TB patients knew their HIV status, with a coinfection rate of 38%.

The project achieved 99% on the number of TB clients that know their HIV status due to the project’s

continued sensitizations on active case finding in all the supported HFs, which were done as part of

mentorship and review meetings. The project will continue working through the cough monitors, some of

whom are now supported by The Global Fund partners, to strengthen HF-level active case finding and

referral for TB diagnosis and treatment. The screening of clients for TB in the outpatient department triage

area by the HTS screeners, as well as the eligibility screening for HIV, will continue.

36

With 503 TB patients with known HIV status, the project reached 50% of the annual target of 1,003.

8.2 TB screening

All clients who receive ART are to be screened for TB at each visit using an MOH algorithm. Use of

GeneXpert for assessing suspected cases is prioritized, with those turning positive initiated on treatment.

The individuals that screen negative for TB are initiated on a six-month TB-preventive therapy.

Key results

During Q2, 22,663 of 23,234 clients currently on ART were screened for TB, representing a 98%

screening rate, as highlighted in Table 55. Additional results through Q2 include the following:

• 98% of all clients currently on treatment were screened for TB; the screening rate in the counties was

at or greater than 97%. All TB data were reviewed during the data-review meetings before

submission for uploading to the DHIS2.

• The project did not provide direct support to any cough monitors across the sites; instead, it worked

with monitors who were supported by other partners at the community level but who were linked to

the sites.

Table 55. TB screening by county (FY20 SAPR).

County TX_CURR Total TB

Screening Percentage

Screened Positive for TB

Kisumu 9,154 9,028 99% 77

Nyamira 14,080 13,635 97% 289

Total 23,234 22,663 98% 366

Source: District Health Information Software (DHIS). Abbreviations: FY, fiscal year; Q, quarter; TB, tuberculosis; TX_CURR, currently in treatment; SAPR, semiannual progress report.

8.3 Provision of isoniazid preventive therapy for TB

The project supported provision of isoniazid preventive therapy (IPT) in all project-supported counties,

with a focus on initiating asymptomatic clients on IPT, along with clear analysis of the IPT outcomes of

those initiated six months earlier. To ensure the sustainability and improvement of IPT documentation and

completion, the project provided capacity-building initiatives and mentoring of HCWs and pharmacists on

accurate documentation in IPT registers, as well as timely ordering of IPT tablets and other commodities.

The project conducted file reviews to establish the IPT status among the comprehensive care center

clients.

Key results

During Q2, 94% (506 of 536) of clients who had started IPT six months prior completed TB prophylaxis

treatment. The remaining had died or been discontinued, transferred out, or been lost to follow-up, as

detailed in Table 56 below. For the SAPR period, 95% (1,007/1,061) completed TB prophylaxis treatment.

37

Table 56. IPT for TB (FY20 SAPR).

Indicator Q1 Q2 SAPR Percentage

Total clients who started IPT 6 months ago

525 536 1,061

Total completed treatment

501 506 1,007 95%

Total dead 5 4 9 1%

Total transferred out 10 10 20 2%

Total discontinued 0 1 1 0%

Total lost to follow-up 9 15 24 2%

Abbreviations: FY, fiscal year; IPT, isoniazid preventive therapy; Q, quarter; SAPR, semi-annual progress report; TB, tuberculosis.

Discussion

The project does not have DATIM-assigned targets for this indicator in FY20. The 95% completion rate is

lower than what was achieved overall in the last FY. No clients discontinued treatment in the reporting

quarter. The majority of the clients were either transferred out or lost to follow-up.

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

9.1 Prevention of mother-to-child transmission of HIV

Afya Ziwani supports 84 HFs with PEPFAR targets for PMTCT. In FY20 Q2, the project supported a total

of 29 facility-based mentor mothers, covering 26 supported PMTCT sites. There was no support to the

community mentor mothers in the reporting quarter. Support in the FY20 Q2 was also provided through

adherence-support counselors, whose services were rendered to high-VL clients. Integration of family

planning services within the comprehensive care centers was continued, including strengthening use of

the pregnancy-intention screening tool.

Key results

Through the SAPR period, 100% (11,355 of 11,355) of women who attended their first ANC visit knew

their HIV status (PMTCT_STAT), reaching 61% of the annual target of 18,574. Table 57 presents total

results by county for PMTCT_STAT, which encompasses all known and newly tested HIV positives.

Table 57. PMTCT uptake by county (FY20 SAPR).

County First ANC PMTCT_STAT Percent

Who Know Their Status

COP Target

Achievement Against Target

Kisumu 3,259 3,259 100% 6,299 52%

Nyamira 8,096 8,096 100% 12,275 66%

Total 11,355 11,355 100% 18,574 61%

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

Abbreviations: ANC, antenatal care; COP, country operational plan; FY, fiscal year; PMTCT, prevention of mother-to-child transmission of HIV; PMTCT_STAT, women who attended their first ANC visit and knew their HIV status; Q, quarter; SAPR, semiannual progress report.

38

Table 58. PMTCT_STAT summary achievements (ANC1) by county (FY20 SAPR).

County PMTCT_STAT Total Positives Known Positive New Positive

No. Percent No. Percent No. Percent

Kisumu 3,259 338 10% 266 79% 72 21%

Nyamira 8,096 273 3% 187 68% 86 32%

Total 11,355 611 5% 453 74% 158 26%

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

Abbreviations: ANC1, first antenatal care visit; FY, fiscal year; No., number; PMTCT, prevention of mother-to-child transmission of HIV; PMTCT_STAT, women who attended their first ANC visit and knew their HIV status; SAPR, semiannual progress report.

Of the 11,355 women with known HIV status at an ANC first visit, 4.0% (453) were known positives at

entry and only 1.4% (158) were newly tested HIV positive (Table 58). The higher rate of known positives

at ANC entry can be attributed to the women’s confidence that the PMTCT program enables them to have

an HIV-negative child, along with improved quality of life with good VLS. Table 59 summarizes the

number of HIV-positive pregnant women on ART, by county.

Table 59. PMTCT_ART summary achievements by county (FY20 SAPR).

County

FY20 SAPR Annual Target

Achievement Positives On ART Percent

Kisumu 337 337 100% 960 35%

Nyamira 270 270 100 % 460 58%

Total 607 607 100% 1,420 42%

Source: Ministry of Health (MOH) 711/MOH 731 reports; semiannual progress report.

Abbreviations: ART, antiretroviral therapy; FY, fiscal year; PMTCT, prevention of mother-to-child transmission of HIV; PMTCT_ART, HIV-positive pregnant women on antiretroviral therapy; SAPR, semiannual progress report.

While 100% of women at first-contact ANC knew their HIV status, the project only reached 42% of its

annual target of 1,420 pregnant women starting maternal ART. The discrepancy in performance can be

attributed to a lower-than-expected number of first ANC visits, more so in Kisumu County, as well as the

low prevalence of HIV in Nyamira County.

PMTCT cohort analysis (viral load suppression)

PMTCT cohort analysis was conducted in all PMTCT-supported sites in project Year 3 Q2 to track VLS

(Table 60).

Table 60. Average VLS among PMTCT clients (FY20 Q2).

Category

Pregnant Breastfeeding

< 15 years

15–19 years

> 20 years Total < 15

years 15–19 years

> 20 years

Total

Number samples taken

1 6 132 139 0 25 351 376

Number suppressed 0 6 119 125 0 22 319 341

% suppression 0 100 90 90 0 88 91 91

Source: National AIDS & STIs Control Programme/early infant diagnosis website. Abbreviations: FY, fiscal year; PMTCT, prevention of mother-to-child transmission of HIV; Q, quarter; VLS, viral load suppression.

39

The overall average suppression was 90% among pregnant mothers and 91% in the breastfeeding

mothers. The pregnant mothers who were younger than 15 years old had the lowest suppression at 0%

(one sample considered). The project will continue to work with the facility staff, especially the maternal

and child health staff, to ensure timely VL sample collection is done, mothers with high VL are monitored

closely with timely enhanced adherence counseling, and those eligible are switched to second line ART.

PMTCT cohort analysis (retention)

PMTCT cohort analysis was conducted in all PMTCT-supported sites to establish client retention at 3, 6,

and 12 months after enrollment (see Table 61).

Table 61. PMTCT cohort analysis (FY20 Q2).

Cadre 3-Months Cohort 6-Months Cohort 12-Months Cohort 24-Months Cohort

N+ K+ Total N+ K+ Total N+ K+ Total N+ K+ Total

Enrolled 76 92 162 70 102 172 116 119 235 109 89 198

Transferred In

0 14 14 0 25 25 0 27 27 3 19 22

Transferred Out

7 1 8 7 6 13 17 16 33 23 10 33

Net Cohort 69 105 168 63 121 184 99 130 229 89 98 187

Defaulted 3 1 4 3 2 5 2 2 4 0 0 0

LTFU 0 0 0 0 0 0 10 3 13 2 11 13

Dead 0 0 0 0 0 0 2 0 2 0 0 0

Stopped 0 0 0 0 0 0 1 0 1 1 0 1

Alive Active

66 104 164 60 119 179 84 125 209 86 87 173

% Retained 96 99 98 95 98 97 85 96 91 97 89 93

Abbreviations: FY, fiscal year; K+, known positive; LTFU, lost to follow-up; N+, new positive; PMTCT, prevention of mother-to-child transmission of HIV; Q, quarter.

As the above table presents, retention for the 3-, 6-, 12-, and 24-month cohorts was at 98%, 97%, 91%,

and 93%, respectively. Known positives continued to have better retention rates across all cohorts,

(except the 24-month cohort) leading to an overall average of 96% retention, against the new positive

retention rate of 93%.

Discussion

The strong performance on the maternal cohort analysis can be attributed to HF-level monthly reviews on

this indicator. In these monthly reviews, the project team used PMTCT cohort analysis dashboards, as

well as the regular chart reviews. The team also identified gaps for follow-up. All of these were discussed

during HF data-review forums to identify retention and suppression gaps for review.

The mentor mother and peer educator program, though currently operating with reduced numbers, was a

contributing factor in the strong performance. During this quarter, the facilities had a boost from the

community health volunteer support on defaulter tracing and household follow-up. A local community-

based organization, Daraja-Mbili, in Nyamira County extended its work with community health volunteers

to a wider region, and this has led to this improved retention. In the subsequent quarters, the project will

continue to support HFs to review PMTCT performance in their monthly data quality assessments and

during subcounty elimination-of-mother-to-child-transmission review meetings.

40

The project continued to face the following challenges: client charges for ANC profile testing in private

and faith-based organization sites, especially in Kisumu County where the project supports the more

urban facilities with clients who prefer private facilities; the limiting of universal access to PMTCT services

and retention up to the fourth ANC visit; and the limited access to community-level structures, due to

funding cuts, that hindered the project team from assisting community health volunteers in ANC mapping

and referrals, which led to community health volunteers referring only a few mothers to the HFs.

9.2 Early infant diagnosis

Key results

The number of EID tests for HEIs between 0 and 12 months old, overall and by county, is shown in

Table 62. In Q2, 272 children were tested, for a total of 537 in the SAPR period, reaching 38% of the

annual target. Breakdown of when the children were tested, by county, is shown in Table 63.

Table 62. Overall EID tests between 0 and 12 months old (FY20 SAPR).

County Q1 Q2 SAPR Annual

Target Achievement

Kisumu 120 146 266 954 28%

Nyamira 145 126 271 453 60%

Total 265 272 537 1,407 38%

Abbreviations: EID, early infant diagnosis; FY, fiscal year; Q, quarter; SAPR, semiannual progress report.

Table 63. EID test performance by monthly periods (FY20 SAPR).*

County

Period of Testing

Total Annual Target (0–2 Months)

Achievement (0–2 Months)

0–2 Months 2–12

Months

Kisumu 243 23 266 860 28%

Nyamira 182 89 271 408 45%

Total 425 112 537 1,268 34%

* The EID points of care were transitioned from the Elizabeth Glaser Pediatric AIDS Foundation to NASCOP. The point of care labs have not been operational since November 2019, which has prompted facilities to revert to the use of dried blood spot in the central testing labs in the Kenya Medical Research Institute/Kisian and Walter Reed Project/Kericho. Abbreviations: EID, early infant diagnosis; FY, fiscal year; SAPR, semiannual progress report

As Table 63 presents, EID testing for infants under 2 months old was at 33% against the annual target in

the FY20 SAPR.

Discussion

In Q2, 272 virology HIV test samples were done as initial polymerase chain reaction (PCR) to HIV-

exposed infants within 12 months of age. This was an improvement from Q1 performance, which was at

265. Against the annual targets, the project achieved 38% at the SAPR. Overall county performance as at

SAPR in Kisumu was 28% and in Nyamira was 60%. For the number of EID tests done between 0 and 12

months old, Nyamira County surpassed the expected 50% performance for the SAPR period. Kisumu

County, owing to the low performance witnessed in Q1, only managed 28% against the country

operational plan 2019 target, slightly above double its Q1 performance. This low performance in Kisumu

was largely due to industrial action that affected this county for the entire Q1. This contributed to low

41

PMTCT_POS identification, as seen across the cascade from first ANC to identification. The project plans

to intensify community activities through use of community health volunteers to do household pregnancy

screening and referral for mothers who are pregnant for confirmation and start of early ANC services.

In this FY, PEPFAR provided disaggregated targets for the EID at 0 to 2 months and 2 to 12 months. The

performance in EID by 2 months of age was, on average, 34% for the two counties. Kisumu County

performed lower than Nyamira when judged against the annual target for the 0 to 2 months, 28% versus

45%, but it had more tests done early, 243 of 266 (91%), compared to 182 of 271 (67%) in Nyamira

County.

The project continued to address an inherent challenge of late presentation to the facility by the

caregivers of infants: HCWs were deficient of skills in drawing PCR samples from infants as they were

identified. Among the strategies that were launched to address this is the system known as expected date

of delivery/early EID-PCR tracking. This system follows the PMTCT mother from pregnancy, to delivery,

to the postnatal period. It works with her to establish an expected date of PCR drawing at the

recommended sixth week after birth. The nurses and mentor mothers began using this system in FY19

Q4.

The reduction in clinical and nonclinical staff could undermine the optimal benefits of this strategy. In

addition, the near collapse of the EID point-of-care system, which had reduced the turnaround time of

results to hours, may prevent optimization of very early infant testing.

Early infant diagnosis cascade and linkage of positive infants

Key results (early infant diagnosis cascade)

Project results for the EID cascade (for initial tests of infants between 0 and 12 months old) for the quarter

are shown in Table 64.

Table 64. Early infant diagnosis cascade—initial tests only (FY20 SAPR).

Category

Q1 Q2 SAPR

Annual Target No. Percent No. Percent No. Percent

Number HIV-positive women (includes post-ANC)

304 322 626

Number initial PCR at 0–12 months old

1,407 265 272 537 38%

Number confirmed PCR positive at 0–12 months old

3 1.1% 14 4.9% 17

Number PCR tested at 0–2 months old

1,268 207 215 425 33%

Percent PCR tested at 0–2 months old, against POS mothers

> 90% 68% 67% 68%

Number confirmed PCR positive at 0–2 months

3 6 9

Number total HEI PCR POS linked to treatment

3 100% 12 86% 15 80%

Number of linked PCR POS with baseline VL

3 100% 10 13 76%

Number total HEI PCR POS died before treatment

0 0% 0 0

Number LTFU 0 0% 0 0

Source: National AIDS & STIs Control Programme/early infant diagnosis website.

42

Abbreviations: ANC, antenatal care; FY, fiscal year; HEI, HIV-exposed infant; LTFU, lost to follow-up; No., number; PCR, polymerase chain reaction; POS, positive; Q, quarter; SAPR, semiannual progress report; VL, viral load.

Using the FY20 annual EID targets for initial samples from infants 0 to 12 months old, the project has

achieved 38% against the expected 50%. This was largely attributable to the low performance in Kisumu

County due to industrial action that affected maternal child health services in the county. Also, this was

affected by low identification across the cascade.

Using the PMTCT_STAT_POS (HIV-positive pregnant women with known status) indicator as the proxy

denominator for PCR testing of infants 0 to 2 months old, Afya Ziwani recorded 215 PCR at initial testing

in Q2 (67% coverage) and 425 initial tests in the SAPR, translating to a 67% coverage. This may be

attributed to the women on follow-up at the project’s HFs (especially those in Kisumu) who had delayed,

deferred, or gone elsewhere to seek infant and child services following the facility closure. Other reasons

that contributed to this low performance were mothers who came late for follow-up; missed opportunities

for sample collection due to several issues; staff reluctance to remove samples was observed across the

regions, where some health providers, especially nurse providers, viewed this activity as not part of their

duties; a skills gap especially among staff in high-volume facilities with frequent staff rotations; and

clients, who had to travel from different locations and came late (i.e., after eight weeks) for sample

collection (some were defaulters who were traced back after eight weeks).

Of the children identified in the SAPR period, 86% have been started on treatment. Two missed

opportunities arose in Q2: one transferred out and the other had not been initiated as at the close of the

quarter but has since been followed up for initiation.

Six infants who were PCR positive in Q2 were below 8 weeks of age and eight were between 2 and 12

months of age. Ten of these infants received a baseline VL—a 71% uptake compared to 100% in FY20

Q1. This is largely attributable to lack of skills in drawing plasma samples from infants since the lab

transitioned from collecting dried blood spot to plasma sample for VL. This led to some samples being

rejected because of hemolysis. The project will continue to build the capacity of HCWs on sample

collection through on-the-job training to avoid rejections and delayed sample collection due to lack of

skills.

HIV-exposed infant positivity and HIV-exposed infant mortality audits

The project conducted the Q2 HEI audit of the 14 infants identified as positive at initial testing and 1 who

turned positive on a second PCR to better understand the possible causes of transmission and find

solutions to prevent such causes, where possible. Table 65 summarizes the findings of the positivity

audits.

43

Table 65. Outcome of HEI positivity audits (FY20 Q2).

Infant PCR Audit Report Maternal Details

General Findings General Findings

Total positive PCR 15 Total mothers audited 15

Total PCR positive audited 15 100% Attended ANC 13 87%

PCR tested < 2 months 6 40% Mother’s age group

PCR tested 2–12 months 9 60% 10–19 years 0

HEI received infant prophylaxis 12 80% 20–24 years 7

Baseline VL 10 67% 25 years and above 8

Exclusive breastfeeding by 6 months

9 60%

Known positives at ANC entry 4 27%

Outcomes Newly diagnosed 11 73%

Enrolled on treatment 14 93% Partner tested 10 67%

Dead 0 0

Maternal prophylaxis received at ANC

4 27%

Lost to follow-up and unlinked 0 0 Good adherence 8 53%

Transferred out 1 7% Hospital delivery 12 80%

Disclosure done 11 73%

Mothers with high VL at ANC 0 0

Abbreviations: ANC, antenatal care; FY, fiscal year; HEI, HIV-exposed infant; PCR, polymerase chain reaction; Q, quarter; VL, viral load.

The mother-to-child transmission (MTCT) audits have revealed different reasons for MTCT of HIV. In this

quarter, key reasons included late identification—about 60% of infants’ PCR were done after 2 months—

and missed maternal prophylaxis (73%). During this reporting period, there was good uptake of ANC

services among mothers but adherence to treatment was an issue, with only 53% reporting good

adherence. Most of these mothers were still struggling to accept their status. Some, who were struggling

with disclosure, were unable to keep clinic appointments; thus, they were late to present to the HFs for

infant PCR. Most of the women’s partners know their HIV status. PNS activities carried out among the

index clients contributed to this outcome.

Missed opportunities for prophylaxis among this cohort, of whom two-thirds were newly positive, calls for

a further qualitative survey among women to understand the plausible reasons for non-adherence to

infant and/or maternal prophylaxis. Young maternal age and low PMTCT knowledge may be contributing

factors.

The project worked with other partners to improve the care given to mothers from delivery through the

postnatal period. Sensitizations at HF and community levels on the importance of hospital delivery, as

well as exit interviews to improve service delivery, were aimed at increasing uptake of skilled delivery.

PCR testing at 2 months old or older was attributed to mothers who presented late at postnatal care,

maternal appointment adherence challenges, and/or incidences of defaulting on treatment at ANC. The

project will work with mentor mothers and peer educators, together with community health volunteers, to

make sure mothers are reminded of the PCR sample collection period for timely early infant diagnosis.

This will be done through implementation of the expected date of delivery/EID-PCR log.

44

HIV-exposed infant cohort analysis (12- and 24-month cohort review)

During the reporting period, MTCT outcome results were reviewed across the 12- and 24-month cohorts.

The primary goal was to establish MTCT rates and the percentage of infants who were retained/active in

follow-up. The HEI cohort analysis outcome data for the 12-month cohort of infants on follow-up at 12

months are presented in Table 66. HEI cohort analysis outcome data for the 18-month cohort reviewed at

24 months are shown in Table 67.

Table 66. HEI analysis of 12-month cohort (FY20 Q2).

HEI Outcome Analysis of 12-month Cohort (at 12 Months)

Absolute Numbers

% Outcomes

Total enrolled into the cohort 252

Active in follow-up 207 82%

Died between 0 and 12 months old 3 1%

Missing 12-month follow-up 8 3%

Identified as positive between 0 and 12 months 5 2%

Transferred out between 0 and 12 months 29 12%

Abbreviations: FY, fiscal year; HEI, HIV-exposed infant; Q, quarter.

Table 67. HEI analysis of 18-month cohort at 24 months (FY20 Q2).

HEI Outcome Analysis of 18-month Cohort (at 24 Months) Absolute Numbers

% Outcomes

Total enrolled into the cohort 233

Active in follow-up 187 80

Active with antibody test at 18 months 181 97

HEI antibody negative at 18 months 181 78

HEI active at 18 months but no antibody test done 6 2.6

HEI identified as positive between 0 and 18 months 7 3

HEI transferred out between 0 and 18 months 23 9.9

HEI lost to follow‐up between 0 and 18 months 11 4.7

Died between 0 and 18 months 5 2.1

Abbreviations: FY, fiscal year; HEI, HIV-exposed infant; Q, quarter.

Overall, the retention rate was 82% for the 12-month cohort and 80% for the 24-month cohort. This is a

lower 12-month retention in this cohort compared to the Year 3 Q1 cohort, which had a retention of 93%.

The MTCT rate was 2.0% for the 12-month cohort and 3.0% for the 24-month cohort (with testing

between 0 and 18 months old). The project recorded 3.0% of infants missing at the 12-month follow-up

and 4.7% at the 24-month follow-up. The transfer out was recorded at 12% in the 12-month cohort and

9.9% in the 24-month cohort.

Discussion (early infant diagnosis cascade)

These data are collected at the HF level and uploaded into DHIS2. HF staff use the data to make

decisions, like early defaulter tracing and mortality audits, to determine the causes of death and how

these can be averted to prevent future deaths.

45

Overall, this is low performance in retention at 12 months compared to the expected PMTCT cohort

analysis retention rate of 90%. This was attributable to the reduced number of mentor mothers, which

affected follow-up and mentoring of mothers to adhere to treatment through 24 months. However, there

has been continued focus on promoting retention of mother-baby pairs by strengthening appointment and

defaulter-tracing systems with the use of the facility missed appointment tracking tool (FMATT) to track

daily defaulters, functional PMTCT PSSGs, quality improvement team meetings with clinicians, mentor

mothers, and capacity-building of HCWs and peer educators/mentor mothers.

Integration of ART and HEI follow-up at maternal and child health clinics also improved retention of

mother-baby pairs, as mothers get all their services from a one-stop shop, which reduces issues of

stigma. Despite this good practice, there were still challenges that hindered high-quality provision of

services to the mothers. This included some HCWs who still viewed HIV as a LIP responsibility. The

project will continue to work with the subcounty health management team to ensure the MOH nurses take

up the PMTCT services by building their capacity through on-the-job training, site mentorship, supportive

supervision, data review meetings, and data quality assessments.

10. Commodity security

The project supports 12 ARV-ordering sites (10 central and 2 stand-alone) around 113 HFs that they link

with to improve supply chain logistics and commodity management. In FY20 Q2, the project achieved full

transition of CALHIV from the nevirapine-based regimen to the currently recommended regimen by

NASCOP. The project ensured the availability of sufficient stock of the new regimen for CALHIV through

mentorship and sensitization of the facility staff and subcounty pharmacist on the appropriate

quantification and ordering process.

10.1 Key results

Nevirapine phaseout in children and adolescents living with HIV

The project transitioned the remaining two CALHIV from FY20 Q1 to non-nevirapine-based pediatric

regimens. As at FY20 Q2, the project had a total of 1,144 CALHIV under 15 years old on treatment.

Efavirenz/abacavir/lamivudine is the most common regimen among pediatrics under 15 years old, with

54% (615) of CALHIV on this regimen. Abacavir/lamivudine/lopinavir/ritonavir is the second-most

preferred regimen, with 28% (322) of CALHIV receiving this regimen. There has been a steady increase

in the number of CALHIV being transitioned to a dolutegravir-based regimen, reaching 12% (140) of all

CALHIV as at the end of the Q2.

Progress in female ART optimization

As at FY20 Q2, the project had a total of 14,804 females above 15 years old, representing 64%

(14,804/23,217) of current on ART. With recent guidance from NASCOP to transition females above 15

years old to tenofovir/lamivudine/dolutegravir, there has been a steady increase in optimization of this age

population from tenofovir/lamivudine/efavirenz to tenofovir/lamivudine/dolutegravir. At end of the reporting

period, the project had a total of 3,447 females older than 15 years of age on

tenofovir/lamivudine/dolutegravir, representing 25% (3,447) of women of ART this age group. In the

coming quarter, the program will continue scaling up female ART optimization. It will focus on sensitizing

HCWs on the NASCOP guidelines that were provided for this population.

46

Last-mile delivery of ARVs in Nyamira County

In FY20 Q2, the Kenya Medical Supplies Authority (KEMSA) added Nyamira County to the list of four

other counties (Kisumu, Machakos, Isiolo, and Embu) for last-mile distribution of ARVs. To kick start the

process, KEMSA offered a one-day sensitization to subcounty pharmacists and facility pharmaceutical

technologists in Nyamira County on appropriate quantification for last-mile distribution.

Last-mile distribution is the process wherein the distributor delivers ordered commodities to all the

ordering HFs across the county, rather than to subcounty central stores. Deliveries are quarterly rather

than monthly; hence, each facility is expected to quantify enough commodities to last for three months

with one month of buffer stock. The process starts with subcounty pharmacists allocating each facility

enough quantities of ARVs to last the whole quarter. The orders are then reviewed by the county

pharmacist before approval and submission to KEMSA for order processing. Each facility is then

expected to receive four months of ARVs based on commodity availability at KEMSA. If any ordered

commodity is missing during initial order processing, KEMSA is expected to back order supplies once the

missing commodities have been received in the warehouse.

Last-mile distribution has helped to eliminate the logistical challenges that were associated with the

previous system, including interruption of supplies, overburdening of the central stores, and additional

costs during redistribution by county and project vehicles.

Multi-month dispensing progress

In FY20 Q2, the project scaled up multi-month dispensing. It reached 62% (14,399/23,217) of those

current on ART with three or more months of drugs. A total of 16,867 were issued two or more months of

drugs, representing 73% (16,867/23,217) of those current on ART. NASCOP provided the guidance to

increase uptake of multi-month dispensing to reduce the frequency of client visits to the health facility

during the COVID-19 period. We expect to report higher percentages in Q3.

Commodity sites’ reporting rates into the Kenya Health Information System

In FY20 Q2, the project achieved an overall 98% reporting rate for submission of monthly ARV reports

into the Kenya Health Information System. Figure 3 shows reporting rate percentages for each project-

supported county in FY20 Q2.

47

Figure 1. Central and satellite ART commodity sites’ reporting rates into KHIS (FY20 Q2).

Abbreviations: ART, antiretroviral therapy; FCDRR, facility consumption and data report & report; FMAPS, facility monthly ARVs patient ssummary; FY, fiscal year; KHIS, Kenya Health Information System; Q, quarter.

Laboratory commodities

The project attained 100% reporting rates for the rapid test kits for each county, as reported in the health

commodity management platform.

10.2 Discussion

HFs maintained a high reporting rate (99.4%) in FY20 Q2 in both project-supported counties in both ARV

and laboratory commodity reporting. The project continued to support county and subcounty pharmacists

in FY20 Q2 with monthly airtime and bundles to ensure timely uploading of reports into the Kenya Health

Information System. Afya Ziwani continued to provide financial and technical support to the monthly ARV

allocation meetings at the county level to ensure accurate commodity ordering. The project also

supported quarterly rapid test kit allocation meetings in both Nyamira and Kisumu counties.

As KEMSA is conducting last-mile ARV delivery to individual sites, the project will work closely with all

facilities to monitor stock levels at facilities and support emergency ordering and redistribution in case a

particular commodity stock is running low.

10.3 COVID-19 risk and mitigation on commodity management

During this COVID-19 period, facilities have been guided to issue up to three months of ARVs to clients.

This will likely put pressure on commodity stock monitoring and management. The project has supported

subcounties to calculate and place commodity orders with KEMSA for this period to ensure there are no

interruptions in issuing up to three months of drugs.

10.4 Capacity-building initiatives in commodity management

The project supported capacity-building initiatives, such as mentorship, on-the-job training, and CME on

commodity management; pharmacovigilance reporting; and use of the electronic ARV dispensing tool

(Web ADT). Afya Ziwani, in collaboration with the Clinton Health Access Initiative, supported updates to

100%

93%98%99%

95%98%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Nyamira Kisumu Project FCDRR FMAPS

48

Web ADT version 3.4, which enables direct uploading of commodity reports into the Kenya Health

Information System.

To promote high-quality reporting, the project continued to provide technical assistance and mentorship

on good commodity management practices to subcounty pharmacists and medical laboratory

coordinators. The project also provided supportive supervision to rural HFs. The project supported small-

scale printing and photocopying of pharmacy tools (e.g., daily activity register, facility consumption and

data report, and facility monthly ARVs patient summary) to improve inventory management at HFs.

11. Health systems strengthening

11.1 Providing mentorship, monitoring, and advocacy capacity-building to county health

management teams and subcounty health management teams

Continuing medical education support

Afya Ziwani used three approaches to provide CME to facility-based staff: (1) on-site short sessions at a

central site based on the NASCOP CME guidelines; (2) online CME sessions over Zoom on specialized

topics, such as short-term regimens for drug-resistant TB; and (3) linking Afya Ziwani staff to the weekly

web-based Extension for Community Healthcare Outcomes (ECHO) platform and case management

sessions hosted at Jaramogi Oginga Odinga Teaching and Referral Hospital by the ICAP project.

In FY20 Q2, 1,645 HCWs from the two counties participated in on-site CME sessions. During the

reporting quarter, 43 HCWs participated in six ECHO sessions. Table 68 shows participation in CME by

topic.

49

Table 68. HF staff participation in CME by topics covered (FY20 Q2).

CME Topic Method

Number of Participants

From AZ-Supported

Sites

Number of HFs

Orientation on EDD/EID PCR tracking tool On site

26 6

PNS sensitization/overview On site

60 12

DMOC overview and documentation On site

128 27

The standards and protocols in roving clinicians Centralized at

subcounty level 6 8

The standards in VL documentation and verification On site 127 54

Updates on pediatric ART optimization—NVP phaseout ECHO 43 11

Treatment failure and IRIS On site 52 13

Pediatric/adult ART optimization On site

45 7

HTS screening tool sensitization On site

78 24

Post-exposure prophylaxis On site

32 6

ART drug-drug interaction On site

11 2

HIV status disclosure On site

28 5

VMMC On site

0 0

Hypertension management in HIV On site

0 0

Data for decision-making On site

34 5

TB active case identification On site

61 11

APOC On site

13 2

FP, preconception care, pregnancy intention screening

On site 108 39

FP integration On site

106 33

PrEP On site

78 14

TB/HIV management On site

40 14

PMTCT package of care On site 35 5

Cervical cancer screening On site 16 4

Appointment management On site 149 52

Standard package of care On site 51 10

Retention review sensitization On site

242 84

GBV overview sensitization On site

91 46

HEI screening at Immunization at 6 weeks On site

34 12

50

Abbreviations: APOC, adolescent package of care; ART, antiretroviral therapy; AZ, Afya Ziwani; CME, continuing medical education; DMOC, differentiated model of care ; ECHO, Extension for Community Healthcare Outcomes; EDD, expected date of delivery; EID, early infant diagnosis; FP, family planning; FY, fiscal year; HF, health facility; HTS, HIV testing services; IRIS, immune response of the immune system; NVP, nevirapine ; PCR, polymerase chain reaction; PLHIV, people living with HIV; PMTCT, prevention of mother-to-child transmission of HIV; PNS, partner notification services; PrEP, pre-exposure prophylaxis; Q, quarter; TB, tuberculosis; VL, viral load; VMMC, voluntary medical male circumcision.

11.3 Human resources for health support

Quantification of staffing for prioritization and planning

In FY20 Q2, Afya Ziwani employed 282 service delivery staff, comprising 79 professional HCWs, 159 lay

HCWs, 8 data clerks, and 36 sample transport bike riders across the two supported counties. Tables 69,

70, and 71 present breakdowns of staff by county and cadre.

Table 69. Health care professionals contracted (FY20 Q2).

County Total Professional HCW

RCO RN PT MLT HRIO

Kisumu 32 13 5 2 2 9

Nyamira 47 14 9 5 5 18

Total 79 27 14 7 7 27

Abbreviations: FY, fiscal year; HCW, health care worker; HRIO, health records information officer; MLT, medical laboratory technologist; PT, pharmacy technologist; RCO, registered clinical officer; RN, registered nurse; Q, quarter.

Table 70. Health care lay workers contracted (FY20 Q2).

County Total Lay HCW

HTS ASC MM PE in CCC CM

Kisumu 53 10 4 15 24 0

Nyamira 106 24 4 14 64 0

Total 159 34 8 29 88 0

Abbreviations: ASC, adherence-support counselor; CCC, comprehensive care center; CM, cough monitor; FY, fiscal year; HCW, health care worker; HTS, HIV testing services; MM, mentor mother; PE, peer educator; Q, quarter.

Table 71. Non-health-care lay workers contracted (FY20 Q2).

County Lay Worker (Other)

Data Clerk Sample Transport Riders

Kisumu 3 8

Nyamira 5 28

Total 8 36

Abbreviations: FY, fiscal year; Q, quarter.

12. Strategic monitoring and evaluation

Key results

In the quarter, 256 HCWs were reached through on-site mentorship on documentation and reporting

tools—44 in Kisumu and 212 in Nyamira. The focus was on addressing documentation challenges in

facility registers—including Daily Activity Registers, the ART register, the ANC register, HEI Cohort

Analysis, and Defaulter Tracing and Outcome Register—and compiling the monthly reports and FMATT.

51

In Nyamira County, mentorship was done in all 90 project-supported sites, particularly on documentation

of registers and patient files and submission of weekly surge reports. In sites where project-supported

staff were not placed, there were challenges with updating patients’ files and registers, and compiling

weekly project reports, high-frequency reports, and surge reports. Weekly data collection/entry and

verification were done during the quarter. Data clerks ensured that data were submitted every Friday,

entered in the Program Reporting Information Management System (PRISM), and reviewed during the

weekly surge data review before submission.

In Kisumu, one surge sensitization meeting and 25 surge data validation and verification exercises were

conducted. The project supported site-level monthly data review meetings in 25 sites before data

submission and 22 quarterly data cross checks for HTS, PMTCT, and C&T.

The project’s two county program offices conducted six monthly data review meetings, three in Kisumu

and three in Nyamira. Data discrepancies were found in the Kenya Health Information System/PRISM.

The project engaged subcounty health records information officers and these discrepancies were

corrected by the 15th of every month. The corrections reduced validation errors at the data processing

level. Additionally, Nyamira County conducted a county MOH HIV review meeting.

The primary EMR that is used in Afya Ziwani–supported sites is KenyaEMR, which is built on top of the

OpenMRS platform. The system is built with Java programming language. It runs on a Tomcat web server

and MySQL database. The EMR is installed on servers that run the Ubuntu operating system.

Collaboration with mHealth Kenya on integrating KenyaEMR with Ushauri and mLab continued. Ushauri

is an automated appointment diary, which will be responsible for sending appointment reminders to

project patients. mLab is a lab-result transmission application that will send lab results of project patients

directly to KenyaEMR. Afya Ziwani was able to successfully integrate KenyaEMR with mLab in five of

project-supported EMR sites. The project will scale this up to all supported EMR sites, as it improves data

quality and completeness in the EMR systems. However, integration of KenyaEMR with Ushauri is yet to

be achieved. Afya Ziwani is working closely with the mHealth Kenya team to achieve this.

Afya Ziwani installed 15 new EMR sites in Nyamira County, which increased the total number of

supported EMR sites from 41 to 56. EMR training was also conducted for Nyamira County, where the

project trained 130 EMR end users and county and subcounty health managers on the registration,

enrollment, C&T, maternal and child health, HTS, and defaulter-tracing modules.

Collaboration with Palladium Group continued. Palladium Group is responsible for the development of the

EMR, and Afya Ziwani is responsible for implementing and supporting the EMR at facility level. The

piloting of the PrEP module at one of the project-supported EMR sites was a success. Palladium has

since incorporated the PrEP module into their latest release of KenyaEMR. This has been upgraded in

five of the project-supported EMR sites. Afya Ziwani will upgrade all of the project-supported EMR sites

with the latest version of KenyaEMR.

Technical support, hardware maintenance, on-site mentorship, and supportive supervision have been

done and will continue to be offered to all EMR facilities. Monthly uploads of EMR data to the national

data warehouse have also been done. Table 72 below shows the service delivery points at project-

supported facilities that implemented EMRs during the reporting period.

52

Table 72. EMR distribution at service delivery points, by county (FY20 Q2).

County # Facilities with EMRs at the Following Service Delivery Points

HTS CCC ANC/Maternity EID TB/HIV

Kisumu 0 17 0 0 0

Nyamira 23 39 3 0 0

Total 23 56 3 0 0

Abbreviations: ANC, antenatal care; CCC, comprehensive care center; EID, early infant diagnosis; EMR,

electronic medical record; FY, fiscal year; HTS, HIV testing services; Q, quarter; TB,

tuberculosis.DREAMS Program Monitoring

The DREAMS program was implemented throughout the quarter. Activities were monitored by tracking

the performance against targets per intervention in all 33 wards in Homa Bay County, 8 wards in Kisumu,

and 8 wards in Migori; the project achieved 72% on the new enrollment and 75% on the social asset

building targets. The monitoring was done daily by the monitoring and evaluation LIP using the enrollment

dashboard; data were compiled weekly for project review. The use of standard operating procedures,

guidelines, data quality checks, and the EBI checklist during sessions in the enrollment period enhanced

the quality of interventions and ensured information was correct for informed decision-making.

The project also conducted focused supportive supervision in 8 wards in Kisumu, 28 wards in Homa Bay,

and 8 wards in Migori. The aim was to ensure adherence to the data management standard operating

procedures, maintain the quality of EBIs, and ensure proper documentation in all the registers, the

database, and the service uptake forms. Training of MWENDO OVC staff on the use of Open Data Kit to

enroll girls was done to support the co-enrollment process. Ward teams, including the mentors and

community health volunteers, were also trained on the use of Open Data Kit to enroll girls. Monthly

mentors’ meetings were conducted in all 51 supported wards. In Kisumu, Kondele, Railway Ahero, and

Kolwa Central wards were put on improvement plans to accelerate enrollment and service provision. The

project produced and distributed required enrollment materials, including AGYW vulnerability and

secondary service eligibility criteria forms, consent forms, assent forms, and service uptake forms.

The project conducted routine data verification checks for data consistency, accuracy, and completeness

of information documented on the registers, service uptake forms, DREAMS database, referrals tool, and

MSP planning and monitoring tool. The project provided targeted mentorship support to the ward

coordinators on programmatic gaps and data quality issues.

The project also focused on improving data quality by conducting LIP bimonthly data review meetings for

all the 51 wards at LIP level. The meetings were conducted in a central place with participation of the

program officer LIP, monitoring and evaluation LIP, and ward coordinators. The meetings were also

supported by the PATH program staff. Kisumu County conducted eight biweekly review meetings to

monitor progress on enrollment and service provision, as well as review progress in achievement of

performance plans for four wards.

Discussion

The project has implemented various activities to ensure timely data collection and reporting. This has

included blocking the first week of each month for data collection and reporting from HFs. This has

improved the response rates and timely submission to DATIM. The project has conducted monitoring and

evaluation activities and provided tools to assist in monitoring/tracking and reporting on missed

53

appointments, defaulters, lost to follow-up, and deaths. The project engaged HFs to facilitate weekly

surge reports and review of progress to ensure that monthly summaries are consistent with the weekly

aggregates.

54

Performance monitoring: Data tables

Please refer to the performance data tables in the attachment.

55

Constraints and opportunities

In the last two weeks of the quarter, the national and county governments introduced measures that were

aimed at stopping the spread of the novel coronavirus disease, COVID-19. These measures included

social distancing, restrictions on congregating of more than 15 persons, restrictions to travel resulting in

lockdowns, handwashing, and use of protective gear among the HCWs. These measures presented a

challenge as well as an opportunity to the project. These limitations meant that most of the project

activities at the HF and community levels had to stall. In the last two weeks of March, a reduction in the

testing and identification of positive clients was seen as a result of clients’ fears of visiting HFs or being

visited for PNS in the community, as well as providers’ fears of exposure. Anticipating a high defaulter

rate for clients on ART, the project undertook the NASCOP directive of pre-calling clients and providing

three-month refills of ARV, including to those who were on PrEP. For AGYW, the project paused door-to-

door enrollments and restrategized on referrals to the safe spaces that were scantily managed by the

ward coordinators and a few mentors. Service provision was limited to the individual interventions, such

as PrEP and HTS. Secondary services, such as school fees, were stopped, awaiting school reopening.

More strategies such as virtual safe spaces are to be explored for adoption as time unfolds.

56

Progress on gender strategy

Number of people receiving post-gender-based violence clinical care

minimum package

The project’s gender strategy revolves around three key intervention areas: AGYW/adolescent boys, young

men, and GBV.

Adolescent girls and young women/adolescent boys and young men

Gender is a critical determinant of the HIV epidemic, with infection rates for adolescent girls between 15

and 24 years old significantly higher than those of their male counterparts. Also, social norms can condone

violent, nonconsensual, and unprotected sex, which, combined with gender barriers, increase vulnerability,

especially of women and girls. Vulnerability to GBV, especially for AGYW, is highlighted in the project’s

Gender, Youth, and Social Inclusion Analysis. While the analysis did not find significant barriers to access

to services, the project has found that services such as PrEP require specific support to ensure access.

The Afya Ziwani project implements a comprehensive package of service interventions for AGYW, as well

as interventions for adolescent boys and young men; the aim is to achieve primary prevention of HIV.

Provision of activities to prevent and respond to gender-based

violence

GBV interventions are implemented by Afya Ziwani in partnership with the MOH, the county governments,

and other stakeholders that undertake services at the counties. The services aim to prevent and respond

to GBV through case identification and a minimum package of clinical services, referral for psychosocial

care, legal counseling, and police services. The programmatic response by the project is at facility and

community levels. At the community level, the project collaborates with the county and subcounty

community focal person, public health officer for health promotion, reproductive health coordinators, local

community-based organizations (Daraja-Mbili in Nyamira), and the county/subcounty gender department

to conduct education/awareness sessions through trained paralegals, HCWs, peer educators, and male

champions of change.

The project also provides community-level education to provide information and create demand for facility-

level post-violence care services. Other GBV response services offered at the community include active

GBV case identification through screening by community health volunteers, peer educators, and

counselors; referrals and linkages to HFs for clinical management services; and referrals and linkages to

safe houses for psychosocial services and safe shelter services using standard community-facility referral

booklets. The project integrates gender in VMMC mobilization sessions to promote female partner

involvement. The project also continues to work with other partners and gender technical working groups

in supporting nonclinical post violence care services that are offered beyond HFs, such as legal aid, child

protection, and family integration.

Key results

FY20 Q2, Afya Ziwani supported ten sites to integrate post-GBV clinical services into comprehensive HIV

prevention and C&T, up from seven in Q1. Project-supported HFs provided post-GBV clinical services to

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395 GBV survivors (157 from sexual violence and 163 from nonsexual physical violence). Table 73

presents overall project results for FY20 SAPR.

Table 73. Provision of post-GBV clinical services (FY20 SAPR).

Gender-Based Violence Q1 Q2 SAPR Annual Targets

Achievement

Facilities supported to conduct GBV services

Number 7 10 10

GBV survivors attended to

Total 75 320 395 2,951 13%

Sexual violence 53 157 210 830 25%

Nonsexual physical violence 22 163 185 2,121 9%

Number receiving PEP (disaggregate of sexual violence)

46 127 173

Female 34 96 130

Male 12 31 43

Abbreviations: FY, fiscal year; GBV, gender-based violence; PEP, post-exposure prophylaxis; Q, quarter; SAPR, semiannual progress report.

All 320 survivors of GBV in Q2 received a minimum package of post-GBV services, as defined by national

guidelines. However, it was noted that 30 of the sexual survivors did not receive post-exposure

prophylaxis based on eligibility; follow-up is being done to ascertain if this was an omission. Lay

counselors provided on-site trauma counselling as necessary; referrals for complex cases were provided,

as per the county’s established GBV stakeholders’ network.

Discussion

In Q2, the project undertook a review of the GBV performance in FY19 and Q1 of FY20. In FY19, the

project provided post-GBV services to 1,122 (3%) people against an annual target of 41,267; the 3%

performance in Q1 was indicative that achieving the annual target would still be elusive in FY20. Gaps in

the GBV programming were identified, including a near collapse of the reporting system that was

occasioned by lack of capacity among the HCWs, who resorted to referring all cases to county referral

hospitals. To mitigate this, the project embarked on reactivation of the GBV focal persons at county,

subcounty, and facility levels; these persons were supported to sensitize select HFs across the two

counties on GBV management; reactivate the GBV technical working groups; and conduct supportive

supervision. The project provided data capture tools such as post-rape care forms and registers. These

efforts saw an increase in the number of reporting sites to ten and a threefold increase in the reported

cases, from 75 in Q1 to 320 in Q2.

To achieve the annual target of 2,951 cases, continued effort on facility identification and reporting of all

forms of GBV is paramount. As assessment showed that 56 HFs met the criteria of providing a minimum

package of post-GBV services. These facilities are targeted for contribution to achieving the FY20 target.

The project will continue to work with the legal services, strengthen multisectoral GBV referral and linkage,

and promote ownership of the GBV service provision to improve prosecution of the perpetrators.

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Progress on environmental mitigation and monitoring

The project supports an annual environmental mitigation, monitoring, and reporting plan as part of its

annual work plan. The focus this reporting quarter included strengthening health care waste management

at all levels of health care service delivery in supported counties, especially at the testing points, VMMC

minor theaters, and laboratories.

During the reporting period, the project provided health care waste management commodities for

infection prevention and control, supported capacity-building, and conducted supportive supervision with

focus on mentorship and on-the-job training for HTS providers, HCWs, DREAMS LIP staff, and VMMC

teams on proper waste management. The project provided bin liners to nine VMMC sites during the

acceleration period for VMMC in March 2020 and for FF outreaches to facilitate compliance with waste

management policies.

The project also mentored facility staff, especially those in pharmacy and laboratory departments, on

separating and removing expired commodities from their stores; labelling expired commodities clearly to

mitigate accidental use of expired commodities; and following correct procedures for destroying expired

commodities. The project worked closely with counties and hospital management teams to transport

waste generated at facilities without incinerators to functional incinerators.

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Progress on links to other USAID and Centers for Disease

Control and Prevention programs

In FY20 Q2, Afya Ziwani continued to collaborate with three key programs—Human Resources for Health

Kenya, Palladium Group, and mHealth Kenya—as detailed below.

The project collaborated with Human Resources for Health Kenya to strengthen county and subcounty

human resources for health management capacities, including use of iHRIS (integrated human resources

information system). The data for the project’s contracted human resources for health were uploaded into

the system.

The project also collaborated with the Palladium Group to improve county and facility use of EMRs, which

included training project staff on selected KenyaEMR modules. The pilot of the PrEP module at one

project-supported facility was concluded in the quarter, followed by the incorporation of this module into

the latest release of KenyaEMR. This newer version was installed in five of the project-supported

facilities, with others awaiting deployment in Q3.

Finally, the project successfully worked with mHealth Kenya on the installation of two of their information

and communication technology solutions (Ushauri and mLab) into the KenyaEMR in five project-

supported sites.

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Progress on links with Government of Kenya agencies

During the quarter, Afya Ziwani supported several county and subcounty activities and collaborations, as

presented throughout the above sections of this report. Of note, the project partnered with the MOH to

support service delivery activities at HFs and AGYW safe spaces, including capacity-building activities,

such as trainings, orientations, mentorship, supportive supervision visits, and review meetings. Key

collaborations during the reporting period are noted in Table 74 below.

Table 74. Government ministries and departments that Afya Ziwani collaborated with (FY20 Q2).

Government of Kenya Agency Component Areas of Linkage

Ministry of Health Biomedical

services

• Standards of care and SOPs.

• Distribution of key commodities and supplies.

• Facilitation of trainings.

• TWGs.

• National databases.

• Provision of biomedical outreach and referral services for AGYW.

• Support supervision.

Department of Youth and Gender,

Children Services

Youth Enterprise Development Fund

Social asset

building

• Safe spaces for girls.

• Gender-based TWGs.

• Stakeholder forums.

Ministry of Education, Science and

Technology Education

• Safe spaces.

• School fees.

• Vocational training.

Ministry of Internal Security (Kenya

Police)

Provincial administration

County government

Security and

accountability

• Post-GBV care for AGYW—accountability/legal support.

• Security at safe spaces.

• Bursaries.

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; GBV, gender-based violence; Q, quarter; SOP, standard operating procedure; TWG, technical work group.

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Global development alliance (if applicable)

Not applicable.

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Subsequent quarter’s work plan

Table 75 summarizes the status of the FY20 work plan in Q2.

Table 75. Work plan activities and statuses for increased and expanded high-quality HIV services (FY20 Q2).

Key Planned Activities from Previous Quarter(s)

Actual Status Q2 Explanations for Deviations

Complete subcontracts for 4 LIPs to conduct AGYW activities at 51 wards of 24 subcounties of 3 counties

Successfully completed in Q2 N/A

Develop and submit a revised technical and cost proposal for Afya Ziwani in line with the revised geographic and activity scopes

Successfully completed and submitted in Q2

Co-enroll the 9- to 17-year-old girls with Catholic Relief Services/MWENDO

Only 6,820 girls have been co-enrolled. The performance for the 15 to 17-year-olds was not optimal

The OVC/MWENDO project has 80% of the girls enrolled as 9 to 14 years old.

Support facility mentorship activities by the mentoring teams for ART, PMTCT, HTC, lab, and pharmacy

Fully accomplished in the quarter

N/A

Support facility-based CME for TB/HIV service delivery on a quarterly basis

Fully accomplished in the quarter

N/A

Support the laboratory-networking model (CD4, EID, biochemistries, hematology, and viral load)

Fully accomplished in the quarter

N/A

Optimize the pediatric ART treatment

Transitioned all the children on NVP-based regimen and improved the dolutegravir-based regimen from 8.7% to 14.0%

N/A

Support TB/HIV reporting to meet COP19 quarterly targets

Fully accomplished in the quarter

N/A

Support accelerated ART enrollment and retention activities

Fully accomplished in the quarter

N/A

Expansion of EMRs to an additional 13 sites

Fully implemented, with expansion to 15 sites in Nyamira County for a total of 56 project sites

N/A

Support RDQA for EMRs Fully accomplished in the quarter

N/A

Support facility ART/PMTCT defaulter-tracing mechanisms (diaries, peer educators, airtime, and mobile phone–based reminders) and the revised appointment management system

Fully accomplished in the quarter

N/A

Support facility PLHIV support group monthly meetings (including pediatric, male, adolescent, PMTCT, general CCC)

Not accomplished The budget cuts affected the implementation of these activities

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Support HIV counseling and testing of pregnant mothers and mother-baby pairs at ANC and MCH clinics

Fully accomplished in the quarter N/A

Provide HCW mentorship on elimination of mother-to-child transmission of HIV

Fully accomplished in the quarter N/A

Support nonclinical counselors Fully accomplished in the quarter N/A

Support drug-resistant TB patients to access treatment

Fully accomplished in the quarter N/A

Abbreviations: AGYW, adolescent girls and young women; ANC, antenatal care; ART, antiretroviral therapy; CCC, comprehensive care center; CD4, cluster of differentiation 4; CME, continuing medical education; COP, country operational plan; EID, early infant diagnosis; EMR, electronic medical record; FY, fiscal year; HCW, health care worker; HTC, HIV testing and counseling; LIP, local implementing partner; MCH, maternal and child health; MWENDO, Making Well-informed Efforts to Nurture Disadvantaged Orphans and Vulnerable Children; NVP, nevirapine; N/A, not applicable; PLHIV, people living with HIV; PMTCT, prevention of mother-to-child transmission of HIV; PrEP, pre-exposure prophylaxis; Q, quarter; RDQA, routine data quality assessments; TB, tuberculosis.

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Budget and expenditure details

The project’s total expected costs are US$64,993,553. The current cumulative obligation is at

US$36,847,312. The project’s cumulative expenditure, as presented in Figure 4, is US$33,702,822.

Figure 4 also shows the project’s expenditure status and financial projections.

Source: Project financial records, March 2020.

Abbreviations: FY, fiscal year; Q, quarter.

$33,702,822

$1,543,052 $1,674,070

$8,151,603

$3,402,636

$36,847,312

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

$35,000,000

$40,000,000

CumulativeExpenses (Oct-17

- Mar 20)

FY 20 Q3(ProjectedExpenses)

FY20 Q4(ProjectedExpenses)

FY20budget FY20 (ActualExpenses to Mar

20)

CumulativeObligation

Expenditure Status and Projections

Figure 4. Expenditure status and financial projections (pipeline) in US dollars (FY20 Q2).

65

Actual expenditure and future projections details

Total Expected Costs: US$64,993,553.00

Cumulative Obligation: US$36,847,311.87

Cumulative Expenditure (March 2020):

US$$33,702,821.59

Actual expenditures for the FY, against major budget line items, are presented in Table 76.

Table 76. Actual expenditure details, in US dollars (FY20 Q2).

Line Items Obligation FY20 Q2

(Cumulative Expenditures)

FY20 Q3 (Projected

Expenditures)

FY20 Q4 (Projected

Expenditures)

Personnel $6,330,979.64 $397,981.89 $318,385.51

Consultants $94,724.74 $0.00 $0.00

Travel and transportation

$609,098.93 $39,646.65 $31,717.32

Other direct costs $19,634,520.25 $853,219.68 $682,575.74

Overhead $6,115,131.03 $252,203.70 $201,762.96

Fixed fee $918,367.00 $0.00 $439,628.39

Total $36,847,311.87 $33,702,821.59 $1,543,051.92 $1,674,069.93

Source: Project financial records, March 2020.

Abbreviations: FY, fiscal year; Q, quarter.

Expenditure notes

Table 77. Expenditure notes.

Personnel The project maintained a lean staffing level during the reporting period.

Consultants The project does not anticipate hiring any consultant in the next two quarters.

Travel and

transportation

This has significantly reduced, as the project implements HIV service delivery activities in two counties, Kisumu and Nyamira. A fall in the staffing level has also contributed to the reduction in the travel and transportations costs.

Other direct costs This has reduced significantly, in keeping with the reduced FY20 funding levels. However, the project plans to make direct school and vocational education payments to support AGYW in the next quarter.

Overhead Calculated as per contract terms and conditions.

Fixed fees Earned as per contract terms and conditions. Due to be earned in Q4.

Abbreviations: AGYW, adolescent girls and young women; FY, fiscal year; Q, quarter.

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Activity administration

Personnel There was a change in key personnel during the reporting period, with the Director of Finance and

Administration, Paul Madao, transitioning out of the project. The position was taken up, in acting capacity,

by Terry Opiyo. The project has advertised the open position and plans to fill it in Q3

Contract amendments The project received a fully executed contract modification from the USAID contracting officer on March

13, 2020. This was after submission of a revised technical and cost proposal early in Q2. The

modification expunged the positions of Deputy Chief of Party and Health System Strengthening Advisor

from the key personnel list and introduced revised requirements for the Chief of Party. The project has

commenced the recruitment of the two key personnel positions, the Director of Finance and

Administration and Chief of Party. The contract modification also bore the consent for the two key-

population LIPs, Keeping Alive Societies’ Hope, and Men Against AIDS Youth Group.

Subcontractors The project terminated the subcontract with Kenya Red Cross Society, which had been engaged in FF

programming. No other new engagements were made; however, the project kicked off the internal PATH

process of engaging the two key-population LIPs, which shall sign subcontracts in Q3.

Other significant approval(s) from USAID The contracting office approved Afya Ziwani’s fixed fee submission for FY19 Q4 of a total of US$348,132.

The project also secured an approval for the second six months of the AGYW work plan.

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GPS information

Please see the GPS information sheet in the attachment.

68

Success story: Viral resuppression in a child and an

adolescent in Nyamira County

Case 1: Nyamusi Subcounty Hospital

This is the case of a 9-year-old male, born on May 22, 2012, who was under the care of his stepmother and

father. The child was abandoned by his mother at the age of 1 month after she was diagnosed HIV positive

in the early postnatal period. Both the child’s stepmother and father were HIV negative.

The child was diagnosed HIV infected through antibody testing at 5 years old on May 11, 2017; it was most

likely a case of vertical transmission. He was initiated on treatment on November 15, 2017, on an

efavirenz/abacavir/lamivudine regimen. The child was being brought to the clinic by his stepmother. After

six months of antiretroviral therapy, a routine viral load test on May 22, 2018, showed high copies of 46,291.

Enhanced adherence sessions commenced, including a home visit, to determine any barriers to treatment.

The sessions revealed that the child was left on his own to come to the clinic to pick up his drugs and to

take his drugs. A one-on-one talk between an adherence support counselor and the child revealed that the

child was not taking his drugs since he did not know how to take them, and his stepmother and father could

not support him. In the session, the child’s said, “Mama and Baba tell me: ‘Go away and take your drugs

sick child’’’ (translated from the Abagusii language).

After establishing this lack of positive parenting, the facility decided to fully involve the father in his child’s

treatment. The caregivers shared that they stopped supporting the child to get treatment because of the

following reasons: Stigma was the major issue; the parents did not want to be associated with an HIV-

infected child. Lack of knowledge about HIV/AIDS was the second issue; the parents were worried their

other children would be infected by this child, so they discriminated against him and prevented him from

having any social contact with other members of the household. Other issues included the challenge of

raising an HIV-positive child when the parents were both HIV negative and, for the stepmother, the fact that

she was raising someone else’s child.

In counseling sessions, the father was assured that his child would be in better health if he were on

treatment than if not and that his child would live longer if he adhered well to treatment. The father also was

reminded that the child needed the support of his caregivers to live and do well on treatment. The father

was still resistant, so the Public Health Officer was brought on board to explain to the father the Public

Health Act consequences if he refused to support the child to access and stay on treatment. With this

“threat” and continuous counseling, the father slowly developed positive thinking. He started to follow the

guidance that the providers gave him during the enhanced adherence sessions. He later offered to be a

treatment buddy for the child and invited the child’s stepmother into the counseling sessions to provide

more support to the child.

The father adhered to appointments and every intervention to monitor the child as he took his drugs. A

repeat viral load test on January 4, 2020, showed the child resuppressed, with 184 copies. At the household,

the child was accepted positively and given the chance to associate with the other children without

discrimination. The child was also linked to a program for orphans and vulnerable children for support.

The child is currently doing well on treatment. Partial disclosure has been initiated by the caregiver.

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Lesson learnt: Caregiver literacy classes are key for caregivers to understand HIV/AIDS and their role in

supporting the infected. The facility is in the process of engaging the father as a caregiver mentor to other

caregivers.

Case 2: Kenyoro Health Center

This is the case of an adolescent client, who was born on June 15, 2003. She is 16 years old now. She has

been enrolled on a tenofovir/abacavir/lamivudine regimen for 13 years. Since May 2015, she has been

followed up at Kenyoro Health Center comprehensive care center.

The client had been adhering well to her medication until she attended boarding school. There, she became

afraid to take her medication as advised, so she left some drugs at home. Her viral load results from a

sample collected in June 2019 were 1,814 copies/mL. Since she was in school and defaulted for two

months, enhanced adherence counseling sessions were delayed. The sessions were initiated on November

20, 2019.

The major issue identified as a barrier to treatment was stigma from her peers, which resulted in her

skipping her daily medication at the appropriate time. Facility providers decided to involve one of her

confidants, preferably a teacher to monitor and guide her through her medication while at school. The client

identified the school Deputy Principal, with whom the facility collaborated to conduct directly observed

therapy sessions. The Deputy Principal could call the adolescent at the time that she needed to take her

medication so that she could take them from the Deputy Principal’s office daily. The facility and the Deputy

Principal also ensured that the adolescent had extra drugs in case the Deputy Principal was away from

school. After three months of satisfactory adherence and follow-up with the Deputy Principal by the health

provider, a confirmatory viral load test on February 20, 2020, showed that the adolescent resuppressed,

with 105 copies/mL.

After the client confirmed her HIV-positive status, she decided to be open and to serve as a role model for

the many adolescents who suffer from stigma associated with HIV. She began serving as a mentor and

champion to other adolescent clients in the facility. During an adolescent clinic that was held on April 21,

2020, the client was successful in convincing an adolescent defaulter through a phone call to come for care.

On April 24, 2020, the adolescent who had defaulted since November 2019 came back for treatment. The

client is now a treatment buddy and mentor to the adolescent who defaulted due to disclosure and stigma

issues.

The client, who is now an adolescent champion, has decided to be open and to share her HIV status in her

school and community to support other adolescents who are suffering from stigma.

Lessons learnt: Disclosure and support improve adherence to treatment, especially among children and

adolescents. Giving adolescents the chance to choose their confidant is a plus. In this case study, this built

trust between the adolescent and her confidant; thus, they achieved the Operation Triple Zero initiative

outcomes.