ABSTRACT. In 2015, the Joint United Nations Programme on HIV/AIDS (UNAIDS) published global

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2 ABSTRACT In 2015, the Joint United Nations Programme on HIV/AIDS (UNAIDS) published global rates on HIV/AIDS in its AIDS by the Numbers report. According to the report, it was estimated that 35 million people were living with HIV in 2014, of which 24.7 million (> 70%) were living in Sub-Saharan Africa 1. As one of the total of fifteen countries accounting for 75% of this global estimate, Kenya was categorized as a high burden HIV countries with 5% of its population living with HIV 1. As the case remains that African communities, by far, continue to be the most affected in the world by the HIV/AIDS epidemic, factors such as poverty, poor health care systems, and limited resources for prevention and care contribute to the spread of the virus in the these developing communities. These same factors affect communities in Kenya which already suffers from a high disease burden. In particular, Marsabit County is the largest county in Kenya with a vast landscape and a primarily nomadic population which poses challenges to accessibility to health care. For this reason, efforts such as the services and treatments provided by the Tumaini Medical Centre remain essential to address the inequalities and shortcomings in response to the HIV/AIDS epidemic in developing communities. This paper is a program plan and evaluation of the activities at the Medical Centre as they relate to comprehensive HIV/AIDS treatment and services in Marsabit County. 1

3 Table of Contents INTRODUCTION... 2 Introduction to Tumaini Medical Centre... 2 Rationale for Medical Services in Marsabit County, Kenya... 4 Rationale for HIV/AIDS Services... 7 PROGRAM CONTEXT... 9 Political Context:... 9 Social and Environmental Context: Economic Context: REVIEW OF LITERATURE HIV Care and Treatment Practices at Health Facilities in Kenya PROGRAM OBJECTIVES Main Objectives Short-term objectives: Long-term objectives: Activities to Accomplish Objectives PROGRAM STRUCTURE Program Theory Organizational Structure of Tumaini Medical Centre Clients and Recruitment PROGRAM EVALUATION Evaluation Overview Evaluation Questions CONCLUSION Barriers / Limitations Recommendations Acknowledgements APPENDICES Appendix A. Marsabit Community Leaders Interview Report Appendix B. Global HIV Estimates Appendix C. Kenya MOH Data Collection Registers References

4 LIST OF ABBREVIATIONS AIDS ADS ADSMKE ANOVA ANC ART AZT AZT/3TC BW CCC CDC CHW EID EMR FACES FH FBO GDP HAART HITSystem HIV KAIS MCH MTCT M&E MOH NGO NACC Acquired Immunodeficiency Syndrome Anglican Development Services Anglican Development Services of Mount Kenya East Analysis of Variance Antenatal Care Antiretroviral Therapy Zidovudine Combivir Blood Water Mission Comprehensive Care Clinic Center for Disease Control and Prevention Community Health Workers Early Infant Diagnosis Electronic Medical Record Family AIDS Care and Education Services Food for the Hungry Faith Based Organization Gross Domestic Product Highly Active Anti-Retroviral Therapy HIV Infant Tracking System Human Immunodeficiency Virus Kenya AIDS Indicator Survey Maternal and Child Health Mother to Child Transmission Monitoring and Evaluation Ministry of Health Non-Governmental Organization National AIDS Control Council 3

5 PCR PLWHIV PMTCT USAID TB VCT WHO Polymerase Chain Reaction People living with HIV Prevention of Mother to Child Transmission United States Agency for International Development Tuberculosis Voluntary Counseling and Testing World Health Organization 1

6 INTRODUCTION In 2009, the international relief and development organization Food for the Hungry and grassroots organization Blood:Water (BW) partnered on health programs in Marsabit, Kenya and founded the Tumaini Medical Centre. The partnership between the two organizations established a health center which provides two facets of service: comprehensive care and treatment for HIV/AIDS, and affordable medical services for the general population in Marsabit. Seven years from its launch, an appraisal of the continued support of HIV/AIDS services at the Medical Centre is upcoming. This paper focuses on an evaluation of the activities at the Medical Centre as they relate to comprehensive HIV/AIDS treatment by examining: 1) the services provided, 2) the process of implementation of services, and 3) the impact of services in the targeted population. Sustainability of these activities beyond funding is discussed in recommendations. Introduction to Tumaini Medical Centre Food for the Hungry (FH) was founded in 1971 with a focus on servicing disadvantaged communities globally. This organization sponsors child development programs, agriculture and clean water projects, health and nutrition programs, and education and micro-enterprise loans in efforts to address both short and long term development of impoverished communities within which it operates. The FH-Kenya office was established in 1976 in response to the drought in Kenya s semi-arid rural communities 2. FH provided emergency relief support in the Marsabit District throughout the drought period and remained in Kenya in sponsorship of various relief and development programs within the country 3. In 2008, FH-Kenya partnered 2

7 with BW to undertake clean water projects in the Marsabit District 4. This partnership later led to the establishment of the Tumaini Medical Centre. BW s structural approach in the partnership was to provide technical, financial, and organizational support to the development and maintenance of the Medical Centre 5. The contracted period of BW s partnership with FH, in support of the Tumaini Medical Centre, was for seven years. In such, the sponsorship of BW for the evaluation of the activities at the Medical Centre align with the imminent appraisal of their continued sponsorship of the Medical Centre. Through alignment with FH, the Medical Centre became financially and operationally supported by the non-governmental organization (NGO), The Anglican Development Services of Mount Kenya East (ADSMKE). ADSMKE programs focus on sustainable food production and security, community based health care services, environmental conservation, social welfare and economic activities, and community development education and relief services 6. ADSMKE has a prominent presence in Kenya, covering approximately 34% of the land area in the country and operating strategically through its extension stations. The Marsabit region has three ADSMKE services stations: in Isiolo, Marsabit, and Sololo 7. Although the Tumaini Medical Centre is based in the Marsabit service station, this partnership with ADSMKE has led to the expansion of the Medical Centre through the establishment of a satellite site in Isiolo. The main objective of the Tumaini Medical Centre is to improve the health of people living with HIV (PLWHIV) in the Marsabit district by increasing their access to comprehensive HIV/AIDS care and treatment. Additional efforts include increasing the effectiveness of clinic services at the medical center and maximizing access to affordable medical services for the general population. To accomplish this, the Medical Centre offers onsite laboratory, pharmacy, 3

8 and voluntary HIV counseling and testing services that are supported and funded by ADSMKE, the United States Center for Disease Control and Prevention (CDC), the United States Agency for International Development (USAID), the Kenyan Ministry of Health (MOH), and Global Fund. More specifically, Anglican Development Service (ADS) and FH support funding for the facility and clinic and also staff resources. BW, alongside the CDC, USAID, the MOH, and Global Fund, support funding for antiretroviral treatments, clinic equipment, voluntary counseling and testing (VCT) services, community outreaches, comprehensive care clinic (CCC) treatments, and condoms supplies. Additional CCC services at the center are funded through revenue from patients payments. Rationale for Medical Services in Marsabit County, Kenya The revised Constitution of Kenya, enacted on 27 August 2010, established a new system of governance through which the country was divided into 47 counties, each with its own devolved government. Marsabit County is the largest county in Kenya, covering 70,961 square kilometers and bordering Ethiopia to the north (see Figure 1. Kenya County Map). Within its geographical region, Marsabit is comprised of four constituencies: North Horr, Laisamis, Saku, and Moyale. The ethnic communities within these constituencies include the Rendille, Gabbra, Borana, and Turkana. In 2013, the World Bank estimated the total population in Kenya to be 41.8 million, of which the estimated total population in Marsabit County was 306, In 2013, the gross domestic product (GDP) per capita was 1, USD 9 and approximately 46% of the Kenyan population lived below poverty line 10. In contrast, the 4

9 poverty headcount in Marsabit County in 2014 was almost double the national average, at 80% 11. An estimated total of 26% of those living in Marsabit County only have a primary level of education 12. Furthermore, approximately 68% of those living in the county have no formal education 12. Within the county, only 38% of residents have access to improved sources of water which comprise protected springs and wells, boreholes, and, piped and rain water collection 12. A total of 27% of the population in Marsabit use improved sanitation 12. In 2014, the number of health institutions in Marsabit County which includes hospitals, health centers, maternity & nursing homes, medical clinics & VCT centers owned by government, private sector, NGOs and faith-based organizations (FBOs), totaled Of this, there are only two major district hospitals in the county, Marsabit District Hospital and Moyale District Hospital. From an interview with community leaders within Marsabit County, the vast landscape and the primarily nomadic population of the county pose challenges to accessibility to health care (Appendix A). Additionally, unaffordable cost of services as well as a lack of confidentiality of PLWHIV were both cited as concerns with the accessibility and treatment at district hospitals. Further, it was noted that many of the health centers in the county lack adequate funding for staffing, treatments, and equipment. 5

10 Figure 1. Kenya County Map 14 6

11 Rationale for HIV/AIDS Services The global response to the HIV/AIDS epidemic has celebrated some successes in the recent years. The global rates published in the 2015 UNAIDS report, AIDS by the Numbers, show a decrease of 35% since 2000 in new HIV infections and a 42% decline in AIDS-related deaths since The report also indicates that by 2014 the global coverage of people receiving antiretroviral therapy (ART) had reached 40% and as of June 2015, 15.8 million people affected by HIV were accessing treatment 15. These successes, however, have also highlighted inequalities in the global battle against HIV/AIDS and significant gaps and shortcomings in response, particularly in developing countries. Tables 1, 2, and 3, listed in Appendix B, detail the geographical distribution of estimated global rates of people living with HIV, new HIV infections, and AIDS related death in all age groups, respectively from 2011 to It is estimated that of the 35 million people living with HIV, 24.7 million (> 70%) live in Sub-Saharan Africa 1. Furthermore, of the fifteen countries accounting for 75% of this global estimate, Kenya was categorized as one of these high burden HIV countries, with 5% of its population living with HIV 1. The disease burden in Kenya has also been associated with an estimated 20% of maternal mortality, 15% of deaths in children under five years of age, and 29% of annual adult deaths in the country in As the case remains that African communities, by far, continue to be the most affected in the world by the HIV/AIDS epidemic, factors such as poverty, poor health care systems, and limited resources for prevention and care contribute to the spread of the virus in the these developing communities. These same factors affect communities in Kenya which already suffers from a high disease burden. Therefore, efforts such as the services and treatments provided by 7

12 the Tumaini Medical Centre remain essential to address these inequalities and shortcomings in the global response to the HIV/AIDS epidemic in developing communities. In its own race to curb HIV/AIDS rates and comorbidities in the country, Kenya has enlisted many initiatives and programs. One of these programs is the Kenyan National AIDS Control Council (NACC) which provides a strategic framework for mobilizing and coordinating resources to address the HIV/AIDS burden in the country. In alignment with this effort, in 2015 the NACC published its second edition of the HIV County Profiles. The document provides data based on 2014 HIV estimates in the country and the estimated HIV burden in Marsabit county including: Overall prevalence of HIV in adult in the county was 1.2%; Prevalence of infections was higher in women (1.6%) than that of men (0.7%); Estimated number of adults living with HIV was 1,500; Estimated number of children living with HIV was 229; and, Estimated number of pregnant women living with HIV was 120. Additionally, the first experience of sexual intercourse before the age of 15 was approximately 55% of the population and the annual ART coverage in adults and children was estimated at 86% and 57%, respectively. The NACC identified HIV counseling and testing, linkage to care, and treatment as critical measures to disease reduction in Marsabit County. Lastly to further note, as Tuberculosis (TB) is a priority communicable disease in Kenya, there is rationale to also enhance HIV/AIDS services to address these opportunistic infections, particularly in PLWHIV. In its 2014 annual report, the National Tuberculosis, Leprosy, and Lung Disease Program within the Kenyan Ministry of Health reported a total of 672 cases of TB in Marsabit County with 8

13 73.7% of cases reported from the public sector and 26.3% from the private sector 11. Of the reported 672 cases, 11.3% were in children 11. Additionally, the TB/HIV co-infection rate was estimated at 9% for the year Enhancement in services to also address TB could aid to reduce TB incidence and mortality and morbidity associated with the disease. PROGRAM CONTEXT The Tumaini Medical Centre was designed as a program that addresses the health needs of the disadvantaged population in Marsabit County. Therefore, the center offers HIV/AIDS testing and care services coupled with comprehensive health care. Factors influencing health services delivery in Marsabit County not only include local beliefs and behavior towards HIV/AIDS but also political, social, and economic factors. Political Context: In August 2010, the Republic of Kenya became a multi-party democratic state that is divided into two levels of government: the national government and the county government. This subsequently established the current 47 devolved county governments in Kenya. The county government is comprised of a County Governor, a Deputy Governor, and the Public Service Committees 17. Though the national and county governments are distinct, they remain inter-dependent. Since the establishment of the county government, Marsabit County has experienced positive notable changes including: an increase in boreholes, increase in farming equipment available in the county, improvements to resources available to government operated medical centers, and the provisions of ambulances. In such, this devolved government has provided opportunities for improvement in the lives of community members in Marsabit. 9

14 As a center providing comprehensive HIV treatment and care, Tumaini Medical Centre partners with government centers and the district hospitals for referrals and to ensure a cascade of care for PLWHIV in the county. The increased resources to the county s health institutions allow improvements to undertake an integrated approach to care. An example of this can be seen in the reporting structure for HIV related care and the follow-up conducted. Tumaini Medical Centre follows Kenya s MOH reporting structure. The patient health data collected at the Medical Centre is reported via various reporting tools and registers, (see Appendix C), which are provided by the county government and are monitored monthly by a county health advisor. Increased resources to the county health department has meant an increase in monitoring of the reported data and collaborative discussions of care of PLWHIV in the county, as well as improvements to follow-up care for those at the Medical Centre and the District Hospital. In addition to the establishment of county governments, under Article 27 of the new Constitution, discrimination on the basis of one s health status is outlawed. This also provides equality between men and women and allows the use of affirmative action to address past discriminations. Furthermore, Kenya s HIV and AIDS Prevention and Control ACT of 2006 provides a legal framework for the protection and promotion of public health and for the provision of appropriate treatment, counseling, support, and care of PLWHIV or at risk of HIV infection. Section 25 of the ACT, also established the HIV and AIDS Tribunal of Kenya which adjudicates cases relating to violation of HIV-related human rights 18. The seven-member Tribunal is the first of its kind globally and has jurisdiction to hear and determine complaints from Kenyans who are facing stigma, discrimination or criminalization based on their HIV 10

15 status 19. The political context surrounding HIV care in Kenya is beneficial for the success of the Tumaini Medical Centre. Social and Environmental Context: As indicated within the previous section, legal measures have been implemented to address Kenya s battle with stigma and discrimination related to HIV/AIDS within the country and its population. According to the 2013 Kenya Stigma Index Survey, stigma and discrimination was reported by more than 45% of the Kenyan population, and an estimated 15% of PLWHIV reported discrimination by a health professional through disclosure of their HIV status without consent 20. This discrimination also permeates the families of PLWHIV, their communities, and the structures and institutions in which they may be employed or seek services. National data also shows that women living with HIV face greater discrimination or a higher level of stigma compared to men; 4.9% versus 2.7% 20. Sexual behavior and gender violence also burdens the country. Approximately, 33% of girls and 17% of boys in Kenya have reported at least one incident of rape by the age of 18 and approximately 22% of girls reported their first experience of sexual intercourse as being forced 20. In a discussion with community leaders within Marsabit County on community members behavior towards PLWHIV, increased stigma and discrimination from family members upon serostatus disclosure was reported. These factors have caused many community members living with HIV to not seek care or disclose their status in fear of negative response and/or discrimination. National averages indicate that individuals who are experiencing stigma are more than four times more likely to also report poor access to care

16 Environmental factors contributing to poor access to care in Marsabit include the vast landscape of the area and poor transportation reliability. Marsabit is accessible by road, however due to the poor condition of the roads, ground transportation is limited to 4 by 4 vehicles during the dry season and bus servicing the neighboring county, Isiolo, and further restricted during wet seasons due to exacerbated road conditions. This limited access to the county impacts transportation of resources such as water and medical supplies to the Medical Centre. For example, the Tumaini Medical Centre currently has access to water via a L water tank installed at the Medical Centre. However, water supply for the tank is delivered from Nairobi, Kenya, a journey of at least 12 hours via ground transportation. Poor road conditions may delay the arrival of water resupply. Pharmacy supplies for the Medical Centre are generally delivered via air travel. Marsabit has two airstrips, servicing charter aircraft. Supplies are transported from the FH-Kenya Nairobi office to the Medical Center. However, even this mode of travel is also dependent on the weather in the area; due to its high cost, air transport is generally not used except by NGOs and government officials traveling to and from the area. Economic Context: The economic backbone of Marsabit County is its livestock 21. However, the poor infrastructure in the county, particularly, the roads and transportation options, have diminished the potential marketability of the region. This in turn has limited the ability of community members to access health facilities. The county could see improvements in transportation conditions and standard of living soon, due to many long-term projects already underway and those scheduled to start in the near future in Marsabit. One such major project that will affect 12

17 Marsabit is the Lake Turkana Wind Power Project (LTWP) which aims to provide 310 megawatts of reliable, low cost wind power to the Kenya national grid, equivalent to approximately 20% of the current installed electricity generating capacity. Such an investment will not only benefit the residents of Marsabit County but also improve the infrastructure which is one the main barriers to accessing and providing continuous health care 21,22. REVIEW OF LITERATURE Factors influencing the delivery of HIV/AIDS health services in Marsabit County include the globalized strategic approach to health services targeting those that are at-risk of the disease, communities in high HIV burden countries, and PLWHIV. This approach is published in the consolidated guidelines on HIV/AIDS testing services and treatments released by WHO and UNICEF. As Tumaini Medical Centre has incorporated these guidelines within its health services program to address the disease burden in Marsabit County, the following literature review will focus on the uptake of these guidelines at health centers in Kenya, the challenges faced, and the impact of the services on these respective communities HIV rates. There were two keys questions that were addressed in the literature review. Both focused on the generalized topic of practices of HIV care and treatment at health facilities. The evaluation of the Tumaini Medical Centre will focus on the services provided, their effectiveness, and challenges. In addition, based on the higher incidence of HIV infections in women versus men in Marsabit, the literature focused on women interventions. 13

18 HIV Care and Treatment Practices at Health Facilities in Kenya I. Key Question What are factors influencing the implementation of HIV/AIDS Screening and Treatment guidelines in Kenya? Search Strategy PubMed online archives was searched with the terms HIV AND Screening AND Guidelines AND Kenya. This initial search yielded forty-two results, two of which were found relevant to the key question after review of abstracts. PubMed was also searched with the terms HIV AND Treatment AND Guidelines and Kenya. This initial search yielded one hundred and seven entries, two of which were found relevant to the key question after review of the abstracts and one was a duplicate. After pulling and reviewing the articles, a final set of two articles from both searches were included in this section of the literature review. Articles Overview & Appraisal Article 1 Finocchoario-Kessler, Clark, Khamadi, Guatney, et al. Progress Toward Eliminating Mother to Child Transmission of HIV in Kenya: Review of Treatment Guidelines Uptake and Pediatric Transmission at Four Government Hospitals Between 2010 and The article outlined and discussed the results of an analysis of data reviewed from 1,365 HIV+ mothers at four government hospitals in Kenya: two district hospitals in Western Kenya and two urban Nairobi health facilities (one high volume facility and one referral maternity hospital). The hospitals were chosen based on ongoing implementation of HITSystem intervention during the review period. The four hospitals within the article were piloting the 14

19 online intervention between April 2011 and December The participants were chosen as they enrolled their HIV-exposed infants in early infant diagnosis (EID) services at the selected hospitals. At the time of the review, the WHO prevention of mother to child transmission (PMTCT) guidelines were as follow: WHO PMTCT Guidelines Option A: Antepartum: AZT starting as early as 14 weeks gestation. Intrapartum: At onset of labor, sdnvp and first of AZT/3TC Postpartum: Daily AZT/3TC through 7 days postpartum OR Option B: Triple ARTs starting as early as 14 weeks gestation and continued intrapartum and through childbirth if not breastfeeding or until 1 week after cessation of all breastfeeding. OR Option B+: Regardless of CD4 count, triple ARVs starting as soon as diagnosed, continued for life. The article examined the trends in administration of each regimen type and also the timing of treatment initiation. The results from the study illustrated a trend towards earlier administration of ART PMTCT regimens at the hospitals, and late PMTCT implementation was high when averaged across the four hospitals. The authors noted statistically significant improvements between 2010 and 2012 and pediatric HIV transmission was shown to decrease across the four hospitals between 2010 and To note, there are limitations to the study results and that must be taken into consideration when evaluating the results that includes the gap between initial 15

20 administration of a PMTCT regimen and what occurs before, during, and after child delivery. Additional details are shown in Table 4. Article 2 Onono, Owuor, Turan, Bukusi, et al. The Role of Maternal, Health System, and Psychological Factors in Prevention of Mother-to-Child Transmission Failure in the Era of Programmatic Scale Up in Western Kenya: A Case Control Study. The article outlines a case control study that was conducted across 31 MOH facilities in Western Kenya, specifically Migori, Kisumu, and Homabay counties. The study setting included facility based HIV registers, hospital and laboratory surveillance systems, and locator information and systems for tracing of HIV+ pregnant mothers and their infants. Inclusion criteria for study participation included: (1) have attended antenatal clinic at least once and tested HIV+ during the antenatal clinic visit at any of the 31 participating health facilities, (2) have an infant with a definitive diagnosis (positive or negative) via polymerase chain reaction (PCR) test, who is between 6 weeks to 6 months old, (3) mothers at least 18 years old, and (4) able and willing to give written informed consent. Controls in the study were defined as HIVinfected mothers of infants aged 6 weeks to 6 months with an HIV negative test result in the infant; cases were defined HIV-infected mothers of infants aged 6 weeks to 6 months with a definitive diagnosis of HIV in the infant. Infant diagnosis must have been known between November 2012 and June Study procedures included interviewer-administered questionnaires covering (1) knowledge and attitudes about the benefits of PMTCT interventions, (2), status disclosure, (3), accessibility 16

21 to a healthcare facility, (4), perceptions of health care facility, (5) information provided by the health care providers during clinic visit, (6) cultural and religious beliefs and traditions in health seeking behavior, and (7) perception of outcome of HIV-infected infants. HIV related stigma and partner related stigma was also evaluated through the questionnaires. The study also reviewed additional data from prenatal, labor, and delivery records, maternal HIV records, laboratory reports, and home visit records, and guidance compliance by providers based on what was documented in medical charts of the study participants and multiple medical registers at each facility. The study sample size was estimated based on historical data from the FACES PMTCT program. The resulting sample size was 200 with a case to control ratio of 1:3. The study results indicated that newly diagnosed mothers, during the course of pregnancy, were at increased odds of MTCT. Non-adherence to maternal ART for prophylaxis and lack of ART treatment intake by infants were associated with increased odds of MTCT. Interestingly, the study results, which differed from prior studies, indicated that stigma and other psychological factors did not increase odds of MTCT. Factors often associated with MTCT have however included personal and economic reasons as well as stigma, lack of disclosure, cultural factors, lack of accurate health information, lack of social support, side effects of ARTs, and overcrowded health systems. In terms of health facility related factors, the results indicated weaknesses within the health system: delay in initiation of ART regimen and health care providers not following guidelines for prescription of ART for mothers and infant; factors also associated with increased odds of MTCT. Recommended improvements to these weaknesses were cited as (1) increased autonomy over resources at lower level facilities, (2) linkage between performance 17

22 management interventions and facility wide human resources management, (3) development of accountability systems for health workers and managers responsibilities, and, (4) cultivation of supportive relationship between health systems and women participants. The strength of the study results is that mothers self-reports could be corroborated with information from routine data review at the health facilities. Limitations to these results are also provided in Table 4. Table 4. Question 1 Articles Overview Author(s) Study Design & Methods Outcomes Measured Limitation of Evidence Clinical based sample of mothers engaged in EID may not be representative of higher-risk mothers Retrospective cohort and infants most vulnerable to HIV analysis at four Providers adherence transmission government hospitals to WHO PMTCT Recorded data by healthcare between April 2011 and guidelines rates providers may not an accurate December 2012 reflection of treatment taken by Finocchoario- participating mothers Kessler, Clark, Trends in PMTCT Reported data is limited to HIV Khamadi, Guatney, Maternal and infant data administration infected mothers who presented for et al. collection through EID with their infants HITSystem or EID Registry Data is limited to medical chart review Pediatric HIV for mothers receiving ANC at same transmission rates and hospital where they sought treatment Verbal informed consent predictors Data is limited to completeness and of participants accuracy of clinical records and PMTCT registries Demographic variables were limited to only entered data in HITSystem 18

23 Onono, Owuor, Turan, Bukusi, et al. Matched case control study Administration of questionnaires Review of medical registers and charts of study cases and controls Individual, sociocultural, and health system factors contributing to PMTCT failure Evaluation of guideline compliance by providers Infant HIV infections may have been missed due to variance in time period of measurement of infant HIV status Over/Under reporting of treatment taken or given to infants by participating mothers II. Key Question: What are factors influencing the implementation of HIV/AIDS Prevention Guidelines in Kenya? Search Strategy PubMed online archives was searched with the terms HIV AND Prevention AND Guidelines AND Kenya. This initial search yielded seventy-four results, four of which were found relevant after review of abstracts; two were duplicates from question 1 search results. After excluding these duplicates, a final set of two articles were included in this section of the literature review. Articles Overview & Appraisal Article 1 Odeny, Newman, Bukusi, McCelland, et al. Developing Content for a mhealth Intervention to Promote PostPartum Retention in Prevention of Mother-to-Child HIV Transmission Programs and Early Infant Diagnosis of HIV: A Qualitative Study The article evaluates a qualitative study conducted on a mobile phone text message intervention in the Nyanza region of Kenya among pregnant women. Participants in the study were patients or referred patients from providers at health facilities supported by Family AIDS 19

24 Care and Education Services. These facilities offer PMTCTC services and testing for infant HIV infection. Health workers were recruited from MCH clinics. Recruitment was conducted through purposive sampling for five focus groups which would be representative of potential recipients of text messages and the health workers that they would routinely interact. There were between eight and ten participants in the following four focus groups: health workers from MCH clinics; women attending antenatal clinics; women attending postnatal clinics; women enrolled in PMTCTC programs. In the fifth focus group, there were eight women representing the other four focus groups. Four clinic staff members were also recruited to participate in cognitive interviews; they would represent clinical and community health service providers with experience working in the study design. There were a total of 41 participants. Group discussions were held in the primary languages of the region: English, Kiswahili, and Dhuluo. Participants verbally consented to the study, were assigned identification numbers in place of their real names, and informed that all discussions would be confidential. The discussion topics were formed from the Health Belief Model construct and included (1) perceived susceptibility, (2) perceived severity, (3) perceive benefits, and (4) perceived barriers. A final discussion topic addressed cues to action and self-efficacy. Participants were also given the opportunity to offer ideas, besides sending messages at the close of each discussion. Audio recordings from the discussions were transcribed and translated to English. A team of content experts which included a behavioral scientist and two physician-epidemiologists with experience in test messaging interventions for HIV prevention and expertise in the fields of HIV prevention and treatment categorized the discussion recordings in themes and sub-themes which were subsequently used to develop the focused text messages. The draft text messages 20

25 were pre-tested with a follow-up focus group. A second pre-testing was also completed through individual cognitive interviews after development of messages from the follow-up focus group. The participants in the second pretest included experts with backgrounds as a community liaison, an HIV experience nurse, a local social scientist, and a community mobilizer/community health worker (CHW). The resulting messages from the second round of pretest were then refined and finalized by the initial team of content experts. The discussion groups highlighted fears of being forced to disclose status if attending clinics for delivery or postpartum visits, a false perception of HIV prognosis, and a fear of the mental and emotional burden of knowing your child s HIV+ positive within the community. Perceived barriers to clinic attendance included cost of transport, religious beliefs, fear of HIV testing, lack of information, cost of treatment, lack of information/knowledge of importance of antenatal, delivery, and postpartum care; and, clinic wait time. Perceived barriers to health systems included poor communication between patients and healthcare workers, lack of compassion, and unfriendly and discouraging staff interaction. Some of the perceived benefits to clinic attendance were immunization and testing for infants, nutritional counseling, and maternal health assessments such as exclusive breastfeeding to minimize HIV transmission. In soliciting cues to actions, participants voiced enhancement of self-efficacy and knowledge of patients; involvement and education of partners in retention and support of mothers; collaboration between clinic workers and traditional birth attendants; positive reinforcement during communication and education; and, a need for greater time window in scheduling follow-up visits. 21

26 The study design and focus on mobile phone text message interventions is supported by the literature highlighting the benefits and improve of adherence to ARTs through these interventions. Nonetheless, the study had several limitations which are outlined in Table 5. Article 2 Olluoch, Kwaro, Sempijia, Katana, et al. Better Adherence to Pre-Antiretroviral Therapy Guidelines after Implementing an Electronic Medical Record System in Rural Kenyan HIV Clinics: A Multicenter Pre-Post Study The article discusses a multicenter retrospective study comparing quality of care indicators before and after the introduction of an electronic medical record (EMR) system at 17 health facilities providing HIV care and treatment services in the Nyanza province of Western Kenya. The benefits associated with the integration of EMR systems in delivering quality health care for chronic illnesses have been shown through various studies. This study assesses the effect of change when facilities change from paper based to an electronic based medical record system by evaluating CD4 testing in HIV-infected persons in their pre-art care period. The Pre-ART care period is regarded as the period between a confirming HIV-positive test (generally secondary testing) and eligibility for ART initiation based on Kenyan ART guidelines. This care is offered at no cost to patients in Sub-Saharan African countries; during this period, a range of treatments and services are provided. Of key note is the CD4 cell count and viral load measurements completed during this period are important indicators of the degree of immunosuppression and prognosis for those starting ARTs, respectively. 22

27 The facilities were selected based on adequate electricity and security for computers. The clinics, in total, had a patient population of approximately 39,203 active patients receiving HIV care and treatment as of September The facilities were categorized as follow: four district hospitals providing both inpatient and outpatient services, eleven health centers headed by a clinical officer (equivalent of a physician assistant), and two dispensaries that provide limited outpatient services and are headed by a nurse. The EMR system installed at the facilities was developed in 2007 and is called the Comprehensive Care Center Patient Application Database (C-PAD). Mandatory variables in the system are demographic data, vital signs, medication, and key laboratory measurements. Data entry take approximately 10 minutes and about 5 minutes to update records at follow-up visits. Pre-EMR data was generated from the MOH257 registry, completed at the facilities, and entered retrospectively for all patients who initiated HIV care pre-emr system installation. This data was compared to the electronic data captured for the patients who enrolled in HIV care post-emr. The data evaluated was time from enrollment into HIV care to the baseline CD4 testing and time from the first to the second CD4 test. The standard practice for follow-up CD4 testing is every 6 months. The study results indicated an association between EMR use with improved adherence to pre-art care guidelines. The average time between first and second CD4 testing was found to be closer to the recommended practice of 6 months when using EMR compared to paper system. A key strength to the study was the number of facilities included and the standardized guidelines and EMR system utilized by all facilities. Limitations to the study design and analysis are outlined in Table 5. 23

28 Table 5. Question 2 Articles Overview Author Study Design & Methods Outcome Measured Limitation of Evidence Passive recruitment of participants Selection bias as participants selected where women present at the clinic Perceived and in favor of participating in group Odeny, Newman, Qualitative study susceptibility activities Bukusi, McCelland, Focused group discussions Perceived severity Exclusion of men who could have et al. Perceived benefits provided professional and personal Perceived barriers. perceptions Lack of consensus on frequency of text messages EMRs are fully used at point of care due to infrastructure problems Patient records were an enrolment date or CD4 dates was not entered Olluoch, Kwaro, Ssempijia, Katana, et al. Retrospective study CD4 testing in HIVinfected persons were excluded Approximately 60% of patients did not have a CD4 test result record Cause and effect relationship between EMR use and outcome variables could not be determined Selection bias in health facilities Applicability to Tumaini Medical Centre: Many of the perceived barriers and highlighted factors influencing uptake and adherence to treatments, MTCT, and retention are similar between the facilities and regions highlighted in the literature review and the Tumaini Medical Centre. Although the staff at Tumaini Medical Centre is reputable in Marsabit for their compassion and relationships with 24

29 clients, patient barriers to clinic attendance and retention also included: cost of transport, religious beliefs, fear of HIV testing, fear of disclosure, cultural factors, distance from the center, lack of information/knowledge of importance of care, clinic wait time, etc. In addition to these barriers, the location of the Tumaini Medical Centre in Marsabit adds a strain to the resourcing of staff due to its location. Many of those employed at the clinic are not from the Marsabit region and therefore leave family behind for employment. This has left the center with a high turnover rate as clinic staff find opportunities closer to their family. The recommendations and improvements found within the literature are applicable to Tumaini Medical Centre in addressing its barriers to increased and continued HIV care and treatment. Of particular note is the recommendation for increased autonomy over resources. It may be possible that because various stakeholders are involved in the funding and operations at the Medical Centre, a breakdown in communication between stakeholders as well as between stakeholders and on-the-ground staff influences staff empowerment and accountability of responsibilities. The articles were also selected for inclusion and pertinence to the evaluation of services at Tumaini Medical Centre, as they touch on facets of services, such as EMRs and text message follow-up interventions that are currently implemented at Tumaini Medical Centre. A review of the effectiveness of such interventions at similar facilities thus seemed merited. 25

30 PROGRAM OBJECTIVES The primary goal of the Tumaini Medical Centre is to improve health of PLWHIV in Marsabit County, Kenya by increasing access to comprehensive care (testing & counseling) and treatment, increasing the effectiveness of clinic services at the Medical Centre, and maximizing access to affordable medical services for the general population. Main Objectives Improve HIV/AIDS & sexual health knowledge to decrease stigma related to disease and encourage lifestyle changes among community members living in Marsabit County. Improve clinic services to increase enrolment and retention at the Medical Centre. Improve access to care in the community surrounding Tumaini Medical Centre by involving community leaders and community health workers and strengthening the referral system. Short-term objectives: Within one year, Tumaini Medical Centre staff will increase the number of community members that have been tested and are aware of HIV status in Marsabit. Strategy: Reach a target number of 2000 individuals living in Marsabit County through HIV counseling and testing sessions conducted during community outreach programs and medical campaigns. 26

31 Reach a target number of 500 pregnant women living in Marsabit County through HIV counseling and testing sessions conducted during community outreach programs and medical campaigns. Within one year, Tumaini Medical Centre staff will improve immunity of HIV /AIDS clients (inclusive of pediatrics) through enrolment of positively tested individuals on ARTs. Strategy: Enroll a target of 100 new clients to receive ARTs according to national/international guidelines. Provide complete course of ART prophylaxis to at least 50 pregnant women with collaboration of CHWs for treatment adherence follow-up. Train at least 10 new CHWs to deliver ART series according to national/international guidelines and deliver HIV related palliative care including Tuberculosis (TB)/HIV services. Conduct CD4 test for enrolled clients, according to national/international guidelines, to monitor ART treatment and HIV immunity. Within one year, Tumaini Medical Centre will improve symptom management and psychological health of HIV/AIDS clients after Highly Active Anti-Retroviral Therapy (HAART) initiation. Strategy: Provide general HIV related palliative care (including TB) to at least 500 individuals through coordination with CHWs. Conduct CD4 test for new clients and after every 6 months for enrolled clients. 27

32 Provide registered HIV clients with HIV counseling, psychosocial support, and care coordination at follow-up visits with onsite social worker. Within one year, Tumaini Medical Centre staff will reduce opportunistic infections of TB in patient population at the Medical Centre by 50%. Strategy: Screen at least 500 HIV positive clients for TB and initiate treatment/prophylaxis, as needed for all TB infected clients. Establish a baseline value of HIV positive clients with TB infection through screenings and continue to monitor cases. Provide registered TB clients with mental health and disease counseling. Within one year, Tumaini Medical Centre staff will increase the reported use of condoms in the catchment area by at least 30%. Strategy: Establish a baseline value for use of condoms in the catchment area by conducting interview during community outreach programs, medical campaigns, and Medical Centre clinic visits. Provide condom use counseling during clinic visits and include discussion session in community outreach programs and medical campaigns. Establish a target of 50 condom service outlets or dispensing sites inclusive of local convenience stores, local pharmacies and laboratory clinics, and markets with the assistance of CHWs. 28

33 Long-term objectives: Within five years, Tumaini Medical Centre will observe measurable changes in HIV knowledge and stigma among community members in Marsabit. Strategy: Tumaini Medical Centre staff will partner with community leaders quarterly to lead discussion on HIV and HIV related stigma in the community. Establish a baseline value for number of reported cases of negative response and/or discrimination during serostatus disclosure and in healthcare setting in catchment area through clinic counseling sessions, outreach programs, and medical campaigns; and, continue to monitor number of reported cases. Provide voluntary HIV/AIDS health surveys at Medical Centre, outreach programs, and medical campaigns. Tumaini Medical Centre stakeholders will continue to use measurable indicators and health education training. Within five years, Tumaini Medical Centre will observe measurable improvements in health seeking behavior (initiation of treatment/care and/or counseling; request for assistance in disclosure; and/or compliance to follow-up clinic/counseling visits at the medical centre) among PLWHIV in Marsabit. Strategy: Provide CHWs with training and tools to host monthly discussions within their respective catchment areas addressing fear of testing, fear of disclosure, HIV/AIDS prevention, transmission, and treatment/care. 29

34 CHWs and Tumaini Medical Centre will continue to report monthly on number of clients who have initiated or sought out treatment/care, assistance in disclosure, and/or counseling in their respective catchment areas. Recruit and train at least 5 new CHWs from remote location of Marsabit County. Tumaini Medical Centre staff will lead quarterly discussions with CHWs examining barriers to improved health seeking behaviors to compare with current barriers to examine trends. Tumaini Medical Centre stakeholders will annually measure number of clients that have initiated care or counseling and number of clients who remain in follow-up care at the centre; stakeholders will evaluate barriers to access to care (i.e.: accessibility, clinic wait time, cost) and implement at least one measure to address identified barriers. Activities to Accomplish Objectives To achieve these objectives, several key activities must be implemented. The following outlines these recommended activities: Conduct community outreach programs with incorporated counseling & testing. Conduct monthly follow-up of clients. Coordinate monthly with County hospital, Anglican Church, county government, and local clinics to integrate local infrastructure in medical campaigns and community outreaches. Conduct at least four CHWs training workshops. 30

35 Conduct at least four discussion sessions annually between clinic staff and community leaders to examine community HIV knowledge and HIV related stigma. Coordinate condom distribution at service outlets and dispensing sites in the community. Conduct mobile medical campaign with screening/testing and counseling in surrounding communities of Marsabit County. Request access to 4x4 vehicle from Nairobi office and coordinate use/availability with planned mobile medical campaign. Develop CHWs training material and reporting tools. Develop HIV/AIDS curriculum, following national guidelines, for training sessions and community leader discussion sessions (topics include: testing and counseling; prevention of sexual transmission; care/treatment; HIV & TB; stigma/discrimination) Develop HIV/AIDS health surveys Meet with local community leaders to improve referral system and measure continuity of care. Train CHW on HIV opportunistic infections and to deliver HIV related care including TB screening. Train CHW to deliver ART services according to national/international guidelines. 31

36 People Table 6. Tumaini Medical Centre Logic Model INPUTS OUTPUTS OUTCOMES IMPACT Activities Outputs Short-term Objectives HIV Program Manager Clinic Officer Clinic Data Officer Clinic Social Worker Clinic Patient Community Leaders CHWs Organizational Tumaini Medical Centre Stakeholders Local clinics County government Funding Staffing Develop CHWs trainings and reporting tools Develop HIV/AIDS curriculum Develop HIV/AIDS health surveys Clinic staff will conduct at least four CHWs training workshops Train CHWs on delivery of ART series Train CHWs on delivery of HIV related palliative care including TB/HIV services Clinic staff facilitate quarterly workshops with community leaders Finalized training curriculum, materials, and tools. CHWs trained on delivery of ART series and HIV related palliative care including TB/HIV services Workshops conducted for CHWs Workshops conducted for community leaders Increase number of community member tested and aware of HIV status in Marsabit Improve immunity of HIV/AIDS clients Improve symptoms management and psychological health of HIV/AIDS clients after HAART initiation Improved health of PLWHIV in Marsabit County Increased access to comprehensive care (testing & counseling) and treatment Medical Supplies Decreased opportunistic Infrastructure Outreach & Medical campaigns Materials & Resources HIV/AIDS Health Curriculum Training tools/guidelines ARVs TB Treatments Condoms Supplies Off-site Testing Supplies 4x4 Vehicle for transportation Clinic staff and CHWs will distribute condom supplies CHWs will hold monthly discussions/workshops in their catchment areas Clinic staff will conduct outreach events and medical campaigns Clinic staff will conduct community outreach programs with incorporated counseling & testing. Clinic social worker will conduct Condom service outlets / dispensed sites supplied HIV and TB positive clients counseled Community outreach events and medical campaigns completed Patient retention HIV and TB positive clients treated infections Increased condom use Long-term objectives Improved HIV knowledge and stigma in the community Improved health seeking behavior among PLWHIV Maximized access to affordable medical services in Marsabit Sites for monthly follow-up of clients. trainings/workshops Program manager and clinic officer will coordinate monthly with County hospital, Anglican Church, county government, and local clinics to integrate local infrastructure in medical campaigns and community outreaches. 32

37 Table 7. Monthly Progress Report OUTCOME INDICATOR # OF TARGETED CONDOM SERVICE OUTLET ESTABLISHED THIS MONTH. # OF INDIVIDUALS REACHED WITH COMMUNITY OUTREACH PROGRAMS # OF PREGNANT WOMEN WHO RECEIVED HIV COUNSELLING AND TESTING AND RECEIVED THEIR RESULTS # OF PREGNANT WOMEN PROVIDED WITH A COMPLETE COURSE OF ANTIRETROVIRAL PROPHYLAXIS # OF INDIVIDUALS PROVIDED WITH GENERAL HIV RELATED PALLIATIVE CARE (INCLUDING TB) # OF CHWS TRAINED TO DELIVER HIV RELATED PALLIATIVE CARE INCLUDING TB/HIV SERVICES # OF HIV POSITIVE PATIENTS SCREENED FOR TB IN HIV CARE AND TARGET ACTUAL THIS MONTH % TARGET ACHIEVED IMPACTS 4 Increased awareness on condom use 166 Increased awareness of HIV status 41 Increased awareness of HIV status 4 Improved immunity of HIV/AIDS clients 41 Improved health of HIV/AIDS clients after HAART initiation 1 Improved immunity of HIV/AIDS clients 41 Decreased opportunistic infections PROBLEM FACED HOW PROBLEMS WERE ADDRESSED COMMENTS 33

38 TREATMENT INITIATED # OF REGISTERED TB PATIENTS WHO RECEIVED COUNSELLING* NUMBER OF NEW CLIENTS RECEIVING ANTI- RETROVIRAL THERAPY # OF CHWS TRAINED TO DELIVER ART SERVICES ACCORDING TO NATIONAL/INTER NATIONAL GUIDELINES # OF HIV CLIENTS WHO RECEIVED COUNSELLING AT FOLLOW-UP VISITS.* # OF HIV CLIENTS TESTED FOR CD4 COUNT.* # OF CHWS TRAINING WORKSHOPS # OF CHWS REPORTING & DISCUSSION SESSIONS # OF DISCUSSION SESSIONS WITH COMMUNITY LEADERS TUMAINI STAKEHOLDERS EVALUATION OF SERVICE REPORTS Decreased opportunistic infections 8 Improved immunity of HIV/AIDS clients 1 Improved immunity of HIV/AIDS clients 41 Improved health of HIV/AIDS clients after HAART initiation 41 Improved health of HIV/AIDS clients after HAART initiation 0.4 Improved quality of care 1 Improved health seeking behavior among PLWHIV 0.4 Improved HIV knowledge and stigma among community members 1 Improved quality of care QUANTITATIVE VALUES PROVIDED IN TARGETS (BASED ON SHORT AND LONG TERM OBJECTIVES) WERE DERIVED FROM ALREADY PRESET ANNUAL STAKEHOLDERS REPORTING EXPECTATIONS. 34

39 PROGRAM STRUCTURE Program Theory A program theory is defined as an underlying hypothesis of how a program is expected to work and is generally established before the program work begins 23. As the Tumaini Medical Centre has been operating since 2009, a program theory is not being applied through this paper. However, in evaluation of its services and impact in Marsabit County, the constructs of the center as a health program in the community one might expect the center to work through a community organization model as the outputs and outcomes of activities carried at the center are aligned with the characteristics of the model. The community organization model empowers communities to improve health through a participatory decision making process. Characteristics for the model include (1) understanding of the context and root cause of health issues, (2) collaborative decision making and problem solving, (3) focused efforts on specific issues, (4) active engagement and participation from various groups and organization within the community, (5) development and maintenance of capacity to produce a lasting change in the community, and (6) the provision of feedback to the community 24. Organizational Structure of Tumaini Medical Centre The organizational infrastructure through which Tumaini Medical Centre operates can be divided into two major functioning sections: 1) building/facility and staffing and, 2) funding for CHWs, pharmacy treatments, condom supplies, laboratory equipment, VCT services, outreaches and medical campaigns, and administrative resources (laptop, printers, etc.). The 35

40 Tumaini Medical Centre direct clinic staff includes 11 employees: two clinicians, one supporting nurse, one social worker, one pharmacist, two laboratory technicians, two administrative staff overseeing billing and client registration, one data officer, and one cleaning/janitorial staff. All report to an FH coordinator based in Marsabit who collaborates with an ADS coordinator also located in Marsabit to oversee the day-to-day activities at the clinic. Both coordinators report to the HIV program manager for FH-Kenya. This program manager is based in Nairobi, Kenya and conducts at least quarterly oversight visits to the clinic. The program manager oversees monthly reporting to FH overhead and to supporting stakeholders. Clients and Recruitment The Tumaini Medical Centre was designed to provide comprehensive HIV care through one central location and to reach rural areas in Marsabit County through community outreach events, medical campaigns, and CHWs. The center is equipped with treatment for pregnant women, adults, and pediatrics, in accordance with national/international guidelines. As of May 2015, approximately 505 PLWHIV were in care at the medical center; of which 363 clients were on ARTs. Recruitment of many of the clients consist mostly of word of mouth, community outreaches, medical campaigns, and CHWs reaching out to members of their communities. Due to the high stigma associated with HIV in the community, many of those that are HIV positive often hide their status from family members and/or sexual partner(s) and only seek treatment for associated symptoms. These opportunistic visits offer clinic staff a chance to discuss testing of additional family members and a mediation for revealing HIV status to family member(s) 36

41 and/or sexual partner(s). Additionally, counseling is provided for initiation of HAART as well at these visits. PROGRAM EVALUATION Evaluation Overview The evaluation plan will examine 1) the services provided, 2) the process of implementation of services, and 3) the impact of services in the targeted population through evaluation questions. The intended outcome of the evaluation is to determine the effectiveness or ineffectiveness of the center s services in meeting the program objectives; to highlight barriers and areas for improvements; and, to determine the impact of the medical center on the target population needs. Tumaini Medical Centre s stakeholders may subsequently use this assessment to appropriately allocate additional funding and support and to identify and minimize barriers in efforts to maximize and strengthen the center s services and impact to the community. Though this evaluation is formative, stakeholders should prepare a summative evaluation by appraising services and outcomes in terms of dollar costs and values. Evaluation Questions The primary goal of the Tumaini Medical Centre is to improve health of PLWHIV in Marsabit County, Kenya by increasing access to comprehensive care (testing & counseling) and treatment, increasing the effectiveness of clinic services at the Medical Centre, and maximizing 37

42 access to affordable medical services for the general population. The evaluation questions presented here focus on these goals and the program objectives identified in previous sections. Topic: Services Provided Short-term objectives: Within one year, Tumaini Medical Centre staff will increase the number of community members that have been tested and are aware of HIV status in Marsabit. Within one year, Tumaini Medical Centre staff will reduce opportunistic infections of TB in patient population at the Medical Centre by 50%. Within one year, Tumaini Medical Centre staff will increase the reported use of condoms in the catchment area by at least 30%. Table 9. Services Provided Evaluation Planning Table Evaluation Question Evaluation Method (s) Participants Were community outreach and medical campaign effective in the community? Were health talks culturally sensitive? According to clinic patients, were counseling sessions culturally appropriate in sexual health knowledge and selfefficacy? Could clinic patients understand what they were told in counseling sessions? Are voluntary testing options (TB, HIV) integrated in initial counseling sessions? Open-ended interviews, clinic enrollment review Focus group discussions, clinic surveys, open-ended interviews Clinic surveys, open-ended interviews Focus group discussions, clinic surveys, medical records review Community members/leaders, Clinic staff Clinic patients, Clinic staff Clinic patients, Clinic staff, CHWs, FH administrative staff Clinic patients, Clinic staff 38

43 Topic: Service Implementation Short-term objectives: Within one year, Tumaini Medical Centre staff will improve immunity of HIV /AIDS clients (inclusive of pediatrics) through enrolment of positively tested individuals on ARTs. Within one year, Tumaini Medical Centre will improve symptom management and psychological health of HIV/AIDS clients after Highly Active Anti-Retroviral Therapy (HAART) initiation. Table 10. Services Implementation Evaluation Planning Table Evaluation Question Evaluation Method Participants Were CHWs trained in delivery of ART series according national guidelines? Does Tumaini Medical Centre follow a standardized training protocol? How is the process updated/regulated? How many patients that were enrolled 6 months ago returned for follow-up CD4 count testing? What barriers exist that prevented patients from continuing care? How were these overcome? Were Tumaini Medical Centre s efforts to ensure follow-up care effective or ineffective? In what ways can follow-up care be improved? Document review (training logs, training material), open-ended interviews Document review (training logs, training material), open-ended interviews Clinic registers and medical records review, clinic surveys, open-ended interviews Focus group discussions, medical records review, open-ended interviews Focus group discussions, clinic surveys, open-ended interviews CHWS, Clinic staff, FH administrative staff Clinic staff, FH administrative staff Clinic staff, Clinic patients, CHWs Clinic staff, FH Administrative staff Clinic staff, FH Administrative staff 39

44 Topic: Program Impact Long-term objectives: Within five years, Tumaini Medical Centre will observe measurable changes in HIV knowledge and stigma among community members in Marsabit. Within five years, Tumaini Medical Centre will observe measurable improvements in health seeking behavior (initiation of treatment/care and/or counseling; request for assistance in disclosure; and/or compliance to follow-up clinic/counseling visits at the medical centre) among PLWHIV in Marsabit. Table 11. Program Impact Evaluation Planning Table Evaluation Question Evaluation Method Participants How have clinic patients perceptions of knowledge and lifestyle change, or lack of change, altered over the duration of treatment at the medical center? As a result of increased involvement of community leaders? What were baseline factors or potential confounders that may have contributed to HIV transmission? Has health seeking behavior and/or sexual health knowledge changed in the community? What other factors and potential confounders may have contributed to community knowledge? How can Tumaini Medical Centre measure the effect or lack of effect of the program on the health of the community? Focus group discussions, open-ended interviews, surveys Focus group discussions, open-ended interviews, surveys Focus group discussions, open-ended interviews Document review (monthly, quarterly reports), document review of epidemiological data, open-ended interviews Community Members/Leaders, CHWs, Clinic patients, Clinic staff Community Members/Leaders, CHWs, Clinic Staff, FH Administrative Staff, Stakeholders Community Members/Leaders, CHWs, Clinic Staff Clinic Staff, FH Administrative Staff, Stakeholders 40

45 CONCLUSION The affordable health services and cost-free HIV treatment and care services offered at the Tumaini Medical Centre have tackled access to care issues and complex socioeconomic contexts that have impacted the health seeking behavior of residents in Marsabit County. Considering the HIV/AIDS disease burden in Kenya, a health center being established in the often forgotten northern part of Kenya was warranted. However, after seven years of operations the center is due for re-evaluation of continued financial, technical, and organizational support per contractual terms. This overview of the Tumaini Medical Centre s health program coupled with the literature review of varied programs of similar characteristics to Medical Centre and the challenges it has faced and continues to face are presented here in efforts to provide stakeholders preliminary context for evaluation of the program and determination of its next phase. Barriers / Limitations Social, religious, and cultural beliefs surrounding healthcare and HIV knowledge and access to care in Marsabit are associated with risks to HIV transmission and positive health seeking behaviors for PLWHIV. Stakeholders must be sensitive to these factors and adapt the program to overcome these limitations. Additionally, in such a resource limited, rural location, risks related to clinic staff empowerment and accountability must also be challenged as the relationship between provider and patient is central to the uptake of positive health behavior. 41

46 The Tumaini Medical Centre in Marsabit has experienced in increase in staff turnover due to the location of the center and the outsourcing of clinic jobs. Additional limitations to the evaluation of the program include time constraints and limited resources affecting planned activities and/or objectives. Recommendations Based on these potential limitations, the following recommendations for the evaluation of the program are proposed: Begin measurement of program effects since 2009 by incorporating longitudinal data from clinic registers and stakeholders reporting tools. This collective data may also be used as baseline data to study the effect of the center s services post evaluation and improvements. Enhance collaboration and communication among clinic staff and stakeholders by hosting informative discussion sessions where challenges faced by clinic staff in delivery of services and proposed cues of actions can be further explored and implemented. Improve the cultural sensitivity and knowledge surrounding HIV/AIDS by increasing collaboration with community leaders in leading community outreaches and intervening with support in status disclosure. Use focus groups and the logic model to draft a monitoring and evaluation (M&E) plan to be implemented as part of continued sponsorship of the health program. Continued efficiency and effectiveness of health services in meeting the health needs in the community is integral to planning measures for capacity building, community 42

47 empowerment, and sustainability beyond sponsorship, which frame the next life phase of the program. Acknowledgements Thanks to all Blood:Water, Food for the Hungry-Kenya, and Tumaini Medical Centre staff: Aida Samir; Barak Bruerd; Nadia Kist; Erin Todd; Aaron Sands; Jake Smith; Zachary Kaimenyi; Jacquie Mwihaki; Ivy Ongoro; Felix Ilayesa; Joyce Mukoru; Catherine Wamuyu; Eunice Lokuru; and Amina Dibo. 43

48 APPENDICES Appendix A. Marsabit Community Leaders Interview Report The interview was conducted by Grace Nissao on August 13 th, 2015 in Marsabit, Kenya during practicum placement with Blood:Water and Food for the Hungry-Kenya. The discussion topics with the interviewees were social stigma of HIV in Marsabit County and the impact of Tumaini Medical Centre in the community. The interview was conducted face to face at one of the elders home. I was accompanied to the meeting by one of Tumaini Medical Centre clinic staff, Daniel Ngacha, and community health worker (CHW), Amina Dibo, who also served as interpreter during the interview. There were 6 community leaders within Marsabit County who attended the meeting. These community leaders were elders of various villages within Marsabit County. The meeting began with a discussion on social stigma in Marsabit County related to HIV. The elders voiced that there still remains a negative stigma within the community associated with being HIV positive and in such, many of those that are HIV positive often hide their status and only seek treatment for associated symptoms. The elders further noted that in addition to encouragement of community members to get tested and disclose status to family members or sexual partner, if there is fear of negative response, the community members should be encouraged to also reach out to elders for support in disclosing status with family members. In discussion of the impact of the Medical Centre in Marsabit County, the elders provided positive feedback primarily highlighting the affordability of treatments and services at Tumaini compared to other clinics in the county and the county hospital. The elders also highlighted the compassion of the clinic staff to community members which, in light of much of the stigma remaining in the community related to HIV, the care and compassion of the clinic staff is critical to upping voluntary testing and counseling. Additionally, the elders highlighted the voluntary 44

49 testing outreaches previously held in the community as key opportunities to reach members of the community that remain reluctant to come to the center for testing and treatment. In closing of the meeting, the elders and I discussed opportunities to address HIV stigma in the community and to increase voluntary testing. The elders noted that community outreaches organized and led by the elders may lead to greater participation of community members. At such events, the clinic staff may join to provide voluntary testing and counseling. Additionally, the elders will use these events to speak on the social stigma associated with HIV within the community context. A particular event was not finalized during the meeting however the elders voiced eagerness to join forces with the Medical Centre to lead outreaches and to continue to meet to discuss further context of the stigma in the community and potential opportunities to address these. 45

50 Appendix B. Global HIV Estimates 25 46