In Nairobi, Kenya, nearly 10 percent of adults—more than 320,000 people in total—are living with HIV. By the time they turn 15, more than 20 percent of young people have engaged in sex with low condom usage. In Coast Province, HIV prevalence is 8.8 percent and, like Nairobi, it is nearly 20 percent higher among women. Although the majority of men say they are willing to find out their HIV status, only 28 percent have ever actually been tested. The effects of HIV are compounded by other health problems, including endemic malaria in Coast Province. Substantial fractions of the populations of Nairobi and Coast face important barriers to health, notably limited access to health services, especially for youth and vulnerable women. Through APHIAplus Nairobi-Coast, Pathfinder is providing these two provinces with the resources necessary to change that.
Through APHIAplus, USAID promotes a transition from an emergency-response approach to building sustainable systems that ensure all people can equitably access services for HIV and AIDS, tuberculosis, reproductive health and family planning, and maternal and child health.
The APHIAplus (AIDS, Population and Health Integrated Assistance Plus) Nairobi-Coast program is a five-year flagship health services delivery program funded by USAID and implemented through a partnership between Pathfinder International, ChildFund International, Cooperative League of the USA, Population Services International, and the Network of AIDS Researchers of Eastern and Southern Africa. Building on work carried out by COPHIA (Community-Based HIV and AIDS Prevention, Care, and Support) and AIDS, Population and Health Integrated Assistance (APHIA II) (1999–2010), the program supports Nairobi province and Coast province in the implementation of their respective health services development plans. The program’s stakeholders are Kenyan governmental agencies, non-governmental organizations, faith-based organizations, and the private sector.
To improve health outcomes, the program supports the provinces to maximize their existing service delivery capacity; integrate maternal, newborn, and child health, nutrition, water, and sanitation interventions; and apply resources to existing programs that allow the provinces to more quickly address social determinants of health, especially for poor, marginalized, and underserved populations.
APHIAplus serves all districts in Nairobi-Coast province, excluding Tana River. The area is characterized by large urban centers but also includes rural, isolated areas and drought-stricken arid lands. The epidemiology of the HIV and AIDS epidemic in Nairobi-Coast requires attention to a large number of the most at-risk populations including discordant couples, men who have sex with men, intravenous drug users, and commercial sex workers. Gaps in service delivery to youth and vulnerable women are also still important in the area.
In the last year, the government of Kenya went through a devolution process, creating county-level federal administration of government services. Pathfinder has been a leader in rethinking the decentralization of health services through the APHIAplus project.
APHIAplus is unique in its country-led implementation strategy. The program works in close collaboration with Ministries of Health in each district to promote a coordinated approach and carry out activities at every level—through the provincial and district health offices, penetrating down to the district health facilities, and reaching communities. At the national level, USAID complements service delivery with mechanisms, such as trainings and health management information systems. Through APHIAplus, USAID promotes a transition from an emergency-response approach to building sustainable systems that ensure all people can equitably access services for HIV and AIDS, tuberculosis, reproductive health and family planning, and maternal and child health.
"One thing that helped so much when we started this clinic: I made sure that among the community health workers, there were those living with HIV. So if their clients get weak and need support, these providers can share their own stories. They became ambassadors." -Sarah Mithamo, Pathfinder-trained counselor at the Rueben Clinic in Nairobi, Kenya
Partnering with Communities
APHIAplus works closely with local implementing partners to target key affected populations where they live. Supporting the government of Kenya’s 2006 Community Strategy—a flagship program to reform primary health care—the program works with civil organizations to design, implement, and evaluate interventions that engage communities and promote healthy behaviors. This includes activities to:
- Improve home- and community-based care for people living with HIV and their families
- Support orphans and vulnerable children
- Address the social determinants of health
In just two years, the program helped districts in establishing 167 “community units”. Each unit includes 50 community health workers and supports 1,000 households with essential services and information. Units are linked to specific health facilities, where clients are referred for additional quality care.
ADVANCING INTEGRATED HEALTH CARE
To help provinces continually improve their quality of care, APHIAplus strengthens health facilities at the district level and below, with an emphasis on improving the quality of HIV and AIDS care and treatment, as well as services for tuberculosis; malaria; and maternal, newborn, and child health. The program works with district stakeholders and facility management teams, and aligns interventions with provincial and district health plans. Through innovative activities, such as mentorships and technical zonal meetings, the project builds the skills of medical professionals, so they can address the many, interconnected health needs of their clients.
In order to improve HIV diagnostics and monitoring, APHIAplus supports the provinces’ lab networks to manage CD4 tests. To improve maternal and child health services, the program supports “integrated outreach days,” where women can access family planning and get screened for cervical cancer at the same time.
Preventing Gender-Based Violence
In 2005, the US government launched the Women’s Justice and Empowerment Initiative, aimed at preventing gender-based violence. Today, APHIAplus is implementing this important initiative to raise awareness of gender-based violence, improve law enforcement, and support survivors. The programs’s strategy addresses the needs of women and girls and integrates gender, using community sensitization activities that are dynamic and expansive.
PREVENTING MOTHER-TO-CHILD TRANSMISSION OF HIV
Kenya has set the goal to eliminate new HIV infections among Kenya’s women and children. Building on past efforts and experiences, APHIAplus builds the capacity of facilities and providers to
promote and deliver prevention of mother-to-child transmission of HIV (PMTCT) services. Strengthening linkages between facilities and communities, the program ensures that all mothers attending antenatal care can receive HIV testing.
This technical highlight provides a brief overview of Pathfinder’s experience implementing the Kenyan Community Strategy through the USAID-funded APHIAplus (AIDS, Population, and Health Integrated Assistance Plus) Nairobi-Coast project (2011-2014).
This practical guide presents evidence and example activities that serve as a resource for program implementers and planners working to prevent HIV among female sex workers (FSWs), men who have sex with men (MSM), and people who inject drugs (PWID).
In 2011, Pathfinder’s APHIAplus Nairobi-Coast project facilitated the expansion of a gender-based violence (GBV) prevention and response program in Kenya that works to strengthen both the community and health systems.
This technical update describes Pathfinder’s framework for combination HIV prevention with key affected populations and its application in Coast province since 2011.
PAST PROJECT: With support from the Government of Kenya, this project used an integrated model of AIDS, population, and health to expand access to quality, sustainable HIV and AIDS and TB prevention, treatment, and support and family planning services.
PAST PROJECT: This project improved health service delivery by strengthening access, quality, and integration of facility-level services, supporting community capacity building and building multi-sectoral collaboration.
PAST PROJECT: This community-based HIV and AIDS prevention, care, and support program secured the health and quality of life of people living with HIV and AIDS, orphans/vulnerable children, and their families/caregivers by strengthening previous interventions.
With funding from the Fogarty International Center of the National Institutes of Health, Pathfinder has begun a new project to test the effectiveness of a mobile phone-based continuing medical education strategy among Vietnamese community-based physician assistants.
Supported by Pathfinder International, the MacArthur Foundation, and the Packard Foundation, the Health of the People and Environment in the Lake Victoria Basin initiative, or HoPE-LVB, has employed the PHE model to address food insecurity, weak health infrastructure, environmental degradation, high maternal and infant mortality, and inadequate water, sanitation, and hygiene.