Preventing Mother-to-Child HIV Transmission in Kenya

Preventing Mother-to-Child
Transmission of HIV/AIDS in
Kenya
A Public Health Intervention Proposal by the Kuinua Foundation
12/12/2013
MacalesterCollege
Lisa Levoir

1
About the Kuinua Foundation
The Kuinua Foundation seeks to eliminate mother-to-child transmission of HIV/AIDS in
Kenya through prevention and treatment programs. The foundation is a 501(c) 3 nonprofit and
has a small office in the U.S. as well as a regional base in Mombasa, Kenya. The foundation is
composed of a program director, a head medical and research director, a director of
communications, advocacy, and development, a public health expert with experience with
planning and implementation, and a data analyst capable of aggregating and analyzing health
data. In addition to these staff, the foundation relies on health workers and the established
centralized health systemin Kenya, including the newly modernized electronic health records
and developing health centers.1 Although the foundation recognizes that there are multiple
prongs to preventing mother-to-child transmission of HIV, it specifically is seeking grant funding
to expand antiretroviral coverage in Kenya according to the most recent WHO Option B+
recommendations. The Kuinua Foundation is requesting grant funding for a transitionary period
to demonstrate to the government of Kenya and international donors that Option B+ is more
effective than previous systems in the context of Kenya. We as a foundation feel that we are in
a unique position to pilot new approaches before country governments. In order to impart a
comprehensive impact, the foundation will foster new partnerships and nurture current
relationships with current programs operating both in Kenya and internationally.
About HIV and Mother-to-Child Transmission
Human immunodeficiency virus targets the body’s immune system. A person’s immune
function is measured by the amount of CD4 cells in the blood (fewer CD4 T cells result in
immunodeficiency).2 HIV is transmitted via bodily fluids, such as blood, breast milk, semen, and
vaginal secretions, and is usually diagnosed through blood tests detecting the presence or
absence of HIV antibodies.3 The most advanced form of HIV infection is acquired
immunodeficiency syndrome (AIDS), and is defined by the development of severe clinical
manifestations (like co-infections or cancer).4
The transmission of HIV from a HIV-positive mother to her child can occur during
pregnancy, labor, delivery, or breastfeeding.5 Mother-to-child transmission of HIV can
essentially be prevented if both mother and child are provided with antiretrovirals at all stages
in which the infection could occur.6 It is imperative that we work to prevent these infections at
the beginning of a child’s life to give them the best chances of good health. Otherwise, most
1 "Study: Electronic Health Records Improve Care in Kenya." International Business Times, March 21,
2011.
2WHO. "HIV/AIDS Factsheet.”, accessed November 30,
2013, http://www.who.int/mediacentre/factsheets/fs360/en/index.html.
3 WHO. "HIV/AIDS Factsheet.”, accessed November 30,

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HIV-positive infants will die before their second birthday if they don’t receive proper medical
interventions.7
In sub-Saharan Africa, 9% of maternal mortality is related to HIV/AIDS.8 Children that
live with HIV face stigma and difficulties because of the disease as well as side effects from their
medications. Although HIV babies now have better chances at survival, their mortality is still
“thirtyfold higher than similarly aged children.”9 Each year in Kenya, 20,000 children become
HIV infected after exposure to HIV during pregnancy or delivery, or as a result of
breastfeeding.10
National HIV seroprevalence in Kenya is between 6 and 7.4 percent in working age (15-
49) populations.1112 Although prevalence is higher in urban areas, 70% of people infected with
HIV in Kenya live in rural areas.13 While over 98% of Kenyans are aware of HIV, only 36% have
been ever been tested.14 Voluntary counselling and testing (VCT), including provider-initiated
testing, is on the rise in Kenya- about two-thirds of health facilities in Kenya provide HIV
counselling and testing services.15 About 1,530,000 women were estimated to be pregnant
within the last 12 months, and 87,000 to 96,100 of these women were estimated to be living
with HIV and in need of antiretroviral therapy (ART) to prevent mother-to-child transmission
(PMTCT).16 Of those, 45,397 pregnant women living with HIV received antiretroviral (ARVs) for
PMTCT, which is estimated to be about 53%.17 Progress has been made; in 2011, 69% of HIV-
positive pregnant women received ART, and 14.9% of infants born to HIV infected women
became infected.18 This means about 31% of pregnant women in Kenya did not receive
antiretrovirals in the last year, a gap that the Kuinua Foundation would like to fill with Option
B+ recommended antiretroviral therapy (ART).
The good news is that about 92% of women in Kenya visited an antenatal care clinic at
least once during their pregnancy.19 While there has been progress since the beginning of the
epidemic, there are still gains to be made in testing, prevention, and ART coverage. The Kuinua
Foundation will measure this proposal’s progress by recording how many infants are infected
with HIV within 1 year of birth.
About Kenya’s Health System
Kenya’s health care system is composed of public and private facilities and is based on a
national reference hospital and the system extends through county and district hospitals and all
7 UNICEF. Children and AIDS: Fifth Stocktaking Report, 2010.
8 UNICEF. Children and AIDS: Fifth Stocktaking Report, 2010.
9 Belluck, Pam. "As HIV Babies Come of Age, Problems Linger." New York Times, November 5, 2010.
10 Kenya Office of the President National AIDS Control Council. The Kenya AIDS Epidemic, 2011. P.20
11 ICAP Global.Health. Action. Columbia University Mailman School of Public Health."Where we Work: Kenya.”
accessed 11/20,2013,http://icap.columbia.edu/where-we-work/Kenya.
12 PEPFAR. Kenya Operational Plan Report: PEPFAR, FY 2012. P.8
17 UNICEF. Sixth Stocktaking Report Children and AIDS, 2013. P.55
19 UNICEF. Sixth Stocktaking Report Children and AIDS, 2013. P.55

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the way down to rural centers and dispensaries.20 Currently, Kenya is decentralizing from the 8
current provinces to 47 autonomous counties.21 Kenya’s population is unevenly distributed, and
more people live in rural areas than urban areas.22 Most districts in Kenya reported that fewer
than half of their facilities could access electricity 100% of the time.23 Nearly all districts have at
least one facility offering PMTCT services, but only 66% of districts have a facility providing
antiretroviral therapy.24
The Kenyan health systemis based on three kinds of facilities: hospitals, health centers,
and health sub centers (including dispensaries and mobile clinics).25 Health centers and
dispensaries are the first contact facilities for people seeking medical care, although hospitals
can still serve as primary care facilities. The rural poor rely on health centers, dispensaries, and
faith based organizations (FBOs). 26 The public sector operates more than half of all health care
facilities and funds 30% of Kenya’s total health care cost, 20% is supported by private
organizations like Christian missions, and the remaining half of the cost is supported by
households.27 With grant support, the Kuinua Foundation plans to remove this cost burden to
treatment to facilitate better access to treatment necessary to prevent mother-to-child
transmission of HIV. Because of the nature of the project, and current governmental support,
the Kuinua Foundation is targeting all women of childbearing age (15-49) in Kenya.
Awareness of the benefits of prevention services needs to grow. In 2008-09, more than
30% of Kenyans surveyed were not aware that ARVs during pregnancy could reduce the risk of
transmission.28 Fortunately, Kenya has made progress on access to antenatal care. 93% of
women receive some sort of antenatal care, and 47% receive four or more antenatal visits.29
The more women access care, the more they can be reached by HIV testing services,
counselling, and treatment. Efforts are needed to prevent the transmission of HIV to women of
childbearing age, increase the availability of family planning services, prevent transmission
through interventions and care for women and their families.
Social Determinants of Health
Social Factors:
1. Resource Constraints
a. Free access to ARVs is very important in preventing and treating HIV
2. Lack of maternal health care
a. Clinics may only be located in urban areas or have trouble reaching all women in
the country
22 Kenya Ministry of Health and WHO. Service Availability Mapping (SAM), 2007. P.2
27 Kenya Ministry of Health and WHO. Service Availability Mapping (SAM), 2007. p.6

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b. Facilities may not have a large enough budget to employ competent or fulltime
staff. In fact, Kenya lacks adequate numbers of doctors and nurses, as shown by
the two graphs below.30
c. In the most recent service availability mapping report from the WHO, it was
reported that fewer than half of all districts reported the ability to carry out tests
measuring CD4 cell levels, as shown in dark green in the map below.31
d. Poorer women access skilled birth attendants at much lower rates than
wealthier women32
e. Women living with HIV must be able to access family planning services, if they
can “prevent or delay pregnancies,” then “these services could avert HIV
infection in infants”33
32 UNICEF. Kenya: PMTCT http://www.unicef.org/aids/files/Kenya_PMTCTFactsheet_2010.pdf 2010.

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3. Gender-related determinants
a. The HIV epidemic disproportionately affects women, they account for 59.1% of
adults living with HIV.34 The difference grows among women of childbearing age
(15-49 years), where women account for nearly twice as many infections as men
(8% and 4.3%, respectively).35
4. Geographic Factors
a. Women located in rural areas may have a more difficult time accessing PMTCT
services because they are distributed so widely, as shown in the graph below.36
b. Immunological susceptibility to HIV infection is increased from poor housing
and/ or nutrition.
c. Regional variation in HIV infections is high in Kenya.37
d. There are more HIV infected people in rural areas (72%) than urban areas, due to
the nature of the population.38 This creates barriers to access to care. The Kuinua
Foundation would simplify access to care by distributing ARVs that women can
take if they test positive in an ANC clinic visit.
e. Only 58% of antenatal care sites offer HIV testing in Kenya39 The Foundation will
work to expand HIV testing to all ANC facilities.
5. Logistical obstacles
33 WHO. "Sexual and Reproductive Health: Prevention of Mother-to-Child Transmission of HIVand Family
Planning.", accessed November 12, 2013

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a. Testing in some places takes at least a day, which confers to increased trips to
the clinic. 40 Faster test kits will be distributed as a part of this grant proposal so
that women receive their result while at their first visit.
6. Prevalence of HIV/AIDS
a. A poor system for ARV delivery is related to higher HIV/AIDS prevalence.
b. Chronic unemployment is also related to higher HIV/AIDS prevalence.
c. Unsafe sex practices, especially those of a cultural nature, may be more likely to
transmit HIV/AIDS as well as result in conception
i. HIV/AIDS is generally prevalent in women of childbearing age “women
between the ages of 15 and 24 are more than twice as likely as young
men to be living with HIV.”41 This is in part due to female anatomy and in
part due to the women’s stance in society.42
Individual Factors:
1. Lack of contraception
a. Lack of contraception is both socially motivated; the individual morbidity is
relative to personal choices, which is a consequence of ill health.
b. In order for HIV transmission to be possible from mother to child during or
shortly after pregnancy or birth, the woman has to be pregnant and have
HIV/AIDS, “unintended pregnancies are high among HIV-positive women.”43
c. On average, Kenyan girls are less knowledgeable than males regarding HIV and
are less likely to use condoms.44
2. Poorer women access skilled birth attendants less frequently or at suboptimal times.45
a. Women do not access HIV care due to lack of money.46
b. According to the report, pregnant women access ART (antiretroviral therapy) less
often than the general population, especially if they live in isolated areas or
areas with weak health systems.47
c. Women may not receive treatment if they don’t qualify for Highly Active
Antiretroviral Therapy (HAART)
i. Among women who accessed referred care after exiting maternal care, in
one study in Nairobi found that 33% of women did not qualify for HAART
due to their CD4 count48
40 Msellati,Philippe."ImprovingMothers' Access to PMTCT Programs in West Africa:A Public Health
Perspective." Social Science & Medicine 69,no. 6 (9, 2009):807-812.
43 WHO. "Sexual and Reproductive Health: Prevention of Mother-to-Child Transmission of HIVand Family
Planning.”,accessed November 12, 2013, http://www.who.int/reproductivehealth/topics/linkages/pmtct/en/.
46 Otieno, Phelgona A., Pamela K. Kohler,Rose K. Bosire,Elizabeth R. Brown, Steven W. Macharia,and GraceC.
John-Stewart. 2010."Determinants of failureto access carein mothers referred to HIV treatment programs in
Nairobi,Kenya." AIDS Care 22, no. 6: 729-736.EBSCO MegaFILE, EBSCOhost (accessed November 19,2013).
47 UNICEF. Options B and B+: Key Considerations for Countries to Implement an Equity-Focused
Approach, 2012. P.2

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ii. Kuinua seeks to change this determinant by placing all HIV-positive
expectant mothers or HIV-positive women of childbearing age on Option
B+ recommended triple antiretrovirals.
d. Poorer women have to pay more out of pocket for their care. The poor may
encounter more costs as they try to save money.
i. Lack of access might result in a lower standard of care as well as less
postnatal care administered
e. About 92% of women in Kenya access antenatal care (ANC), although much of it
is initiated after the optimal point to start treatment (28 weeks).49 This is related
to differential vulnerability as well as consequences of ill health and can be
combatted with public service announcements and informational campaigns.
3. Lack of Access
a. The Kuinua Foundation has a high priority to make an impact on access to care
by simplifying treatment protocols and advertising the importance of accessing
treatment
b. A woman may have financial, educational, or societal barriers to attending a
clinic. Lack of access to a clinic would be a differential vulnerability for MTCT.
c. Limited access to family planning services contributed to unplanned or
unwanted pregnancy, which increases the number of cases of mother-to-child
transmission.50
d. Permission from a male figure
i. This would also be a differential vulnerability intrinsic to some societies,
especially if some male partners believe that they will have the same HIV
result as their partner. This is related to women’s role in family and
society.
4. HIV related stigma also results in difficulties with openly discussing the epidemic. Fear of
discrimination or disapproval also may deter people from seeking treatment services
that they need.51
a. Fear of test result causes women to not return to ANC facility
b. Women who don’t return to ANC or don’t receive prophylaxis will have higher
chances of transmitting HIV/AIDS to their baby52
c. Women may fear the social implications of a positive result (a consequence of ill
health).
d. If a woman doesn’t return to a facility and their child is infected with HIV/AIDS, it
will take longer for their child to receive treatment, which is related to
differential consequences, vulnerability, and a consequence of ill health.
5. Perceptions on quality of care as well as ease of treatment
Nairobi,Kenya."
52 WHO, Mother to child transmission of HIV http://www.who.int/hiv/topics/mtct/en/index.html

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a. The Kuinua Foundation has a high priority to change perceptions of care and
ease of treatment with its interventions both in the clinic (specific ARVs
distributed) as well as in society through advertisements and word of mouth
from other women
b. If a woman or her family don’t believe that treatment will improve their
condition, they are less likely to seek out care. This is related to differential
vulnerability. Attitudes among healthcare workers may also decrease the quality
of care a woman receives.53
c. Women have also cited lack of confidentiality as a reason to avoid certain
healthcare facilities.54 This could be considered a consequence of ill health and a
differential vulnerability.
d. Women may also avoid certain facilities due to a dislike of the facility, a factor
that is related to the conditions or resources available, so a differential
vulnerability.55
i. Limited access to timely, reliable CD4 testing, makes it difficult to identify
which women need treatment, is a challenge in resource-constrained
settings56
Interventions
Option B+ provides triple ARV drugs to all HIV-positive women beginning at diagnosis in
the antenatal clinic and continues this therapy for life.57 Option B+ simplifies the antiretroviral
therapy regimen and delivery. It also provides protection from mother-to-child transmission in
later pregnancies or sexual transmission.58 The same fixed-dose-combination triple ARV
regimen used for PMTCT and can be used for a national first-line ART program.59 This simplifies
drug forecasting, procurement and supply, as well as stock monitoring.60 It also simplifies
messaging: once ART is started, it must be continued for life.
According to the WHO’s Kesho Bora study, “there is no apparent risk to the health of
mothers or their babies associated with the triple-ARV regimen.”61 They further concluded that
Nairobi,Kenya."
Nairobi,Kenya."
56 WHO. Programmatic Update: Use of Antiretroviral Drugs for Treating Pregnant Women and
Preventing HIV Infection in Infants, 2012.
61 WHO: Department of Reproductive Health and Research. Kesho Bora Study: Preventing Mother-to-
Child Transmission of HIV during Breastfeeding, 2011.

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it is optimal to start expectant mothers (and those planning on pregnancy) as early as possible
on ARVs, ideally providing priority access to HIV testing and ARVs to eliminate mother-to-child
transmission of HIV.62 According to another case study, care could be made more attractive to
transitioning mothers by including “health education, counseling, free services, and
compassion”63 Expectant mothers are therefore to be provided with free ART, and encouraged
to exclusively breastfeed to ensure their child’s best health (breastfeeding reduces the risk of
infants dying from diarrhea, pneumonia, and malnutrition and fosters natural immunity)64
Currently, Kenyan women breastfeed their babies for an average of 22 months, but only about
77% of children whose feeding could be classified in 2011 were receiving exclusive
breastfeeding from their HIV-positive mothers.65
The Kuinua Foundation hopes collaborate with other organizations to increase partner
involvement, create a standardized referral process, and standardize HIV education for mothers
diagnosed with HIV during pregnancy because these approaches have been proven effective.66
In addition, the Foundation will rely on the work done by other organizations and donors. The
US government, a potential ally, is the predominant donor in the HIV response in Kenya.67 The
US government country operation plan for Kenya in 2012 includes converting women on Option
B in Kenya to Option B+.68 Additionally, the Global Plan aims to eliminate new HIV infections
among children by 2015.69 The plan was adopted in 2011 and focuses on 22 priority countries
with high estimated numbers of pregnant women living with HIV, including Kenya, making the
plan a good partner for the Kuinua Foundation. Elizabeth Glaser Pediatric AIDS Foundation
(EPGAF) could contribute or advise on “bringing technical staff together across country
programs to share lessons learned and practical implementation of high impact
interventions.”70 Kuinua is also interested in collaborating with an organization concerned with
poverty and malnutrition to combat the incidence of impoverished women selling their ARVs.
This organization will make it worth it to these women to keep taking their medicines. While
this may seemlike an ambitious amount of partnerships and collaborations, the Kuinua
Foundation board members currently have strong connections in the public health community
and plan on continuing their relationships while at the Foundation and pursuing this grant.
Other necessary skill sets
Nairobi,Kenya."
66 Otieno, Phelgona A., Pamela K. Kohler, Rose K. Bosire,Elizabeth R. Brown, Steven W. Macharia,and GraceC.
Nairobi,Kenya."
67 PEPFAR. Kenya Operational Plan Report: PEPFAR, FY 2012. P. 3
69 UNICEF. Options B and B+: Key Considerations for Countries to Implement an Equity-Focused Approach, 2012.p.2
70 Elizabeth Glaser Pediatric AIDS Foundation. Prevention of Mother-to-Child Transmission of HIV. p.2

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There are limited resources and pressing needs for broader MNCH (maternal, neonatal,
and child health), so HIV programs like Kuinua’s need to “maximize cost effectiveness [and]
benefits from other health programs”71
The foundation itself will not be able to improve transportation and infrastructure that
would improve access to clinics. In this grant cycle, the foundation will also be unable to
provide personnel that follow migrant populations that might not otherwise access care. The
Foundation, because it lacks extensive expertise in advertising, will also seek to collaborate with
advertising organizations that work to reduce stigma, bring expectant mothers into clinics, and
inform the population about the importance of testing and treatment. Since the Kuinua
Foundation primarily is focusing on a pilot of new treatment options, it will not be allocating
monies to HIV infection prevention in the general population. Instead it will reply on the
programs and systems currently in place from the national government and PEPFAR to make
most of the impact in that respect. Despite this, the Foundation recognizes that prevention of
HIV infection and access to family planning services is just as important as treatment and plans
to coordinate efforts with other organizations. As a part of this prevention, the foundation also
plans to work in other programs to increase partner involvement in the ANC and PMTCT
settings.
Although the foundation is planning to prevent mother-to-child transmission of HIV, at
this time it is not capable of providing treatment for infants that are infected with HIV. The
foundation will monitor testing in order to measure the grant’s impact, but it will rely on other
systems in place to care for HIV-positive infants. The Foundation understands the difficulties of
implementing a vertical program into a horizontal system and will work to the best of its ability
to make positive and necessary (not redundant) changes.
Since the foundation is planning on tracking multiple data points for the duration of the
grant, it will rely partially on the current health system, including new online records, where
available. The foundation will devise some additional data tracking and analysis to cover what is
not already provided. Existing health personnel will be trained in collecting data that is not
already recorded by the current health infrastructure in Kenya.
Strategic Plan
In order to achieve these objectives, the Kuinua foundation has devised a strategic plan for
implementation. The desired impact is to reduce the incidence of new HIV infections in infants
(under 1 year) to less than 5% of births from HIV-positive mothers in Kenya by 2018 with 2013
baselines. The outcomes, outputs, and inputs are divided thematically to make these objectives
more clear. While ambitious, those of us at The Kuinua Foundation hope that donors will join in
making a difference in the lives of expectant women and their children in Kenya. In 2018, after
the grant is implemented, the Foundation hopes to reevaluate the impact it has had on the
incidence of mother-to-child transmission of HIV. Using the data the foundation has
aggregated, a final report will be commissioned and a new proposal will be drafted after 4 years
of implementation, as deemed necessary.
1. Outcomes:

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a. All expectant mothers presenting at an ANC facility are offered a test for HIV at
their first visit within 16 months of program implementation
1. This will be assessed by survey asking whether women received
antenatal care before their last child was born, and if so, whether
clinic staff told them about HIV and offered them a confidential
HIV test. If so, did they agree to the test and receive results?
2. HIV testing is available at all ANC facilities within 1 year of
program implementation
b. All expectant mothers that test positive for HIV are given Option B+ triple
antiretrovirals as soon as diagnosed regardless of CD4 count, and offered
treatment for life72
i. Women that are tested for HIV understand that their test is confidential
because it is communicated before the test.
c. All infants born in a health care facility are tested for HIV status, regardless of
their status of their mother, within 16 months of program implementation
i. All expectant mothers in Kenya that test positive for HIV are provided
with Option B+ recommended triple antiretrovirals within 32 months of
program implementation.
d. All infants (under 1 year) born to HIV-positive mothers receive Option B+ drugs
(AZP and NVP) for the first 4-6 weeks of life, according to WHO guidelines within
32 months of program implementation.73
1. This means that they receive NVP or AZT from birth through 4-6
weeks of age regardless of feeding method74
e. ARV are properly stored according to WHO standards or manufacturer directions
when supply chain is instated within 1 year of program implementation and
assessed by third party semiannually
i. Changes are made according to evaluation within 3 months of evaluation
conclusions
ii. This means that expired drugs are not distributed and medicines are
properly labeled
1. Labeling must include easy-to-understand instructions and ARVs
must be distributed in large enough quantities so that women
only have to revisit facilities at their next ANC visit or every 3
months after birth
a. Expectant mothers are competent in medicine
administration within 18 months of program
implementation as assessed at the care facility at each
checkup and each time the woman returns to refill her
prescription
Preventing HIV Infection in Infants, 2012. P. 2
74 UNICEF. Options B and B+: Key Considerations for Countries to Implement an Equity-Focused Approach, 2012.P.3

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f. ART supply chain is functional, according to external assessment, within 16
months of program implementation
i. This means that high quality drugs are delivered to the appropriate
facilities in necessary quantities, and include 3 months of backup ARVs,
barring emergency
ii. Distribution is monitored and recorded in paper system, and reported to
the reference hospital quarterly, beginning when labs receive ARV and
continuing for duration of project. Effectiveness of delivery is assessed on
an annual basis and new processes, if necessary, are devised and
implemented within 3 months of assessment.
g. Advertisements are effective in transmitting information and swaying public
opinion, within 2 years of implementation.
i. A survey will assess how many women hear and are receptive to
advertisements annually, with necessary changes devised and
implemented before the release of new annual advertisement
campaigns. The survey will also include a sections establishing that
women understand that once ART is initiated, it is continued for life.
h. 100% of women that present to an ANC facility are told about HIV, including its
symptoms and treatment, by a trained health worker within 6 months of
program implementation using IMCI-like flowcharts
i. This will be measured by exit surveys and evaluated annually for areas for
improvement, and any necessary changes will be implemented within 3
months of assessment.
ii.
i. All infants delivered in the ANC care setting or with a community health worker
are tested at birth of birth for HIV within 32 months of program implementation
i. Regardless of result at birth, infants will be provided with ARV
prophylaxis for 4-6 weeks after birth according to WHO Option B+
recommendations75
ii. HIV test results will be used to track program effectiveness
j. Exclusive breastfeeding rates among HIV-positive mothers increase to 90%
within 4 years of program implementation, as assessed by the current health
system
i. Rates are examined annually and additionally approaches and
partnerships are considered
2. Outputs:
a. Health care workers and birth attendants are educated in ART administration
from women and infants within 24 months of program implementation
i. This includes a supervisory systemfrom doctors for abnormal cases or co-
infections, as well as quarterly checkups on data records
b. ARVs and HIV test kits are procured within 9 months of program implementation
Preventing HIV Infection in Infants, 2012. P. 2

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c. Distribution systemand supply chain for ART and HIV test kits implemented
within 1 year of program implementation
d. Data tracking system for patients implemented within 6 months
i. Health care workers are trained in how to use the system
ii. Paper based system, with data sent from dispensaries and primary health
clinics sent to national reference hospital quarterly
e. Education systemfor women of childbearing age (15-49) distributed and
implemented within 9 months of program implementation
f. IMCI-like flowcharts are distributed to healthcare facilities and community
health workers to assist in counselling and educating about HIV/AIDS and
pregnancy
i. Informational calendars and pamphlets are available to women
presenting at ANC facilities as measured by semiannual third-party visits
g. Women of childbearing age (15-49) are aware of the benefits of exclusive
breastfeeding, prevention, and treatment, as assessed by a KAPs survey within 2
years of program implementation
h. Healthcare workers are educated on the importance of confidentiality and
compassion when it comes to HIV testing, and are competent as determined by
assessment within 2 years or program implementation.
i. Advertisements run across the country targeting women of childbearing age (15-
49) on radio and television within 6 months of design. Advertisements of this
nature will run throughout the project, with different versions created every
year.
3. Inputs:
a. Funding acquired from donor within 1 month of program implementation
b. Education systemfor women of childbearing age (15-49) devised within 3
months of program implementation
i. Includes information on transmission (either during pregnancy, delivery,
or breastfeeding), testing availability, and treatment (within the Option
B+ system, so for life)
1. Is composed in a manner that accommodates language barriers
and illiteracy, although Kenya’s literacy rate is 85%76
c. ART supply chain is devised and established (within the centralized context of
Kenya), within 6 months of program implementation
i. Distribution systemand proper protocols are established according to
WHO recommendations
d. HIV test (effective for both women and infants) supply chain is also established
within the current health system, including backups for 3 months, barring
catastrophe, within 6 months of program implementation
i. Test kits can be distributed with ARVs, should they come from the same
supplier

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e. Monitoring systemdevised and implemented within 6 months of program
implementation by data analyst and equivalent representatives from existing
programs
i. System will track data for women visiting facilities, whether women are
counselled regarding HIV and transmission during pregnancy as well as
breastfeeding, women and their children tested for HIV and their
serostatus, delivery of ARVs, and relevant health outcomes as
additionally capable (i.e. if facilities are able to test for CD4 count, these
data are included)
f. Advertising targeting women of childbearing age explaining HIV/AIDS and the
possibility of transmission during pregnancy is devised within 6 months of
program implementation.
i. Advertising includes the message that once ART is initiated, it is
continued for life
g. IMCI-like flowcharts are devised to guide health workers in counselling and
educating about HIV/AIDS and pregnancy within 3 months of program
implementation
i. These packets include calendars and informational pamphlets for women
to take home with them with all of the information written down in a
clear manner
Budget
The Kuinua Foundation is requesting $50,000,000 per year for a five year intervention. This is
because the Foundation seeks to provide for antiretroviral therapy that the government of
Kenya cannot initially afford as well as for advertisements targeted at women of childbearing
age (15-49) in Kenya, which amounts to about 11 million women.77 With these monies, the
Foundation hopes to fill the gap left by PEPFAR and other donor organizations.
i. 5% of the budget will be directed to personnel, including living and travel stipends
ii. 15% advertising and information dispersal, including (but not limited to) the creation
and dispersal of IMCI-like flowcharts and informational pamphlets for women
iii. 62% for new ARVs according to WHO Option B+ recommendations and test kit
financing
iv. 3% to pay for rent and minimal utilities at base in Mombasa and US
v. 15% data collection and evaluation, including the production of new
recommendations as directed in the strategic plan
Abbreviations and Acronyms:
AIDS: acquired immunodeficiency syndrome
ANC: Antenatal care
ART: anti-retroviral therapy
ARV: anti-retroviral drug
77 CIA. "The World Fact book: Kenya." accessed 12 December,
2013, https://www.cia.gov/library/publications/the-world-factbook/geos/ke.html.

15
AZT: azidothymidine
CHW: Community Health worker
EGPAF: Elizabeth Glaser Pediatric AIDS Foundation
FBO: faith-based organization
HIV: Human immunodeficiency virus
HAART: Highly Active Antiretroviral Therapy
HEI: HIV exposed infants
ICAP: International Center for AIDS Care and Treatment Programs
IMCI: Integrated management of childhood illnesses
KAPS: knowledge, attitude, and practices
MCH: Maternal and Child Health
MDG: Millennium Development Goal
MTCT: mother to child transmission
eMTCT: eliminating mother-to-child transmission
PMTCT: preventing mother-to-child transmission
NVP: nevirapine
PEPFAR: U.S. President’s Emergency Plan for AIDs Relief
UNAIDS: United Nations Program on HIV/AIDS
UNICEF: United Nations Children’s Fund
Works Cited
Prevention of Mother-to-Child Transmission of HIV. Washington D.C.: Elizabeth Glaser Pediatric
AIDS Foundation, 2013. http://b.3cdn.net/glaser/2751cebfc5144b7683_oym6bfjdp.pdf.
"Study: Electronic Health Records Improve Care in Kenya." International Business Times, March
21, 2011.
Belluck, Pam. "As HIV Babies Come of Age, Problems Linger." New York Times, November 5,
2010.
CIA. "The World Fact book: Kenya.” accessed 12 December, 2013,
https://www.cia.gov/library/publications/the-world-factbook/geos/ke.html.
ICAP Global. Health. Action. Columbia University Mailman School of Public Health. "Where we
Work: Kenya.” accessed 11/20, 2013, http://icap.columbia.edu/where-we-work/kenya.
Kenya Ministry of Health and WHO. Service Availability Mapping (SAM), 2007.
Kenya Office of the President National AIDS Control Council. The Kenya AIDS Epidemic, 2011.
Kenya Office of the President National AIDS Control Council. Kenya National AIDS Strategic Plan
2009/10-2013/13: Delivering on Universal Access to Services, 2009.

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Msellati, Philippe. "Improving Mothers' Access to PMTCT Programs in West Africa: A Public
Health Perspective. “Social Science & Medicine 69, no. 6 (9, 2009): 807-812.
Otieno, Phelgona A., Pamela K. Kohler, Rose K. Bosire, Elizabeth R. Brown, Steven W. Macharia,
and Grace John-Stewart. "Determinants of Failure to Access Care in Mothers Referred to
HIV Treatment Programs in Nairobi, Kenya." AIDS Care 22, no. 6 (06, 2010): 729-736.
PEPFAR. Kenya Operational Plan Report: PEPFAR, FY 2012.
UNICEF. Sixth Stocktaking Report Children and AIDS, 2013.
———. . Options B and B+: Key Considerations for Countries to Implement an Equity-Focused
Approach, 2012.
———. Kenya: PMTCT 2010.
———. . Children and AIDS: Fifth Stocktaking Report, 2010.
WHO. "HIV/AIDS Factsheet.”, accessed November 30, 2013,
http://www.who.int/mediacentre/factsheets/fs360/en/index.html.
———. . Programmatic Update: Use of Antiretroviral Drugs for Treating Pregnant Women and
———. . Antiretroviral Drugs for Treating Pregnant Woman and Preventing HIV Infection in
Infants: Towards Universal Access, Recommendations for a Public Health Approach. WHO
HIV/AIDS Program, 2006.
———. "Sexual and Reproductive Health: Prevention of Mother-to-Child Transmission of HIV
and Family Planning.”, accessed November 12,
2013,http://www.who.int/reproductivehealth/topics/linkages/pmtct/en/.
WHO: Department of Reproductive Health and Research. Kesho Bora Study: Preventing Mother-
to-Child Transmission of HIV during Breastfeeding, 2011.

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