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USAID/KENYA
 CARE AND SUPPORT PORTFOLIO
FINAL EVALUATION REPORT
(June 21, 2004)
Presented to the Office of Population and Health
USAID/KENYA
Prepared by:
Sandra Haim—Team Leader
Deryck O. Omuodo—Consultant
Other Team members:
Pauline Mwololo, NASCOP
Janet Paz-Castillo, USAID
Dr. John Wasonga, USAID
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Table of Contents
ACRONYMS..................................................................................................................................................5
EXECUTIVE SUMMARY ..........................................................................................................................6
BACKGROUND............................................................................................................................................8
USAID’s HBC IMPLEMENTATION PROCESSES...............................................................................9
USAID’s HOME-BASED CARE PROGRAMS: A BRIEF OVERVIEW ..........................................10
PREVENTION ............................................................................................................................................13
VOLUNTARY COUNSELING AND TESTING ACTIVITIES....................................... 13
Recommendation:......................................................................................................... 13
PEP ACTIVITIES ............................................................................................................ 13
Recommendation:......................................................................................................... 14
BCC AND IEC ACTIVITIES........................................................................................... 14
Recommendations: ....................................................................................................... 14
CONDOM USE/DISTRIBUTION.................................................................................... 15
PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT)......................... 15
Recommendations: ....................................................................................................... 16
STIGMA REDUCTION................................................................................................... 16
Recommendation:......................................................................................................... 16
TRAINING AND SUPPORT.....................................................................................................................17
INCENTIVES .................................................................................................................. 17
Recommendations: ....................................................................................................... 17
SUPPORT OF THE CHW................................................................................................ 17
Recommendations: ....................................................................................................... 19
TRAINING OF CHW ...................................................................................................... 20
Recommendations: ....................................................................................................... 20
BARRIERS TO EFFECTIVE HBC CARE.............................................................................................21
STIGMA .......................................................................................................................... 21
Recommendations: ....................................................................................................... 21
WEAK REFERRALS AND LINKAGES......................................................................... 21
Recommendations: ....................................................................................................... 22
LACK OF SUPPORT TO CAREGIVERS ....................................................................... 22
Recommendations: ....................................................................................................... 23
LACK of FOOD/ADEQUATE NUTRITION................................................................... 24
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Recommendations: ....................................................................................................... 25
MITIGATION OF THE CLINICAL EFFECTS OF HIV/AIDS..........................................................26
ANTIRETROVIRAL DRUGS (ARV).............................................................................. 26
Recommendations: ....................................................................................................... 27
MITIGATION OF THE SOCIAL EFFECTS OF HIV/AIDS ..............................................................28
INCOME GENERATION ACTIVITIES.......................................................................... 28
Recommendation:......................................................................................................... 28
ORPHANS AND VULNERABLE CHILDREN (OVC)................................................... 28
Ready-to-Learn/Speak for the Child.............................................................................. 30
Recommendations: ....................................................................................................... 31
SUSTAINABILITY.....................................................................................................................................32
Recommendations: ....................................................................................................... 32
CONCLUSION............................................................................................................................................33
THE WAY FORWARD .............................................................................................................................35
ANNEX 1......................................................................................................................................................38
Team Members................................................................................................................. 38
ANNEX 2......................................................................................................................................................39
Methodology .................................................................................................................... 39
ANNEX 3......................................................................................................................................................41
Bibliography..................................................................................................................... 41
ANNEX 4......................................................................................................................................................42
Scope of Work.................................................................................................................. 42
ANNEX 5......................................................................................................................................................48
Evaluation Tool................................................................................................................ 48
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ACKNOWLEDGEMENT
The team would like to acknowledge and thank all those who assisted in this evaluation in
particular, the PLWHA and their families who opened their homes and shared their concerns
and struggles with us. We also would like to express our appreciation of the CHW who have
shown devotion and commitment to their communities.
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ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
ART Antiretroviral Therapy
ARV Antiretroviral (Drugs)
BCC Behavior Change Communication
BUCOSS Butula Community Based Services
CBO Community Based Organization
CHV Community Health Volunteers
CHW Community Health Workers
COGRI The Children of God Relief Institute
COPHIA Community Based HIV/AIDS Prevention, Care and Support Program
DHMT District Health Management Team
FBO Faith Based Organization
FHI Family Health International
FP Family Planning
FPAK Family Planning Association of Kenya
GoK Government of Kenya
HBC Home-Based Care
HIV Human Immunodeficiency Virus
IAP Integrated AIDS Program
ICROSS International Community for Relief of Starvation and Suffering
IEC Information, Education and Communication
IGA Income Generating Activity
IMPACT Implementing AIDS Prevention and Care Project
KARI Kenya Agricultural Research Institute
KENWA Kenya Network of Women with AIDS
K-Rep Kenya Rural Enterprise Program
LIP Local Implementation Partner
MOH Ministry of Health/Medical Officer of Health
NASCOP National AIDS and STI Control Program
NGO Non-Government Organization
OI Opportunistic Infection
OVC Orphans and Vulnerable Children
PEPFAR Presidential Emergency Plan for AIDS Relief
PEP Post-Exposure Prophylaxis
PSI Population Services International
PLWHA People Living with HIV/AIDS
PMTCT Prevention of Mother-to-Child-Transmission of HIV
PTC Post Test Club
REEP Rural Education and Economic Enhancement Program
SFTC Speak for the Child
STI Sexually Transmitted Infection
TASO The AIDS Support Organization (Uganda)
TBA Traditional Birth Attendants
TOT Training of Trainers
USAID United States Agency for International Development
VCT Voluntary Counseling and Testing
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EXECUTIVE SUMMARY
This evaluation of the USAID/Kenya’s HIV/AIDS care and support portfolio was to review
the status of home-based care (HBC) for persons living with HIV/AIDS (PLWHA), orphans
and vulnerable children (OVC), and related activities and make recommendations regarding
the contributions of these activities towards the revised and expanded HIV/AIDS strategy.
During the evaluation, the evaluation team (hereinafter referred to as the “team”) found that
family members are the predominant caregivers for PLWHA in the home. These family
members require supplies, education and support in order to provide this care. Health
facilities, whether public, private or faith-based, play a key role in the delivery of HBC.
Clinicians provide diagnosis, clinical management and treatment to ill clients as well as
supervision and training to community health workers (CHW). The CHW are generally
members of the community with little or no medical background who are offering their
services either voluntarily or in return for minimal incentives. Many of the CHW are on the
same socioeconomic level as the patients and often have income generation activities and
cannot devote all their time to HBC. Many CHW abandon the care activities due to their own
illness, or because they have obtained full time employment elsewhere. Although their clients
are asking for food, medication, supplies, and/or transport assistance, CHW can only offer
some very basic services and good will.
Stigma and poverty complicate the community’s ability to provide care. Some families have
rejected PLWHA who in turn often change residence in order to escape from stigma. Others
are fearful that visits from CHW will indicate to their neighbors their HIV status. Many
PLWHA informed the team that they had never been to a voluntary counseling and testing
(VCT) center.
The team found that caregivers of PLWHA and CHW lack the necessary skills, supplies
and/or support to care for the PLWHA. Availability of medications and food supplementation
vary and depend on the HBC program’s ability to secure outside funding for these needed
resources. Support groups for emotional counseling and income- generating activities for
caregivers or bedridden clients are lacking. Provision of training and supervision for the CHW
is not uniform. Families do not have the training and the needed resources to care for the
clients adequately. None had a home-based care kit for the provision of care in the home.
Linkages between implementing partners providing HBC and health care facilities vary
considerably. Some facilities have staff that actively participates in HBC as supervisors to
provide training and guidance to CHW and that make home visits for care and treatment to
bedridden clients. In other cases, health care facilities had contributed only minimally to HBC
activities, yet these linkages are crucial to HBC. Individuals with advanced HIV/AIDS require
close monitoring of symptoms if they are to begin ARV therapy or medications for
opportunistic infections (OI). Throughout the evaluation, the team noted that CHW, who do
not have medical training, are conducting home visits without an initial plan of care developed
in conjunction with a medical provider. None of the HBC programs that the team visited had
implemented a plan based on physical, nutritional, psychosocial assessment of the client.
Regular and frequent supervision and on the job training are therefore needed.
This evaluation established that the basic daily needs of PLWHA and their families such as
food, soap, linen, clothing and drugs are generally lacking. Primary care needs such as
palliative medications, and opportunistic infection prophylaxis are also lacking. Almost none
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of the PLWHA visited were on antiretroviral therapy (ART). The evaluation also established
that in order for antiretroviral drugs (ARV) to reach those in most need, increased awareness,
stigma reduction, transport and nutrition needs, and methods of distribution must be
addressed.
From a care and support perspective, HBC in Kenya is in its infancy and is largely donor￾driven. The Government of Kenya (GoK) specifically, National AIDS and STI Control
Program (NASCOP) has developed HBC guidelines, but it lacks financial and human
resources to monitor implementation of the guidelines. HBC services are fragmented due to
the numerous donors who have not made coordinated efforts in the provision of HBC
services. The GoK and its partners should facilitate NASCOP to refine and more vigorously
support the HBC models through monitoring and evaluation of HBC, dissemination of
information, and through a more active participation in HBC. Without active involvement of
NASCOP, and a coordinated response by donors, faith-based organizations (FBO) and non￾governmental organizations (NGO), home-based care will be unable to address the HIV/AIDS
epidemic adequately and consistently.
Future strategies in planning and implementation of HBC should include upgrading the
quality of service delivery for care and support through the strengthening of linkages with
health care facilities as well as ensuring that the necessary supplies and treatments are
available to the PLWHA. Additional health care facility staff will require training and
sensitization in order to provide more supervision to CHW and to effectively refer clients to
HBC. Comprehensive Care Centers can play a pivotal role in the provision of HBC to
PLWHA through their staff participation as referrers and supervisors as well as in the
provision of comprehensive care to the PLWHA. Replicating the Port Reitz Palliative Care
Center, which initiates care and education of the PLWHA and the family during the hospital
stay through a successful linkage with the CHW, and provides a holistic approach to care, is
advised. Future strategies should also consider addressing the high rates of stigma with a more
inclusive approach whereby clients with other terminal illnesses can receive services.
Sustainable HBC programs were noted to be those that were either strongly linked with the
health infrastructure and included capacity building of the community through linkages with
food security and income generation activities and mission hospital home-based care
programs which provided clinical supervision and a focus on psychosocial support of
recipients and providers of HBC.
The future of USAID funded HBC programs should be in the direction of ensuring that its
programs are strongly linked to existing health facilities and that all programs include the
necessary components or linkages for prevention, outreach, income generation, capacity
building, psychosocial support and food security activities. Because of the diverse and
numerous needs of OVC, services provided to them should be specific to this population and
will need to address, the many issues facing the growing number of OVC in Kenya.
The team considers that the gains and shortcomings or constraints experienced so far in the
implementation of programmatic activities can be looked upon as opportunities and lessons
learned that should improve performance and enhance benefits. The evaluation team has made
many recommendations in this report that may require selective implementation, depending
on the priorities of USAID and the needs on the ground.
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BACKGROUND
In 1998, USAID/Kenya designed a strategy to address the areas of HIV prevention, and care
and support for PLWHA and the families that care for them. Under this plan, specific
activities have emphasized a community-based approach to providing physical and
psychosocial support to adults and children affected by AIDS. Such activities have made
progress on a number of objectives, including:
• Improving the ability of local communities to identify their needs in home-based care
by engaging in extensive community mobilization and participation of local leaders
and community members;
• Increasing the capacity of local NGOs engaged in prevention and treatment programs
by partnering with institutions with resident technical expertise;
• Strengthening existing systems of home-based care, support, and referral for HIV+
adults and children by linking doctors, nurses, social workers, and community health
workers; and
• Helping communities identify the specific needs of HIV positive orphans and
vulnerable children and specific needs of their caregivers, and facilitating support for
these individuals.
According to the 2003 Kenya Demographic and Health Survey (KDHS), adult seroprevalence
is 6.7%. Over 100,000 people died from AIDS in 2003 (AIDS in Kenya, NASCOP). Currently,
1,100,000 adults (age 15-49) and 62,000 adults over the age of 50 are living with HIV.
Approximately 100,000 children are currently infected with HIV. One of the worst impacts of
AIDS deaths to young adults is an increase in the number of orphans. There are currently
1,700,000 OVC under the age of 18 from all causes and over 900,000 children under the age
of 15 have lost one or both parents to HIV/AIDS (KDHS Preliminary Report, 2003).
Given the nature of the epidemic in Kenya, and Kenya’s strong partnership with the
Government of the United States of America in efforts to mitigate the impact of HIV/AIDS,
Kenya was among twelve African nations chosen to benefit from significant resources from
the Presidential Emergency Plan for AIDS Response (PEPFAR). These additional resources
carry a requirement to reach aggressive targets for prevention, care and support, and treatment
with ART. Most relevant to this report is an expectation of reaching 1.25 million HIV
positive Kenyans (including OVC, home-based care, and other non-ART clients) and treating
250,000 PLWA with ARV by the year 2008 (PEPFAR Targets).
The objective of the evaluation of the USAID/Kenya’s care and support portfolio was to
review the status of home-based care, OVC, and related activities, and make
recommendations regarding the contributions they can make to this revised and expanded
HIV/AIDS strategy. Specific attention of the evaluation was to focus on the extent to which
presently funded programs can scale up and/or offer some of the complex care and treatment
services under proposed PEPFAR, as well as scale up of prevention of mother-to-child
transmission (PMTCT) initiatives.
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USAID’s HBC IMPLEMENTATION PROCESSES
HIV/AIDS care and support programs have focused on how to achieve greater community
participation, both in minimizing congestion on the formal health sector and in meeting the
extensive needs of people infected and affected by HIV. Donors, local FBO, NGO, and
community outreach groups look upon community mobilization as key to the sustainability
and success of care and support strategies. There is an enormous potential for home care
teams to contribute to HIV prevention and care and support at the family and community
levels. However, the team noted that community involvement, particularly in the provision of
services, can be difficult to initiate or sustain and is especially hard to establish on a wide
scale. The reality is that families and communities are not always able or ready to help
relatives or friends who have AIDS. This is partly due to the great stigma associated with HIV
and AIDS, as well as the fact that most of these families tend to lack the skills and resources
to care for such ill persons. Many of the community health workers are on the same socio
economic level as the patients and simply cannot afford to do much except share good will.
Community health workers tend to suffer from burn out, or simply do not have the time or
commitment to sustain their volunteerism.
USAID funds IMPACT, COPHIA, COGRI, and AED to work with local NGOs to provide
services that address prevention of HIV and care and support of PLWHA at the community
level. In order to improve the quality of life of families affected by HIV, the home based care
programs have focused on; prevention and behavior change activities, training of CHW,
developing working relationships with health facility staff, forming community committees,
and creating linkages with food security, medical provisions, nutritional support and
microfinance activities.
Currently, USAID funded HBC programs are being implemented in one of two ways: 1)
Community-based (either by NGO, CBO or FBO) or, 2) Health facility-based (mission or
government hospitals). A third approach is emerging whereby a CBO or NGO is incorporated
within a health care facility that offers comprehensive services such as ICROSS in Nakuru
and to an extent COPHIA in Thika and in Port Reitz. (Table 1) Where the HBC services are
health facility based (mission hospitals and /or government hospitals), the team saw a stronger
linkage with health care personnel. The team noted that mission hospitals and FBO had
stronger psychosocial support for CHW and PLWHA but economic barriers prevent many
from obtaining the needed medical services. Community based organizations such as some
that COPHIA is working with, varied in their access to food, medications and the provision of
support services, as well as their focus and hub of activities (pharmacy, versus outpatient
clinic versus community outreach). Community based organizations, for the most part had
weaker linkages with health facilities, and weaker support to the caregiver. It is outside of the
scope of this evaluation to appraise and comment in detail on each.
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Table 1: Home-based care models
HOME-BASED
CARE MODELS
Linkages
with HC
facilities
Psycho-social
support
Community
mobilization
and
outreach
Access to
medications,
supplies,
nutrition
support
Drawbacks Linkages with
ancillary facilities
(VCT, PMTCT, STI,
TB CLINICS)
Health Facility
Based
Mukumu Hospital
St. Mary’s Hospital
Bungoma Hospital
strong stronger in
mission
hospitals
variable dependent on
institution
cost
stigma (for
FBO)
limited
geographical
coverage
variable
Community-Based
COPHIA
AED
COGRI
weak stronger with
PLWHA
networks or
FBO
usually
strong
donor
dependent
and variable
lack of
technical
supervision
isolated
(stand alone)
weak
Emerging
integrated model
COPHIA (Thika
and Port Reitz)
ICROSS (Nakuru)
strong available as
part of
services
offered
variable donor &/or
institution
dependent
need for
collaboration
possible high
cost
strong
USAID’s HOME-BASED CARE PROGRAMS: A BRIEF OVERVIEW
1. COPHIA
The Community-Based Program on HIV/AIDS Care, Support and Prevention (COPHIA) is
the largest home-based care program funded by USAID in Kenya. Initially, it was to run for
three years, from June 1999 and implemented through Pathfinder International (PI). Following
a Mid-term evaluation conducted in June-July 2001, USAID granted a cost extension until
June 2003, followed by a second extension from July 2003 to June 2005. COPHIA’s approach
is to build the capacity of communities, local implementing partners (LIP), community
volunteers, PLWHA, members of vulnerable households such as orphans and caregivers to
enable them to develop appropriate skills. Provision of home-based care (HBC) to PLWHA is
the primary focus for the COPHIA project.
One of COPHIA’s approaches to HBC is to use existing cadres of community-based workers
who are active and in touch with local residents to provide support and to bridge the gap
between hospital professionals and caregivers at home. The project also provides training for
LIP as a way of building their capacity. At Mukumu Mission Hospital, the evaluation team
was able to get more insight into the workings of the COPHIA approach to HBC that uses a
cross referral model (community to health facility and health facility to community with
outreach follow up) through CHW backed up by clinical supervisors from the hospital. This
model works effectively and efficiently for those who can afford it. It also provides the
essential clinical links that add value to HBC. The format of providing services is
comprehensive and includes, among other things:
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• Hospital admissions based on assessment of patient condition
• Provision of home-based care and outreach services
• Provision of VCT services
• Diagnostic testing including CD4 count
• Links with a micro-finance scheme
• Presence of a post test club (PTC) within the health facility that links with other
support groups
The other approach that COPHIA uses is the community-based model in which the
responsibilities for providing HBC and support services are community-based, and volunteer
or community-driven. In implementing this model, local implementing partners in the form of
youth groups, women’s groups, FBO, CBO, and community pharmacies (Bamako Initiative
Centers) receive funding specifically to promote community mobilization and provide HBC
and support. COPHIA also trains health facility staff and more experienced CHW or
community members to provide supervision to the CHW. Some of these partners (KENWA,
REEP, Redeemed Gospel) also provide primary medical care in the form of health clinics
staffed by a nurse. Community based organizations are usually accessible and play an
important role in prevention activities. These organizations are often able to mobilize
additional resources.
2. FHI/IMPACT
At St. Mary’s Hospital in Mumias, the team found that FHI/IMPACT uses a health facility￾based model with a component of community outreach. Community health workers are the
link between the hospital and the community-based caregivers. Several levels of support are at
work in this model. At the hospital, there is a multi-disciplinary team consisting of doctors,
nurses, auxiliaries and social workers contributing to home-based care related services. Nurses
and CHW make regular home visits to provide needed services, deliver supplies or monitor
the progress of clients. A social worker can provide services directly, supervise service
provision by the HBC caregiver, or refer the client to the nearest appropriate referral center.
The Bungoma program, now under the MOH but previously run by FHI/IMPACT and
ICROSS, also uses this model based at Webuye Sub-District Hospital.
FHI/IMPACT has recently begun introducing a new model for care that involves the
establishment of comprehensive care centers at selected sites within the Kenyan
government’s general hospitals in Western, Rift Valley, Nairobi and Coast Provinces. Six of
these centers are already operational with 16 more proposed in the near future. An
FHI/IMPACT comprehensive care center offers a wide range of services, including VCT, OI
prophylaxis and management, ART, nutritional advice, PLWHA support, STI treatment and
management, treatment of TB, adolescent counseling and services, and reproductive health
services. Great opportunities thus exist for the expansion of HBC outreach services that can
easily operate out of these comprehensive care centers that would seal the gaps for clinical
supervision and other needed HBC services.
3. ICROSS
ICROSS, which is a partner of IMPACT in Bungoma and a REACH partner in Nakuru, is
unique in that it includes aspects of sanitation and nutrition. The sanitation component
involves digging of VIP pit latrines while the community food bank involves maintaining a
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food (largely beans and dry maize) surplus over the course of the year. Teachers, religious
leaders and other community members have been able to secure donations in the form of food
from large farms or well to do benefactors. This surplus is stored and PLWHA who are in
greatest need are able to access the food supplies. The ICROSS model also includes working
with both Government health facilities and private health providers to back up community
outreach HBC. The policy of ICROSS is not to stay on sites beyond introducing this model
and establishing its operational linkages with those of the government, community and private
providers with the goal of future ownership and sustainability.
4. THE LEA TOTO PROJECT
The Children of God Relief Institute, (COGRI) manages the Lea Toto Project in order to
provide homecare services to HIV infected children up to age of 18 years. Activities include
community mobilization, outreach activities and home visits. Social workers provide
supervision to the CHW. The Lea Toto Project has two nurses who provide basic medical care
including drugs for opportunistic infections (OI) to clients and their families in their clinics.
There is also a food distribution program through CRS for malnourished children. Sick
children are referred to nearby health facilities. There are support groups for CHW and there
is regular supervision of the staff by outside facilitators. There is a plan to offer microfinance
loans to CHW and caregivers.
5. READY-TO-LEARN/SPEAK FOR THE CHILD
The Ready-to-Learn/Speak for the Child (SFTC) project, implemented by the Academy for
Education and Development (AED) addresses the physical, cognitive and psychosocial needs
of under five OVC by providing support and education to caregivers regarding the emotional
development and health of children. Another aspect is to build capacity of other organizations
in Kabras Location in Western Province, to deliver OVC support and services in their
communities. SFTC has obtained funds for food distribution that is solely for their OVC target
group under the age of five years. SFTC assists preschool age children to enroll in pre￾schools. The project has developed linkages with health facilities to ensure that OVC and
caregivers seek out health services for vaccinations, and other medical care.
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PREVENTION
Current USAID funded HBC programs all have a component of prevention. Partners have
made significant strides in mobilizing communities through the formation of community
implementing committees as well as sensitizing various religious groups and other
organizations. CHW refer clients and community members for VCT, PMTCT and STI clinics,
distribute condoms, and mobilize and educate their communities. Youth groups have been
trained as peer educators to conduct behavior change activities in order to reduce stigma
associated with HIV/AIDS in their communities and improve self-risk perception among
youth. CHW have been trained to address issues of stigma and prevention as well as provide
care and support to PLWHA. The question remains whether CHW, as volunteers with no
clinical background can adequately address all the issues of HIV prevention as well as provide
care and support to the PLWHA. In the future, consideration should be made as to whether
some of the prevention activities could be shared with the existing group of Kenyan public
health technicians.
VOLUNTARY COUNSELING AND TESTING ACTIVITIES
As part of the questionnaire administered during the evaluation, sixty nine PLWHA were
asked the following question, “Have you or anyone in your household ever been to a VCT
center?” In Mombasa, 42%, Western, 24% and Central 19% reported never having been to a
VCT center. VCT and knowledge of serostatus may encourage people to reduce risky
behavior. It can also be an entry point for the provision of other services such as PMTCT, TB
detection and treatment, ARV, and psychosocial support. These clients are recipients of HBC
services in the form of health education, medications, nutrition support etc, but are unwilling
to discuss their illness or HIV status with the person providing them care.
In some of the areas that the team visited, people lamented of a lack of VCT centers
(Kongowea in Coast Province, Bungoma and Kabras in Western Province). In the larger
hospitals such as Thika, and Coast General, there is a two-week waiting period for VCT
services due to high demand. CHW and program staff informed the evaluation team that there
might not be enough VCT centers to cater to all who need these services. However, there may
in fact be underutilization of VCT centers in some areas and over utilization in other areas due
to issues of stigma. People may prefer VCT centers located in large hospitals where they may
be able to maintain their anonymity.
Recommendation:
1. Prior to consideration of adding or expanding current VCT centers, USAID
should collaborate with NASCOP and implementing partners to conduct a needs
and service utilization assessment that would establish the level of usage of
existing VCT centers.
PEP ACTIVITIES
While transmission of HIV in health care settings is not a major mode of transmission,
prevention of such a transmission should be part of health care service delivery. In resource
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poor health facilities with a high patient population HIV prevalence rate, the risk of
occupational transmission may be higher.
PEP activities were for the most part nonexistent in health facilities visited. The team asked
health care facility managers if PEP activities were in place. Out of seven health facilities
visited, only two had posted the PEP guidelines (FPAK in Nakuru, and Tawfiq Hospital in
Malindi). Neither of these facilities actually stocked ARV. The five government facilities
visited had not yet posted guidelines nor had they begun to educate hospital personnel. This
policy needs to be fully implemented not only as a response to work related injuries but also
to address rape victims who in some areas of Western province are being referred to Nairobi
for PEP. Addressing the problem of occupational risk and exposure may also boost staff
morale and thus improve patient care.
Recommendation:
2. Those identified to be responsible for the distribution of PEP guidelines should
ensure incorporation of training so that health care staff is aware and
knowledgeable of those guidelines, as well as have the necessary medications and
supplies needed to implement them.
BCC AND IEC ACTIVITIES
CHW indicated that they actively participated in the distribution of Information, Education
and Communication materials (IEC). However, upon inspection of homecare bags, there were
no educational materials in the form of pamphlets, brochures, stickers or leaflets for
distribution to their clients or other members of the community. The team noted that a number
of CHW did not read or speak in English. All area managers stated that the behavior change
communication (BCC) and IEC materials were inadequate. Some LIPS had file cabinets with
some IEC and reference material stored away that seemed difficult to access.
Recently, NASCOP produced a number of home-based care documents for use at various
levels of implementation. They include a policy guide, a service program guideline, a training
curriculum, a reference manual, an orientation pack for health workers, a flip chart for training
CHW and a pamphlet. Dissemination/distribution of the guidelines seems haphazard and non￾existent at the care providing level.
The team saw BCC in the form of PSI trained youth groups in Western and Central Provinces.
However, in the Mombasa area the team did not meet any representatives of youth groups and
it was not clear as to whether these groups are currently active.
Recommendations:
3. If IEC items are made available to implementing partners, the distribution of
these items should include instructions and training on methods of use. Some
reference materials for CHW who are illiterate or read/speak only Kiswahili is
needed.
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4. COPHIA should work more closely with PSI to ensure that PSI funded youth
groups are more visible in the Coast Province and promoting the COPHIA care
and support activities.
CONDOM USE/DISTRIBUTION
A large number of clients interviewed stated they did not use condoms for various reasons: In
Mombasa, 24 out of 31 (77%) PLWHA interviewed stated they did not use condoms, whereas
in Central province the rate was 81% (17 out of 21) and it was 71% (12 out of 17) in Western
province. The most common reason for not using condoms was that the client was practicing
abstinence. However, as ART becomes more accessible to these clients they are likely to
regain health and become sexually active. In this regard, CHW will need to be equipped to
engage their clients in discussions about condom use.
CHW carried and distributed condoms, but only two carried a penile model for demonstration
of condom use. All health facilities and collaborating agencies visited by the evaluation team
distributed condoms with the exception of St Mary’s and Tawfiq Hospital for religious
reasons. Several CHW also stated that for religious reasons they could not discuss or
distribute condoms. Each health facility distributed from 250 to 1000 pieces weekly.
PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT)
In order to assess women’s awareness of PMTCT 28 women were asked the following, “Do
you know how HIV can be transmitted to babies?” and “Do you know how transmission of
HIV can be prevented in babies?” Thirty nine percent of the women in Western Province (7
out of 18) and 63% (5 out of 8) in Mombasa did not know how HIV could be transmitted to
babies. Regarding prevention of transmission, 67% (12 out of 18) of women in Mombasa did
not know how HIV transmission could be prevented from mother to child, whereas 50% (4
out of 8) of the women in Western province stated they did not know. In Central Province,
there were only 2 respondents both of who knew at least one method of transmission and
prevention.
As per the COPHIA 2003 Cost Extension Proposal, future refresher trainings would include
community-based interventions for PMTCT. While the team did not directly assess the CHW
knowledge of, or training in PMTCT, none of the CHW mentioned any involvement with
PMTCT education to the community or to their clients as one of the services/activities they
provided.
Five of the health facilities visited by the team offer PMTCT services (Tawfiq Hospital￾Malindi, Nakuru Hospital, Port Reitz Hospital-Mombasa, Khunyangu Sub District Hospital￾Butula, and Redeemed Gospel-Nairobi). The number of PMTCT clients per week was;
Redeemed-10, Tawfiq-5, Nakuru: n/a, Port Ruiz-33, Khunyangu-30, and Port Reitz-33.
The need for CHW participation in the mobilization of communities regarding PMTCT
activities was reported in the 2003 Evaluation of UN supported pilot projects of PMTCT
activities in Kenya. More CHW should be trained in counseling of ANC clients for VCT
testing, and to educate women on the importance of exclusive breast feeding for the first six
months after birth. According to the 2003 Kenya Demographic and Health Survey,
supplementation of breast milk starts early. Only 29% of children under the age of 2 months
are exclusively breast-fed. This figure drops to 9% in children under 4 months of age who are
16
exclusively breast-fed. CHW can also catalyze leaders of communities to endorse men’s
involvement in PMTCT. Lack of male support hinders women from receiving PMTCT
services especially HIV testing, completing ARV treatment, and using breast milk substitutes.
Recommendations:
5. There should be greater collaboration between CHW and TBA and PMTCT
health care staff to educate women and their partners in the community about
PMTCT services. Ministry of Health and its collaborating implementers should
include TBA in CHW trainings on infection prevention and PMTCT.
6. In order to increase the effectiveness of PMTCT services, CHW should take a
more active role in counseling ANC clients for VCT testing, educating women on
PMTCT, exclusive breast feeding and the importance of family planning.
STIGMA REDUCTION
Stigma was raised as an issue by CHW in almost sites visited. Butula in Western Province
was an exception. Here, many PLWHA had come out openly with their HIV status. CHW
stated they no longer mobilize for VCT as clients themselves are bringing in friends and
relatives for testing. When asked why stigma had declined in this area, it was partially
attributed the decline to a “Butula AIDS Day” where 60 people declared their status. They
also mentioned their close proximity with Uganda as an explanation and responded that HIV
had been particularly widespread and devastating in the Butula area, therefore accepted by the
community as a problem that needed to be tackled openly. They also mentioned the fact that
past political leadership in the area (the immediate former MP) had confronted the matter
openly.
Methods and amount of time devoted to addressing stigma varied. Most HBC programs were
addressing stigma through youth group activities such as theater groups presented to churches,
community gatherings and schools. CHW were involved in mobilizing their communities and
discussing condom use, transmission of HIV and the importance of VCT.
Members of PSI funded youth groups were well spoken and active in their work, most were
living positively, and many requested CHW training. They discussed the difficulty in raising
HIV/AIDS awareness in schools. As part of COPHIA’s two-year project extension one of the
three community activities was to focus on increasing self-protective behaviors among in￾school and out-of-school youths ages 15-24. Youth groups cited the teachers’ attitudes as
major blocks to sensitizing children particularly those under age 15. They described many
teachers as lacking adequate knowledge of HIV/AIDS in terms of the transmission and
precautions.
Recommendation:
7. In the future, the prevention activities of care and support programs should address
HIV education in schools at a younger age and in particular, target teachers.
17
TRAINING AND SUPPORT
INCENTIVES
All COPHIA supported CHW receive a minimal financial incentive of Shs. 2,000/=. The
incentive provided, cannot be considered a salary yet for some CHW this is their only source
of income. In the event that CHW are to be paid for their work, careful consideration would
have to be given to the criteria and selection of community members being chosen as CHW.
This would mean that they are recruited through a competitive process.
Many of the CHW have been given bicycles and uniforms. CHW verbalized their appreciation
for the bicycles, as they must often travel long distances to visit clients as well to attend
supervisory meetings. COPHIA has agreed to provide uniforms and bicycles to all CHW. Yet,
in all the sites visited a portion of the CHW did not yet have uniforms or bicycles.
In Mombasa, and Malindi, CHW receive Shs. 2,000/= transport allowance per month. In
Malindi, the CHW allocate Shs. 500/= out of this monthly allowance directly to Tawfiq
Hospital on behalf of each new client they refer to the hospital for basic supplies, care etc.
Some CHW complained that the hospital would not accept a second referral in the same
month as the hospital would not get an additional Shs. 500/=. In Mombasa, CHW allocated
Shs.50/= -100/= to each client. While it is commendable that the entire group of CHW in
Coast province had agreed to allocate 1/4 of their allowance to needy clients, giving a few
coins to each client is an ineffective and unsustainable method for assisting these clients.
ICROSS Community Health Volunteers (CHVs) and clinical supervisors, and IMPACT
CHW, appeared to do their work on a voluntary basis. They are involved in microfinance
schemes, receiving loans to start small businesses. There was no difference in caseload noted
between CHW who received an incentive and those that did not.
Recommendations:
8. USAID and other donors should consider providing special funding to Tawfiq
Hospital in defined areas in order for the hospital to have a stronger waiver
system instead of accepting donations from CHW for newly referred clients.
9. If CHW in the Coast Province are to continue donating 1/4 of their incentive to
needy clients, a more sustainable method should be developed whereby the Shs.
500/= is invested for or on behalf of the clients to enable them and their
dependants to benefit in the form of loans, medications, or food.
10. Every effort should be made for future CHW training and support activities to be
comparable throughout all HBC programs and with a more timely distribution of
necessary supplies and equipment.
SUPPORT OF THE CHW
Out of the 69 PLWHA visited, the team observed provision of care only once. Most of the
time, CHW did not have a homecare kit while accompanying evaluators on home visits. When
possible, home care kits were inspected, and depending on who was supplying the contents,
18
they varied from adequately filled to severely lacking anything to provide care. In order to
assess adequacy of materials, the team asked CHW what was in their homecare bag that day.
Thirteen percent of CHW in Western province and 16% of CHW in Central stated they did
not have any materials whatsoever. In Central and Western Provinces, almost 50% of CHW
did not have disinfectants. Thirteen percent of CHW in Central and 26% of the CHW in
Western did not have any gloves in their bags. (Table 2)
In homes visited, there were no available HBC kits. This meant that bedridden clients did not
have Jik, gloves, soap, dressings or basic medications.
Table 2: Items carried by CHW (as percentage)
Stocking homecare bags only once
in a month is inadequate to meet
the needs on the ground. CHW
had an average of 4-6 mobile
clients and 1-2 bedridden clients.
They make an average of 8-12
home visits per week. One bottle
of Jik, and a few bars of soap, one
box of latex gloves, and one roll of
toilet paper might be adequate for home visits but is not enough if they are expected to assist
clients and caregivers. CHW sometimes borrow from one another but their bags are restocked
by COPHIA only once per month.
Regarding support groups, 18 of the 31 CHW (60%) interviewed in Mombasa, reported that
they did not belong to a support group as compared to 29% (9 out of 31) in Western and 27%
(8 out of 30) in Central. Those that did, most often cited the benefit of the support group as
financial (getting K-Rep loans). The community health workers are in a difficult situation of
being friends, neighbors or acquaintances of the clients, usually in similar economic
situations, as well as often being of positive status themselves. They report exhaustion, feeling
overwhelmed, and emotional burnout and describe feeling compelled to reach into their
pockets to buy their clients food, drugs, or pay their transport to the hospital.
Clinical supervision of CHW is for the most part, weak. The team noted that it was strongest
in the Thika area as well as within ICROSS and mission based hospitals. In Thika and
Nakuru, the team found that both area managers and clinical supervisors were well aware of
the health status and issues of their clients. In Mombasa, COPHIA field supervisors were
unaware of several critical field issues that required their attention and intervention. COPHIA
has identified supervisors as TOTs who are either senior experienced CHW or clinical officers
working in health care facilities. Some of these TOTs are assigned to health facilities and are
overwhelmed with other duties. The discrepancy between available TOTs with little to no
formal clinical background, and those with extensive clinical background has several effects.
Meetings with supervisors vary from daily, to weekly to monthly. (Table 3) Sick or bedridden
clients may not get the best medical consultation from a non-clinical TOT. Their client will
have to travel to a health facility for medications and treatment while when a clinically trained
TOT makes home visits and carries drugs, they may be able to provide care and treatment in
the home and thus relieve the burden on the health facility.
TABLE 2 CONTENTS OF HC BAG
CENTRAL
(N=30)
WESTERN
(N=31)
MOMBASA
(N=30)
Gloves 87% 74% 97%
Soap 60% 58% 87%
Dressings 43% 65% 73%
Drugs 13% 29% 7%
Disinfectants 53% 55% 90%
Nutritional supply (porridge or vitamins) 20% 10% 3%
IEC materials 17% 16% 27%
Other(nail file, tongue depressor,etc) 53% 23% 30%
None 13% 16% 0%
19
Table 3: Percentage of CHW reporting on frequency of
meetings with supervisor
It was noted during the evaluation
that CHW were not using initial
assessments or care plans. CHW
should use an assessment or “care
plan” regularly to assess the needs
and issues of each client. A clinical
supervisor would do this within the
first month then reviewed and adjusted as Without a basic evaluation of each client’s status,
needs, issues and goals, there is no guiding standard to give direction to the CHW in how to
proceed with his or her work. Both CHW and supervisors should be assessing whether CHW
have reached the goals set, or whether the goals need to be revised.
As per NASCOP homecare guidelines, each CHW should have an average caseload of 6 to 7.
The motivation of CHW should be considered in relation to caseloads. Some have made
volunteerism a career. Others look at it as a stepping-stone to paid work. Others tend to
concentrate on other money earning ventures. Some CHW are ill or are caring for ill family
members. Western province seems closest to this targeted number having an average of 6.1
clients. In Central Province, CHW had an average of 4.8 clients and in Mombasa 4.3.
Caseloads varied anywhere from 20 to 1. For reporting purposes, some CHW are counting all
clients who have been referred to them including those who have resumed daily activities and
no longer require homecare. Clients who no longer require services should be discharged
from the active register list.
Recommendations:
11. Care and support programs should assist in the formation and functioning of
support groups for CHW on how to deal with burnout.
12. It should be a priority for care and support programs to reach out to MOH staff
to raise the awareness of the need for successful collaboration with health facility
personnel to provide homecare services. All CHW should have equal access to
and supervision from clinicians in the field. This will benefit the clients as well as
the CHW.
13. All homecare kits should have adequate stocks of basic materials for
providing care to the client as well as enough to assist in creating a homecare kit
for the home. Stocks of supplies should take cognizance of the number of
bedridden clients each month.
14. Care and support programs and NASCOP should be sure to undertake the
implementation of initial plans of care in all HBC programs. The plans should be
prepared within the first month of the registration of a new client by a clinical
supervisor together with the CHW on the case. This care plan, of which a copy
would be left in the home with the caregiver, would include general status of the
client, care to be provided by caregiver, goals, and issues that need to be
addressed by the CHW.
 Meetings with Supervisor
CENTRAL
(N=30)
WESTERN
(N=31)
MOMBASA
(N=30)
 Weekly 37% 45% 43%
 Monthly 33% 16% 23%
 2xmonth 17% 16% 20%
 >2x week 7% 10% 7%
 Never 7% 0% 7%
20
TRAINING OF CHW
The CHW were asked to list all refresher and in-services (on other topics) that they had
attended. A significant number stated they had not attended either a refresher and/or an in￾service since beginning with the project. (See Table 4) Some CHW raised the issue that
refreshers and in-services were presented as theory rather than by demonstration or
practicums.
Table 4: Attendance and types of training sessions for CHW
PAST TRAINING
CENTRAL
(N=30)
WESTERN
(N=31)
MOMBASA
(N=30)
Initial Training 100% 100% 100%
In-service training 67% 68% 57%
Refresher training 27% 26% 37%
Community health workers were asked, “What kind of services do you provide in the home?”
(Table 5) The CHW were free to think about their work, and offer the evaluator examples of
what they did, or list in general terms what they do. Less than 65% of all CHW mentioned
infection prevention specifically.
Table 5: Services provided in the home by CHW
SERVICES PROVIDED IN THE HOME
CENTRAL
(N=30)
WESTERN
(N=31)
MOMBASA
(N=30)
Other 33% 3% 13%
Nursing Care 67% 58% 63%
Administration of Medicines 27% 16% 43%
Health Education 80% 94% 87%
Counseling 73% 87% 53%
Nutrition Support 50% 71% 73%
Infection Prevention 57% 65% 50%
Recommendations:
15. All CHW should have the homecare manual in their bags, and other information
should be provided to those who cannot read English.
16. Since the CHW are adult learners with varying educational backgrounds,
refresher and in-service trainings should be offered on a quarterly basis, with a
concentration on actual demonstrations and practicums rather than theory.
Clinical supervisors should use the opportunity presented by their weekly
meetings to discuss either new issues, or review previously taught topics.
21
BARRIERS TO EFFECTIVE HBC CARE
 STIGMA
Stigma remains a barrier to accessing services. As stated previously, some clients of HBC
have not been to a VCT center and are unwilling to discuss their status. CHW are providing
care and support to some people who are unwilling to discuss their HIV status openly.
CHW in Mombasa region, reported fewer referrals: three out thirty (10%) to VCT than
Western 7 out of 31 (23%) and Central 10 out of 30 (33%) in the week prior to the evaluation.
This is consistent with reports of high rate of stigma and denial in the Mombasa region. The
team noted that the community health workers in all areas visited verbalized the difficulty
they had with stigma and the attitudes the community had towards them.
The CHW also expressed to the team that, due to the nature of their work, their communities
often stigmatize them. In all the sites visited community health workers told evaluators that
they were referred to as “those who work with HIV”. It seems that for some CHW this in itself
was a problem. Since CHW are themselves members of the communities they are serving,
stigma may be a barrier for them as service providers as well. On the other hand, there were
scattered complaints of CHW not maintaining confidentiality, or lacking the skills to approach
the discussion of the client’s need for VCT.
In Thika, the Integrated AIDS Project (IAP) PLWHA support group refused to meet with
evaluators in the same location as the CHW. The clients did not feel comfortable revealing
themselves to other CHW. In several locations, there were stories of HIV concordant couples
that refused to discuss or disclose their positive status with their spouses.
Recommendations:
17. All CHW and other social and community workers should be trained in
counseling to most effectively refer members of their community for VCT.
18. Further consideration should be taken as to whether a more inclusive HBC
program that provides services to all those that need them could decrease the
stigma associated HIV/AIDS and with the CHW.
WEAK REFERRALS AND LINKAGES
Referrals and linkages between HBC and health facilities are crucial to the health care
continuum. CHW that have no formal clinical training require clear communication from
healthcare providers regarding the care and needs of their clients.
Effective referral systems between HBC and adjacent health facilities vary considerably from
site to site. Most CHW had a referral form to send with clients to a VCT center, clinics, or
hospitals. In some instances, the evaluators were informed that CHW personally accompany
22
their clients to the health care facility. This ensures communication but may not be the best
use of their time.
Clinical supervisors for the most part have been able to access waiver systems from their
institutions for their HBC clients. Of seven health facilities visited, five (Khunyangu, Tawfiq,
Nakuru, FPAK-Nakuru, Port Reitz) stated that a waiver system was in place.
The government facilities do not formally refer their clients to HBC. The exception to this
was the Palliative Care Center of Port Reitz in Mombasa that calls the CHW in to meet the
client before discharge and initiates home based care training of caregivers prior to the
discharge of the client.
In Nakuru, ICROSS has developed strong linkages, and the clinical supervisors who work in
health facilities do meet regularly with their community health volunteers (CHV) for
supervision and joint home visits.
In Thika, Speak and Act has developed strong linkages with hospital staff. It was started by 30
CHW who were working independently and then registered as a CBO. The hospital has
provided them with a weekly meeting venue, as well as clinical supervisors were are able to
make weekly home visits with the CHW they supervise.
Recommendations:
19. Care and support programs should strongly encourage health facilities,
particularly where clinical supervisors work, to formally refer clients using
referral forms to HBC. This would facilitate an initial assessment and provide
CHW and family caregivers adequate information regarding the care and needs
of the client.
20. Since the Port Reitz palliative care center model seems to be working very well,
replicating it in other health facilities where possible would enhance linkages
between hospital and home through the initial training of caregivers. Involving
CHW closely with these palliative care centers could improve the care of the
PLWHA through more accessible and ongoing communication between clinical
staff and the families or caregivers of the PLWHA.
LACK OF SUPPORT TO CAREGIVERS
While HBC can decrease the burden of care on hospitals, the caregivers at home take on an
additional burden. Many of the caregivers visited are caring for several orphaned children and
were the sole breadwinners of the family. In addition, they must provide palliative care, food,
medicine, and personal care to one or more sick or dying relative. Caregivers require enough
training and instruction as well as psychosocial counseling and support to deal with this
increased burden. During the evaluation, caregivers were found to be predominantly family
members with the exception of Central Province where out of 14 caregivers four were either
friends or neighbors. It is presumed that in urban slum areas, family members have less of a
role in caring for PLWHA and the issue of institutional care in the form of hospice, or respite
care may be needed.
23
Fifty-six caregivers were asked, “Do you belong to a support group?” In Western Province
41% (9 out of 22) of caregivers belong to a support group. In Mombasa 10% (2 out of 20) and
in Central Province 21% (3 out of 14) stated they belong to a support group.
The team was informed by caregivers that they lacked necessary skills and knowledge to
adequately care for the PLWHA. Caregivers were asked “In what areas did you receive
training from the community health worker?” (Table 6) Many caregivers stated that they lack
the skills and training to provide palliative care, to administer medications correctly, to
identify signs and symptoms of TB or other illnesses that require medical attention as well as
to implement infection control measures in the home. In Western Province, 77% reported that
they had not received additional training from the CHW in the past year. In Mombasa, 65%
and in Central 43% caregivers stated they had not received additional training.
Table 6: Skills transfer from CHW to caregiver in home
AREAS OF TRAINING FROM CHW
WESTERN
(N=22)
MOMBASA
(N=20)
CENTRAL
(N=14)
Personal/palliative care 41% 50% 57%
Administration of medications 23% 40% 29%
Nutrition care support 50% 55% 64%
Signs/symptoms of TB 9% 40% 21%
Signs/symptoms requiring medical follow up 27% 40% 36%
Infection control 41% 50% 64%
Have you received additional training in past year? YES 18% 35% 57%
NO 77% 65% 36%
Recommendations:
21. Caregivers require additional training and support in order to care for
 PLWHA.
22. Care and support programs should assist in the formation and functioning of
support groups for caregivers, train and provide counseling to support group
members.
24
LACK of FOOD/ADEQUATE NUTRITION
When caregivers were asked, “What is the most difficult condition for you when caring for the
client?” providing palatable meals was one of the most frequently mentioned issues
particularly for Western and Central. They cited lack of food, and/or lack of appropriate food
for an ill client (Table 7).
Table 7: Percentage of caregivers reporting on the most difficult conditions en￾countered when providing care to PLWHA
DIFFICULT CONDITIONS WESTERN (N=31) MOMBASA (N=17) CENTRAL (N=21)
Diarrhea 14% 10% 14%
Pain 5% 5% 7%
Providing palatable meals 32% 5% 36%
Bedridden 18% 25% 0%
Skin 5% 5% 0%
Nausea/vomiting 5% 25% 0%
No difficulty encountered 5% 25% 29%
No appetite 0% 10% 7%
No response 0% 5% 14%
When asked, “What makes it difficult for you to provide care in the home? They mentioned
lack of food and lack of money most often. (Table 8)
Table 8: Percentage of caregivers reporting on why it is difficult to provide
care to PLWHA
DIFFICULTY IN PROVIDING
CARE WESTERN (N=31) MOMBASA (N=17) CENTRAL (N=21)
No supplies 27% 5% 29%
No money 68% 60% 36%
No time 5% 5% 14%
No food 50% 25% 57%
No drugs 15% 7%
Distance 9% 5% 0%
Bedridden 9% 0% 0%
Other 30% 14%
HIV/AIDS patients frequently suffer from lack of appetite and difficulty swallowing food due
to thrush and diarrhea due to opportunistic infection or malabsorption. They are weak, often
malnourished, and depleted of essential nutrients. These conditions, combined with the need
to take numerous medications, require a balanced, supplemented nutritional intake. HIV
infected patients require more calories than non-infected individuals do. The need for
additional food was voiced throughout the sites visited, and a variety of ways to provide
clients with an increased nutritional intake are being implemented.
In Rongai, Nakuru District, ICROSS has assisted the community members in starting a
community food bank that has maintained a surplus over the course of the year. Teachers,
religious leaders and other community members have been able to secure donations in the
form of food from either large farms or well to do benefactors. This surplus is stored and,
PLWHA who are in greatest need are able to access the food supplies. BUCOSS in Busia has
started a demonstration kitchen garden project with indigenous plants of nutritional and
medicinal value. CHW sell some of these greens as part of IGA as well as give some to their
clients in need. Ready-to-Learn in Kabras and Speak and Act in Nakuru plan to collaborate
25
with agricultural organizations to provide seeds and education to clients and caregivers
regarding gunnysack gardens, and small kitchen gardens.
The Provincial AIDS Control Officer for Coast Province made the team aware of the fact that
in this region only 4% of arable land is under cultivation and out of a total of six districts, four
are on relief food. The population here has relied on donor funded food relief for a long time.
A portion of the population consumes raw cassava, a food of poor nutritional value.
Recommendations:
23. The health care and agricultural sectors should collaborate and work closely
together in order to increase food supplies to PLWHA and their families. GoK
agricultural extension officers and CHW should join forces in the promotion of
kitchen gardens and/or subsistence farming methods.
24. Ministry of Health, together with its development and implementing partners,
should design a strategy for modifying care and support programs to include
components of food supplements for clients in greatest need. More community
groups should be encouraged to start food banks and kitchen garden projects
such as those in Rongai and Busia.
25. When implementing community based organizations and groups are able to
secure outside funding for necessities such as food, or medications, they should
negotiate or seek assistance for secure storage for these items as a matter of
priority. For example, Integrated Aids Program (IAP) in Thika has been able to
secure food from an outside funding source, but does not have a space to store it.
26
MITIGATION OF THE CLINICAL EFFECTS OF HIV/AIDS
ANTIRETROVIRAL DRUGS (ARV)
At the time of initiation of HBC in Kenya, the objectives were predominantly to provide
palliative care in the home, as a way to lessen the burden on overwhelmed hospitals. With
ART becoming more accessible in Kenya, other issues have developed. HBC programs will
have to consider these emerging issues if they are to participate in or support a successful
large-scale distribution of ARV. For many of the PLWHA visited by the team, ARV seemed
like the only answer. Yet, the questions that came up repeatedly were how ARV would be
taken on empty stomachs and how the clients would get these medications regularly.
Throughout the sites visited, lack of food and money was the biggest issue
Until now, ARV have been offered at charges between Shs. 1,500/= and 4,500/= per month.
Diagnostics required such as CD4 count, blood work and x-rays also are billed to the client.
Even where ARV are available free of charge, access has been limited by transport and
stigma. The number of children on ARV is negligible.
During the evaluation, some clients and caregivers had never heard of ARV, or misunderstood
them to be “cures” for HIV. Some clients had been referred to hospitals by CHW for ARV,
only to learn that beginning ARV required several visits, diagnostics and commitment in
terms of money and time. Clients who are eligible for ARV will need food supplements in
order to take these medications. It is unclear what role CHW would have regarding the
provision and administration of ARV. Lack of knowledge of clinical manifestations of
HIV/AIDS among the CHW is widespread. (Table 9) It is doubtful they could play any role
in identifying potential candidates for ARV or OI drugs without intensive training.
Table 9: Percentage of CHW identifying possible sign/symptoms of AIDS
SIGN/SYMPTOMS OF AIDS CENTRAL (N=30) WESTERN(N=31) MOMBASA (N=30)
Prolonged fever 27% 61% 27%
Prolonged diarrhea 47% 84% 73%
Rashes 63% 48% 67%
Lymph node swelling 17% 19% 13%
Unintended weight loss 50% 68% 80%
Prolonged cough 53% 68% 57%
Thrush 57% 45% 43%
Herpes zoster 63% 42% 50%
Night sweats 7% 3% 3%
A major concern regarding ARV therapy is compliance, which could be hindered by lack of
food and lack of funds for transport needed to obtain the medications regularly. There also has
to be an uninterrupted supply of these drugs at the distribution centers. The team noted that
over 39% of PLWHA in Mombasa (12 out of 31) and 33% of PLWHA in Central Province (7
out of 21) were taking TB medications. All the clients who were taking TB drugs stated that
these drugs never run out. Health care facilities confirmed that stocks of TB drugs are
maintained throughout the year. If processes that have ensured availability of TB drugs could
be put in place for ARV, some of these problems could be circumvented.
27
Recommendations:
26. Care and support programs should enhance the capacities of CHW through
further training and sensitization on ARV provision, particularly in the areas
related to benefits, compliance and need to notify the physician in the case of
possible side effects of the drugs.
27. USAID, NASCOP and implementing partners should further explore the
possibility of linking the TB and HIV/AIDS programs to make it possible to
distribute ARV drugs in a similar manner as TB drugs.
28. Care and support programs should sensitize communities on what ARV are, as
well as provide clear information on what the procedure for assessing eligibility
actually entails.
28
MITIGATION OF THE SOCIAL EFFECTS OF HIV/AIDS
INCOME GENERATION ACTIVITIES
Poverty is exacerbated by HIV/AIDS. The majority of PLWHA in Kenya are those between
the ages of 18-45 who are usually the family breadwinners. As their disease becomes more
advanced, they are unable to work and the family income is compromised. Caregivers are
severely stretched with the burden of providing medical care and supportive care to debilitated
members of the family. In addition, the CHW who is working voluntarily also has a family to
care for. Thus, economic opportunities for the PLWHA, CHW and caregivers are greatly
needed. With an income, families can afford to buy medications and or food both of which
when lacking, can be barriers to effective home-based care. During the evaluation, CHW
informed evaluators of small-scale business ventures begun through their participation in
support groups offered by HBC programs that have raised the levels of their household
incomes. Representatives from K-Rep informed the team that repayment of loans was
generally over 90%. As part of the evaluation, PLWHA were asked if they were receiving
assistance in the form of IGA and found that only a few of the clients interviewed were
receiving microfinance loans (Mombasa 3% N=31, Western 12% N=17, Central 14% N=21).
There were more CHW reporting access to microfinance loans than caregivers or PLWHA.
This is attributed to the greater number of support groups being offered to CHW than to
PLWHA and caregivers. K-Rep loans are distributed through these support groups. In order
for a PLWHA to obtain a loan, there must be a support group as a mechanism to guarantee the
loan.
Recommendation:
29. All HBC programs should include a component of microfinance schemes and
ensure that they are made available to PLWHA and/or their caregivers through
an accessible and available number of support groups for PLWHA and their
caregivers.
ORPHANS AND VULNERABLE CHILDREN (OVC)
The increasing and alarming number of orphans in Kenya presents an enormous challenge to
government, communities and families as well as to the agencies and organizations assisting
them. Institutional care is not a preferred method for the care of children in African nations.
Decentralized family and community-based initiatives must be strengthened. The burden of
orphans in society affects other structures such as health, education, and social services.
Access to these services decrease as wage earners fall sick and are unable to work.
Vaccination coverage in Kenya has decreased from 65.4% in 1998 to 59.2% in 2003(KDHS
2003). “One fifth of Kenyan children are underweight, with 4% classified as severely
underweight”(KDHS 2003). There has been an increase of 30% in both infant and under five
mortality rates from 1989 to 2003. Infant mortality was 60 deaths per 1,000 live births in 1989
and in 2003 increased to 78 per 1,000. Under-five mortality increased from 89 per 1,000 live
births to 114 per 1,000 (KDHS 2003).
The evaluation team noted that care and support programs are addressing the OVC crisis in
several ways as well as through the identification and registration of OVC. The CHW in all
29
COPHIA sites are identifying OVC as part of their work in the community. Unfortunately,
this has simply become a new burden for the CHW as the numbers are on the incline and
available resources are limited. The needs of these children include medical care,
vaccinations, food, clothing, psychosocial counseling, school uniforms, preschool fees, and at
times legal assistance. In older children, they include secondary school fees, or vocational
training. As part of the evaluation, caregivers of OVC were asked, “What services do you
receive for the OVC?” Central and Western regions indicated a higher response rate than
Mombasa for counseling, food/seeds, clothes, and school fees. This higher response rate can
be attributed to some respondents being recipients of services from either Lea Toto or SFTC.
For the most part, due to lack of resources, willing and able caregivers and the legal
requirements, the needs of OVC are not being adequately addressed. Individual CBO are
attempting to provide needed services but unfortunately, the problem is overwhelming and
these CBO cannot address all the multifaceted issues pertaining to OVC.
The two USAID funded OVC programs that the team visited have important components
serving a great need, but each were found to be lacking necessary requirements and in the
future, should combine their components to form a more inclusive/integrative approach which
would address more OVC issues. Care and support programs specifically for OVC must
include HIV prevention in order to prevent further cases of orphans. Education and outreach
activities on family planning and PMTCT and VCT must be incorporated into any OVC
program. Home care provided by either mentors, social workers or CHW must address HIV
testing particularly so that early treatment of OI and AIDS can be initiated. The government is
needed to stimulate collaboration among donors and agencies to design and implement
strategic plans, monitor that children’s rights are being protected through monitoring of
service provision and assist on legal issues and resource procurement. Community volunteer
groups who are caring for children should be given needed training and small incentives such
as microfinance opportunities.
Speak for the Child and Lea Toto project are two USAID funded projects providing services
specifically directed to OVC. The entry point for services varies considerably from one
program to the other. Speak for the Child has identified orphans or vulnerable children
(having lost one parent) from birth to age five. Lea Toto provides services only to children
who are verified as HIV positive and their families.
The criteria used for eligibility for services were seen as limitations by the team. In the case of
The Lea Toto Project, a parent or caregiver may have a sick child who would benefit from
services offered but for reasons of stigma, is unwilling to have the child tested for HIV. Often
a caregiver will wait until illness is very advanced before seeking out assistance and agreeing
to have the child tested. On the other hand, SFTC, which provides HBC to OVC, has not
incorporated counseling for HIV testing in the children to whom they provide services. Proper
education on infection prevention, PMTCT and treatment with ARV or OI drugs cannot take
place without first addressing the issue of HIV status in these children.
The Lea Toto Project
The Lea Toto Project is a community-based project that seeks to provide education care and
resources to HIV infected children and their families. Lea Toto conducts mobilization
activities and has formed implementing management committees. Forty-five peer educators
have been trained in BCC, in order to target peers in schools. There are six social workers
(SW) and two volunteer SW who provide supervision to the CHW. Two Lea Toto nurses
provide basic medical care to clients and their families from clinics in Kawangware and
Kangemi where they have OI drugs, and a VCT center. Nurses may make home visits when
30
necessary. Sick children are referred to neighboring health care facilities. The
accomplishments include caregiver support groups and monthly counseling sessions to
address burnout, an quarterly award to the hardest working CHW, training of caregivers in
solar skills and micro enterprise development and provision of CRS food donations to
neediest children.
Out of six caregivers interviewed receiving services from Lea Toto, four claimed that the last
time the CHW visited the home was over one month ago. Linkages with neighboring health
facilities do not seem to have been fully developed. There is no communication back to Lea
Toto regarding medical needs upon discharge from neighboring hospitals. CHW have no
homecare kits. They have been given bags, umbrellas and shoes. There is no waiver system in
place with Nyumbani so that neither comprehensive care (such as ARV) nor diagnostics can
be obtained from Nyumbani.
The Lea Toto Project has addressed psychological, legal, and resource issues but has not
strengthened linkages with health facilities to the extent it should. Given that for reasons of
stigma, caregivers are only consenting for HIV testing once a child shows signs of advanced
AIDS, these children can be presumed to be quite ill and would benefit from increased
medical care. This medical care should come in the form of trained medical personnel who
supervise CHW and also make home visits when possible. CHW, if provided with necessary
supplies and training in HIV/AIDS, could in turn transfer skills to caregivers and provide
palliative care to sick children.
Ready-to-Learn/Speak for the Child
Speak for the Child (SFTC), has addressed the physical, cognitive and psychosocial needs of
OVC under the age of 5 by providing support and education to caregivers regarding the
emotional development and health of children. Community volunteers, coach and problem
solve with caregivers around issues in nutrition, health and psychosocial care. Another of its
objectives is to build capacity of other organizations in Western Kenya to deliver OVC
support/services in their communities.
In homes where SFTC provides care, evaluators noted that children had dolls, or other play
material, and caregivers stated they were educated in emotional care of children as well as in
nutrition. SFTC has received funding for food distribution that is solely for this target group
of children. SFTC has purchased and distributed seed and fertilizer for caregivers. All pre￾school age children visited were in preschools. SFTC has developed linkages with health
facilities to ensure that OVC and caregivers seek out health services for vaccinations. Almost
all children seen by the team were up to date with their vaccinations.
Unfortunately, the serostatus of the clients were not known because mentors do not advise on
HIV testing of children whose parents either have died of AIDS related illnesses or who show
signs of advanced AIDS disease. SFTC will refer ill parents or caregivers to COPHIA
program working in the area but the children must be referred directly to health care facilities.
The children may remain in the program until age five and then begin to be phased out slowly
from the project since the mandate is for up to age five only.
Cognitive and developmental growth are critical issues which when a caregiver is sensitized,
may affect the child’s care in a positive manner. This program provides important components
31
to vulnerable children living in poverty by ensuring that they are cognitively and emotionally
cared for in addition to be being adequately nourished and vaccinated. Since many of these
children are at risk for HIV, and the fact that ART may soon be available to them, a more
direct health education approach must be taken whereby mentors are trained in HBC of
HIV/AIDS children as well as in counseling for HIV testing. The fact that children at age five
are slowly phased out of the program, returns the burden on communities and families again
as they must find other sources of support.
Recommendations:
30. All OVC programs should include care and support activities for HIV infected
children through the establishment of strong linkages with health care facilities as
well the enhancement of skills in counseling and care.
31. OVC programs should allocate funds for secondary school education as a priority
for children who qualify to continue their education. Vocational training should
be limited to children who did not qualify for secondary school.
32
 SUSTAINABILITY
The evaluation team did not find any comprehensive sustainability plan in any of the projects.
The strongest sustainability indicators for care and support were seen in:
• The experiment with community food banks by ICROSS in Rongai,
• The nascent kitchen garden experiments in Western Province, and
• Access to micro-finance for small-scale business ventures that can address the
livelihoods of the families affected by HIV/AIDS.
• Strong working linkages between health care facilities and home-based care as seen in
ICROSS Nakuru, Speak and Act in Thika, and the Mission Hospitals.
• The focus on the spiritual aspects of volunteerism by faith based organizations.
Proceeds from successful small businesses make it possible for clients to meet the costs of
producing or purchasing food, buying drugs, paying school fees and meeting daily household
expenses. Several partners raised the issue of the sustainability of ARV therapy. Using donor
funds for compensating CHW and volunteers for their time and services is also not
sustainable.
Recommendations:
32. USAID and the implementing agencies will need to address sustainability more
specifically in the subsequent phases by providing functional sustainability
indicators and benchmarks.
33. The cross referral model that includes clinical supervision (COPHIA’s Mukumu
Hospital and IMPACT’s St. Mary’s Hospital) appears to be sustainable. This
model should be strengthened.
34. USAID should make deliberate efforts to broaden the scopes of both IMPACT
and COPHIA projects to link HBC to wherever comprehensive care centers are
already established, or due to be established.
35. Both COPHIA and IMPACT can benefit from the ICROSS model that also
includes sanitation and community food bank components, and working with
private providers. This model should be replicated by both COPHIA and
IMPACT in Coast and Western Provinces.
36. The kitchen garden concept for ensuring food supplies, food security, and income
to the sick is sustainable and should be promoted and implemented as part of
care and support.
37. USAID should increase its investment portfolio in the micro-finance assistance
through K-Rep loans to enable larger numbers of PLWHA to access the micro￾financing facility and benefits. This scheme holds promise for sustainability as it
establishes economic independence for households and thereby creating base for
socio-economic survival of the sick and their families.
33
CONCLUSION
With the AIDS epidemic still in full force, there is a need to expand, replicate and/or scale up
existing programs that have shown promise in curbing the effects of the scourge. In addition
to preventive measures currently underway, care and support must continue to be provided to
those already infected and affected by HIV/AIDS. HBC programs must be comprehensive,
incorporating services that address the physical, emotional, psychosocial and economic needs
of those infected and affected. During this evaluation, the need for successful integration of
the healthcare infrastructure with community-based services was recognized as key to
ensuring that medical services and supplies reach the PLWHA. The team found that
sustainable HBC programs are those that are strongly linked with the health infrastructure and
include capacity building of the community through linkages with food security and income
generation activities.
The provision of medical care, (which in the future will include ART), and psychosocial care
to PLWHA and their families will be more effective where stronger linkages exist.
Caregivers in the home will need more training and support in the future to ensure that
PLWHA receive proper palliative care. Stigma remains a challenge in most areas and
continues to hinder services. A more inclusive approach to HBC may need to be considered in
the future whereby homecare services are provided to all those that require them. This would
make a more rational use of resources and would assist in the capacity building of a larger
group of recipients. A HBC program that mainstreams HIV/AIDS rather than isolating it as a
qualitatively different medical condition could have a strong impact on stigma and denial.
Many CHW are respected members of, and selected by their communities to be trained to
provide HBC services on a voluntary basis. Currently, due to lack of education, training,
supplies, and linkages with and supervision by medical providers, the CHW were found to
have a minimal effect as providers of HBC to PLWHA. Half of all CHW have only a primary
level of education. In order to enhance the effectiveness of delivery of HBC by CHW, either
selection criteria will have to specify higher levels of education and previous training and
include a salary or more frequent trainings and refresher courses with closer supervision and
monitoring by clinicians will need to be integrated into the programs. For reasons of cost as
well as sustainability, it seems likely that they will require the latter. They will also need
adequate materials and supplies to perform their work. Their role should not be as the initial
trainers of caregivers but rather to reinforce training and education that was initiated by a
referring health facility. To extend the lifespan of the many young people affected, HIV/AIDS
care requires close monitoring of symptoms in order to effectively treat opportunistic
infections and to monitor ART. The CHW have weakly linked health care providers and
families mainly through referrals to health care facilities and minimal skills transfer and
education to families. CHW can play a role in communicating information between PLWHA
and their caregivers and health care providers, they can reinforce training initiated by health
care providers, they can make observations and relay those observations. CHW cannot be
expected to carry the brunt of care and support in the communities particularly without the
education, training, skills, and supplies that are required.
Thus, the future role of the CHW should be linked closely with healthcare facilities that
become the center of the CHW activities. This working relationship can be attained through a
more active role on the part of the health care provider. It is the HC provider who should
guide the care and the CHW who will facilitate it. The health care provider is needed to
34
actively supervise the CHW, initiate training of the caregivers, provide counseling, initiate a
plan of care, as well as provide the necessary medical care. These clinicians are needed to
monitor the status of bedridden clients and reevaluate treatments. Health care facilities need to
be strengthened, with more personnel trained and aware of the need for appropriate care and
support of the HIV/AIDS client.
35
THE WAY FORWARD
The ICROSS programs have focused on developing linkages with health care providers in the
public and private sector with a goal of sustainability of these linkages. This approach seems
to have demanded more accountability on the part of the government for outpatient care of
PLWHA. In a short-term period ICROSS has established linkages between HBC and MOH
staff. The CHV, working voluntarily together with medical personnel in health facilities, are
providing care, education and support to PLWHA and their families. CHV include malaria
prevention (through distribution of mosquito nets) and sanitation (through building of VIP
latrines) as part of their care and support activities. The inclusion of these additional activities
that are not necessarily associated with HIV/AIDS clients may help reduce stigma of current
HBC programs. The CHV have also identified and assisted in the mobilization of community
groups to meet some of the nutritional and financial needs of their communities. The ICROSS
model is a sustainable model that has involved government health facilities in HBC more
thoroughly than other models. The team recommends that the current staff of projects in
Bungoma and Nakuru receive a funding extension to ensure a smooth handing over to the
government.
An approach similar to that of ICROSS should be implemented whereby the health facility is
established as the hub of home-based care and community activities. Some of the currently
funded HBC programs of COPHIA should be incorporated into either the existing or planned
FHI/IMPACT Comprehensive Care Centers or other health care facilities. Health facility
personnel should provide clinical supervision to all CHW. An example of where this is
already happening is in Thika where the CHW of Speak and Act are supported by Thika
district hospital through provision of meeting venues and some clinical supervisors who are
available to make joint home visits with CHW. Health care personnel should formally refer
clients that require home-based care to a representative of home-based care who is on the
premises. When possible, an office and/or meeting area should be available for support
groups, conferences and trainings. All field managers should be clinically trained and
involved in supervision, monitoring and evaluation, with the goal of handing over to the
health facility. Healthcare providers should receive training in care and support and HBC and
in the role of the CHW. Discussions at the provincial level should take place to ensure that
added HBC responsibilities of HC staff are authorized and sanctioned. The CHW should
continue to play a role in community mobilization and prevention activities in close
collaboration with other cadres of health workers.
While the TASO model in Uganda cannot be a panacea, Kenyan care and support managers
should have opportunity to review this and other notable HBC programs in Africa to adopt
what may work in their own circumstances. In the TASO model, a team of one physician,
nurse and counselor, located on the grounds of provincial health centers with a catchment area
encompassing a thirty-five kilometer radius (each center has its own vehicle), provide
homecare and other supportive services. A clinic is held twice weekly and home visits are
conducted for bedridden clients. A users’ fee of approximately .30$ is charged per visit.
Counselors and staff within TASO are very active in AIDS awareness and advocacy issues.
PLWHA or “members” are encouraged to join support groups and live openly and positively.
TASO center has different donors and different community initiatives depending on the
community’s needs. TASO also strengthens the health facility in which they are located by
providing the center with basic drugs.
36
KENWA in Nairobi is a COPHIA partner that is demonstrating the capacity to grow and
expand. It has an infrastructure that could handle ARV and other clinical services. The fact
that there is strong leadership that understands the issues surrounding PLWHA, and the fact
that all CHW are PLWHA, goes very far in addressing stigma, which is one of the biggest
blocks to provision of HBC services. The team recommends that USAID consider additional
allocation of funding to KENWA with the purpose of expanding its services to a greater
number of PLWHA and OVC.
As USAID’s largest recipient of funds for home-based care in Kenya, COPHIA has played an
important role in training and mobilizing over 700 CHW in their communities.
The policy of CHW incentives is not sustainable, and should be reassessed. The contents and
method for restocking homecare kits must also be reviewed. In regards to some of COPHIA’s
implementing partners, of which there are many and most are relatively newly formed CBO, it
is supposed that a great deal of time and effort is expended on upgrading and monitoring and
maintaining program performance and response mechanisms throughout the regions. A more
cost effective and less time-consuming method for COPHIA would be to work with fewer
organizations that can be scaled up to provide services to larger areas and to more people.
Some of COPHIA’s implementing partners have the potential for replication or expansion, but
not without further upgrading and closer monitoring and evaluation of current activities. There
is need for a systematic and comprehensive capacity assessment of current COPHIA partners
and their capabilities for expansion.
The mission hospital HBC programs currently being funded by COPHIA and FHI/IMPACT
have the necessary linkages with health care staff, as well as a sustainable infrastructure and a
focus on psychosocial support. HBC in other similar hospitals could be replicated.
Distribution of ARV at no charge would have the necessary network in place to ensure that
the medications are available to those found to be eligible. These organizations would need
additional funding so that their services could be made available to a greater number of
PLWHA and OVC at affordable costs.
Current HBC programs do not have the capacity, resources or training to address the growing
number of OVC. Children require several other facets of care not included in caring for adults.
Home-based care services for children will remain nonexistent unless these services are set up
explicitly for children. Programs for OVC will need to be comprehensive. They must address
medical, nutritional, developmental issues as well testing/disclosure, psychosocial and legal
matters. Existing OVC programs are few and address some but not all the aforementioned
issues. SFTC must address HIV testing in vulnerable children enrolled in its program. Lea
Toto must develop stronger working relationships with medical facility staff trained to
supervise the CHW in the field.
The evaluation has not mentioned urban slum areas in particular, but the team found that
PLWHA are receiving less care in these areas because they often do not have relatives as
primary caregivers. In urban areas, it was noted that more caregivers were friends or
neighbors who could not provide round the clock care. Food security was also a bigger
problem as land for farming or even planting a kitchen garden is unavailable. In urban areas,
there might be a need for communities to come together to provide care in the form of
hospice, institutional, or respite care.
37
Infrastructure for care can improve the access to and utilization of ART, and it is a basic
requirement. Palliative care services in Kenya are needed on a much larger scale than is
currently available. Services should be available for adults and children living with HIV
disease and their families, from diagnosis through death and bereavement. The model of
palliative care as seen in Port Reitz should be replicated in other regions. Port Reitz is a short￾term, 14 bed in-patient facility located on the grounds of the district hospital of Mombasa that
provides holistic care, linkages to ancillary services and discharge planning. Training and
education of the caregiver is initiated prior to discharge as well as linking the CHW with the
family. This facility provides care to anyone with a terminal illness. While the client is in the
hospital, issues of nutritional needs, financial needs, medical needs (ARV) and psychosocial
needs are addressed. The approach of training the caregivers prior to discharge ensures that
families are more knowledgeable and skilled to deal with care of the PLWHA as well as more
prepared to face issues of stigma and denial. Caregivers are expected to remain with the
clients throughout the duration of the hospital stay. The newly established relationship with
health care providers continues after discharge through follow up clinic visits and support
groups. The health care provider links the CHW with the family, through a formal referral and
introduction that may give greater credibility to the CHW. Ideally, a palliative care center
should be set up in each district health center where a number of beds are reserved for
HIV/AIDS and terminal illness patients. Staff in each district hospital would be identified as
palliative care staff trained in counseling as well as in HIV/AIDS care. These staff members
would share the work of palliative care, education and training of clients and families and
would supervise the community health workers. Health facility staff should be able to arrange
their work schedules in order to spend two days per week in the field seeing bedridden clients.
These district health centers could also become satellite centers for ARV distribution once
clients have been enrolled.
It should be mentioned that in most government facilities where the stronger linkages with
homecare had been established, the team found more motivated health care personnel, who
were committed to helping the HIV/AIDS population (Port Reitz Hospital, Coast General
Hospital, Bungoma Sub District Hospital, Provincial General Hospital in Nakuru, Thika
District Hospital). It was also noted that these facilities had undergone some structural
renovations and improvements, and the general atmosphere of staff and clients was more
amenable. USAID should continue to fund renovations and structural improvements
particularly in health facilities which could or are currently participating in home-based care
activities.
The GoK should be continually encouraged to invest funds and participate more
comprehensively in HBC activities, particularly as a source of support and supervision to
CHW as well as proper treatment for PLWHA. It should assume full responsibility for the
training of the relevant district level staff in care and support of PLWHA at the health facility
and community levels where appropriate. The GoK, through NASCOP, should be actively
involved in monitoring and evaluating all HBC activities. In addition, NASCOP should be a
full participant in any future coordination efforts of all donors involved in HBC. Further, the
GoK should consider the inclusion of medicines and food/nutritional supplementation in the
HBC kits as a way of augmenting its HBC services. Where possible, there should be linkages
with private sector providers to ensure that private facilities participate in HBC services.
Wherever possible, USAID should be involved in NASCOP strategic planning activities as
well as considering the sustainability of care and support programs by encouraging active
government participation and planning activities.
38
ANNEX 1
Team Members
Sandra Haim Team Leader, Consultant
Deryck Omuodo, Consultant
Pauline Mwololo, NASCOP
Janet Paz-Castillo, USAID Kenya/OPH
Dr. John Wasonga, USAID Kenya/OPH
39
ANNEX 2
Methodology
Quantitative information was obtained through questionnaires to:
• Seven health care facility staff members
• 56 family/friend caregivers,
• 91 CHW
• 100 beneficiaries (PLWHA and OVC).
• 28 women of childbearing age
Qualitative information was obtained through:
• Observations of 74 homes
• Unstructured interviews with area managers of IMPACT, COPHIA, COGRI and AED,
stakeholders and provincial and/or district health officers
The following is a list of collaborating agencies and locations that were visited during the
evaluation:
WESTERN PROVINCE
Busia REEP
Butula BUCOSS
Shingalu Mukumu Hospital
Kabras East Jua Kali
Kabras West Speak for the Child
Bungoma ICROSS
Webuye ICROSS
Mumias St. Mary’s
Kakamega Prison
Kakamega Provincial District Officer
NAIROBI
Mathare KENWA
Soweto KENWA
Korogocho Redeemed Gospel Church
Riruta RICOAN
Karangware LEA TOTO
Kangemi LEA TOTO
THIKA
Thika town/ District Hospital
Kiandutu Speak and Act
Mangu IAP
NAKURU
40
Nakuru District hospital
FPAK
Kaptembwa ICROSS
Rongai ICROSS
MOMBASA
Coast Province General Hospital
Port Reitz District Hospital
Changamwe Jomvu BI
Bangladesh BI
Kisauni Freretown BI
Mtopanga BI
Malindi Tafiq Hospital and HBC
Likoni Mtongwe BI
Shika Adabu BI
Meetings were held with the following stakeholders:
FHI/IMPACT
PATHFINDER
NASCOP
NACC
ICROSS
PACC in Mombasa
Provincial medical officers in Kakamega and Thika
41
ANNEX 3
Bibliography
Central Bureau of Statistics. Kenya Demographic and Health Survey 2003 Preliminary
Report. Available at http://wwwcbs.go.ke
Farmer P, Landre F, Mukherjee J et al. Community-based approaches to HIV treatment in
resource-poor settings. Lancet. 2001:358 404-409.
Fru Nsutebu E, Walley J, Mataka E. Scaling-up HIV/AIDS and TB home-based care: lessons
from Zambia. Health Policy and Planning. 2001; 16(3) 240-247
Jackson H, Anderson S. Homecare for people with AIDS. In Lamptey P, Gayle H, Eds.
HIV/AIDS Prevention and Care in Resource Constrained Settings. Arlington, VA: Family
Health International, 2001 pp.579-601
Karim Q, Kalibala S, Katabira E, et al. Home-based care. In Essex M, Mboup S, Kanki P, et
al. Eds. AIDS in Africa (2nd edition). New York: Kluwer Academic, 2002
Osborne MC, van Praag E, Kackson H. Modes of care for patients with HIV/AIDS. AIDS
1997 11:S135-S141.
Ramanathan K, Tarantola D, Marlink R. Access to HIV and AIDS Care. In Essex M, Mboup
S, Kanki P, et al. Eds. AIDS In Africa (2nd edition). New York: Kluwer Academic, 2002
Russel M, Schneider H. A Rapid Appraisal of Community-based HIV/AIDS Care and
Support programs in South Africa. Johannesburg: Center for Health Policy, University of
Witwatersrand, 2000
Van Praaag E. Lessons Learned From Home Care Programs. First SADC Conference on
Community Home Based Care. Gabarone, Botswana, March 5-8 2001.
42
ANNEX 4
Scope of Work
1.0 Introduction/Rationale
USAID/Kenya continues to make progress towards its Intermediate Result 2, “Increased use
of proven, effective interventions to decrease risk of transmission and mitigate the impact of
HIV/AIDS” under the Mission’s Strategic Objective 3, “Reduced fertility and risk of
HIV/AIDS transmission through sustainable integrated family planning health services”.
Based on stakeholder consensus, in 1998 USAID/Kenya designed an HIV/AIDS strategy
designed to address areas of prevention of HIV transmission in conjunction with care and
support for persons living with HIV/AIDS (PLWHA) and the families that care for them.
Under this comprehensive HIV strategic approach, specific activities have emphasized a
community-based approach to providing physical and psychosocial support to adults and
children affected by AIDS. Such activities have made progress on a number of objectives,
including:
• Improving the ability of local communities to identify their needs in home-based care
by engaging in extensive community mobilization and participation of local leaders
and community members;
• Increasing the capacity of local NGOs engaged in prevention and treatment programs
by partnering with institutions with resident technical expertise;
• Strengthening existing systems of home-based care, support, and referral for HIV+
adults and children by linking doctors, nurses, social workers, and community health
workers; and
• Helping communities identify the specific needs of HIV+ orphans and vulnerable
children and specific needs of their caregivers, and facilitating support for these
individuals.
This evaluation will review the current status of home-based care, OVC, and related activites
make recommendations regarding the contributions they may make to the revised and
expanded HIV/AIDS strategy currently under review by USAID/Washington. The following
programs will be examined:
• The Community-Based Program on HIV/AIDS Care, Support, and Prevention
(COPHIA)
• FHI/IMPACT – St. Mary’s Hospital
• FHI/IMPACT – ICROSS, Bungoma
• Community REACH – ICROSS, Nakuru
• CRS/COGRI – Lea Toto orphans support project
• Academy for Educational Development (AED)’s Ready to Learn/Speak for the Child
Project
The results of this evaluation will guide USAID/Kenya’s future endeavors in comprehensive
community-based HIV/AIDS care and support activities. Specific attention will focus on the
extent to which presently-funded programs can scale up and/or more offer some of the
complex care and treatment services that will be expected under the Presidential Emergency
43
Plan for AIDS Response (PEPAR) and Prevention of Mother-to-Child Transmission (PMCT)
initiatives.
2.0 Background
The 2002 UNAIDS report on the global HIV/AIDS situation ranks Kenya as fourth worldwide
in terms of number of people infected with HIV. Kenya’s national seroprevalence has
remained at 10-13% for several years, indicating that although levels may have peaked, the
nature of any possible decline remains uncertain. There is significant regional variation in
prevalence and incidence of HIV in Kenya.
Given the nature of the epidemic in Kenya and Kenya’s strong partnership with the USG to
date in efforts to mitigate the impact of HIV/AIDS, Kenya was designated a Rapid Scale-Up
country under USAID’s Expanded Response to HIV/AIDS Strategy and is among twelve
African nations to benefit from significant resources from PEPAR. To achieve the global
targets set forth under PEPAR, as well as targets described by the United Nations General
Assembly Special Session on HIV/AIDS (UNGASS) and proposal objectives of the Global
Fund for AIDS, TB, and Malaria (GFATM), by 2008 USAID/Kenya’s strategy plans, in
concert with partners, to:
• Reduce HIV seroprevalence by 20-30% among 15-24 year olds;
• Provide access to prevention of mother to child transmission (PMCT) counseling and
services for 25% of pregnant women who are HIV positive; and
• Ensure care for 25% of the people infected with HIV and 25% of the children affected
by AIDS.
USAID/Kenya is committed to partnering with the Government of Kenya to help achieve
these goals, and expects to add goals related to treatment as PEPAR and PMCT requirements
are made clear.
3.0 Scope of Work
3.1 Objectives
The evaluation team will examine activities in USAID/Kenya’s Care and Support Portfolio to
assess the following:
• the progress of individual projects and the portfolio as a whole towards the
achievement of specific project objectives and USAID/Kenya’s Intermediate Result 2;
• the overall performance of projects and areas in which they should place more
emphasis in order to improve results;
• the pace of project implementation given project extensions and expansions of scope,
and any general changes in area of emphasis and changes in specific activities
necessary to successfully carry out project objectives;
• the viability of the current diverse, comprehensive mandates (i.e., are there “mission
creep” issues in terms of expecting HBC providers to be all things to all people);
• the current and potential role of this portfolio of activities to developing sustainable
community-based care and support of HIV+ individuals and the families that care for
them;
44
• the current and potential relevance of this portfolio of activities to the needs of
children affected by HIV/AIDS;
• overall challenges and lessons learned; and
• key areas of future focus for the portfolio, the value and potential for expansion into
longer-term, more comprehensive activities and the actions necessary to realize this.
3.2 Participants, critical skills, and audience for the evaluation
Team Members:
• Team leader (likely a US-based expert)
• Local expert consultant
• UNICEF staff member
• MOH staff member
Audience:
• Mission management
• OPH portfolio managers
• Project implementers
Key Informants
• Project representatives
• Home based care workers and recipients
• MOH/NASCOP personnel
• USAID staff
• Other donors, as appropriate
3.3 Issues to be addressed by the team
3.3.1 Topical Issues
The evaluation will include, but not be limited to, an exploration of the scope and
effectiveness of current efforts and potential capacity in the following program areas:
Prevention
• behavior change communication and IEC materials;
• distribution of condoms;
• voluntary counseling and testing (including post-test clubs, synergies between
activities engaging in VCT, and community mobilization for VCT);
• treatment of sexually transmitted diseases; and
• reduction of stigma surrounding HIV+ individuals and adults/children with AIDS.
Care and support
• appropriate training in both community awareness raising/mobilization and in home
care;
• strategies and incentives for sustained participation of community health workers;
• effectiveness of referrals for clinical/tertiary care and referrals from clinical/tertiary to
community (including referrals for TB, other OIs, family planning, and STIs);
45
• physical and psychosocial support specifically designed for children with or affected
by HIV/AIDS and their families;
• effectiveness of current home-based care, focusing on –
ß psychosocial benefit/s to clients and family members
ß palliation or “comfort care”
ß identification and appropriate referral for treatment of opportunistic infections
(especially TB);
• potential for contribution to future care/treatment objectives, including –
ß prevention and/or treatment of common opportunistic infections, including
community-based DOTS for TB treatment
ß distributing and/or monitoring effective adherence to more complex treatment
regimens, including ART; and
• care for pregnant HIV+ women, including knowledge of and referrals for prevention
of mother-to-child transmission.
3.3.2 Process Issues
The team will assess issues related to the process of implementation of prevention, care and
support activities, including, but not limited to the following.
Achievement of goals and objectives
The evaluation team will assess and comment on the extent to which projects have:
• met stated goals and objectives;
• developed and implemented appropriate monitoring and evaluation tools to track
progress towards stated goals and objectives;
• developed capacity of partner organizations;
• acted upon/implemented recommendations from previous assessments; and
• responded to changed environment for HIV/AIDS treatment and care by revising goals
and objectives, where appropriate.
Reporting:
While the primary objective is to assess programmatic effectiveness, the team will also assess
the degree to which projects have complied with USAID reporting requirements.
3.4 Specific activities
Activities to be conducted by the team will include, but not be limited to:
• Entry conference with USAID/Kenya staff during which the team will present a
proposed schedule for undertaking the evaluation;
• Review of relevant documentation (including project studies, status reports,
evaluations, USAID HIV/AIDS strategy documents, and other reports related to
community-based home care programs in Kenya).
• Meetings with project staff of individual projects;
• Site visits and meetings with MOH officials and other stakeholders including project
staff, community health workers, and families;
46
• Structured interviews conducted with a representative sample of home-based care
providers and their clients/family members of clients to assess their satisfaction with
the project in question and to secure recommendations for future program
direction/project improvement; and
• Exit conference during which the team will present the first draft of the evaluation
report, highlighting key findings and recommendations.
3.5 Report and recommendations for future program direction
The team leader will submit a draft report to USAID prior to the post-evaluation debriefing.
The final report will be submitted no later than 14 days from the date of the final debrief to
USAID. The document will be organized as follows:
I. Executive Summary
II. Background
III. Summary of key findings and conclusions
IV. Recommendations for future directions
V. Annexes
a. Scope of Work
b. Evaluation Team Members
c. List of Interviewees
d. Methodology
e. Questionnaire tools
3.6 Level of effort
3.6.1 Proposed schedule
The evaluation will take place during the first four weeks beginning February 9, and
will include:
• A desk review of materials
• Team briefing and orientation
• Site visits and interviews
• Completion of written report
• Presentation to USAID on March 3, 2004
Total number of working days for Team Leader: 25 (18 on-site, 7 for final report preparation)
Total number of working days for Team Members: 20
3.7 Logistics and Support
Office space and equipment, travel/transportation support, per diems, hiring of
consultants
USAID will provide travel, transportation, per diem expenses, and consultant fees. The
Team Leader will be in charge of the travel budget for the team e.g. taxi fare. The
Team Leader and the local consultants will be expected to provide their own laptop
47
computers. Arrangements for field transportation and office space will be negotiated
by USAID/Kenya with appropriate project representatives.
3.8 Relationships
The team leader will report directly to the Senior HIV Advisor for Care and Treatment
Activities, Office of Population and Health. The team leader will work closely with
OPH’s Senior Technical Advisor in AIDS and Child Survival, and other OPH staff as
necessary.
3.9 Completion of deliverables
The contract will be considered successfully completed when the Team Leader
submits to USAID/Kenya the final report document.
Before the debriefing on March 4, 2004, the Team will submit its first draft report to
USAID. USAID OPH will provide comments not later than March 11, 2004. The
team leader will submit a final document free of typographical and grammatical errors,
in both paper and electronic versions, not later than March 25, 2004.
Payment Options: 20% upon submission of the first Draft to OPH and 80% upon
submission of an acceptable final report.
48
ANNEX 5
Evaluation Tool
Project:
Area Manager:
Date:
Please provide the following information:
1. Objectives of project
2. Size and population of project area
3. Estimated number of target population
4. Current number of clients being served
5. Prevention strategies
a. BCC and IEC information and materials adequate ______Yes______No
b. Quality of information and materials ______Adequate______Inadequate
c. Number of condom promotion activities in past month_________
d. Number of community mobilization activities in past month________
e. Number of condoms distributed in past month________________
f. Number of abstinence promotion activities in the past month
6. Number of currently active CHWs___________
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Area Manager
7. Number of CHWs who ceased working in past year _____________
8. Level of formal education of CHWs (indicate number in each category)
None ______ primary to standard 4 _________completed primary ______
completed secondary school ______ Tertiary _____other ______
9. List all types of in-service training and number of participants at each in past year
10. How many clients have been referred to other facilities in the last one week
Number of clients Reasons for referrals
………………………………. ……………………………
………………………………. ……………………………
………………………………. ……………………………
………………………………. ……………………………
11. List of other organizations that are supporting care and support programs in your
project areas and what they do?
12. In the past year, how often have supplies for CHW kits run out?
Only once______often_______supplies not stocked___________
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
The following will be by discussion with Area Manager
13. What has the project implemented from the home based care policies and guidelines?
14. What has the project implemented from the orphans care policies and guidelines?
15. Accomplishments of the project
16. Lessons that have been learned from the implementation of the project
17. What you see as the future direction of the project
18. Constraints experienced in implementing the project
19.Request Area Manager to provide verification/confirmation on current number of
clients being served
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Project:
Health Facility (identify HIV/AIDS service provider):
Date:
Please provide the following information:
1. What structures does your health facility have in place to offer HIV/AIDS care and
support services to client/patients in relation to:
Out patient services
………………………………………………………………………
In patient services
………………………………………………………………………
Follow-up services
………………………………………………………………………
2. Are the service provider adequately prepared to offer HIV/AIDS care and support
services………………..
Explain………………………………………………………………….
…………………………………………………………………………
3. How is your institution involved in capacity building for enhancing provision of
HIV/AIDS care and support services for the following:
Health workers
……………………………………………………………………..
Community members
…………………………………………………………………….
Family/care givers
…………………………………………………………………….
Clients/patients
…………………………………………………………………………………
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Health Facility
4. What referral system do you have in place;
Formal with referral letters
………………………………………………………………………
Informal by word of mouth
………………………………………………………………………
5. How many clients do you refer for community home based care per week and for what
reasons do you refer?
…………………………………………………………………………………
6. How many clients are referred to this facility from community home based care per
week and for what reasons?
…………………………………………………………………………………
7. Who are your collaborators in the implementation of care and support services and
which are the areas of collaboration;
…………………………………………………………………………………
 How often do you meet…………….
9. Accessibility of services to clients;
Free services?
Chargeable? How much?
Waver system in place?
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Health Facility
10. In the past year, how often have you run out of any of the following?
Only once often don’t stock
ARVs
OI drugs
TB medications
Viral load test
CD4 test
Eliza test
11. What post exposure prophylaxis (PEP) activities do you have in place?
a. Counseling and testing ………………………………………………..
b. ARV…………………………………………………………………..
c. Educating health workers and community on PEP …………….........
If yes, how often…………………………………………………….
12. What are your current programs and the total number of clients seen in the past one week?
PMCT…………………………………
VCT………………………………….
ARV…………………………………..
HBC……………………………………………………
STI Management………………………………………...
Condom promotion and distribution…………………….
Others……………………………………………………
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Health Facility
13. What do you know about COPHIA/IMPACT/ICROSS activities
……………………………………………………………………………………
……………………………………………………………………………………
14. Are you satisfied with the way services are provided at the community level?
Explain
………………………………………………………………………………………
55
Project:
Community Health Worker [ ]:
Community Social Worker [ ]:
Date:
1. What do you know about activities related to the following
COPHIA……………………………………………………………..
IMPACT…………………………………………………………….
ICROSS……………………………………………………………..
2. What type of services do you provide as a community worker
Other………………………………………………………………
Nursing care ………………………………………………….
Giving medication…………………………………………….
Health education ………………………………………..
Counseling ..………………………………………………….
Nutrition care support………………………………………
 Infection prevention………………………………………………..
3. When did you begin working as a community worker?
…………………………………
4. What type of training have you received including in-service while on this project
Type of training Duration of training
………………………………….. ………………………..…….
………………………………….. ………………………..…….
………………………………….. ………………………..…….
………………………………….. ………………………..…….
List the number of clients that you are caring for this week and their condition.
Mobile bedridden
………………………………….. ………………………..…….
5. What is the highest number of clients have you cared for in a given week?............
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Community Health/Social Worker
6. How many home visits do you make in a week? ……………………………..
7. How often are you involved in community mobilization and other prevention activities
Weekly [ ] Twice a month [ ]
Monthly [ ] Others…………………………..
8. What supplies and drugs do you have for the provision of care?
Gloves [ ] Disinfectants [ ]
Soap [ ] Nutritional supplements [ ]
Dressing materials [ ] IEC materials [ ]
Drugs (specify)………………………… other [ ]
9. How many clients have you referred to the health facility in the last one week
Number of clients Reasons for referral
………………………………….. ………………………..…….
………………………………….. ………………………..…….
10. What records do you keep and how do you use them?
Type of records Use
………………………………….. ………………………..…….
………………………………….. ………………………..…….
11. How often do you meet with your supervisor?
Daily [ ] Twice a week [ ]
Weekly [ ] Twice a month [ ]
Monthly [ ] Others …………………………..
What are the advantages and disadvantages of these meetings?
Benefits
……………………………………………………………………………
………………………..………………………………………………….
Drawbacks
……………………………………………………………………………
………………………..………………………………………………….
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Community Health/Social Worker
12. Do you know the signs and symptoms of AIDS?(tick as per responses)
Fever > 1 month ……. cough > 1 month ……….
Enlarged lymph nodes ……. thrush of the mouth ……….
General pruritic dermatitis ……. recurrent Herpes Zoster………
Weight loss <1 month ……. persistent diarrhea ………..
Disseminated progressive Herpes simplex ………
13. Are you currently a member of a caregivers’ support group?
Yes ……… No ……….
If yes, have you found it beneficial? In what ways?
If no, why not?
14. What are the factors that would make provision of services better?
…………………………………………………………………………………
………………………..………………………………………………………..
…………………………………………………………………………………
15. What are your constraints in providing care?
…………………………………………………………………………………
………………………..……………………………………………………….
…………………………………………………………………………………
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Project:
Observation checklist (Home)
Date:
1. How is the care provider received in the home?
Positively received [ ]
Negatively received [ ]
Neutral [ ]
2. What does the community worker discus during visit
……………………………………………………………………………
How does the home environment look like?
Well maintained [ ]
Needs some improvement [ ]
Neglected [ ]
3. Is there a home care kit available?
Yes [ ]
No [ ]
If yes, what is the condition? ………………………………………..
4. Is there clean water available for use?
Yes [ ]
No [ ]
Comments……………………………………………………………
5. Is there food available for the client? Comments
Yes [ ]
No [ ]
6. Any care being provided during the visit?
Yes [ ]
No [ ]
If yes, observe the process of care giving
7. What is the general condition of the client?
Good (up and about) [ ]
Fair (sickly but not bedridden) [ ]
Bedridden [ ]
8. Who are the other members of the family
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Project:
Care Giver:
Date:
1. Is your client your relative, friend, or neighbor?
2. Do you know the nature of the clients’ illness?…………yes……………no
3. What types of care/support do you provide
Nursing care …….
Counseling …….
Medications ……..
Nutrition care support ……..
Infection prevention ……..
Health education ……..
Other ……..
4. In what areas did you receive training?
Personal/palliative care ………
Administration of medications ………
Nutrition ………
Signs and symptoms of Tb ………
Signs and symptoms requiring medical followup ………
Infection control ………
 5. Have you received any additional training or information in the past year?
Explain……………………………………………………………………………
6.How many clients are you currently caring for
Adults …………
Orphans …………
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Care Giver
5. How often does the HCW visit you in the home?
Less than once per week ………….
More than once per week ………….
Irregularly ………….
6. Which signs and symptoms in a client would you refer to a medical
Facility…………………………………………………………………………
7. What is the most difficult condition for you to manage in your patient?
Explain
 8. What supplies and drugs do you have for the provision of care?
Gloves Disinfectants
Washing Nutritional supplements
Dressing materials Drugs (specify)…….
9. What makes it easy for you to care for your patient?
Explain
19. What makes it more difficult for you to provide care in the home?
Explain
20. Are you currently a member of a caregivers’ support group?
Yes………….. No ……………
If yes, Have you found it to be beneficial?……………….yes….…………..no
If no, Why not………………………………………………………………….
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Project:
Clients/Beneficiaries PLWAs)
Date:
1. What are your major health problems?
2. What do you know about IMPACT/ICROSS/COPHIA activities?
3. What services do you receive from the project?……………………………………
…………………………………………………………………………………
4. What services do you receive from the CHW?
Nursing care …….. Medications …….
Health education …….. Counseling …….
Nutrition care support…….. Infection prevention …….
Other ……..
4. What benefits do you get from the services?………………………………………...
…………………………………………………………………………………
5. Has anyone in your household ever been to visit a VCT center?……………..
……………………………………………………………………………
6. What drugs do you take?
Name of drug use availability (sometimes/always)
7. Do you or your partner use condoms?
8. For what purpose do you or your partner use condoms?
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Project:
Orphans and Vulnerable Children (OVC):
Date:
The following information on OVCs to be obtained from care-givers and family members
a. Source of psychosocial support, if any
b. Level of awareness of the effects of HIV/AIDS and related problems
c. Knowledge of COPHIA/IMPACT/ICROSS activities
d. Services received from projects
e. Benefits of such services
f. Enrollment in school
g. If there is any legal support, or if OVC requires legal support
h. If food supplies required are adequate
i. Nutritional status of OVC (determine by observation)
j. Vaccinations up to date
k. Clothing: Has ………….Does not have…………
l. The last time visited by a CHW and what the CHW did on that last visit
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EVALUATION OF USAID CARE AND SUPPORT PROGRAMS
Project:
Women:
Date:
1. What do you know about activities related to the following projects?
COPHIA………………………………………………………………………
ICROSS…………………………………………………………………………
IMPACT………………………………………………………………………
2. Have you ever received services from these projects?
VCT …………
Post test club ………….
Income generating activity ………….
Home based care ………….
Nutritional care ………….
3. Do you use condoms? …..yes …….no
Explain…………………………………………………………………………
4. Do you know how HIV can be transmitted to babies?
Breast milk ………….
In utero/during delivery …………..
Doesn’t know …………..
5. Do you know how transmission of HIV can be prevented in babies?
Drugs …………
Do not breast feed …………..
Doesn’t know …………..