AB Programs in Sherkole and Shimelba Refugee Camps This is a new activity for FY07. This proposal comprises the follow-on phase of a project intended to provide prevention services to refugees living in camp settings and the local host community living in and around these camps. The prevention project was initiated with funding from State's Bureau of Population, Refugees and Migration in October 2004 as a complementary component of a pilot VCT center targeting Sudanese refugees living in Sherkole camp and the local host community, in the Benishangul-Gumuz region in western Ethiopia. This year, services in Shimelba refugee camp, located in the Tigray region, will also be added.

This activity is programmatically linked to "Voluntary Counseling and Testing for Sudanese and Eritrean Refugees" (COP ID 10561) and "Condoms and other Prevention Activities for Sudanese and Eritrean Refugees" (COP ID 10646).

This proposal has been developed in consultation with the Ethiopian regional liaison office of the UN High Commissioner of Refugees (UNHCR) and the Ethiopian Government's Agency for Refugee and Returnee Affairs (ARRA). Representatives from UNHCR and ARRA, along with staff from implementing agencies such as IRC spent the first half of 2006 conducting a gap analysis of HIV/AIDS programming in Ethiopia's seven refugee camps. Stakeholders identified the expanded activities that are the most critical, while emphasizing the need for establishing a minimum package of basic services that will be provided at each camp. This entire refugee population is considered inherently at risk, due to the transient nature of the refugees, their vulnerability to sexual exploitation, and their lack of access to information

IRC coordinates its activities closely with UNHCR, as well as with ARRA, who is responsible for providing basic health care services in each of the camps. In addition, they also collaborate with the local HAPCO and will work with other PEPFAR partners in order to provide appropriate training to all organizations who are working in the camps.

Sherkole The prevention activities are a component of the overall CT services offered to the refugees of Sherkole camp residents of the local host community. The goal is to provide community-wide CT and HIV/AIDS awareness and health education through strategic behavior change communication campaigns and community group discussions. AB messages will also be tailored for community and religious leaders, youth and adolescents, focusing on those who are even more vulnerable to HIV transmission, including women and girls.

Prevention activities are coordinated with the Sherkole refugee camp health clinic staff, community health workers, non formal education and vocational classes, as well as the schools within the camp. For this follow-on proposal IRC will continue with the current awareness-raising activities on HIV, including other STI, while emphasizing personal risk awareness through integrated AIDS education and strategic BCC campaigns targeting vulnerable groups. Complementing these activities is a new community participation strategy that will be put into place as a pilot project in Sherkole camp in October 2006 called Community Conversations, developed by the United Nations Development Program (UNDP). Community Conversations involves engaging communities in interactive discussions with the aim of creating a deep understanding about the HIV epidemic, identifying and exploring factors fuelling the epidemic in their respective context, and assisting these communities to reach decisions and take actions to mitigate the effects of the disease in their community. The Community Conversations strategy will be expanded to the Shimelba refugee community should it prove to be successful with the Sudanese refugees.

Support will continue to be provided to the existing anti-AIDS youth clubs in Sherkole. These clubs are an important tool for disseminating STI and HIV/AIDS messages and to effectively illustrate behavior change options to the community at large. Three peer education groups will be supported (one adult peer education group and two youth peer education groups), which are actively educating youth and adults on HIV/AIDS and STI. Further support and training will be made for the peer education groups to build their capacity as community mobilizers. For Sherkole camp, specifically, in light of the Sudanese refugee repatriation taking place, more interventions are planned to engage community

leaders, women and youth in health education activities on HIV/AIDS issues to raise the awareness of as many refugees on these issues as possible prior to their return to Sudan.

Shimelba In Shimelba, IRC will build on prevention programs that were started in Shimelba with a small amount of funding from the State Department's Bureau of Population, Refugees and Migration (PRM) in 2005. The anti-AIDS youth clubs will be strengthened, with an emphasis placed on recruiting additional female members. In addition, the HIV/AIDS peer educators will be increased from eight to ten, and will receive additional support and training.

Assuming that Shimelba receives funds in 07 for a counseling and testing center, CT will be seen as another context in which to spread the prevention message. In addition, the AB message will also be integrated with existing gender-based violence prevention classes, which are funded by an existing cooperative agreement with PRM.

Various types of IEC and BCC materials, such as posters, leaflets or billboards will be procured, or designed with the collaboration of the refugees and the local host community, and distributed to clients of the VCT centers and/or placed in strategic locations within the targeted communities. These materials will reinforce the project outreach activities and provide a further resource for the targeted communities to understand and put into practice the AB message.

Activities in the application for continuation of current activities include:

In Sherkole: (1) Continue to provide technical and material assistance as needed for the youth anti-AIDS clubs in both the refugee and the local host communities; Provide support to the youth and adult peer education groups; (2) Conduct video shows and other activities for out-of-school youth; (3) Distribute BCC materials on the modes of HIV prevention and other AIDS-related materials; (4) Conduct AB education sessions in non-formal education sessions, alternative basic education centers, accelerated learning classes and the refugee school; (5) Target refugee community leaders and religious leaders for HIV/AIDS awareness raising activities; (6) Conduct group discussions on HIV/AIDS with vulnerable groups such as youth, girls and women; and (7) Collaborate with Community Conversation facilitators to promote the AB message.

In Shimelba: (1) Continue to provide technical and material assistance as needed for the youth anti-AIDS clubs in both the refugee and the local host communities; (2) Provide support to the youth and adult peer education groups; (3) Distribute BCC materials on the modes of HIV prevention and promote AB as the means to avoid new infections; (4) Conduct video shows and other activities for out-of-school youth; (5) Conduct AB education programs awareness sessions in non-formal education sessions, alternative basic education centers, accelerated learning classes and the refugee school; (6) Target refugee community leaders and religious leaders for conducting appropriate AB trainings and the proper delivery of AB messages; and (7) Conduct group discussions on HIV/AIDS with vulnerable groups such as youth, girls and women

Condoms and other Prevention Activities for Sudanese and Eritrean Refugees

This is a new activity for FY07. This proposal intends to provide prevention services to refugees living in camp settings and the surrounding local host community. The prevention project was initiated with funding from State's Bureau of Population, Refugees and Migration in October 2004 as a complementary component of a pilot VCT center targeting Sudanese refugees living in Sherkole camp and the local host community, in the Benishangul-Gumuz region in western Ethiopia. This year, services in Shimelba refugee camp, located in the Tigray region, will also be added. A small percentage of funds for this activity will be used to procure roughly 135,000 condoms that will be distributed in both camps and surrounding communities, while the majority of the money will be spent on staff time for community social workers and health managers in each of the camps.

This activity is programmatically linked to activities "AB Programs in Sherkole and Shimelba Refugee Camps," (1005) and "Voluntary Counseling and Testing for Sudanese and Eritrean Refugees," (5606).

The proposal was developed in consultation with the Ethiopian regional liaison office of the UN High Commission of Refugees (UNHCR) and the Ethiopian Government's Agency for Refugee and Returnee Affairs (ARRA). Representatives from UNHCR and ARRA, along with staff from implementing agencies such as IRC spent the first half of 2006 conducting a gap analysis of HIV/AIDS programming in Ethiopia's seven refugee camps. Stakeholders identified the most critical deficiencies, while emphasizing the need for a minimum package of basic services at each camp. This entire population is considered inherently at risk, due to the transient nature of the refugees, their vulnerability to sexual exploitation, and their lack of access to information.

IRC's track record of implementing successful multi-sectoral programs in these two camps, combined with their local and expatriate staff expertise in reproductive health and HIV/AIDS interventions, makes this organization well suited to deliver quality prevention programs to the residents of Sherkole and Shimelba refugee camps. IRC coordinates its activities closely with UNHCR, as well as with ARRA, which is responsible for providing basic health care services in the camps. In addition, they also collaborate with the local HAPCO and will work with other PEPFAR partners in order to provide appropriate training to all organizations who are working in the camps.

Sherkole Camp Other prevention activities are a component of the overall CT services offered to the refugees of Sherkole camp and the surrounding community, with the goal of the larger AB program complementing this effort. In addition to awareness-raising activities, condoms will be supplied free at 28 distribution sites that are located within Sherkole camp and for the five distribution sites within the local host population. Community health workers, clinic staff, and other leaders will conduct trainings to encourage correct consistent condom use. Prevention activities in Sherkole are coordinated with the ARRA camp health staff and IRC's refugee incentive workers who provide community health education in educational and home-based settings. For this follow-on proposal, IRC will continue with the current awareness-raising activities on HIV, while emphasizing personal risk awareness through an integrated approach to AIDS education and strategic BCC campaigns targeting vulnerable groups. Complementing these OP activities is the community participation strategy that will be put into place as a pilot project in Sherkole in October 2006 called Community Conversations, developed by the United Nations Development Program (UNDP).

In light of increasing repatriation of Sudanese refugees, more interventions are planned to engage community leaders and especially women in activities on HIV/AIDS issues to raise awareness as far as possible prior to their return to Sudan. This endeavor is significant as refugees who go back to their homeland after living in camps outside (as opposed to those who have been internally displaced) often become leaders on return. These returning refugees often have had access to more services than their neighbors at home have had, including issues of education, water and sanitation training, and community health education. Therefore, it is critical that we train these refugees so that they can share the prevention message with their neighbors and minimize further spread. Residents

surrounding camps, which include sex workers who work in border towns, will receive targeted messages concerning correct consistent condom use.

Shimelba Camp Like Sherkole, prevention activities in Shimelba are coordinated with the ARRA refugee camp health clinic staff, as well as community health workers. Shimelba's need for prevention and care activities is unique because the population is 70 percent male, and gender-based violence is a significant issue in the camp. Although HIV/AIDS awareness among the population is high and there has been a demand for CT services in recent years, health clinic data on the rates of STI suggest that refugees are not taking measures to reduce their risk of infection. Therefore, IRC will work with ARRA health clinic staff, anti-AIDS clubs, community health workers and non-formal education teachers to stress the importance of condom use to those residents who can not/will not practice abstinence or be faithful. Creating appropriate messages on condom use for the Shimelba residents will be challenging, as the camp population is comprised mainly of two distinct ethnic groups who speak different languages, have vastly different education levels, and whose family composition and cultural norms are also quite different. For the ethnic Kunama residents, who are traditionally pastoralists with large families and very little education, community health workers will share prevention messages by convening informal meetings and coffee ceremonies during which correct consistent condom use will be discussed and demonstrated.

For the Tigrinya-speaking camp members, condoms will be promoted among the large number of single males aged 18 -59, as well as with the smaller number of married couples. These education sessions will be held in conjunction with the many adult non-formal education classes that have been organized by Tigrayan refugees, in addition to other reproductive health classes. In addition, the camp's Women's Association will serve as a forum for delivering targeted training and messages on the correct consistent condom use.

Finally, all prevention and awareness raising activities for all ethnicities will be coordinated with the camp's gender-based violence (GBV) coordinator, who is responsible for addressing and preventing GBV in the camp.

Activities in both Sherkole and Shimelba will include:

1) Make condoms available to all refugees and to the local host community with education on correct usage; 2) Conduct group discussions on HIV/AIDS with the most at risk populations in the camps and the surrounding communities, including commercial sex workers; 3) Collaborate with Community Conversation facilitators to raise HIV/AIDS awareness; 4) Provide condoms to all CT clients who want them; 5) Distribute BCC materials on the modes of HIV prevention and other AIDS-related materials; and 6) Deliver targeted messages, in all camp languages, that will demonstrate and promote correct and consistent condom use.

This program is an expansion of a COP06 activity (originally awarded to a different partner) that targets refugees in three camps, namely Dimma, Bonga, and Fugnido in Gambella region. No FY06 funds have been disbursed to this project because the change in partner has not yet been approved by Washington. The objective of this project is to provide VCT services to 35,494 Sudanese refugees and an estimated equal number of host populations around Dimma and Fugnido camps and to establish strong referral linkage for PMTCT services for mothers who turned out to be HIV+ during antenatal HIV testing.

This proposal is programmatically linked to "HIV Prevention Services for Refugees and Host Populations in Ethiopia" (COP ID 5739), "Condoms and Other HIV Prevention Services for Refugees and Host Populations in Ethiopia" (COP ID 5786), "Assistance to Orphans and Vulnerable Children in Six Refugee Camps in Ethiopia" (COP ID 1049), "Palliative Care in Four Refugee Camps in Ethiopia" (COP ID 1066), and "Universal Precautions and Post Exposure Prophylaxis in Six Refugee Camps" (COP ID 1022).

This proposal has been developed in consultation with the government's Agency for Refugee and Returnee Affairs (ARRA). Representatives from UNHCR and ARRA, along with staff from implementing agencies such as IRC spent the first half of 2006 conducting a gap analysis of HIV/AIDS programming in Ethiopia's seven refugee camps. Stakeholders identified the expanded activities that are the most critical, while emphasizing the need for establishing a minimum package of basic services that will be provided at each camp. Based on the current level of activities in the seven different camps, it was agreed that UNHCR would initiate activities in camps that did not yet have a strong prevention and/or counseling and testing foundation, while various implementing partners, namely IRC, would continue and expand work in camps where they had already established a foothold. All activities are coordinated closely with ARRA, who is responsible for providing basic health care services in each of the camps, as well as all other implementing partners. UNHCR has also developed a working relationship with the local HAPCO and will work with other PEPFAR partners in order to provide appropriate training to ARRA health clinic staff, as well as staff from other implementing partners.

The need for continued support of VCT services in the Gambella region is strong. Evidence from ANC surveillance in Dimma and Fugnido suggests that the incidence of HIV infection in the region is 12.9% and 2.8%, respectively, while the national average for the rural population from the same study was 2.2%. Infection rates for syphilis in the two camps were also significantly higher than the national average. VCT services will be used as an entry point for the comprehensive AB and C prevention programs that will be implemented in 07.

Implementing programs in this region will require significant logistical and material inputs due to the often tenuous security situation in the camps. Intra- and inter-ethnic conflicts frequently erupt in the Gambella region, most notably with the ambush and murder of three ARRA officials in December 2003, just 10 miles outside of the town of Gambella. Therefore, all trips to Dimma and Fugnido camps must be made with an armed military escort, which brings considerable costs and requires additional logistical maneuverings just to carry out routine visits. Therefore, construction costs for the VCT center will be higher than normal due to this situation.

IEC/BCC activities that raise awareness and create demand for VCT service will be conducted. Community awareness raising activities, which will be implemented under AB and OP programs, will be linked to this VCT service in Dimma and Fugnido camps. Counseling and testing will serve as a gateway to both prevention activities, as well as care and treatment services for clients who test positive. Pregnant mothers will be routinely screened for HIV during their antenatal follow up and positive cases will be provided basic health care including prevention of opportunistic infections and will be referred for Nevirapine treatment in the closest facility where this service is available. Positive newborns and family members will also receive appropriate care including referral service for ART, if required. In addition, UNHCR will create linkages among existing PEPFAR partners who are operating in the region, including JHU which is operating in the health centers, in order to improve the level of service provided in the health center and to take advantage of additional government and regional resources.

The following are specific activities to be undertaken under this project:

1) Continue the VCT service in Dimma camp by covering staff salaries and other running costs. 2) A new VCT center will be established in Fugnido camp. 3) Counselors and other staff for the new VCT center will be recruited and trained. 4) Refresher training will be provided for existing counselors and VCT staff in Dimma. 5) VCT kits and consumable laboratory materials will be procured and supplied regularly. 6) A referral linkage to existing public health institutions will be established and made operational for PMTCT services.

Added July 2007 Reprogramming: See UNHCR M & E increase and UNHCR VCT increase for narrative changes.

Voluntary Counseling Testing for Sudanese and Eritrean Refugees

This is a continuing activity from FY06. This proposal comprises the follow-on phase of a project intended to provide VCT services to refugees living in refugee camp settings and the local host community living in and around these camps. A CT project was initiated in October 2004 as a pilot VCT center targeting Sudanese refugees living in Sherkole camp and the local host community, in the Benishangul-Gumuz region in western Ethiopia. This follow-on proposal will continue with established CT activities, while expanding current activities to include CT services for Eritrean refugees in Shimelba camp in the Tigray region. These services will be integrated with the AB and OP activities that have been proposed in COP07.

This activity is programmatically linked to "AB Programs in Sherkole and Shimelba Refugee Camps" (COP ID 1005) and "Condoms and other Prevention Activities for Sudanese and Eritrean Refugees" (COP ID 1034).

This proposal has been developed in consultation with the Ethiopian regional liaison office of the UN High Commissioner of Refugees (UNHCR) and the Ethiopian Government's Agency for Refugee and Returnee Affairs (ARRA). Representatives from UNHCR and ARRA, along with staff from implementing agencies such as IRC spent the first half of 2006 conducting a gap analysis of HIV/AIDS programming in Ethiopia's seven refugee camps. Stakeholders identified the expanded activities that are the most critical, while emphasizing the need for establishing a minimum package of basic services that will be provided at each camp. This entire refugee population is considered inherently at risk, due to the transient nature of the refugees, their vulnerability to sexual exploitation, and their lack of access to information.

IRC's track record of implementing successful multi-sectoral programs in these two camps, combined with their local and expatriate staff's expertise in reproductive health and HIV/AIDS interventions, makes this organization well suited to deliver quality counseling and testing services to the residents of both Sherkole and Shimelba refugee camps. IRC coordinates its activities closely with UNHCR, as well as with ARRA, who is responsible for providing basic health care services in each of the camps. In addition, they also collaborate with the local HAPCO and will work with other PEPFAR partners in order to provide appropriate training to all organizations who are working in the camps.

Sherkole In Sherkole camp, the provision of CT services has been well received by both the refugee and the local host populations. IRC is offering CT services via two methods - a static site that is integrated within Sherkole refugee camp's health clinic and weekly sessions in four outreach sites within the local host community. HIV testing began on 12 April 2005 and by 26 May 2006, 1307 clients had been tested and counseled, with an average of 93 people being tested per month. A very strong and effective referral system has been set up between the VCT center, the ARRA health clinic and the regional hospital in Assosa, to enable all HIV+ clients to access the necessary medical and follow-up services they require, such as cotrimoxazole prophylaxis and other opportunistic infection treatment, CD4 count monitoring, anti-retroviral therapy and psychosocial support. Close observation is also done for tuberculosis co-infection detection amongst the HIV+ refugees.

As part of expanding CT services, the capacity building of the Maternal and Child Health (MCH) and other relevant staff of the ARRA health clinic in the prevention of mother to child transmission (PMTCT) of HIV is scheduled to commence in September 2006, with a focus on the proper administration of Nevirapine for the pregnant woman and the newborn. Nevirapine will be made available in the ARRA MCH clinic when possible and it will be procured from the Assosa regional hospital.

A challenge faced by IRC is the difficulty for referred HIV+ clients in more remote outreach CT sites to access the medical services in Assosa. A solution being discussed with the regional HAPCO office in Assosa is to make available a vehicle which would be able to transport referred HIV+ clients to and from Assosa as needed. IRC is currently trying to fill this gap, but a lack of sufficient vehicles is a great obstacle to maintaining consistent access to medical services for HIV+ clients.

In Sherkole, FY07 activities will: (1) Continue to offer quality CT services through the static site to both refugees and members of the local host community (2) Continue to offer quality CT services to the local host community through mobile CT efforts (3) Conduct community awareness-raising activities to promote CT and PMTCT (4) Continue to build the capacity of VCT center staff through on-going in-service trainings on counseling and management (5) Maintain good relations and strong referral network that has been established between the VCT center, the ARRA health clinic, the Assosa regional hospital, the New Life After Test post-test club, the Tesfa Bilichat PLWHA association and the regional HAPCO office (6) Continue with the capacity building of health facility staff in the counseling for PMTCT and the proper administration of Nevirapine (7) Ensure that Nevirapine stock outs do not occur in the ARRA MCH clinic - by providing commodities management training and support for relevant health staff (8) Provide support for the New Life After Test Club and Tesfa Bilichat PLWHA Association as needed (9) Provide transport for HIV+ clients who do not have access to medical and/or other support or wrap around services (10) Conduct monthly coordination meetings with VCT staff and the ARRA health clinic (11) Encourage and try to facilitate the establishment of more community support structures, such as post-test clubs for CT clients, with a focus on PLWHA (12) Advocate for the establishment of more PLWHA support associations in the region with established local or international organizations, at the Addis Ababa level.

Shimelba A VCT center is planned for the Eritrean refugees living in Shimelba refugee camp, located in northern Ethiopia in the Tigray region. From the results of two formative knowledge, attitudes and practices surveys conducted in 2003-04 in Shimelba camp, the IRC learned that 92.8% of the refugees surveyed were interested in knowing their HIV status. As in the case with Sherkole camp, the IRC proposes to establish a VCT center in Shimelba camp which will be integrated within the existing ARRA health clinic compound and will be complemented by continuous CT and HIV/AIDS sensitization and awareness-raising activities. Outreach CT services will be established for the local host community if needed. BCC campaigns will provide targeted and tailored messages to the refugees in Shimelba camp and the local host community to promote the benefits of knowing one's HIV status through CT. A post-test support club will be established and referral networks and linkages will be made with local health authorities and facilities for follow-up medical and wrap around services.

In Shimelba, FY07 activities will: (1) Construct a CT center integrated with the ARRA health clinic (2) Recruit and train 1 VCT Manager, 3 VCT counselors and 1 VCT lab technician and procure all necessary laboratory materials and supplies and data analysis.

Plus up: PEPFAR Ethiopia will fund the International Rescue Committee to support specialized geographical information systems and geospatial data analysis by: 1. Supporting PEPFAR to present mapping products and conduct spatial analyses of existing PEPFAR activities and socio-economic, epidemiological, physical and infrastructural variables related to HIV/AIDS; 2. Maintaining updated USG mission activities to determine synergies across technical portfolios (e.g. USAID Basic Education Services, Alternative Livelihoods and Transitions, Business, Economic Growth, Agriculture and Trade and Health, AIDS, Population and Nutrition Offices). 3. Responding to requests for specialized geospatial analyses to ensure programming efficiencies. This will assist in stakeholder outreach, standardization of program implementation and performance tracking of facility and community services."

Table 3.3.13: