Preventing Mother to Child Transmission of HIV for Refugees and Host Community Populations in Ethiopia

The United Nations High Commission for Refugees (UNHCR) would like to expand, and officially

implement, the PMTCT program in the Fugnido, Kebrebayah, and Afar camps and host populations.

UNHCR will create linkages among existing PEPFAR partners who are operating in the region, including

Columbia University in the Somali Region, Johns Hopkins University in the Gambella region, and the

University of Washington/I-TECH in the Afar region, in order to improve the level of service provided in the

health center and to take advantage of additional government and regional resources.

In 2007, responding to the need for PMTCT, and under the voluntary counseling and testing (VCT) budget,

UNHCR began to bring PMTCT to the refugee and host populations by delivering Nevirapine (NVP) in

camps where possible, and by providing referrals for mothers for treatment in regional hospitals where

necessary. In addition, seven midwives were trained on PMTCT.

In 2008, UNHCR is applying for separate PMTCT funds in order to expand its PMTCT services. In 2008,

training/refresher training will be conducted for new/existing midwives on PMTCT. Counseling and testing

staff will be trained on the provision of testing to all pregnant women who present at antenatal care (ANC)

sites. The staff will also be trained on how to educate the women on the general protocol for PMTCT (which

is currently NVP in the camps), and the importance of using this service. If camp health centers are

identified as ART sites, they will be able to dole out dual therapy. Currently, however, this is not the case,

and NVP remains the prescribed course for PMTCT amongst refugee and host-community populations. All

pregnant mothers will be tested for HIV during antenatal follow-up, and HIV-positive women will be provided

with basic health instruction, including information on prevention of opportunistic infections (OI) and NVP

protocols.

HIV-positive newborns and their family members will receive appropriate care, including ART referral as

required. Midwives and traditional birth attendants (TBA) will be trained on safe delivery, breast health, and

exclusive breastfeeding so that they can provide this information to mothers. This activity will promote safer

infant-feeding for women with HIV because all HIV-positive mothers will receive counseling and support on

infant-feeding practices.

NVP will be provided by the Rational Pharmaceutical Management Plus (RPM+) program and will be given

to women in the camps so that they do not have to travel to regional hospitals for delivery and PMTCT

services.

Trained social workers/psychologists will be hired for each camp and the surrounding host community to

provide psychosocial services to mothers who test positive for HIV. These professionals will either be from

universities, as part of practical experience, or from the professional community. The same social workers

will provide services for all PEPFAR service areas. For example, counselors at VCT clinics can counsel only

on testing, even though some patients might require further assistance. Therefore, patients who test at VCT

sites will be referred to these social workers for psychosocial counseling, as necessary. The same social

workers will also serve other clients (e.g., those in the OVC program, people who have expressed

difficulties with condom negotiation, and rape victims).

The number of trained social workers hired will be determined by the number of camp residents at the time

of implementation.

HIV Prevention Services for Refugees and Host Populations in Ethiopia

This program targets the populations living in Fugnido, Kebribeyah, Teferiber, and Afar camps. These

activities aim to reduce the transmission of HIV by promoting delayed sexual activity, abstinence, and

faithfulness within the refugee and host communities. The prevention activities in the AB section are part of

a larger comprehensive plan for HIV/AIDS in the refugee camps in Ethiopia and were developed in

consultation with the Ethiopian Governmental Agency for Refugee and Returnee Affairs (ARRA).

In order to prevent the spread of HIV, an integrated package of activities is required to increase knowledge,

reduce risky behaviors, promote protective attitudes, develop safe practices, and reduce stigma and

discrimination among refugees and surrounding host populations. The activities in this service area will

mobilize the community through various activities in order to implement "AB" (Abstinence, Be faithful)

principles, and emphasize information-education-communication (IEC) and behavior-change

communication (BCC), as being central to successful HIV-prevention initiatives. IEC includes various

activities, from intensive one-on-one education, to mass dissemination of information, while BCC is a

multilevel tool for promoting and sustaining risk-reducing behavior-change in individuals and communities

through various communication channels. Targeted IEC/BCC activities that rapidly increase knowledge,

stimulate community dialogue, promote advocacy, reduce stigma and discrimination, and promote demands

for prevention, care, and support services in and around the camps will be implemented.

Materials for the camps will be created in all relevant languages and will accommodate relevant learning

and communication styles. In addition to the difficulty posed by multiple languages, implementing programs

will require significant logistical inputs due to the tenuous security situation. Intra- and inter-ethnic conflicts

frequently erupt in the Gambella region; three ARRA officials were murdered in December 2003, just ten

miles outside of Gambella town. Trips to Fugnido camp must be made with armed military escort, which

adds considerable cost and additional logistical maneuverings just to perform routine visits. Despite these

difficulties, the need for prevention activities in Gambella is great. Data from the Ethiopian Ministry of

Health's 2005 antenatal clinic (ANC) surveillance data suggests that the HIV prevalence in Fugnido was

2.8%, while the national average for rural populations was 2.2%. Syphilis rates were also significantly higher

than the national average.

The AB campaigns described below will fill a critical need in the refugee communities and within the host

populations. Implementing prevention programs in Kebribeyah and Teferiber, in the Somali region, poses its

own set of challenges. Although Kebribeyah has housed displaced Somalis for more than ten years, the

level of services is decidedly lower than in many other camps. Prevention activities began in 2007 in

Kebribeyah, and the region is characterized by a general ignorance of HIV/AIDS and modes of

transmission. This lack of knowledge, combined with frequent risky behaviors (including abduction and rape

of young girls, and practice of female genital mutilation in extremely unsanitary conditions) points to the

need for implementation of services and prevention activities. There is high interaction between residents of

Kebribeyah camp and the adjacent Kebribeyah town; as a result, interventions will target both refugee and

host communities. Teferiber is a new refugee camp and services and activities will be implemented using

2008 funds.

The following specific activities will be implemented:

Culturally appropriate IEC/BCC materials (posters, leaflets, brochures, billboards, etc) will be developed,

adapted, and produced in local languages for refugees and host communities. This material will emphasize

sexual abstinence before marriage, partner fidelity, and social norms promoting AB principles. Materials will

also address stigma and discrimination against people infected with, and/or affected by, HIV/AIDS, as well

as gender-based violence (GBV). ARRA and IP will hold a contest for the creation of the best AB message

within the camp. The winning design will be placed on billboards to be erected within the camps. Murals,

conveying AB messages, will be painted on the walls of buildings by the youth in the camps. The youth will

be from one of the AIDS clubs already established. Resource centers exist within each camp and additional

material will be printed by UNHCR and provided for residents in the camps. The printing of material, and the

contests held within the camps, requires paper, paints, and markers.

As part of an ongoing activity, forums for religious and opinion leaders will be conducted four times per year

by our implementing partners working the refugee camps. The forums for discussion will take place for a full

day. It is important to have the support and cooperation of the local leaders, and their input will help in the

creation of appropriate interventions regarding AB in the community. In addition, they will assist IP in the

education of the local community on HIV/AIDS and prevention.

Community conversations will be conducted by IP in order to engage the community in discussions and

solutions to the spread of HIV. The number of staff trained, and the total population served, is difficult to

estimate in the refugee context. The number of refugees served in Ethiopia is dependent on the political

situation in the local countries. In addition, the camps listed are subject to change based on the political

situation, both in and out of Ethiopia. In 2007, one community conversation leader, and one other

community service worker, were trained for each camp. (This full-time community conversation leader will

be hired at 3,420 birr per month, will train a staff within the camp, and will follow-up with staff each month.

The leader will train facilitators from the community (approximately 30 per camp). The community

conversation facilitators will be both male and female and will come from each of the ethnic groups (both

within the camps and the host communities). Each month the staff will meet with the full-time leader to

review barriers, problems, and solutions. Leaders will be hired and facilitators chosen for all new camps.

Refresher trainings will be provided within camps for all leaders, and facilitators.

Coffee conversations will be conducted six times in each of the camps and will be conducted separately for

men, women, youth, and commercial sex workers. Each ceremony will have a topic and will be run by

facilitators who will be provided with incentives for their work. Approximately 20 coffee-conversation

facilitators will be trained and will conduct the ceremonies with the assistance of IP.

Camp coordinators and resource coordinators were trained on multisectoral approaches to coordination of

voluntary counseling and testing (VCT) and capacity building of program managers. This three-day

workshop conducted in 2007 will be implemented again in 2008.

Peer educators will be used to promote and spread AB messages throughout the refugee and host

Activity Narrative: communities. Peer educators will be both male and female and will come from each of the ethnic groups

living in the camps and host communities. The peer educators (one for each 500 refugees) will be trained

for two days on peer education; that training will be provided to both returning and new peer educators. The

peer educators will also be used to promote counseling and testing and provide support to identified OVC. T

-shirts, hats, and bags will be provided to the peer educators so that they are easily recognizable. Bicycles

purchased in 2007 for peer-educator supervisors will be repaired and replaced, and bicycles will be

purchased in the new camps for the newly hired supervisors. Senior peer educators will be identified and

trained using OP funds.

Social workers, divided equally between males and females, will be hired to assist with the spread of

prevention messages. The social workers will work with OVC in VCT clinics and with people living with

HIV/AIDS (PLWH). There will be approximately 200 social workers trained per camp-300 for Fugnido (this

number will be raised depending on population size). Bags and t-shirts will be purchased for social workers.

Anti-AIDS clubs will be available both in and out of local schools. The anti-AIDS clubs will be involved with

the local competition for creating AB messages to be placed on billboards, etc. The clubs will provide

opportunities for youth to become involved with interactive drama that will convey AB messages. The drama

created will be produced for entire communities. In 2007, staff was trained on interactive drama and theater.

New staff will be trained on this initiative. Approximately a dozen staff members will be trained. Youth will be

involved in Sports for Life, provided by DICAC. DICAC was trained in 2007 by the Academy for Educational

Development (AED), a PEPFAR partner. AED will also provide training in peer education for implementing

partners. New staff will be trained on implementing Sports for Life by the IP. In 2007, 16 people were trained

in Sports for Life and refresher trainings will be provided to existing staff while new staff in each camp will

be trained. Materials and resources for Sports for Life will be provided and distributed by DICAC. Additional

sports equipment will be distributed to each of the camps.

Funding will be set aside for the celebration of Women's Day, World Refugee Day, World AIDS Day, and

GBV Day. Implementing partners will decide the activities for each camp.

Universal Precautions and Post-Exposure Prophylaxis

Universal precautions must be followed in all settings, including refugee settings. The following activities will

enforce universal precautions for the prevention of HIV transmission, including distribution of post-exposure

prophylaxis (PEP) kits for rape victims, complemented by AB, Other Prevention (OP), and voluntary

counseling and testing (VCT) components as part of a comprehensive HIV/AIDS program. This activity

complements prevention projects for refugees living in Fugnido refugee camp in Gambella region,

Kebribeyah and Teferiber camps in Somali, Sherkole camp in Benishangul-Gumuz, Shimelba camp in

Tigray and a new camp in the Afar region. Services will be provided to all camp residents as well as

residents of the surrounding host community.

This proposal was developed with the Government of Ethiopia's Agency for Refugees and Returnee Affairs

(ARRA), which is responsible for providing basic camp health services. All activities are coordinated closely

with ARRA and with other implementing partners (IP). UNHCR has developed a working relationship with

the local HIV/AIDS Prevention and Control Office (HAPCO) and will work with other PEPFAR partners to

provide appropriate training to ARRA health staff, as well as staff from other IP. The number of staff trained,

and the total population served is difficult to estimate in the refugee context. The number of refugees served

in Ethiopia is dependent on the political situation in the adjacent countriesIn addition, the camps listed are

subject to change, based on the political situation both in and out of Ethiopia.

Health clinics within the camps are staffed and administered by ARRA. Although ARRA provides sufficient

basic-health services for large camp populations, they are often under-resourced and lack staff adequately

trained in universal precautions and the provision of PEP. Shortages of supplies (e.g., heavy-duty gloves,

aprons, masks, eye shields, and safety boxes for disposal of sharp materials) or improper use are common.

Cleaning, disinfecting, and sterilization procedures are often inadequate, and most camps do not have

incinerators. The provision of PEP is required for healthcare workers who have possibly been exposed to

HIV through, for example, needle sticks, and for victims of rape and sexual violence. Due to the social

stigma associated with rape and gender-based violence (GBV), incidents of rape are often unreported and

accurate incidence rates are unavailable. Staff working in each camp will closely monitor incidents of

reported rapes.

Staff (including law enforcement) working in the camps (approximately 15 people from each camp) were

trained in 2007 on the importance of reporting of rape within 72 hours so that victims can receive PEP within

the 72 hour timeframe. In 2008, new staff will receive this training and refresher trainings will be provided to

returning staff. The training will be provided by ARRA and by the International Rescue Committee (IRC) in

Shimelba and Sherkole.

In 2007, 40 health staff were given a refresher training on universal precautions to prevent medical

transmission of HIV. In 2008, health staff will again be given refresher training on universal precautions,

including staff working in Afar region. Staff will also be trained on delivery of PEP and the appropriate

clinical response to rape for which UNFPA has developed clinical guidelines. Two trainers from each camp

will be trained on PEP and the trainers will train the remaining health workers in the camps. Linkages will be

made with other PEPFAR partners who can assist ARRA on trainings, including Johns Hopkins University

(JHU), Columbia University, and University of Washington/I-TECH.

Eighteen cleaners were trained on protecting themselves from coming into contact with potentially

contaminated materials. Training will again be provided to staff in 2008. Local staff will be trained or

refreshed on universal precautions and 60 kits will be provided to each camp for the TBA.

A total of eight PEP kits will be provided to each camp - five adult and three pediatric kits. Funds will also

be provided for additional materials, such as syringes, needles, boots, goggles, gloves, aprons, detergents,

and antiseptics (approximately 3,000 birr per camp). The equipment will supplement existing equipment

purchased with 2007 funds, and will be purchased in their entirety for the new camp in Afar. Funding will

ensure the presence of ten pairs of boots, ten goggles, ten aprons and ten pairs of gloves per camp. Funds

will also be provided for the maintenance of the incinerator in order to ensure proper disposal of medical

waste.

Manuals and guidelines, provided by ARRA and/or our university partners, will be provided for staff working

in each of the refugee camps.

Condoms and other HIV Prevention Services for Refugees and Host Populations in Ethiopia

The goal of this activity is to promote correct and consistent condom use in Fugnido, Kebribeyah, Teferiber,

and Afar refugee camps. All activities are coordinated closely with the Government of Ethiopia's Agency for

Refugee and Returnee Affairs (ARRA), which is responsible for providing basic camp health services, and

with our other implementing partners (IP). The United Nations High Commissioner for Refugees (UNHCR)

has developed a working relationship with the local HIV/AIDS Prevention and Control Office (HAPCO) and

will work with other PEPFAR partners to provide appropriate training to staff from ARRA and other IP.

UNHCR's other prevention (OP) programs create a demand for condoms and provide an adequate,

sustainable supply to the public in general and to targeted groups in particular. In refugee camps, the entire

population is considered inherently at-risk to due to transience, vulnerability to sexual exploitation, and lack

of access to information. Intensive condom promotion activities, supported by appropriate information-

education-communication (IEC) materials, and by increasing the number of condom outlets, will be

implemented in the camps. Syndromic management of sexually transmitted infections (STI) according to

guidelines will be ensured.

Creating appropriate interventions and materials for the camps will be challenging because they must be

created in all relevant local languages and must accommodate the different learning and communication

styles of each population. Furthermore, implementation in all camps and host communities will require

significant logistical inputs due to the tenuous security situation; intra- and inter-ethnic conflicts frequently

erupt in Gambella region, most notably with the murder of three ARRA officials in December 2003, just ten

miles outside of Gambella town. All trips to Fugnido camp require armed military escort, which adds

considerable cost for simple routine visits. Despite these difficulties, the need for prevention activities is

great. Data from the 2005 Ethiopian Ministry of Health's (MOH) antenatal clinic (ANC) surveillance suggests

an HIV prevalence of 2.8% in Fugnido camp, while the national average for rural communities was 2.2%.

Syphilis prevalence was also significantly higher than the national average; as a result, condom and other

prevention activities described below will meet critical needs.

Implementing prevention programs in Kebribeyah and Teferiber in Somali region poses its own set of

challenges. Although Kebribeyah has housed Somali refugees for more than a decade, the level of services

is much lower than in most other camps. Prevention activities were implemented in Kebribeyah in late 2007.

There is a general lack of knowledge about HIV and how it is transmitted, and the population is engaged in

risky behaviors, including abduction and rape of young girls. Condom usage is extremely low or

nonexistent, and the promotion of correct, consistent condom use will require significant efforts using

various media. Kebribeyah camp abuts Kebribeyah town, and there is frequent interaction between the two.

Interventions will target both refugees and the host communities.

The following activities will be implemented in Fugndio, Kebribeyah, Teferiber, and Afar camps:

UNHCR will procure and distribute condoms in all camps through a variety of mechanisms. The number of

condom outlets within the camps will continue to be expanded to reach a total of 200 in all of the camps.

Wooden condom dispensers were built and made available in 2007, and their presence will be expanded.

Money will be provided for their maintenance in 2008 and dispensers will be placed in the new camps in

Afar and Teferiber. The boxes will be strategically placed in bathrooms within the communities so that men

and women can take the condoms privately. Supervisors, provided with a stipend, will be hired in order to

monitor and restock condom supplies at each of the boxes and condom outlets in the camps and host

communities. This is necessary to ensure that supplies are constantly available.

Twenty four trainers, the senior peer educators, will be trained from all camps in peer education and

condom distribution and education. The trainers will also be trained in the use of penis models for condom

demonstrations. Models will be purchased for each of the new camps and used by peer educators in

demonstrating the importance and use of condoms. Peer educator kits will be purchased for each of the

peer educators so that they can educate their peers on correct condom use. Additional social workers will

be hired in order to effectively monitor peer educators, the population, and provide care and support to

those who need it. The social workers will also promote counseling and testing services, as well as testing

for STI. Condom use is typically not supported within the communities and therefore it is important for peer

educators and social workers to promote condom use and work with local community leaders on

implementing effective messages and tools to raise awareness of, and support for, condom use.

Condom and other prevention activities will work in tandem with the interactive drama groups and anti-AIDS

clubs developed under AB activities. Sports for Life activities will include messages about the importance of

condom use for protection against HIV amongst the older youth served by the activities. In addition,

community conversations and coffee ceremonies will focus on the importance of condom use and the ability

of condoms to help prevent the transmission of HIV and other STI. The activities will target all members of

the communities in general, as well as specific groups such as commercial sex workers.

Health workers in each camp will receive training on STI management and the importance of promoting

counseling and testing when treating and testing patients for STI. Universities working in the regions will

assist in ARRA's training for health workers.

Palliative Care for Refugees

This continuing activity will focus on activities for refugees living in Fugnido camps in Gambella region,

Teferiber and Kebribeyah camps in Somali region, and a new camp in Afar region. Services will be provided

to all camp residents and residents from surrounding local communities who avail themselves of services in

the refugee camps. This proposal was developed in consultation with the Government of Ethiopia (GOE)

Agency for Refugee and Returnee Affairs (ARRA).

The entire refugee population is considered inherently at-risk for HIV/AIDS due to their transience,

vulnerability to sexual exploitation, and lack of access to information. Implementing programs in these

regions requires significant logistical and material inputs due to the tenuous security situation. Intra- and

inter-ethnic conflicts frequently erupt in Gambella region, notably with the murder of three ARRA officials in

December 2003, just 10 miles outside Gambella town. All trips to Fugnido camp require armed military

escort, which adds considerable cost and logistical maneuvering for routine visits. Although the security

situation in Kebribeyah is not as bad as in Gambella, this region is historically under-resourced and under

threat of violence due to proximity to Somalia and the frequent conflicts between the Ethiopian military and

local rebel factions.

Not all people living with HIV/AIDS (PLWH) need ART; however all need basic health care and support.

This should include routine monitoring of disease progression and prophylaxis and treatment of

opportunistic infections (OI) and complications of immune suppression. In Ethiopian refugee settings, there

is no comprehensive palliative-care program addressing the needs of people living with the virus. This

project aims to strengthen basic health care services in general, and the diagnosis and treatment of OI in

particular, for PLWH in four refugee camps through capacity building, training of health workers, and

providing essential drugs for OI prevention and treatment. Linkages will be made with existing PEPFAR

partners working in regional health centers throughout the target areas, including Johns Hopkins University

(JHU), University of Washington/I-TECH, and Columbia University.

Working with the refugee communities in Ethiopia is a challenging endeavor. The number of refugees is

dependent upon the political situation of the neighboring countries. In 2008, with the inclusion of services in

a refugee camp in Afar region, new challenges will occur because the population in that region is

traditionally nomadic. Implementing partners will have to be creative in order to get services to this

population and will refer patients for services, such as food distribution, in order to provide care and support

to those who need it.

The following will be undertaken:

Basic palliative-care packages will be provided to all HIV-positive clients. The kits will include pain

medication, vitamins, antiseptics, dressings, gauze, gloves, and soap. The number of kits is difficult to

estimate because work with refugee populations in Ethiopia is ever-changing and depends on the political

situation in the surrounding countries. However, UNHCR will provide palliative care to 300 people living in

the refugee camps. The expansion of counseling and testing activities will increase the number of people

known to need care, particularly when it is expanded into sexually transmitted infections (STI) and

tuberculosis clinics. In order to adhere to the national guidelines, the existing TB program will be

strengthened by technical assistance to health workers. In addition, those who test positive for HIV will be

referred to STI, TB, and health facilities to ensure that they are tested and treated.

In 2007, 28 health workers were trained on palliative care, including ART. In 2008, returning health workers

will receive refresher training while all new staff will be required to undergo the complete training. UNHCR

will also work with university partners in the region to develop and implement trainings for medical staff. The

HIV/AIDS Prevention and Control Organization (HAPCO) will train staff on care and support in each camp.

An estimated 28 people will be trained. Palliative care is closely coordinated with universal-precaution

activities, and post-exposure prophylaxis will be provided to rape victims reporting within 72 hours. In 2007,

law enforcement was trained on appropriate responses to rape, and ARRA staff were trained on responding

to rape in a clinical setting.

UNHCR will procure a CD4 counter from UNFPA for a reduced price to be used in refugee camps. This will

limit the number of visits refugees need to make to the regional hospital—visits that are both time-

consuming and costly. Generators will also be procured for health facilities so that CD4 counters can be

used in the hospitals. Two medical staff from each of the camps will be trained on the use of the counter by

university staff. Clients who test positive for HIV will be monitored but referrals will be made to regional

hospitals so that refugees can receive ART. In order to ensure that refugees receive care from these

hospitals, transport and funds will be provided so that they can travel to and stay in the region while they are

receiving their monthly care. This service will be extended to approximately 80 persons. Referrals will be

provided by ARRA.

Home-based care for AIDS patients will be introduced through training and support for care providers from

the community. HAPCO will train social workers on home-based care and support. Implementing partners

(these differ from camp to camp) will hire one social worker for every 2,500 people in each camp; that

person will be trained in provision of home-based care. The cost for this is 350 birr per month per social

worker. The social workers, both male and female, will be from the local communities, including host

populations, and will speak the same language as the population with which they are working.

Essential OI drugs (not including those required for treatment of TB) such as cotrimoxazole, fluconazole,

and acyclovir will be purchased and provided to refugee health centers for treatment of patients. HAPCO

will train new staff on care and support and provide refresher training as needed.

Health-center staff will procure and distribute palliative-care packages to all HIV-positive clients.

Implementing partners will provide material support to HIV-positive patients and their families that includes:

blankets, kitchen sets, clothes, and buckets. New staff involved in the distribution of material support will be

trained on delivery and use of the packages.

In 2007, support was provided to groups of people who had come out as HIV-positive. Implementing

partners assisted them with education, agricultural assistance, and stigma-breaking. In 2008 we will

Activity Narrative: increase support to these groups so that they can expand and provide further support to other people in the

community who test positive for the virus through our expanded counseling and testing services. Those who

test positive will be referred to and included in these local groups. This activity will be provided to

approximately 300 people.

Assistance to Orphans and Vulnerable Children

This continuing intervention will provide OVC care and support in and around Fugnido, Kebribeyah,

Teferiber, and Afar refugee camps. Both Afar and Teferiber are new camps and activities were not

implemented there in FY07. Orphaned and vulnerable children can suffer social, emotional, and economic

consequences. Their problems are not well-addressed, especially in refugee settings. FY07 marked the first

time that the United Nations High Commissioner for Refugees (UNHCR) and implementing partners began

to offer programs for OVC in Ethiopian refugee settings. Using the results from the pilot project, Sudanese,

Somali, and Eritrean OVC living in both the camp and host populations will be supported by strengthening

family and community capacity, providing skills training to older children, and support for younger children.

This program was developed with the Government of Ethiopia's Agency for Refugee and Returnee Affairs

(ARRA). All activities are coordinated closely with ARRA, which is responsible for basic health care in the

camps, as well as all other implementing partners. UNHCR collaborates with the local HIV/AIDS Prevention

and Control Offices (HAPCO) and coordinates with other PEPFAR partners to train ARRA health staff and

staff from other implementing partners (IP).

Implementing programs in these regions will require significant logistical and material inputs due to the

tenuous security situation; intra- and inter-ethnic conflicts frequently erupt in Gambella region, most notably

with the murder of three ARRA officials in December 2003, just ten miles outside Gambella town. All trips to

Fugnido camp require armed military escort, which adds considerable costs and logistical maneuvering for

routine visits. Although the security situation in Kebribeyah and Teferiber is not as bad as Gambella, this

region is historically under-resourced and lies in an area under threat of violence due to its proximity to

Somalia and the frequent conflicts between Ethiopian military and local rebel factions. The population in

Afar region is traditionally nomadic; as a result, implementing programs within that community will be

particularly challenging.

The following will be undertaken:

Using best practices and lessons learned from a pilot project implemented in two refugee camps in 2007, IP

will identify OVC using PEPFAR-established criteria and the program developed in 2007 by the International

Rescue Committee. Children determined to be eligible will be enrolled in activities, and will be linked to

existing services within the refugee camps. Camps will need to conduct an initial assessment (which will be

completed by a consultant) in order to determine eligibility in such a way that does not label OVC as such to

the community. OVC who are HIV-positive will be followed closely to ensure that they are receiving

adequate and appropriate medical support. All OVC will be linked to medical services to ensure that they

are receiving the help they require. In addition, children will be referred to psychosocial staff on a case-by-

case basis.

In 2007, peer educators were trained by the Academy for Education Development (AED) in each refugee

camp as an AB activity. Training for new peer educators will be expanded in the new camps for 2008.

Refresher trainings will be provided for peer educators who were trained in 2007. IP will use a percentage of

OVC as peer educators to provide support for identified OVC and link OVC to youth activities, such as

interactive theater and Sports for Life, that are provided in the camps. Additional support will be provided to

OVC using the social workers hired by our IP. One supervising social worker will be hired for each camp to

ensure that the needs of the OVC are being met. Camp social workers will refer OVC to services provided

in the camps, including healthcare, schools, food-distribution sites, and counseling.

As part of a comprehensive approach to HIV and AIDS interventions, parents who test positive for HIV at

counseling and testing sites will be assessed to determine whether children in the household meet the

requirements for consideration as OVC. The same will hold true for youth who test positive at the

counseling and testing facilities. If so, they will receive services provided for OVC. Education materials such

as stationery, books, and school uniforms will be provided to all OVC enrolled by UNHCR and its IP.

UNHCR's IP will also provide life and vocational skills training for older children in their care. Social workers

trained by UNHCR's IP will train OVC caregivers on the care of children with HIV. This training will include

information on nutrition, basic hygiene, and healthcare.

Small scale agricultural and gardening programs will be implemented within households of OVC.

Implementing partners who work on community-service projects will initiate these activities with identified

households. Additional vegetables grown can be sold as part of an income-generating project. OVC will also

be provided with kitchen sets to open tea houses within the camps as part of an income-generating project.

Materials will be provided so that they can renovate structures and create the tea houses.

In order to coordinate the activities for OVC which include AB, Other Prevention (OP), and voluntary

counseling and testing (VCT), a coordinator will be hired for each camp to assess and ensure coordination

and linkages across the service delivery areas.

Through these activities, the project aims to reduce the suffering and improve the lives of 600 OVC.

UNHCR, following OVC guidance from the Office of the Global AIDS Coordinator, will develop pertinent

program indicators, and distinguish between direct primary and indirect supplemental services in semi-

annual and annual reports, indicating how they address gender equity in their programs. UNHCR will be

required to come up with an exit strategy to create smooth transition of the program from PEPFAR funding

to community/UNHCR and government support.

VCT Services for Refugees and Host Populations in Ethiopia

This activity will provide voluntary counseling and testing services to members of the host community in

Fugnido in the Gambella region, in Kebrebayah and Teferiber in Somali region, and a new camp and host

population in the Afar region for Eritrean refugees. In all camps, information-education-community/behavior-

change communication (IEC/BCC) activities that raise awareness and create demand for voluntary

counseling and testing (VCT) services will be conducted. Community-awareness-raising activities, which will

be implemented under AB and Other Prevention (OP) programs, will be linked to this VCT activity in order

to provide a comprehensive approach to HIV/AIDS prevention and care.

Counseling and testing (CT) will serve as a gateway to prevention activities, as well as to care and

treatment services for clients who test positive for HIV. The United Nations High Commissioner for

Refugees (UNHCR) will also create linkages among existing PEPFAR partners who are operating in the

regions, including Columbia University (Somali Region), Johns Hopkins University (Gambella Region), and

University of Washington/I-TECH (Afar Region) in order to improve the level of service provided in the

health center and to take advantage of additional government and regional resources. The number of

refugees served in Ethiopia is dependent on the political situation in the adjacent countries. In addition, the

camps listed are subject to change based on the political situation, both in and out of Ethiopia. The majority

of people testing for HIV will come from Fugnido camp. Testing will be more difficult in the Somali and Afar

regions due to the religious and cultural backgrounds of target populations.

The following activities will be undertaken:

Counselors (1-2 male, 1-2 female, depending on the camp size and makeup) and nurses for counseling and

testing centers will be recruited and trained as needed by an implementing partner (IP). Counselors will be

representative of each ethnic group living in the camps and host communities and will be hired if not already

present in the camps. Staff will be trained in confidentiality, counseling (pre- and post-test), procurement,

and use and storage of rapid HIV test kits. Rapid test kits (Capillus, Determine, and Unigold) and

consumable laboratory materials will be procured and supplied regularly to the counseling and testing

centers. Ten Capillus, seven Determine, and five Unigold rapid testing kits will be purchased.

In-service CT training will be carried out for all healthcare providers. Refresher training will be given to staff

who received training in 2007. Training for providers and counselors will include provider-initiated

counseling and testing (PICT).

Referral linkages to existing public-health institutions will be established and made operational. Testing staff

will refer to those receiving HIV tests to family planning, sexually transmitted infections (STI), and

tuberculosis (TB) clinics. Patients entering STI and TB clinics will be urged to get tested for HIV at the clinic.

ARRA staff working in the clinics will refer those who test positive for HIV to local hospitals so that they can

have a CD4 test and can be monitored and given ART at the appropriate time. If CD4 counters are available

in the camps, the tests will be done in the camps. Palliative-care funds have been requested to purchase

equipment to monitor CD4 counts within the refugee camps so that refugees do not have to make the long

trip to the regional hospital each month. Funds will be provided to the refugees so that they can get to the

regional hospital and receive care.

Testing sites will be expanded to youth centers in order to increase the number of people tested. The new

sites will be established at youth centers so that the youth do not have to go to the health facilities in order

to get tested. This will be implemented first in Fugnido, and an additional nurse will be hired to conduct the

tests, as well as to counsel patients. If this is successful, additional lay counselors will be hired to assist in

the provision of services. In addition, a CT site must be created for refugees in the Afar Camp.

Those testing positive for HIV will be referred to a social worker and to nutritionists working in the camps

who can provide support and information on food preparation. If nutritionists are not available in the camps,

they will be hired by local implementing partners (approximately two per camp). Counseling and referrals

are not limited to those who test positive, but will also be provided to those who test negative so that they

remain negative.

Links will also be made to the groups of people living with HIV/AIDS which were created under OP in order

to provide support and additional services for HIV-positive persons. Children of those testing positive for

HIV will be assessed in order to determine whether or not they require OVC services, as part of OVC care.

As part of AB, community conversations and coffee ceremonies will promote the importance of counseling

and testing. Peer counselors will encourage HIV testing, and the youth programs will implement

components stressing the importance of testing for HIV. At the quarterly conversations with local and

religious leaders listed under AB, IP will stress the importance of CT and will try to encourage local leaders

to support the services within the community. Specific outreach will be done at women's groups, amongst

women in the community, and with commercial sex workers to encourage them to be tested for HIV. Testing

days will be implemented at youth centers and at other locations aside from the clinic itself to ensure that

testing is easily accessible to the populations.

Monitoring and evaluation system of the VCT services will be put in place and implemented accordingly.

Strategic Information

Monitoring the level and trend of HIV infection is an integral component of a comprehensive HIV response.

Data enable policy makers and planners to appreciate the magnitude of the problem, allocate resources,

and monitor effectiveness of interventions. Unfortunately, in refugee settings in Ethiopia, there is a dire lack

of HIV prevalence and behavioral data. Refugees have not been integrated into national HIV sentinel

surveillance or community-based surveys. The burden of HIV/AIDS amongst refugees is not understood.

Under this project, technical assistance and training will be provided to a cross section of implementing

partners' staff members in Ethiopia through expert consultation, on-site visits, as well as meetings. A

mission will be conducted each quarter to see first-hand the monitoring of PEPFAR programs and the

surveillance systems. Technical assistance will be provided during these visits, as well as throughout the

funding cycle. On-the-job training and supervisory support will be strengthened. A time-limited consultant

will be hired to support healthcare providers and provide technical support to carry out sentinel surveillance.

UNHCR will train implementing partners on data collection systems and the use of indicators.

In 2007, the United Nations High Commissioner for Refugees (UNHCR) trained 150 people on strategic

information (SI). This training will be continued and UNHCR staff will train implementing partners (IP) on

data collection and program monitoring in Addis Ababa and within the camps. The consultant will review

monthly data submissions and will discuss them with IP.

In order to develop and implement a single-point surveillance system, UNHCR will collaborate with

universities working in the regions of Ethiopia. The universities will conduct the surveillance and supply the

data to UNHCR in Addis. Universities will also train partners working in the camps to ensure that they are

well-versed in data collection and use of computers.

UNHCR will synthesize information collected on refugees and manage a database. Information will be

provided by IP and organizations, including the Government of Ethiopia (GOE), working with the refugee

populations in the country. UNHCR will ensure that data is shared with IP, USG, and relevant partners and

interested organizations.