The goal of UNHCRs program is to support and promote HIV and AIDS policies and programs to reduce morbidity and mortality and to enhance the quality of life among refugees and other Persons of concern (PoC) in Ethiopia. The objectives are to ensure PoC human rights, integrate HIV policies and programs into PoC programming, reduce HIV transmission and morbidity, ensure HIV positive PoCs have access to HIV services, increase PoCs and refugee support staff HIV knowledge and awareness, and ensure UNHCRs data are included in national HIV surveillance systems and that refugee programs are routinely monitored and reported on. The geographic cover is Gambella (Fugnido camp), Benshangul Gumuz (Sherkole camp), Tigray (Shimelba and My-Ani camps), Afar (Aysaita, Berhale), Somali (Kebribeyah, Sheder, Awbarre, Melkadida and Bokolmanyo camps) and in Addis Ababa (urban program). The target population is approx. 290,000 refugees, which includes all age groups, men and women, and the surrounding community. UNHCR will work towards strengthening partnerships and contributions from different funding sources (eg IGAD) and the government of Ethiopia (eg ARV drugs, HIV test kits etc). JHU, ICAP and I-TECH will partner with UNHCR in providing HIV trainings and technical and material support in M&E). The program supports the goals of the GOE and USG Partnership Framework and the Global Health Initiative.

All eligible individuals are planned to receive at least one care service which includes either facility-based or community-based or both facility-based and community-based care services in the reporting period with the support of the federal and regional HAPCO and Ministry of Health in order to optimize the quality of life of adults living with and affected by HIV. The target population will be all PLWH and their families which mainly includes adults .

PLWH will be referred appropriately to health facilities, counseling and social protection services with focus on women. The social protection includes livelihood programs such as multi-storey gardening (MSG) and chicken rearing for all PLWH and those at risk of gender violence. Multi-storey gardening is a simple farming technology, which is aimedat producing vegetables to supplement the food basket for micronutrients provision and addressing food insecurity in resource poor settings like the refugee camps.

Development of support groups for PLWH will continue in order to involve more of them in designing and implementing advocacy packages. Caregivers at the health facility and social workers will be identified and trained on HBC (Home Based Care), including clinical care (at the health facility level), nursing care, counseling and psycho-social support. The HBC program will be strengthened thanks to the referral linkages established through the care clinics described above. HBC will also serve an important role in the system of monitoring adherence to treatment provided; specifically, HBC will enable UNHCR to effectively trace defaulters and refer them to the care clinic. In addition, UNHCR will support provision of HBC kits by partner organizations. Other services that will be provided include: hygiene and sanitation for HIV-infected persons and their care givers, nutrition counseling linked to clinical and home-based care for all HIV-infected persons; HIV counseling about high risk behavior for all HIV-infected persons based on ABC, on an ongoing basis; Provision of condoms and referral for HIV-infected persons to other preventive services, especially family planning and STD clinics; Counseling for discordant couples to promote risk reduction behaviors; HIV counseling and testing for sex partners of HIV-infected persons and referral to care and prevention for persons identified as HIV-infected.

UNHCR plans to maintain the existing OVC programs in the camps and also expand services in two refugee camps (Kobe and Haloweyn) that recently opened in 2011. The OVC program will focus on community support and coordination, family household strengthening and improving quality service delivery.

Interventions will focus on the family unit and the community so as to promote the best interest of the child. Measures to prevent gender inequality, to mitigate further degradation of family structures, and to reduce social marginalization and stigmatization will be taken. UNHCR will support family capacity, whether the head of household is an ill or widowed parent, an elderly grandparent, or a young person, in order to build a protective environment for vulnerable children. Priority will be given to keep siblings together, encourage and maintain strong links with extended families, reintegration of children back into the community, and securing a stable, family-based placement. UNHCR will also strive to fortify the abilities of the target communities, local government and indigenous institutions to continue providing for vulnerable childrenand their families for sustainability. Children and their families will be encouraged to participate, to the fullest extent of their capacities, through the entire program. This will be promoted through child rights clubs, coffee ceremonies with community members and leaders on child protection topics etc.

UNHCR will also create and maintain existing safe social spaces for children, such as youth centers and child friendly spaces. UNHCR will concentrate on the following service areas: health care, protection, nutrition, shelter, and education and/or livelihood support programs.

In refugee settings in Ethiopia, there is a dire lack of HIV prevalence and behavioral data. Refugees have not been consistently integrated into national HIV sentinel surveillance or community-based surveys.

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. Joint supervision will be enhanced through the involvement of UNHCR, PEPFAR, RHB (Regional health bureau) and RHAPCO (Regional HIV/AIDS Prevention and Control Office) and implementing partners. 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. UNHCR staff will train implementing partners (IP) on data collection and program monitoring in Addis Ababa and within the camps. UNHCR will review monthly data submissions and will discuss them with the IPs. In order to develop and implement a single-point surveillance system, UNHCR will collaborate with universities working in the regions of Ethiopia. The PEPFAR university partners (ICAP, I-TECH and JHU) will support the camps with data collection tools and 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 its own 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 IPs, PEPFAR, and other relevant partners and interested organizations.

UNHCR will continue to promote implementation of safe medical male circumcision services in addition to raising awareness on the advantages of male circumcision with regards to HIV risk reduction and related prevention measures (such as consistent and correct use of condoms). The target population will be the boys and men in Fugnido refugee camp and the surrounding host population, with possibility of expansion to other camps. UNHCR plans to expand the male circumcision program to Sherkole refugee camp which currently has started receiving a new influx of Sudanese refugees and to implement safe medical male circumcision services in addition to raising awareness on the advantages of male circumcision with regards to HIV risk reduction and related prevention measures in the surrounding community.

MC services will be integrated with other HIV/AIDS services in the facilities especially with counselling and testing and SRH (sexual and reproductive health) services. Communication strategies will target male and female individuals through coffee ceremonies, community conversations, posters, pamphlets, mini media activities, and health education sessions in the health centre and through other major camp-wide events etc. These activities will be done in collaboration with camp anti-AIDS clubs, PLWH association and social workers. Awareness raising sessions with community leaders, elders and religious leaders will be enhanced so that they can positively influence their communities to promote safe male circumcision of all boys and men and related HIV prevention measures

UNHCR will work in partnership with JHPIEGO (John Hopkins Program for International Education in Gynecology and Obstetrics), RHB and RHAPCO so as to ensure that resources and expertise are well leveraged.

Technical experts from JHPIEGO will train camp health professionals on safe MC techniques and associated SRH services for men and their families.

UNHCR and ARRA will screen the target population for those who are not circumcised. This will be followed by mass circumcision campaigns, in the camp, in partnership with JHPIEGO.

Capacity will be strengthened to ensure appropriate tracking, follow-up and treatment of any post-operative complications.

Efforts will be made to ensure provision of quality health services at health centre to encourage the community to be circumcised at the health centre and not at home. Medical supplies and equipment will also be procured for conducting male circumcision under local anesthesia and post-operative management. This will be done in partnership with JHPIEGO.

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 they 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 supplies of improper use are common. Cleaning, disinfecting, and sterilization procedures are often inadequate, and some 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. Universal precautions are important to prevent transmission of HIV from patients to health workers and vice versa, either through occupational accidents or through contaminated blood or instruments. UNHCR will continue to strictly implement a series of universal precautions in all camps. This will be done through the provision of protective wear, equipment and reagents as well as through trainings for health workers on universal precautions. Efforts will focus on refresher training for medical and cleaning staff and maintenance of existing medical waste incinerators, thus making it possible to expand the program to the new refugee camps

UNHCR will also ensure that appropriate protocols are in place for the safe disposal of potentially dangerous waste products, such as needles and syringes.

The activities aim to reduce the transmission of HIV by promoting delayed sexual activity, abstinence, and faithfulness within the refugee and host communities.

UNHCR will initiate the provision of AB services in the newly established camps and will continue to implement HIV/AIDS education activities geared towards behavior change and the reduction of risky sexual behavior by:

Training of community and religious leaders and involving them in outreach activities;

Conducting teacher training on life skills and HIV/AIDS curriculum infusion and integration based on the Ministry of Education guidelines;

Training peer educators to instruct youth on sexual and reproductive health with focus on abstinence and faithfulness.

Sport for Life (curriculum developed by Health Communication Partnership (HCP), Ethiopia) is a programme that helps youth protect themselves from HIV/AIDS using different life skills. Youth will develop communication and other life skills that help them make healthy choices and protect themselves from HIV/AIDS.

Interactive Theatre places young people as major actors of their own prevention. The principle of Interactive Theatre is first to present several situations through a drama performance and then to invite the audience to comment on the scenes and join the actors by creating a new character.

Establishing Anti-AIDS Clubs for both in-school and out of school youth.

Education and communication programmes targeting youth will promote risk-avoidance skills, such as delay of sexual debut or abstinence.

Addressing cultural and social norms that increase risks for young people especially young women to have early sexual debut.

Linkage with services, including treatment of STIs and voluntary HIV counselling, testing, and referral, will be provided.

UNHCR will continue to provide quality VCT services for camp-based and urban refugees in Addis Ababa.

UNHCR will also increase VCT outreach and mobile services targeting people in the various camp zones thus increasing the access to quality VCT services in the region. The approach will involve working closely with community leaders, community health agents (CHAs) and community resource persons (CORPs) through trainings and using them in community mobilization. The VCT counselors will prepare work plans which they will share with community leaders. Through work plans and invitations, community leaders will spare time to accompany the VCT team to targeted areas. Due to demand for CT after such awareness campaigns, the mobile VCT team will be encouraged to carry to the field all counseling and testing tools so that those who demand for services are served on the spot.

Provider Initiated Testing and Counseling (PITC) services offered on opt out basis to patients affected by STIs, pulmonary TB, and other conditions suggestive of HIV infection, will be strengthened at all the camp sites. Trainings on VCT and PITC service provision will also be conducted. UNHCR will support efforts to provide confidential HIV counseling and testing within family planning sites. The counseling and testing supervisors will be responsible for quality control and capacity building with respect to the provision of quality VCT and PICT services in all the locations. Counseling support supervision and CT Quality Assurance will also be carried out.

HIV rapid diagnostic tests will be provided freely by the Ministry of Health. UNHCR will continue to collaborate closely with HAPCO and the MOH on quality control and the provision of supplies. UNHCR will increase its efforts to strengthen post-test clubs (PTC) in all camp locations and involve PTC members in education and mobilization activities. The PTC members will be trained on HIV related topics including risk reduction.

UNHCR plans to expand the key population/MARPs program in all the camps which had been piloted in Sherkole, Shimelba and Aw Barre camps. The program has had a very positive response whereby sex-workers even from the most religious communities in the Somali refugee camps opened-up about their sex-work and got series of trainings on condom negotiation, peer education and also received male and female condoms. To generate evidence necessary to implement innovative and impact oriented prevention programs, UNHCR will rollout the program in all the other camps.

UNHCR will maintain PMTCT services in Kebribeyah, Awbarre, Sheder, Sherkole, Shimelba, My Ani, Fugnido, Bokolmanyo, Melkadida and Afar camps and host populations and expand PMTCT service delivery to Adi Harush, Melkadida and the newly opened camps in Liben zone, Dollo Ado woreda: Kobe, Haloweyn and Buramino camps. UNHCR will integrate a package of PMTCT services into routine antenatal and postnatal consultations as part of integrated MCH (Mother and Child Health) services; establish supportive services for HIV pregnant women and their families; and provide HIV care and treatment to all HIV-infected pregnant women, HIV-exposed infants, infected children, partners and family members. UNHCR will provide facility-based and outreach services to improve the quality and equitable coverage of antenatal care, especially as PMTCT services are taken to scale. Delivery and postpartum care services, including periodic evaluation of the progress of pregnancy, labor support and active management of the third stage of labor will also be part of the integrated MCH services. UNHCR will also aim to reduce the risks of gender-based violence related to HIV sero-disclosure by supporting couples counseling and testing and partner participation in PMTCT. UNHCR will also support training to build capacity of healthcare workers to deliver high quality, comprehensive PMTCT services and enhancing monitoring and evaluation systems. UNHCR and its partners will work towards increasing follow-up of HIV-exposed infants and uptake of cotrimoxazole prophylaxis for the prevention of Pneumocystis jiroveci; Promoting best infant feeding practices among HIV-positive women (UNHCR 2009 Guidance on Infant feeding and HIV in the context of refugees and displaced populations); Integrating provider-initiated HIV testing throughout the continuum of maternal-child health services; Enhancing ART services for HIV-infected children; Building connections with communities and empowering them to mitigate the effect of HIV on families. Family planning (FP) services will be provided for HIV-positive women who desire to space or limit births as an important component of the preventive care package of services for women accessing PMTCT services.

UNHCR will continue to ensure that persons of concern (nincluding thousands of 2011 and 2012 new arrivals from Somalia and Sudan) living with HIV have access to timely, quality and effective care, support and treatment services including access to anti-retroviral therapy at a level similar to that of the surrounding host populations.