1. LIST OF RELATED ACTIVITIES This activity is linked to activities in HIV/AIDS Treatment: ARV Services (#6945), Laboratory Infrastructure (#6940), Palliative Care: TB/HIV (#6944), and Counseling and Testing (#6941).

2. ACTIVITY DESCRIPTION CARE International has been supporting the implementation of PMTCT services in Siaya, Migori and Kuria Districts of Nyanza Province since 2001. In FY 2007 the geographical focus of CARE will be Siaya District. Siaya district recorded high HIV prevalence among women: 23.6% in the 2003 KDHS. Siaya has one district hospital, one sub-district and several health centers and dispensaries, for a total of 34 public health facilities on which CARE International will focus. CARE International currently supports PMTCT activities in 26 health facilities. The project is a collaborative effort with the Ministry of Health (MOH). The MOH is responsible for the provision of health facilities and health workers who are trained to provide comprehensive PMTCT services. CARE provides technical assistance and advice on effective models of care and provides strategic oversight. CARE Kenya builds the capacity of the MOH facilities staff to deliver high-quality, efficient and comprehensive PMTCT services, ensures linkages with other PMTCT service providers and communities, promotes early infant diagnosis with appropriate guidance on infant nutrition, ensures linkage of mother and infected infants to care and treatment, and facilitates supportive supervision.

In FY 2007, CARE International will extend PMTCT support to all existing public health facilities, and will refurbish and equip these as needed. The main focus will be on routine counseling and testing of pregnant women in antenatal clinics (ANC) and in maternity units, WHO clinical staging of HIV positive women, provision of cotrimoxazole and antiretroviral prophylaxis to HIV positive women and exposed infants. Emphasis will be laid on provision of a more efficacious regimen (sdNVP + AZT) or HAART to eligible women. The program will provide HIV counseling and testing to 16,735 pregnant women, and provide antiretroviral prophylaxis to 3,562 HIV positive women. Of these, 2,198 will receive sdNVP+AZT, 356 women HAART and 1,008 sdNVP. HIV infected and exposed infants will be followed up postnatally. The care package for HIV infected mothers in post-natal follow up will include counseling on appropriate infant feeding practices, linkage to care and treatment, and linkage to family planning services. The care package for HIV exposed infants will include early infant diagnosis and initiation of cotrimoxazole to a target of 2,198 infants. CARE will train 50 community resource persons as lay counselors as part of the referral system, and 50 health service providers in comprehensive PMTCT which includes Dry Blood Spot (DBS) technique of specimen collection for PCR. Additionally, CARE will organize and coordinate mobile PMTCT and early infant diagnosis services to the facilities without adequate staffing or infrastructure, and promote linkage from PMTCT to care and treatment. Identified infected infant-mother pairs will be linked to care and treatment. In FY 2007, CARE International will consolidate PMTCT activities to enhance male partner involvement using special invitation cards to the partners. CARE will use PLWHA to form support groups and demand creation for PMTCT. Within the facilities, CARE International will enhance supervision to achieve the targets for CT and NVP uptake. In addition, CARE will leverage resources available through their Safe Water Systems (SWS) program that focuses on making water safe through disinfection and safe storage to avoid contamination. Safe water vessels and disinfectant will be provided to women in the PMTCT program. This will improve the safety of infant weaning and reduce diarrhea morbidity. A community mobilization and education component will be included to increase awareness so that community members can make informed choices on issues to do with techniques of disinfecting water, proper hygiene behavior and proper use of safe water storage facilities.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA Community participation and male involvement will significantly contribute to PEPFAR goals for primary prevention, access to care and treatment, and support of those affected and infected. This activity will contribute 1.7% to the 2007 overall Emergency Plan PMTCT targets for Kenya.

4. LINKS TO OTHER ACTIVITIES This activity is linked to the KEMRI ARV program (#6945), KEMRI laboratory program (#6940), KEMRI TB/HIV program (#6944), and VCT (#6941). PMTCT services include

counseling and testing which is largely diagnostic, provision of ARV prophylaxis and appropriate referrals for the management of opportunistic infections and HIV/AIDS treatment. All HIV+ mothers and their family members will be referred to the ART program for on-going care, treatment and support. DBS samples will be packaged and shipped to KEMRI laboratories doing PCR, while samples for CD4 will be sent to regional laboratories doing CD4 count. Patients suspected to have TB will be screened and referred for TB treatment. Partners of HIV positive mothers will be encouraged to come for testing at PMTCT site or to go for VCT.

5. POPULATIONS BEING TARGETED This activity targets adults, pregnant women, HIV+ pregnant women, HIV exposed and HIV+ infants (0-4 years). The PMTCT+ initiatives will also target HIV affected families through providing mechanism for improving access to care of the family members of the HIV+ women. Public health care workers including doctors, nurses and other health care workers for example clinical officers, nutritionists, and social workers, will also be targeted for training using the nationally adopted NASCOP/CDC/WHO approved training packages, to equip them with knowledge and skills to provide comprehensive HIV prevention and care services.

6. KEY LEGISLATIVE ISSUES ADDRESSED Key legislative issues include increasing gender equity in HIV/AIDS programs, reduction of stigma and discrimination, linking care and support programs to income generation activities, and microfinance programs for women.

7. EMPHASIS AREAS Major emphasis will be placed on Quality Assurance and Supportive Supervision; lesser emphasis will be placed on Commodity procurement, Community Mobilization/Participation, Development of Network/Linkages/Referral systems and Training.

Plus up funds will be used within Siaya district to scale up early infant diagnosis activities, diagnostic testing and counseling (DTC) in the MCH, paediatric clinics and paediatric wards, TB clinics and adult treatment centers. Funds will also be used for start up of paediatric care and treatment within the MCH in high volume mature PMTCT sites. This will help increase the number of infants and children accessing diagnosis, care and antiretroviral therapy, and towards achieving the COP 07 EID targets of 2,198 and rapid scale up of children on ARTs. Funds will be used to support training on DBS, dissemination of national algorithm, procurement of test-kits for rapid tests, reagents, supplies and logistics for EID and DTC, and logistics for administration of paediatric ART and care from the MCH.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Condoms and Other Prevention (#9173), Counseling and Testing (#8747) and Palliative Care: Basic Health Care and Support (#6850).

2. ACTIVITY DESCRIPTION CARE Kenya, in partnership with local and indigenous organizations in the Northeastern Province of Kenya, will reach 35,000 in- and out-of-school children, parents, and village elders, and train 300 people to promote abstinence and marital faithfulness. The program will reinforce the protective influence of parents, grandparents, and other caregivers in changing risk behavior and stimulate broad community discourse on health norms and the avoidance of risky behaviors. The overall aim is to increase abstinence until marriage and increase fidelity in marriage. The primary implementing partner in this activity, CARE Kenya, was awarded a cooperative agreement with CDC in late FY 2004. CARE has many years of experience in Kenya. The purpose of this cooperative agreement is for CARE to build the capacity of local and indigenous organizations in the Northeastern Province of Kenya, and to provide sub-grants to local organizations in this area. The recent Kenya Demographic and Health Survey (KDHS) and other surveys have documented very low levels of HIV infection, under 1%, in this remote area of Kenya. Because of this low prevalence and the remoteness of this area of Kenya, to date there has been very little attention paid to the issues of HIV prevention and care in this part of Kenya. However, the road to Garissa, the provincial capital, has recently been improved and thus the population of this area is likely to become more exposed to HIV than in the past. Under this COP, we propose to have CARE support a limited number of sub-grantees. One of these, the Catholic Diocese of Garissa, has a wide coverage on schools in the neighboring Hola district and Wajir district. CARE is currently working with selected community organizations in Garissa and will be expanding its activities into the underserved Wajir district where it has identified a potential local partner, the Wajir South Development agency (WASDA). It will continue to identify local partners in collaboration with CDC and at least 65% of its project budget will go to directly to support sub-grants to local organizations. This activity therefore includes support to the following sub-recipients for activities integral to the program: Garissa Catholic Diocese, Garissa Youth Network; Sisters Maternity Home Group, Mikono Youth Group, Wajir South Development. Funding amounts for these agencies will be determined once new sub-grantees have been identified for FY 2007.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will contribute towards the achievement of the Emergency Plan's prevention targets in AB. It will reach 35,000 underserved youth and their parents and train 300 people to provide AB education and training, including life skills.

4. LINKS TO OTHER ACTIVITIES This activity links to other activities in CARE Kenya HVOP (#9173) CARE Kenya HVCT (#8747) and CARE Kenya HBHC (#6850). It will target strengthening the capacity of local organizations to identify and develop partnerships for referrals.

5. POPULATIONS BEING TARGETED The activities implemented by CARE in this program area will work to prevent HIV infection among children and youth in primary and secondary schools. It will also target special populations including out-of-school youth and underserved mobile populations in nomadic settings. Its capacity building process will target community, program and religious leaders and work with volunteers. Its in-school program will work with teachers to deliver the AB education. It will also target community and Faith Based organizations and largely rural communities. It will target strengthening supportive environments to safeguard the current low HIV prevalence rates.

6. KEY LEGISLATIVE ISSUES ADDRESSED The primary legislative issue addressed in this project is increasing gender equity in HIV/AIDS programs and addressing male norms and behaviors.

7. EMPHASIS AREAS This activity includes an emphasis on local organization capacity development and quality assurance, supportive supervision. It will also deliver IEC services and engage local communities through community mobilization. Human resources are another emphasis.

The factors that increase project costs include the insecurity, distance between locations, severe lack of infrastructure, difficulty in recruiting and retaining qualified staff, and higher staff salaries to compensate for the hardship location. Project costs reflect the current lack of local capacity and need to provide capacity building support to partners in the district.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Abstinence and Be Faithful Programs (#6849), Counseling and Testing (#8747) and Palliative Care: Basic Health Care and Support (#6850).

2. ACTIVITY DESCRIPTION CARE Kenya, in partnership with local and indigenous organizations in the Northeastern Province of Kenya, will reach 5,000 high-risk individuals with condom promotion and other prevention activities. 150 people will be trained to deliver interventions and three condom outlets will be established. Out of school youth, mobile populations including nomads in their migrant nature, business people, truck drivers, partners and clients of sex workers will be targeted with behavioral interventions to reduce their risk of HIV infection and transmission. STI treatment for persons infected with HIV will be strengthened amongst health service providers such as the Sisters Maternity Home. CARE will use innovative approaches of strengthening access to STI services by eliminating barriers such as access to treatment centers through provision of mobile outreach services. An important element in CARE Kenya's other prevention program is to develop a strong focus on Positive prevention by ensuring that specific activities are geared towards reducing the risk of HIV transmission by individuals with HIV. Such interventions would include extensive campaigns for knowing one's Serostatus, a need which can be met through the CT component of CARE's program. CARE will also comprehensively educate its target populations on the need for CT as well as seeking care and treatment early, with a view to lowering viral load and reducing the risk of infection. Other interventions will include behavioral interventions that would help individuals with HIV reduce behaviors that put others at risk. The primary implementing partner in this activity, CARE Kenya, was awarded a cooperative agreement with CDC in late FY 2004. CARE has many years of experience in Kenya. The purpose of this cooperative agreement is for CARE to build the capacity of local and indigenous organizations in the Northeastern Province of Kenya, and to provide sub-grants to local organizations in this area. The recent Kenya Demographic and Health Survey (KDHS) and other surveys have documented very low levels of HIV infection, under 1%, in this remote area of Kenya. Because of this low prevalence and the remoteness of this area of Kenya, to date there has been very little attention paid to the issues of HIV prevention and care in this part of Kenya. However, the road to Garissa, the provincial capital, has recently been improved and thus the population of this area is likely to become more exposed to HIV than in the past. Under this COP, we propose to have CARE support a limited number of sub-grantees and extend its support beyond Garissa town to other divisions in the district as well as to the neighboring Wajir district. Because this is a new intervention area, subgrantees and funding amounts are not available at the time of preparing this COP.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will contribute towards the achievement of the Emergency Plan's prevention targets in the Condoms and Other prevention program area. It will reach 5,000 underserved at-risk people and train 150 people to provide condoms and other prevention services, including a special focus on Positive Prevention. Three condom outlets will be established.

4. LINKS TO OTHER ACTIVITIES This activity links to other activities in CARE Kenya HVAB (#6849) CARE Kenya HVCT (#8747) and CARE Kenya HBHC (#6850). It will target strengthening the capacity of local organizations to identify and develop partnerships for referrals.

5. POPULATIONS BEING TARGETED The activities implemented by CARE in this program area will work to prevent HIV infection among adult men and women and special populations including nomads and migrant populations in underserved nomadic settings and truck drivers. It will target strengthening supportive environments to safeguard the current low HIV prevalence rates. Other populations targeted include out-of-school youth, partners/clients of CSWs and HIV/AIDS affected families, including widows/widowers. CARE will target most-at risk populations including commercial sex workers and discordant couples. It will work with a variety of community leaders including business community especially in Garissa and Wajir towns and community, program, religious leaders and volunteers. Capacity building will target for civil society organizations and the groups rural communities they serve. CARE

will target working with public health care workers of varied cadre to improve access to health care, particularly STI screening and treatment.

6. KEY LEGISLATIVE ISSUES ADDRESSED The primary legislative issue addressed in this project is increasing gender equity in HIV/AIDS programs and addressing male norms and behaviors. It will also address reducing violence and coercion, especially among young Somali girls.

7. EMPHASIS AREAS This activity includes an emphasis on local organization capacity development and quality assurance, supportive supervision and training. It will also focus on community mobilization and participation, human resources and the development of information, education and communication materials. The factors that increase project costs include the insecurity, distance between locations, severe lack of infrastructure, difficulty in recruiting and retaining qualified staff, and higher staff salaries to compensate for the hardship location. Project costs reflect the current lack of local capacity and need to provide training and other capacity building support to partners in the district.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in ARV Services (#9888), PMTCT (#6851), ARV Services (#8805), and Palliative Care (#8867).

2. ACTIVITY DESCRIPTION CARE Kenya will support 4 hospitals in North Eastern Province (Garissa Provincial, Ijara, Wajir and Madera District Hospitals) to provide palliative care services to 700 individuals with HIV including 70 children. The activities will also include training of 50 individuals in the provision of HIV-related palliative care services, refer them to care and treatment, and conduct community-based activities in support of care and treatment. At each site CARE Kenya will provide technical assistance, equipment and supplies, laboratory services, provide drugs for opportunistic infections, and expand access to safe water. In addition, this activity provides support groups linked to each facility, additional community -based services, and the identification of and training for community-based organizations. Activities directed towards the delivery of ARV services will be conducted in close collaboration with the Provincial ART Officer for North Eastern Province.

CARE has many years of experience in Kenya, including implementation of prevention of mother to child transmission programs and capacity building for local organizations. In FY 2005 CARE Kenya had attempted to support local organizations to provide palliative care services; this was unsuccessful due to the paucity of local organizations capable of performing these tasks, and FY 2006 care funds were reprogrammed to the Kenya Medical Research Institute. However, subsequently in FY 2006 CARE Kenya changed its approach and identified local staff to perform technical assistance and supportive assistance to directly assist the health facilities in the provision of care. North Eastern Province has low population density and very low rates of HIV when compared to other areas of Kenya, but is home to vulnerable mobile populations. While the bulk of programming in this province focuses on prevention, it is critical to have palliative care services available. Providing care, even when the need is relatively small, will facilitate prevention efforts such as testing, in that there will be services available for the small number of people who are found to be HIV-positive. By July 2006, this collaboration was supporting care at 4 district hospitals for more than 300 patients including 30 children.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will contribute to the results of expansion of palliative care services for clinically qualified HIV-positive patients, strengthened human resource capacity to deliver palliative care services, and a strengthened referral network for provision of palliative care and ART.

4. LINKS TO OTHER ACTIVITIES CARE'S non-ART activities in North Eastern Province link closely to prevention activities supported by CARE International (#6851), and to coordination of ARV scale up supported through the National AIDS and STD Control Program (#7004)) and APHIA II TBD (#8805).

5. POPULATIONS BEING TARGETED The targeted populations by these activities include health care workers, people living with HIV/AIDS especially HIV positive pregnant women and children (6 - 14 years) and the general population. The nomadic population currently has relatively low rates of HIV; however, our experience has shown that care and treatment linkages are key to the success of prevention programs, and therefore a key to keeping the HIV rates low.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses legislative issues related to stigma and discrimination through community sensitization activities.

7. EMPHASIS AREAS This activity includes minor emphasis in the areas of commodity procurement (for example for drugs for opportunistic infections, lab reagents and other supplies), community mobilization, local organization capacity development, human resources (salaries for health care workers at the clinics), training, and quality assurance and supportive supervision.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in AB (#6849) and OP (#9173) and Palliative Care: Basic Health Care and Support (#6850).

2. ACTIVITY DESCRIPTION In FY 2007, Care Kenya, in partnership with local and indigenous organizations in the Northeastern Province of Kenya, will provide counseling and testing services to 2,500 people in North Eastern Province. For this to be achieved, they will train 6 counselors who will be working in four primarily VCT sites. Care will work in partnership with the Garissa youth network, Sisters Maternity Home (SIMAHO), Mikono community group serving the Malakote community and with Wajir South Development Agency (WASDA) in the neighboring Wajir District. In working with these partners, Care will employ multiple innovative approaches to improving access to counseling and testing. Garissa Youth network will set up a VCT center at the central Garissa market that is a busy hub of business people and has recently attracted a number of sex workers. This facility, also set up as a youth center will target high-risk groups in the town. SIMAHO, a CBO comprised of retired nurses and who provide extensive community outreach will offer provider-initiated counseling and testing and VCT as part of its health care services. Mobile VCT services will be provided to the sparse population through targeting watering points where the nomadic communities congregate to water their flock. These watering points will be venues of providing integrated prevention, basic treatment and care services. Care Kenya is a non-governmental organization primarily working in the north-eastern part of the country. Although the HIV prevalence in north eastern province is very low (less than 1%, KDHS, 2003), there are several major challenges in the implementation of HIV/AIDS programs. This area is vast with a scanty population, and most of the residents are nomadic pastoralists. It is also semi-arid with difficult climatic conditions and unpredictable rainfall. This makes the people travel long distances in search of pasture and water for their flock. One of the other key challenges has been the relative insecurity in the area. Because of this, the cost of services in northern Kenya is high. Care Kenya has worked in northern Kenya assisting in various health and social programs for a long time. It has received support from the Emergency Plan through CDC since FY 2004 to implement mainly prevention activities, especially in the area of AB.

3. CONTRIBUTION TO OVERALL PROGRAM AREA CARE Kenya will provide counseling and testing services to 2500 people and train 6 counselors. CARE will provide CT services to an underserved nomadic population in northern Kenya. In the past North Eastern province was not adequately supported because of the poor infrastructure and also due to insecurity. The security situation has now improved and therefore more services should be made available. This activity will support Kenya's five year strategy of increasing access to prevention and care services

4. LINKS TO OTHER ACTIVITIES In FY 2007, Care Kenya will implement several HIV/AIDS components with the support from the Emergency Plan. Some of the other components include OP (#9173), AB (#6849) and Palliative care (#6850)

5. POPULATION BEING TARGETED This activity will target the population of North-Eastern Kenya. The activity will target the entire population, with a special focus on the youth. However, adults, children and youth will receive all the services. This activity will also target high risk populations like commercial sex workers and mobile populations like truck drivers and migrants.

6. KEY LEGISLATIVE ISSUES BEING ADDRESSED The activity will mainly address gender equity concerns. For socio-cultural reasons, women are often disadvantaged in this region. Services provided by Care will be culturally sensitive, but will endeavor to support women's access to HIV/AIDS services, and to CT.

7. EMPHASIS AREA The activity includes a major emphasis on capacity building for local organizations. It will also address community mobilization, training, and human resources.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Palliative Care: Basic Health Care and Support (#6850, #8867), PMTCT(#6851), and ARV Services (#8805).

2. ACTIVITY DESCRIPTION CARE Kenya will support 4 hospitals in North Eastern Province (Garissa provincial, Ijara, Wajir and Madera District Hospitals) to provide antiretroviral treatment to 300 (250 new) individuals with HIV including 30 children, bringing the total ever treated to 400. The activities will also include training of 50 health care workers in the provision of antiretroviral treatment. At each site, CARE Kenya will provide technical assistance, equipment and supplies, and laboratory services. ARVs are provided at the sites through Kenya Medical Supply agency and through USG central supply currently done through Mission for Essential Drugs (MEDS). In addition, this activity provides support groups linked to each facility, additional community-based services, and the identification of and training for community-based organizations. CARE Kenya will also provide salary support for some staff in accordance with Emergency Plan guidelines. Activities will be conducted in close collaboration with the Provincial ART Officer for North Eastern Province.

CARE has many years of experience in Kenya, including implementation of prevention of mother to child transmission programs and capacity building for local organizations. Northeastern Province has low population density and very low rates of HIV when compared to other areas of Kenya, but is home to vulnerable mobile populations. While the bulk of programming in this province is focused on prevention, it is critical to have care and treatment services available to the small number of people who need them. By July 2006, this collaboration was supporting treatment at 4 district hospitals for more than 100 patients including 5 children.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will contribute to expansion of access to ARV treatment for clinically qualified HIV-positive patients, strengthened human resource capacity to deliver ARV treatment, and a strengthened referral network for provision of ART.

4. LINKS TO OTHER ACTIVITIES These ART activities in North Eastern Province link closely to palliative care and prevention activities supported by the same partner and to coordination of ARV scale up supported through the National AIDS and STI Control Program (#7004) and the APHIA II NEP partner (#8805).

5. POPULATIONS BEING TARGETED The targeted populations by these activities include health care workers, people living with HIV/AIDS especially HIV positive pregnant women and children (6 - 14 years) and the general population. The nomadic population currently has relatively low rates of HIV; however, our experience has shown that treatment linkages are key to the success of prevention programs, and therefore a key to keeping the HIV rates low.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses legislative issues related to stigma and discrimination through community sensitization activities.

7. EMPHASIS AREAS This activity includes minor emphasis in the areas of commodity procurement, community mobilization, development of network/linkages/referral systems. Local organization capacity development, human resources, training, and quality assurance and supportive supervision.