1. LIST OF RELATED ACTIVITIES This activity relates to activities in Counseling and Testing (#8751), Condoms and Other Prevention (#6897) and HIV/AIDS Treatment: ARV Services (#7090). 2. ACTIVITY DESCRIPTION Impact Research & Development Organization (Impact Research) will reach 60,000 youth under the Tuungane behavior change project through providing Abstinence and Faithfulness education and related services through six youth-friendly satellite centers in five major slums of Kisumu, Nyanza Province. Tuungane will also initiate activities with the Suba community. A central referral and coordination center (Tuungane central) will continue to serve as the hub of all AB youth activities and up to 300 youth with receive a curriculum-based training on life planning skills. The Tuungane project will enhance adult involvement in the AB program through training 200 adults, including parents, teachers and religious leaders as supportive adults for the youth. The project will intensify its efforts to reach out to at least 3,000 at-risk girls with behavior change interventions and improve the involvement of girls in all elements of the project. An important need identified by the project in the previous year is addressing sexual violence through integrating it into the education for behavior change activities. This will be coupled with educating youth on the increased HIV vulnerability in the context of alcohol and substance abuse. Tuungane has demonstrated a remarkable strength in implementing intensive and quality interventions in the community and has useful lessons which will be scaled up to the underserved and highly vulnerable population of Suba district in Nyanza. Tuungane will work with schools in Suba as well as with out of school youth including the beach community and the general community of youth and young adults to provide comprehensive AB education. These activities will contribute to our results of improved HIV preventive behaviors among youth, changed social and community norms to promote HIV preventive behaviors in youth and young adults, and models for effective youth interventions tested. The Tuungane project was funded under a CDC Cooperative Agreement in September 2004 and works within Kisumu urban slums whose estimated youth population is 80,000. The project and the specific interventions will be studied for effectiveness by Kenyan evaluators who are part of the staff of Impact Research and Development Organization. Youth will be continually involved in activities that help sustain HIV preventive behavior through periodic training in life skills. To provide a supportive environment for young people's adoption and maintenance of HIV preventive behavior, parents, religious and community leaders will be reached with targeted activities. These changes will contribute to testing a model of effective youth interventions. It will also improve social and community norms to promote HIV preventive behaviors in youth and young adults. Most importantly, it will make significant contributions to improved HIV preventive behaviors for youth through strengthening life skills. 3. CONTRIBUTIONS TO OVERALL PROGRAM AREA Abstinence and faithfulness activities will target youth in the slum areas of Kisumu and selected sites in Suba District. This will significantly contribute to the PEPFAR goals of averting HIV infections among youth. Specifically, this project will train an additional 200 leaders to reach 60,000 youth with AB messages. 4. LINKS TO OTHER ACTIVITIES Tuungane's AB activities in Kisumu slums relate to activities in CT (#8751), OP (#6897) ART UCSF/FACES (#7090). Linkages between existing youth service providers include the Family Health Options Kenya, the Network for Adolescents and Youth in Africa, local youth groups, and the Municipal Council of Kisumu. A strong referral linkage will be strengthened for young people who test positive. Currently, referrals for young couples are made to the KEMRI/CDC PEPFAR-supported patient support center of the Nyanza provincial general hospital as well as the FACES project. 5. POPULATIONS BEING TARGETED This activity targets the general population including men and women of reproductive age as well as youth, especially young girls and boys, as well as primary and secondary school students. It will target PLWHAs and incorporate them into their education program. It will also work with street youth and out-of-school youth. It will strengthen its community involvement through working with community, program, religious leaders and volunteers. In-school programs will involve teachers. Existing community structures will be utilized including youth and community organizations as well as faith-based organizations. The proposed work in Suba will serve rural communities. 6. KEY LEGISLATIVE ISSUES ADDRESSED This project will address key legislative issues particularly gender issues. The project will work at increasing gender equity in its programming, particularly enhancing the

participation of young women in the AB activities. Participatory approaches will be employed to address male norms and behaviors as well as the reduction of violence and coercion through the life skills training. Stigma and discrimination will be addressed through intensive community education and sensitization forums. 7. EMPHASIS AREAS This program will have a major emphasis in community mobilization/participation. Minor emphasis will be place on development of network/linkages/referral systems, information education and communication, training, needs assessment and human resources.

Service Delivery in Facilities and through Mobile approaches: In collaboration with the MOH, the Nyanza Circumcision Consortium, through IRDO, will work on targeted roll-out of MC services in Nyanza. Service delivery capacity-building will be rolled out in district hospitals and some private facilities where providers have been trained and where other USG PEPFAR partners, including KEMRI, are currently working. In addition to training, support will be provided for non-consumable commodities (i.e. autoclaves, instrument packs, surgical lamps, etc…) personnel and other infrastructure that will be necessary for MC service delivery. Service roll-out will initially target areas with high existing demand for MC services and will be integrated into discordant couples services for discordant male partners of women in care and treatment programs. Mobile service provision will be provided by mobile teams consisting of approximately five people (including 1 clinical officer, 1 VCT counselor, 1 surgical nurse, 1 sterilizer/cleaner and 1 driver) targeting high risk groups, such as uniformed services personnel and truck drivers, and areas of very high HIV prevalence. For example, mobile services will be provided in Suba District, Kenya's highest HIV prevalence district, to complement the current door-to-door VCT program that PEPFAR is supporting there. In addition, services will be provided within areas such as the Demographic Surveillance Study area where operational evaluation can be conducted and in other areas where PEPFAR services exist. A critical component of this acitvity will be the provision of AB counselling and interventions for men undergoing both VCT and circumcision. This activity will help to develop several AB interventions that can be used to help reduce any sexual disinhibition which may come as a result of programmatic scale-up of MC.

1. LIST AB (#6896), CT (#8751) and HIV/AIDS Treatment/ARV Services (#7090) and Palliative Care (#6870). 2. DESCRIPTION IRDO will reach 30,000 youth under the Tuungane behavior change project with condoms and other prevention activities. It will continue to work through the six youth-friendly satellite centers in five major slums of Kisumu, in Nyanza Province and a central referral and coordination center at Tuungane central. Tuungane will continue to encourage the involvement of adolescent girls and young mothers through targeted activities for girls. This project will also target various high-risk groups including bodaboda and matatu operators, street youth, out of school youth, partners and clients of sex workers, bar workers and discordant couples. Most importantly, Tuungane will develop interventions for positive prevention among individuals with HIV. These will include behavioral interventions targeting PLWAs. Given Tuungane's focus on girls and young women, another intervention will entail prevention of unintended pregnancies among girls and young women. In addition to the existing STI prevention services offered by this project, Tuungane will intensify STI screening and treatment for individuals with HIV and their partners. Through its linkage with USCF's FACES project, Tuungane will ensure access to care and treatment, including ART for positive people identified through the project. Overall, this project will promote leadership by individuals with HIV in the positive prevention efforts. An important need identified by the project in the previous year is addressing sexual violence through integrating it into the education for behavior change activities and providing PEP. Education and sensitization on alcohol and substance abuse will be integrated into the condoms and other prevention activities whenever appropriate. Tuungane has demonstrated a remarkable strength in implementing intensive and quality interventions in the community and has useful lessons which will be scaled up to the underserved and highly vulnerable population of Suba district in Nyanza. Tuungane will work with youth in Suba as well as with identified high-risk groups, including the beach community to provide comprehensive OP education. Given IRDO's technical capacity, specific interventions will be evaluated for effectiveness by the Kenyan researchers who are part of the staff of Impact Research and Development Organization. Significant changes from 2006 to 2007 for this activity include the scale up to Suba. Another important addition in FY 2007 is the focus on positive prevention. This project will actively involve existing youth community groups to enable it to rapidly expand behavior change activities for youth in the slums. Service delivery will be improved through mobile integrated services including provision of free counseling services for youth, including street youth and referrals for free STI treatment. 3. OVERALL AB activities and information on correct and consistent use of condoms targeting youth in the slum areas of Kisumu will significantly contribute to the PEPFAR goals of averting HIV infections. Specifically, this project will train 200 leaders to reach 30,000 individuals with condoms and other prevention services. Seven condom outlets will be established. 4. LINKS CT (#8751), ART (#7090), AB (#6896) and STI treatment. Linkages between existing youth service providers include the Family Health Options Kenya, the Network for Adolescents and Youth in Africa, local youth groups, and the Municipal Council of Kisumu. A strong referral linkage will be strengthened for individuals with HIV. Currently, referrals for young couples are made to the KEMRI/CDC PEPFAR-supported patient support center of the Nyanza provincial general hospital as well as the FACES project. PLWHAs are referred for psychosocial support to Our Lady of Perpetual Support for People living with HIV/AIDS (OLPS) (#6870). 5. POPULATIONS BEING TARGETED This activity targets the general population including men and women of reproductive age as well as youth. It also targets special populations, mainly most at risk populations such as discordant couples, men who have sex with men, street youth and out-of-school youth. At community level, this program will target community and religious leaders, most of whom will work in a volunteer capacity. Through its alcohol intervention, brothel owners and bar workers will be targeted. Existing community structures will be utilized including youth and community organizations as well as faith-based organizations. It will also work with private and public health care providers to strengthen STI screening and treatment and referrals for HIV/AIDS care and treatment. 6. KEY LEGISLATIVE This project will address key legislative issues particularly gender issues. Participatory

approaches will be employed to address male norms and behaviors as well as the reduction of violence and coercion through participatory education and training. Stigma and discrimination will be addressed through intensive community education and sensitization forums. 7. EMPHASIS major emphasis in Community mobilization/participation. Minor emphasis will be in development of network/linkages/referral systems, Information Education and Communication, training and needs assessment. Plus up: IRDO's Tuungane project will expand its support to at-risk youth in the Kisumu slums and youth/young people involved in alchohol and substance abuse. This expansion will also allow for a minimal start up in a selected location in Suba district, where the Tuungane project has recently set up new project activities focusing on the fisherfolk community of Suba District, Nyanza province. The expansion in Kisumu will allow for an increase in scope to allow coverage of new locations within the five major Kisumu slums. these will include Obunga, Bandari and Nyalenda areas. Tuungane project will intensify its campaigns against sexual violence, which is a rampart practice significantly affecting adolescent girls. These activities will be integrated into the existing broader prevention program, including increasing linkages and referals to CT (High risk youth $50,000 and (High risk adults $100,000). Service Delivery in Facilities and through Mobile approaches: In collaboration with the MOH, the Nyanza Circumcision Consortium, through IRDO, will work on targeted roll-out of MC services in Nyanza. Service delivery capacity-building will be rolled out in district hospitals and some private facilities where providers have been trained and where other USG PEPFAR partners, including KEMRI, are currently working. In addition to training, support will be provided for non-consumable commodities (i.e. autoclaves, instrument packs, surgical lamps, etc…) personnel and other infrastructure that will be necessary for MC service delivery. Service roll-out will initially target areas with high existing demand for MC services and will be integrated into discordant couples services for discordant male partners of women in care and treatment programs. Mobile service provision will be provided by mobile teams consisting of approximately five people targeting high risk groups, such as uniformed services personnel and truck drivers, and areas of very high HIV prevalence. For example, mobile services will be provided in Suba District, Kenya's highest HIV prevalence district, to complement the current door-to-door VCT program that PEPFAR is supporting there. In addition, services will be provided within areas such as the Demographic Surveillance Study area where operational evaluation can be conducted and in other areas where PEPFAR services exist. A critical component of this acitvity will be delivery of services, specifically the surgical cutting procedures involved in male circumcision.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in AB (#6896) and OP (#6897).

2. ACTIVITY DESCRPTION In FY 2007, Impact Research & Development Organization's (Impact Research) Tuungane project will provide HIV counseling and testing (CT) services to 3500 individuals in Kisumu slums and underserved areas in Suba District. This activity will respond to the high demand for counseling and testing created through Tuungane's behavior change activities targeting youth and at-risk populations. Tuungane will work through the 6 youth-friendly satellite centers in 5 major slums of Kisumu, in Nyanza Province and a central referral and coordination center at Tuungane Central. They will train ten counselors to support their fixed and mobile sites. The Tuungane has made remarkable strides in targeting hard to reach and underserved populations such as adolescent girls and young mothers through targeted activities. Other high risk subpopulations to be targeted include bodaboda and matatu operators, street youth, out of school youth, partners and clients of sex workers, bar workers and discordant couples. Most importantly, Tuungane will implement a prevention-with-positives program, working with PLWHAs. Additionally, Tuungane will support couples counseling and disclosure. Communities will be educated on couple discordance and the importance of couples knowing their HIV status together. Tuungane will also incorporate CT into their community outreach activities. Tuungane will also introduce diagnostic HIV testing and counseling (DTC) at its clinic at the Tuungane central youth facility where STI treatment is provided. Nurses and clinical officers currently working in the clinic will be trained and supported to provide DTC. Tuungane will continue providing youth-friendly services and addressing barriers that hinder access to counseling and testing. A coupon referral system and free boda boda transportation will ensure that transportation costs do not hinder people from seeking services. Through its linkage with USCF's FACES project, Tuungane will ensure access to care and treatment, including ART for positive people identified through the project. This far, Tuungane has demonstrated a remarkable strength in implementing intensive and quality interventions in the community and has useful lessons which will be scaled up to the underserved and highly vulnerable population of Suba district in Nyanza. Tuungane will work with high-risk groups in a site in Suba including the beach community to provide counseling and testing services, alongside its behavioral interventions of condoms and other prevention services. This project will actively involve existing youth community groups to enable it make rapid scale up of services. Service delivery will be improved through mobile integrated services including provision of free counseling services for youth and high-risk groups and referrals for free STI treatment.

3. CONTRIBUTION TO OVERALL PROGRAM AREA The Tuungane's CT program will contribute not only to the overall CT portfolio in Kenya, but will also target a special and vulnerable population. They will target the youth, especially young girls in a slum area in Kisumu town. Kisumu town is in Nyanza region, which has the highest HIV prevalence in Kenya. They will also work in the beaches of Suba district, which is also a high risk population. Through this work Tuungane will help implement operational models which can be replicated elsewhere in Kenya with vulnerable populations. Thus Tuungane's contribution is very strategic and should help with future PEPFAR programming.

4. LINKS TO OTHER ACTIVITIES In the past Tuungane has implemented several prevention activities. These will be linked to the CT activity. Some of these programs include; AB (#6896), OP (#6897) and STI treatment. HIV-infected persons identified through this program will be linked to Care and Treatment activities.

5. POPULATION BEING TARGETED The activity will mainly target both the street and out-of-school youth, both male and female. It will also target discordant couples in stable relationships, who will benefit from couple counseling support. It will also target commercial sex workers and some migrant workers among the beach population in Suba.

6. KEY LEGISLATIVE ISSUES ADDRESSED The activity will mainly address gender equity concerns as well as stigma and discrimination issues. By focusing on young people, especially girls, Tuungane will

strengthen gender equity and facilitate women's access to HIV/AIDS services.

7. EMPHASIS AREA Tuungane's CT program will focus mainly on community mobilization and participation. To a lesser extent they will focus on human resource and training to support the continuity of the program.

Service Delivery in Facilities and through Mobile approaches: In collaboration with the MOH, the Nyanza Circumcision Consortium, through IRDO, will work on targeted roll-out of MC services in Nyanza. Service delivery capacity-building will be rolled out in district hospitals and some private facilities where providers have been trained and where other USG PEPFAR partners, including KEMRI, are currently working. In addition to training, support will be provided for non-consumable commodities (i.e. autoclaves, instrument packs, surgical lamps, etc…) personnel and other infrastructure that will be necessary for MC service delivery. Service roll-out will initially target areas with high existing demand for MC services and will be integrated into discordant couples services for discordant male partners of women in care and treatment programs. Mobile service provision will be provided by mobile teams consisting of approximately five people (including 1 clinical officer, 1 VCT counselor, 1 surgical nurse, 1 sterilizer/cleaner and 1 driver) targeting high risk groups, such as uniformed services personnel and truck drivers, and areas of very high HIV prevalence. For example, mobile services will be provided in Suba District, Kenya's highest HIV prevalence district, to complement the current door-to-door VCT program that PEPFAR is supporting there. In addition, services will be provided within areas such as the Demographic Surveillance Study area where operational evaluation can be conducted and in other areas where PEPFAR services exist. A critical component of this acitvity will be the provision of VCT services.

This activity will be implemented through a MC Consortium comprising of Impact Research Development Organization as prime partner, with the following sub-partners: UNIM (Universities of Nairobi, Illinois and Manitoba), Tuungane Project, Nyanza Reproductive Health Society (NRHS), and Partners in Reproductive Health (PIRH). Both Tuungane, administered by IRDO and PIRH, administered by NRHS, will be involved in community education and mobilization. UNIM will be a training Center, IRDO will administer the funds from PEPFAR/CDC and sub-contract NRHS (a registered Kenyan NGO) to oversee performance of UNIM and PIRH.

For this specific activity, UNIM will work closely with NASCOP, the National MC Task Force and other key stakeholders to develop appropriate routine monitoring tools for MC programmatic efforts in Kenya. As a core component of UNIM's MC service delivery, all clinicians (public and private) trained by UNIM will record key monitoring data on NASCOP-approved data collection forms that will be adapted from UNIM's clinical trial protocol. Key data elements will include: adverse events, surgical outcomes, client satisfaction, age of client, consent of client or guardian, and outcomes at post-surgical visits. During year one, closer monitoring of programmatic outcomes will be important. A random sample of approximately 10% of clients, stratified by age group and rural versus urban/periurban residence will be selected for follow-up 30-40 days post-surgery by 2 trained nurses to observe the surgical outcomes and to administer a questionnaire to assess level of satisfaction, history of adverse events, history of clinical visits, and sexual history since surgery. Data will be entered at selected health facilities and transmitted to the UNIM Training Centre. Data will be aggregated and provided to the District Medical Office, the Provincial Medical Office, NASCOP and the National Male Circumcision Task Force.

Table 3.3.13:

Service Delivery in Facilities and through Mobile approaches: In collaboration with the MOH, the Nyanza Circumcision Consortium, through IRDO, will work on targeted roll-out of MC services in Nyanza. Service delivery capacity-building will be rolled out in district hospitals and some private facilities where providers have been trained and where other USG PEPFAR partners, including KEMRI, are currently working. In addition to training, support will be provided for non-consumable commodities (i.e. autoclaves, instrument packs, surgical lamps, etc…) personnel and other infrastructure that will be necessary for MC service delivery. Service roll-out will initially target areas with high existing demand for MC services and will be integrated into discordant couples services for discordant male partners of women in care and treatment programs. Mobile service provision will be provided by mobile teams consisting of approximately five people (including 1 clinical officer, 1 VCT counselor, 1 surgical nurse, 1 sterilizer/cleaner and 1 driver) targeting high risk groups, such as uniformed services personnel and truck drivers, and areas of very high HIV prevalence. For example, mobile services will be provided in Suba District, Kenya's highest HIV prevalence district, to complement the current door-to-door VCT program that PEPFAR is supporting there. In addition, services will be provided within areas such as the Demographic Surveillance Study area where operational evaluation can be conducted and in other areas where PEPFAR services exist. A critical component of this acitvity will be the development and adaptation of training curriculum, implementation guidelines and standard operating procedures that can be used for national guidelines. This activity will also support systems strengthening at the facility level and through training of a professional cadre of Kenyans.

Table 3.3.14: