1. LIST OF RELATED ACTIVITIES This activity will relate to HIV/AIDS Treatment: ARV Services (#6945), (#8797), Laboratory Infrastructure (#6940), Counseling and Testing, (#6948), and Palliative Care: TB/HIV (#6944).

2. ACTIVITY DESCRIPTION The International Medical Corps (IMC) will continue to support the implementation of PMTCT activities, with a geographical focus on the Suba District in Nyanza Province. Suba is a hard-to-reach area in Nyanza Province with a mainland and six main islands which include Rusinga, Mfangano, Remba and Ringiti within Lake Victoria. The infrastructure is particularly poor with very bad roads, and movement between the islands and mainland requires use of a boat, making access to health facilities difficult. Subas are a fishing community with very high HIV prevalence rates among women, 41% in the 2003 KDHS.

IMC is currently supporting PMTCT activities in 22 out of 31 public health facilities in the district. The PMTCT activities of IMC relate to counseling and testing of pregnant women in antenatal clinics (ANC) and in maternity units, and provision of antiretroviral prophylaxis to HIV+ women and exposed infants. IMC is also involved in postnatal follow-up of mother-infant pairs, testing of the woman's partner and other children, and linking those eligible to care and treatment. In FY 2007, IMC-supported facilities will counsel and test 7,400 pregnant women, perform WHO clinical staging and provide antiretroviral prophylaxis for 2,000 HIV pregnant positive women. Of these2,000 women, IMC will provide sdNVP and AZT to 1,000 HIV-positive women, link 300 women to antiretroviral therapy (HAART), sdNVP to 700 women and do PCR for early infant diagnosis on 1,000 (50%) of HIV exposed infants in accordance with the national algorithm. Infants found to be HIV positive at six weeks or thereafter will be linked to pediatric HIV care and treatment if they are eligible. For the infant, IMC will focus on initiation of cotrimoxazole and doing DBS for PCR at six weeks. The postnatal care package for the mother will include counseling on appropriate feeding practices according to national guidelines, linkage to family planning services and linkage to care and ARV treatment. IMC will enhance male involvement through invitation by cards and establishment of a male only clinic. Home-based counseling and testing will be conducted and antenatal women found positive will be referred to the nearest health facility for PMTCT program. IMC will use the national PMTCT curriculum, and NASCOP (MOH) clinical and reporting guidelines, and will continue to participate in the MOH's Technical Working Group to ensure coordination of activities between the sites it supports and the MOH at the district and national level. In FY 2007, IMC will have scaled up to all 31 health facilities in the district, and will focus on consolidation of PMTCT core activities. Despite being in all health facilities, achieving universal access will be a challenge due to the difficult terrain. IMC will use other approaches including mobile PMTCT clinics using boats and establishing a network with traditional birth attendants and community health workers to refer mothers for PMTCT services at the nearest health facility. IMC will use people living with HIV/AIDS (PLWHAs) for peer counseling, formation of support groups, and for demand creation for PMTCT services. Emphasis will be laid on behavior change and prevention of positives. IMC will train 130 service providers in basic PMTCT, and 400 community own resource persons as PMTCT promoters and adherence counselors. Community workers will be an additional resource to supplement the scarcity of Ministry of Health (MOH) personnel.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA PMTCT in Suba District 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 0.74% of the 2007 overall Emergency Plan PMTCT targets for Kenya. The expansion of the scope of services to include early infant diagnosis and male involvement will be an important entry point for other members of the woman's family to be identified and linked to care and ARV treatment.

4. LINKS TO OTHER ACTIVITIES This activity will relate to ARV services through CDC KEMRI (#6945), CDC KEMRI laboratory services (#6940), CDC KEMRI VCT (#6948), CDC KEMRI TB/HIV (#6944) and to ARV Services by the APHIA II Rift Valley (#8797). Linkages to antiretroviral treatment centers, known as Comprehensive Care Clinics (CCC), will be strengthened to ensure immediate and appropriate care for the woman, exposed infants, and family members, optimizing the utilization of complementary services created through PEPFAR funding.

5. POPULATIONS BEING TARGETED This activity targets adults, pregnant women, HIV+ pregnant women, HIV affected families, HIV exposed and HIV+ infants. Health care providers including doctors, nurses and other health care workers for example public health officers will be targeted for training.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity will increase gender equity in HIV/AIDS programming, by providing training providers on couple counseling, risk assessment, and stigma reduction. Community health workers will also contribute towards stigma reduction though their community mobilization efforts.

7. EMPHASIS AREAS This activity has major emphasis on Development of Network/Linkages/Referrals Systems; minor emphasis will be placed on Community Mobilization/Participation, Linkages with other Sectors and Initiatives; Local Organiztion Capacity Development and Training.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in Counseling and Testing (#6907) and Prevention of Mother-to-Child Transmission (#6906).

2. ACTIVITY DESCRIPTION The International Medical Corps (IMC) is already working in the areas of PMCT, CT, and TB/HIV in Suba District. IMC has recently begun providing VCT on a number of islands in Lake Victoria with high concentrations of young male fishermen, fish mongers, and informal commercial sex workers. On some of these islands, the ratio of men to women is as high as six men to one woman. Outreach VCT to these islands has been well accepted, with as much as 20% of the populations on some islands accepting testing. HIV rates in VCT clients are very high; on some islands, over 40% of the women and over 20% of the men tested are HIV infected. IMC has also found that there are many concurrent partnerships and sexual networks, factors which may contribute to high HIV incidence. Additionally, the prevalence of other STDs among the sexually active population is very high at 40%. IMC will intensify community outreach and targeted behavioral interventions for high-risk groups in Suba, primarily focusing on the beach community. It will work with the migratory populations to try to interrupt the high HIV incidence on these islands. IMC proposes to reach these fisher folks and commercial sex workers on 45 beach landings on 12 islands on the Suba part of Lake Victoria. IMC will work in close collaboration with CDC and other implementing partners in Suba to ensure synergy and appropriate linkages between the various services available. IMC will train 200 beach workers from amongst the local community to enable them carry out intensive activities aimed at significantly reducing sexual risk behaviors among 35,000 individuals. 250 condom outlets will be established.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA The program will reach 35,000 at risk individuals, train 200 people and establish 250 condom outlets.

4. LINKS TO OTHER ACTIVITIES This activity is linked to activities in Counseling and Testing (#6907) and Prevention of Mother-to-Child Transmission (#6906).

5. POPULATIONS BEING TARGETED The target population is primarily mobile populations, including business community and community leaders. Commercial sex workers and their partners will be targeted as will public health care workers and traditional healers. Given the high prevalence in Suba district, PLWHAs and HIV/AIDS affected families will be targeted. Adult men and women, out of school youth and discordant couples will be targeted.

6. KEY LEGISLATIVE ISSUES ADDRESSED This project will address social norms and behaviors and reducing violence and coercion. This activity will also make a contribution towards reducing stigma and discrimination.

7. EMPHASIS AREAS Community mobilization is a major emphasis area, while human resources, training and information, education and communication and needs assessment are minor emphases.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in CT (#6907) and PMTCT (#6906).

2. ACTIVITY DESCRIPTION In FY 2007, the International Medical Corps (IMC) will further expand TB/HIV services in Kibera (Nairobi Province), Suba District (Nyanza Province) and Tana and Taita-Taveta Districts (Coast Province). IMC complements national TB and HIV programs' efforts to deliver essential services for hard-to-reach high-risk populations with limited access to health services in these three Provinces. In Nairobi, IMC serves a needy low-income population in the Nairobi slums. In Nyanza, IMC provides essential TB/HIV care to needy fishing communities in Suba District mainland and several islands in Lake Victoria with high TB and HIV rates. In August 2006, IMC laid a strong foundation for TB/HIV activities in Tana River and Taita-Taveta Districts by training 140 health staff and opening up 56 TB/HIV service outlets. IMC surpassed FY 2006 TB/HIV program targets in Kibera and Suba Districts for number of patients served, number of staff trained and number of service outlets established. IMC will build on this momentum and create better patient referral networks and partnerships with other PEPFAR programs (PMTCT, VCT, Care/Treatment) and other partners, including UCSF, KEMRI and local PLWHA organizations in Suba District, FHI at the Coast and national TB and HIV programs at all sites.

In tandem with both PEPFAR and NLTP country strategic plans, greater attention will be given to intensified TB screening for PLWHA and improving access to ART for HIV-positive TB patients and suspects who qualify. The other specific TB/HIV activities will include: diagnostic HIV testing for all TB suspects on an opt out basis, screening of HIV+ individuals for TB, delivery of HIV-related care and support (cotrimoxazole, ARV, nutrition, risk reduction counseling) for HIV+ TB patients and TB preventive treatment. Other activities will include strengthening community participation in and ownership of the TB/HIV program, improving delivery of DOTS at community and household levels, expanding linkages with other partners and programs, tracing treatment defaulters, linking with PLWHA groups to enhance participatory advocacy, strengthening referral linkages between TB and HIV programs, improving infrastructure and expanding training of health workers.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA These activities will result in strengthened delivery of integrated HIV and TB services, including strengthened referral systems, improved diagnostics and treatment of TB among HIV-positive patients and of HIV in TB patients, strengthened capacity of health workers to provide integrated HIV and TB services and strengthened systems capacity for program monitoring and evaluation and management of commodities.

4. LINKS TO OTHER ACTIVITIES These TB/HIV activities will be integrated with ongoing VCT (#6907), PMTCT (#6906) and STI and ARV treatment services in the respective Districts in support of the national programs. These activities will result in strengthened delivery of integrated HIV and TB services, including strengthened referral systems, improved diagnostics and treatment of TB among HIV-positive patients and of HIV in TB patients, strengthened capacity of health workers to provide integrated HIV and TB services and strengthened systems capacity for program monitoring and evaluation and management of commodities.

5. POPULATIONS BEING TARGETED These activities will target TB suspects (both adults and children) and PLWHA identified at VCT (adults), PMTCT (pregnant women), STI (adults), ARV clinics (children and adults) and PLWHA organizations. Efforts will be made to intensify TB screening and TB case finding among PLWHA identified at these sites.

6. KEY LEGISLATIVE ISSUES ADDRESSED Diagnostic HIV testing for all TB patients will be on an "opt out" principle. National guidelines on HIV testing requiring consent, confidentiality and counseling will be observed as standard of care. Increased availability of CT in clinical settings and increased access to HIV-related care for TB patients will help reduce stigma and discrimination.

7. EMPHASIS AREAS

Emphasis areas include commodity procurement, community mobilization, IEC, human resources, infrastructure, and training.

Plus up funds will essentially be used to further expand and strengthen exisitng activities. With PEPFAR support IMC is currrently implementing a Home based counseling and testing (HBCT) program in Suba district. This will eventaully cover the entire population of Suba. The ANC prevalence of Suba is 30%, therefore many HIV infected patients will be identified in the Home Based CT program. Plus up fnds will be used to carry out TB screening in the Home Based CT program. The outreach VCT counselors will be trained in TB screening, and supported to carry out field visits. Although the focus of the TB screening will be HIV positive individuals, sinve the counselors will be at community level, they will also be able to carry TB screening for the all people in the household. By March 2007, 50,000 people will have been counseled and tested in Suba. In the same period, TB screening will have been provided to at least 10,000 of these individuals.

1. LIST OF RELATED ACTIVITIES This activity relates to activities in PMTCT (#6906) and TB/HIV (#6905).

2. ACTIVITY DESCRIPTION In FY 2007, International Medical Corps (IMC) will continue to work in Suba, promoting uptake of Counseling and Testing (CT) in medical facilities, fixed and outreach VCT outlets and through door- to- door testing. Door-to-door HIV testing, which IMC piloted in FY 2006, is especially important in Suba because it is the area with the highest HIV prevalence in Kenya. A door-to-door approach will identify large numbers of previously undiagnosed individuals who will benefit from the rapidly emerging care opportunities and will also increase couples counseling and testing and facilitate the identification of discordant couples. Thus, the initiative will contribute towards realization of Kenya's national prevention, care, and treatment targets. Through these multiple approaches for VCT, IMC will provide CT services to 30,000 individuals, with at least 5,000 of them being referred for care and treatment. An estimated 1200 discordant couples will also be identified and counseled. Core activities will include establishment of 10 additional CT sites in health facilities, provision of mobile VCT, door-to-door CT, strengthening the networks for referral of those testing HIV positive to care. Support to the ten existing VCT sites operating in collaboration with local community based organizations (CBO) will also continue. Periodic Mobile VCT to selected underserved areas of the district will be provided as part of integrated outreach package coordinated jointly with Ministry of Health and CDC/KEMRI GAP program for Nyanza. Service elements during such integrated outreach activities will include CT, TB screening and referral, Prevention with positives interventions, PMTCT and immunization. 36 new CT service providers will be trained to meet personnel requirements for new CT sites and expansion of service through door- to-door testing. These activities will result in increased CT access and better linkage of HIV positive persons to care. In FY 2007 IMC will strengthen its network with the local CBOs to educate the community in Suba on the benefits of CT for prevention and care. In Suba stigma and fear remain major barriers to uptake of CT and utilization of available HIV/AIDS care services. In order to address this challenge, IMC will work with the Ministry of Health and other partners to institutionalize HIV testing as part of diagnostic work up of patients and to strengthen referral linkages between door-to-door CT and care services. IMC will also strengthen compliance with national guidelines for CT services, quality assurance and data management at all points of services delivery including home settings. IMC will also work with local leaders, the religious community and the local media to promote education and dissemination of information.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA IMC's CT work in Suba, is appropriately targeted towards identifying large numbers of HIV infected individuals who are potential beneficiaries of the prevention, care and treatment opportunities created through President's Emergency Fund. The planned CT service output of 30,000 for FY 2007 represents a significant increase from FY 2006 target. At national level, it represents only a modest contribution to the overall 2007 Emergency Plan CT targets for Kenya, but is highly relevant since it targets a population with the highest HIV prevalence in the country. Planned mobile and door-to-door VCT will improve equity in access to essential HIV/AIDS services and will help normalize HIV testing in this high prevalence district. Linkages initiated with FY 2006 funds between CT services and care will be strengthened to ensure achievement of Emergency plan targets.

4. LINKS TO OTHER ACTIVITIES The IMC CT activities in Suba District relate to IMC activities in PMTCT(#6906) and TB/HIV (#6905) activities and collectively constitute an effective comprehensive response to HIV/AIDS epidemic in this area.

5. POPULATIONS BEING TARGETED This activity targets a district with the highest HIV burden in Kenya and where practices that encourage HIV spread such as widow inheritance and premarital sex are common. The district in focus is one where HIV/AIDS services are not readily available to the entire population, partly because of the geography of the area. For example a large part of the district is covered by the water of Lake Victoria, and therefore access is by boat. In FY 2007 the main focus of IMC's effort in Suba will be door-to-door CT. This activity targets the entire population and will be done in phases. The first phase was started in FY 2006, and the acceleration phase will be in FY 2007. The essence of this community-based CT

work is to educate the entire population in the district, with the family as the focus. By educating the entire family, IMC will be achieving several strategic prevention, care and treatment objectives, the main ones being stigma reduction and family support for people in care and treatment.

6. KEY LEGISLATIVE ISSUES ADDRESSED This activity will reduce gender based disparities in the provision of HIV/AIDS services. Part of this will be done through the promotion of couple counseling and disclosure. Analysis of VCT client data at existing IMC sites indicates a low service uptake by couples and low disclosure rate amongst sex partners. The much increased availability of CT services through door-to-door testing, Mobile VCT and in health facilities will help to reduce gender disparities in access to CT and reduce stigma.

7. EMPHASIS AREAS The planned activities will require a major emphasis on human resources for successful implementation since the target district has a severe shortage of service providers both in public and private. Resources to expand human resource capacity to provide other essential HIV/AIDS services are also lacking. IMC will therefore dedicate considerable efforts and funds during FY 2007 towards addressing human resource deficit for its planned activities. Innovative approaches that increase access to CT within home settings and within medical facilities in this area will be implemented. Minor emphasis will be on infrastructure, training of service providers and enhancing linkages to care services outlets to match increased identification of HIV positive individuals that will result from improved CT uptake in the district. Another minor emphasis will be in the area of community mobilization.

Part of the Kenya's MC roll-out strategy will be to build on existing PEPFAR activities. IMC is currently implementing door-to-door testing in Suba District, Kenya's highest prevalence district. Plus-up funding will be used to expand IMC's VCT work to target those who may be eligible for MC services. IMC will develop and incorporate communication messages in their VCT package about MC, together with referral information for facility and mobile service delivery which will also be provided in Suba District with Plus-up support through IRDO. The MC 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). These mobile teams will be coordinated with IMC's HBVCT and mobilization efforts.