THIS IS AN ONGOING ACTIVITY. THE NARRATIVE IS UNCHANGED EXCEPT FOR UPDATED

REFERENCES TO TARGETS AND BUDGETS.

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 30 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 2008, IMC-supported facilities will counsel and test 8,216

pregnant women, perform WHO clinical staging and provide antiretroviral prophylaxis for 2,889 HIV positive

pregnant women. Of these2,889 women, IMC will provide sdNVP and AZT to 1,445 HIV-positive women,

link 578 women to antiretroviral therapy (HAART), sdNVP to 867 women and do PCR for early infant

diagnosis on 1,445 (50%) of HIV exposed infants in accordance with the national algorithm. For the infant,

IMC will focus on initiation of cotrimoxazole and doing DBS for PCR at six weeks. Infants found to be HIV

positive at six weeks or thereafter will be linked to pediatric HIV care and treatment if they are eligible. The

postnatal care package for the mother will include counseling on appropriate infant feeding practices

according to national PMTCT and nutrition guidelines, linkage to family planning services and linkage to

care and ARV treatment. IMC will enhance male involvement through invitation by cards, establishment of a

male only clinic and through home based counseling and testing. 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 2008, 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, and there would still be unmet CT need of about 6000. 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, as well as

expand home based counseling and testing. IMC will address all the four prongs of PMTCT, and lay

emphasis on primary prevention, prevention of unwanted pregnancies and enhance linkage to care and

treatment for mother, partner and children. IMC will use people living with HIV/AIDS (PLWHAs) for peer

counseling, formation of support groups, and for demand creation for PMTCT services. IMC will engage in

task shifting using PLWHA to take up some of the less technical tasks of the HCP. IMC will conduct

orientation of the DHMTs on current interventions like more efficacious regimen, early infant diagnosis,

counseling on infant feeding especially when PCR results show HIV negative and integration of FP into

PMTCT. Emphasis will be laid on behavior change and positive prevention. IMC has trained 60 nurses and

will train a total of 90 by end FY '07. In FY 08 IMC will train 30 nurses in basic PMTCT, and 15 VCT

counselors who will be used in home based counseling, a way of increasing couple counseling and male

involvement. 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 0.68% of the 2008

overall Emergency Plan PMTCT targets for Kenya (1.2 million). 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 children under five years, adolescents of reproductive age 15-24, adults, pregnant

women and people living with HIV. Health care providers including doctors, nurses, and other health care

workers will be targeted for training on PMTCT using the national NASCOP CDC/WHO based curriculum.

6. KEY LEGISLATIVE ISSUES ADDRESSED

This activity will increase gender equity in HIV/AIDS programming through provision of HIV counseling and

testing services of pregnant women, and improved access to other HIV care programs for the HIV infected

woman, her infant and other family members. It will also reduce violence and coercion through stigma at the

community level.

7. EMPHASIS AREAS

This activity includes emphasis on quality assurance and supportive supervision as well as emphasis on

Development of Network/Linkages/Referral Systems; Community Mobilization/Participation, wrap around

programs with Food/Nutrition, PMI through distribution of insecticide treated nets at the MCH, safe

motherhood through focused antenatal care, other Family planning initiatives and TB screening and referral

for treatment and care

THIS IS AN ONGOING ACTIVITY. THE NARRATIVE IS UNCHANGED EXCEPT FOR UPDATED

REFERENCES TO TARGETS AND BUDGETS.

The only changes to the program since approval in the 2007 COP are:

+ Geographic coverage has been revised (or expanded) to include Migori district.

+ FY 2007 PLUS UP ADDITIONS: This plus-up will support expanded activities currently implemented by

the International Medical Corp in Suba district, Nyanza as described in the 2007 COP. IMC is currently

undertaking a district-wide door-to-door family level testing for all of Suba district. This strategic opportunity

will allow for prevention education to be provided at family level as well as at community level as

mobilization for the door-to-door testing is carried on. IMC will therefore implement the Families Matter!

intervention to help parents discuss HIV prevention matters with their adolescent children, including

extended family members who live under their custody. This intervention will cater for the highly vulnerable

adolescent orphans who are an increasing population of highly vulnerable youth in Suba district. A related

challenge in Suba is gender-based violence, particularly inflicted upon adolescent orphans and other

vulnerable children living with hosts, relations and friends. Anti-rape and anti-sexual abuse campaigns will

be conducted as part of the general prevention education. (Gender-based violence $100,000).

+ $28,000 of this activity is programmed with funds from the $7 million FY 2008 plus up for the Healthy

Youth Programs Initiative.

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

400 beach workers from amongst the local community to enable them carry out intensive activities aimed at

significantly reducing sexual risk behaviors among 50,000 individuals. 400 condom outlets will be

established.

3. CONTRIBUTIONS TO OVERALL PROGRAM AREA

The program will reach 50,000 at risk individuals, train 400 people and establish 400 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.

THIS IS AN ONGOING ACTIVITY. THE NARRATIVE IS LARGELY UNCHANGED EXCEPT FOR

+ Linking TB screening with on-going home-based VCT in Suba District.

+ Expansion of HIV prevention, care and treatment activities for TB patients/suspects at all sites.

+ Expansion of TB screening for PLWHA and updated references to targets and budgets.

1.LIST OF RELATED ACTIVITIES

This activity relates to activities in CT (#6907) and PMTCT (#6906).

2.ACTIVITY DESCRIPTION

In FY 2008, IMC will further expand HIV care, treatment and prevention services for TB patients/suspects

on one hand and TB screening for PLWHA on the other at all sites in Nairobi Province (Kibera Slums),

Nyanza Province (Suba District) and Coast Province (Tana River and Taita-Taveta Districts. IMC

complements national 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 mainly fishing communities in

Suba District mainland and several islands in Lake Victoria with high TB and HIV rates. In Coast Province,

IMC will build on its investments on health staff training and on infrastructure to complement efforts of other

TB/HIV partners to achieve regional targets. IMC will adopt a similar approach in Nyanza and Nairobi

Provinces. In Suba District where IMC has started an innovative and successful home-based VCT program,

which will be linked to care and treatment services in the next phase. TB screening for HIV+ clients will be

initiated and expanded as part of the basic care package. IMC will build on these expanded activities to

establish complementary partnerships and better patient referral networks with other PEPFAR programs,

other partners and local PLWHA organizations at all sites. In line with overall TB/HIV program priorities, IMC

will target at least 50% of PLWHA screened for TB, at least 50% access to ART and universal access to

cotrim for those who qualify. Other specific TB/HIV activities will include expanded diagnostic HIV testing for

all TB patients and increased access to HIV prevention targeting the families and sexual partners of those

testing HIV+. Other activities will include strengthening community participation and ownership, improving

delivery of DOTS at community and household levels, tracing TB treatment defaulters, 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 capacity for program monitoring, 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 Provinces in support of the national programs.

5.POPULATIONS BEING TARGETED

These activities will target TB suspects and PLWHA

6.EMPHASIS AREAS

These include facility renovations, local organization capacity development and human capacity

development (in-service training, task shifting, staff retention activities).

THIS IS AN ONGOING ACTIVITY. THE NARRATIVE IS UNCHANGED EXCEPT FOR UPDATED

REFERENCES TO TARGETS AND BUDGETS.

The only changes to the program since approval in the 2007 COP are:

+ geographic coverage has been expanded to include Migori district in Nyanza province. They will provide

the same services in Migori as in Suba. The same level of care and treatment services in Suba will also be

available in Migori, provided by UCSF which is the same PEPFAR funded agency for Suba. The good

partnership between IMC and UCSF (FACES) in Suba will therefore be extended to Migori.

+ the home based CT has been well received in Suba (with acceptance rates of over 90%), hence the

expansion to Migori. However, in order to strengthen referral to care and treatment, IMC in FY 2008 will

continue to support establishment of community based support groups for people living with HIV/AIDS. IMC

will also carry out follow up visits, especially to the homes with HIV positive people. During this second visit,

they will take evaluate the impact of the intervention using different t methodologies. Where necessary,

acceptable and logistically feasible, blood will be taken for CD4 testing at Suba district hospital. IMC will

also continue supporting Male Circumcision through its community level networks.

1. LIST OF RELATED ACTIVITIES

This activity relates to activities in PMTCT (#6906) and TB/HIV (#6905).

2. ACTIVITY DESCRIPTION

In FY 2008, 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 in both Suba and Migori districts. Door-to-door HIV testing was first piloted in Suba by IMC in FY

2006, because Suba had 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 80,000 individuals,

with at least 15,000 of them being referred for care and treatment. An estimated 3,000 discordant couples

will also be identified and counseled. Core activities will include establishment of 40 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. 80 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 2008 IMC will strengthen its network with the local

CBOs to educate the community in Suba and Migori on the benefits of CT for prevention and care. In the

two districts 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 and Migori, 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 90,000 for FY 2008

represents a significant increase from FY 2006 target. At national level, it represents only a modest

contribution to the overall 2008 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 2007 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 2008 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 was 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.

Activity Narrative: 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.