1. ACTIVITY DESCRIPTION & EMPHASIS AREAS

Basic Program Evaluation: What are the social and economic determinants of sexual vulnerability among

adolescent OVC? Which interventions are most effective in preventing or mitigating this vulnerability?

Given the lack of information on the impact of care and support strategies for orphans and vulnerable

children (OVC), and their HIV risk, there is an urgent need to learn how to improve the effectiveness of

program efforts. Growing evidence highlights the elevated risk of adolescent orphans for acquiring HIV

infection and sexually transmitted diseases (Gregson et al., 2005; Kang et al., 2008). While all youth within

Kenya are at sexual risk, adolescent orphans are an underserved and higher risk group due to earlier age of

sexual onset and higher likelihood for teenage pregnancy and engagement in transactional sex (Gregson et

al., 2005; Juma et al., 2007; Nyamukapa et al., 2008; Thurman et al., 2006). Increased understanding of

the multi-faceted needs of adolescent OVC and identification of interventions effective in addressing these

needs are critical. Since adolescents comprise the majority of the OVC population (United Nations

Children's Fund [UNICEF], 2006); however, evidence suggests that the bulk of OVC programs only reach

younger youth (Osborn, 2007; Ruland et al., 2005). OVC programs generally tend to neglect the particular

psychosocial, educational, reproductive health, and livelihood needs of adolescent orphans (Schueller et al.,

2006). In spite of the growing evidence highlighting sexual risk behaviors among adolescent orphans, they

may also lack sufficient access to HIV prevention messages (Juma et al., 2007). Given that the vast

majority of prevention and life skills programs operate within schools (Gallant & Maticka-Tyndale, 2004),

and that orphans consistently have lower school enrollment rates (UNICEF, 2006), many OVC may not be

reached by these services. It is also unknown how many OVC are reached with prevention messages

through out of school programs (Juma et al., 2007). Further, considering the complex psychosocial

challenges facing orphans, it is clear that programs should not focus on HIV education alone.

Comprehensive care and protection packages are necessary to reduce the sexual risk of adolescent OVC

so as to decrease HIV infection among this generation of youth (Thurman et al., 2006). To achieve this end,

a holistic understanding of the situation of adolescent OVC and identification of best practices is imperative.

Considering the scarcity of data in this area, this activity will conduct a basic program evaluation to help

identify which interventions are most effective in mitigating the vulnerability of adolescent OVC. The activity

will identify two EP supported OVC programs within two programs within three unique sites: one operating

within an urban environment, one within a peri-urban setting and one that is operating within a rural setting.

Urban and rural areas have varying HIV rates and adolescents within these environments have different

sexual behavioral patterns and face varying cultural and contextual issues that affect program design and

success. Thus, including a range of models across diverse settings provides valuable insight on the varying

factors and circumstances that affect the well-being of adolescent OVC. The scale-up of services for OVC

is desperately needed, though program design and resource allocation should be grounded in an evidence

base. To fully implement National Plans of Action for OVC, governments, donors and program managers

need comprehensive information on how to reach more OVC with services that improve their well-being.

Information on these topics is very limited and has not been well disseminated. Program implementers,

policymakers, and donors require data on (1) how best to develop and deliver age appropriate programs

and (2) what kinds of programs will have the most impact on improving the quality of life and promoting a

promising future among OVC (reducing their HIV risk). More information about the various types of

interventions, lessons learned from program implementation to date, priority needs of OVC and best

practices for meeting those needs and reducing the impact of HIV on adolescent OVC can ultimately

increase the quality and effectiveness of interventions. Assessments would be conducted to identify key

program priorities and best practices for serving adolescent OVC, reducing their HIV risk, and helping them

achieve their full potential. Assessments will focus on existing EP funded OVC programs working with

underserved, high risk group—adolescent OVC. Within the proposed three settings, including urban, peri-

urban and rural environments, quantitative and qualitative data will be collected at two different times,

yielding data on determinants of quality throughout the three year project period. Child participatory

approaches will be used to ensure feedback from adolescent OVC is incorporated in this activity. The

activity will also incorporate dissemination mechanisms to ensure that policy makers, EP funded partners

are kept abreast of emerging best practices as will have been identified during the course of this evaluation.

The scale-up of services for adolescent OVC is desperately needed, though program design and resource

allocation should be grounded in an evidence base. Program implementers, policy makers, and donors

require data on how best to develop and deliver age appropriate programs and what kinds of programs will

have the most impact on improving the quality of life and promoting a promising future among adolescent

OVC. The emphasis area is Strategic Information (M&E, HMIS, Survey/Surveillance, Reporting).

2. CONTRIBUTIONS TO OVERALL PROGRAM AREA

The study is strongly committed to ensuring that the information from these evaluations is disseminated and

will work with local partners and stakeholders at all levels to encourage the use of the data at the program

and policy levels as well as ensuring that best practices in programming for adolescents are identified and

well documented to facilitate replication and scale up.

3. LINKS TO OTHER ACTIVITIES

This activity will link to APHIA II programs in the country (#9029, #9041, #9048, #9053, #9056, #9067,

#9071, #9073) which are specifically targeting orphans and vulnerable children.

4. POPULATIONS BEING TARGETED

This activity specifically targets orphans and vulnerable children as well as build the capacity of EP partners

in identifying best practices for delivering essential services to adolescent OVC.

5. SECONDARY CROSS-CUTTING BUDGET ATTRIBUTIONS

This activity will contribute $15,000 towards support to education activities for adolescent OVC as well as

attribute $9,000 towards economic strengthening of households for adolescent OVC.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

* Increasing women's legal rights

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

* Malaria (PMI)

* TB

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Estimated amount of funding that is planned for Economic Strengthening $9,000

Education

Estimated amount of funding that is planned for Education $15,000

Water

Table 3.3.13:

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS FROM COP 2008:

+ Alcohol/ substance abuse risk among out-of-school slum-dwelling youth in Nairobi

+ Integrating alcohol risk reduction in HIV counseling and testing

COP 2008

1. LIST OF RELATED ACTIVITIES

This activity relates to activities in AB and OP.

2. ACTIVITY DESCRIPTION

In 2009, Population Council will:

a) Expand activities to integrate counseling and testing services into existing family planning (FP) service

outlets. Integration of CT into FP offers an opportunity for increasing availability and access to CT services

since FP clients will conveniently be offered opportunities for CT. The Population Council will support the

integration of CT into 30 FP Clinics and train 80 FP providers with a target to provide CT to 8,000 clients.

The Population Council will monitor cost effectiveness of this integration to guide decision regarding further

scale up. The proposal to integrate CT into FP is based on feasibility assessment that was conducted by the

Kenya government in partnership a number of partners including JHPIEGO, CDC and FHI. Provision of CT

services in FP outlets will be guided by national standards for CT service delivery and quality assurance.

The program has intense social mobilization to inform potential FP clients about availability and benefits of

CT services at FP sites.

b) Alcohol is an associated known co-factor for HIV acquisition especially among women, but is largely

overlooked in HIV counseling and testing. During COP 06, Population Council tested an alcohol risk-

reduction model involving building the capacity of VCT counselors to advice clients on alcohol use. Because

most VCT clients who consume alcohol do so at hazardous levels (based on WHO AUDIT scale), and

because alcohol consumptions is associated with 3-7-fold increases in sexual risk taking and violence, it is

important that alcohol risk reduction be integrated into VCT, as part of comprehensive risk reduction. It may

also be important to explore alcohol risk reduction in other CT options now available in Kenya including

Provider Initiated Counseling and Testing (PICT), PMTCT, and integrated family planning.

During COP 09, Population Council will work with study partners Liverpool VCT as well as NASCOP to

expand this initiative to 15 additional sites, including expanding into district hospitals in Nairobi and Coast

provinces. During COP9, further expansion into 15 more sites will be undertaken, including a nested study

to examine how alcohol risk reduction can be incorporated into PICT. The results of this study will be used

to develop an in-service training module for use by NASCOP and others. Technical assistance will also be

provided to NASCOP and to pre-service training institutions, such as the MTC, in developing training

resources that could be integrated into existing pre-service training curricula for medical staff to enable them

to routinely include such issues in their counseling. In addition, technical assistance will be provided to

APHIA II and other partners to introduce the in-service counseling model into other service delivery sites.

Technical assistance will also be given to HIV counselor training organizations interested in integrating

alcohol risk reduction into their routine counseling. Anticipated outcomes of COP 09 activities:

• Technical assistance provided to the MOH and other partners to develop policy guidelines concerning

inclusion of alcohol risk reduction in HIV counseling.

• Model introduced into 15 service delivery sites.

• Technical assistance provided to APHIA II partners and HIV counselor training organizations to integrate

alcohol risk reduction in their counseling programs.

• Pre-service training resources developed and adapted for use by key pre-service training organizations.

c) The association between alcohol or substance abuse and sexual risk behaviors which put people at risk

of HIV, is well documented. The use of alcohol and drugs has been shown to be associated with

unprotected sex and having higher numbers of sexual partners, albeit a number of psychosocial factors are

also correlated with these factors. In Africa, HIV risk behaviors and their relationships to alcohol abuse has

been outlined in a number of recent studies. Recent research conducted in Kibera and other informal

settlements in the area of Nairobi, Kenya found that youth who live in these slums are more likely than

youth in the general population to have used alcohol or drugs, especially young boys and men. Alcohol and

substance abusing youth are also more likely to be out of school, to have been involved in both consensual

and forced sexual relationships.

Given this evidence, we propose to implement an intervention study among out-of-school youth living in

Kibera during COP 08. The aims of this study will be: to conduct a baseline assessment of the

characteristics, sexual behaviors, and alcohol and substance use of these youth via a representative

household survey; to identify factors associated with drug use and hazardous, harmful, and dependent

drinking as defined by the WHO; to refer youth identified during the survey as dependent drinkers for

counseling and/or treatment; inform a new youth-targeted intervention which will be developed by the

Support for Addictions Prevention and Treatment in Africa Trust (SAPTA) Centre in Kibera; and to conduct

an endline evaluation after a one-year period to assess the effectiveness of the intervention. During COP 09

we plan to disseminate the outcomes of this study to APHIA II partners and to GOK partners through

dissemination meetings and printing and wide distribution of the report. Anticipated outcomes:

• Adoption and scale up of alcohol and drug counseling prevention and treatment for youth program by

APHIA II partners

• Lessons learned communicated to other APHIA II and relevant GOK partners.

3. CONTRIBUTIONS TO OVERALL PROGAM AREA

This activity will contribute to the result of increased access to voluntary counseling and testing services.

This activity also supports the National Strategy of the Ministry of Health to expand integrated HIV/FP

services in Kenya. The target groups will be trained in counseling to inform clients about issues of HIV/AIDS

and the need for knowing their status.

4. LINKS TO OTHER ACTIVITIES

The activity creates demand for VCT services and will link to the CT services. More information will be given

to clients and the community during community meetings with the local administration so that more

messages and activities are conveyed through this community channel. The activity will also be linked to

Activity Narrative: other Population Council activities in AB and OP.

5. POPULATIONS BEING TARGETED

General population will be targeted who will attend the facility for family planning services and also health

facility staff, family planning clients and providers, doctors, clinical officers and nurses. These included men,

women, adolescents and the community at large. Activities will be coordinated with National AIDS control

program staff as well as with community based groups.

6. KEY LEGISLATIVE ISSUES ADDRESSED

This activity will work towards addressing the issue of stigma and discrimination faced by individuals with

HIV/AIDS and their families.

7. EMPHASIS AREAS

Major emphasis will be training and minor emphasis will be information, education and communication

materials which will be used as a part of community mobilization to raise awareness of knowing your HIV

status.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14974

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14974 4204.08 U.S. Agency for Population Council 6991 384.08 Frontiers in $300,000

International Reproductive

Development Health

7023 4204.07 U.S. Agency for Population Council 4274 384.07 Frontiers in $200,000

International Reproductive

Development Health

4204 4204.06 U.S. Agency for Population Council 3241 384.06 Frontiers in $220,000

International Reproductive

Development Health

Emphasis Areas

Gender

* Addressing male norms and behaviors

Health-related Wraparound Programs

* Family Planning

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14: