IMC has been implementing a project to scale up HIV/AIDS in Kyaka II Refugee Settlement since August 2007. GTZ and IMC with support from PEPFAR have been able to expand HIV/AIDS related services reaching out to both the refugees and the host populations. Networking with Wekomire Health Centre IV has increased with regard to sharing both technical and physical resources. Clinical officers from the Health Center come to the ART clinic to review cases and also help in prescribing doses to the clients. IMC continues to use the CD-4 equipments in Mubende hospital to follow up on the clients. GTZ, in partnership with UNHCR, continues to be the leading partner in the provision of health services at the Bujubuli Health Centre III and Mukondo Health Centre II. Current staffing is 17 including one doctor, 3 clinical officers, 2 Laboratory technicians, 2 Midwives, 1 Comprehensive Nurse, 2 Enrolled Nurses, 1 Psychiatric nurse, and 4 nursing aides. IMC provides support to the Health Center by having on it's staffing rolls, two nurses, one midwife and another counselor. These support the provision of health care especially to patients referred from the ART clinic to enable GTZ staff concentrate on general patients. Current average monthly outpatient attendance is 3,000. The major disease cases seen and treated include malaria, respiratory track infections, diarrhea, and intestinal worms. Monthly antenatal attendance is approximately 350. Kyaka II Settlement is located on the western side of Kyenjojo district and is about 215 kilometers from Kampala (197 kilometers on the Kampala Kyenjojo highway and 18 kilometers from the diversion on a dirt road). The refugee population is accommodated in 23 villages which are divided into 9 zones. The average distance from the zone to the base camp (Bujubuli) is 9.3 kilometers (the farthest village is 18 kilometers from the base camp while the closest is 2 km; 6 zones are located more than 10 kilometers distance). By January 2009, according to Office of Prime Minister (OPM), Kyaka-II settlement has a refugee population of 14,893 and a host population of 14, 783 (total population 29,676). The majority of the refugee population originate from the Democratic Republic of Congo and Rwanda. However the government of Uganda in association with the UNHCR has begun voluntary repatriation of the Rwandese considering that the conditions in Rwanda has improved. Some of the refugees from Rwanda have, however, expressed unwillingness to go back Kyaka II has a young population with the majority of residents within the age range of 0 17 years. The population has remained reasonably constant. There have been new relocated refugees from Kyaka I as well as repatriation of the Rwandese which is ongoing. While the HIV/AIDS response has been scaled up in Kyaka II a lot more needs to be done to ensure delivery of comprehensive services. There are some gaps in service provision which have been identified in the course of implementation of the current project. The proposed project will involve the refugee community in Kyaka-II settlement at all stages of the implementation. Involvement of the refugees as community volunteers and community groups will further strengthen the community's sense of ownership of the project. The project will facilitate the communities in acquiring the skills to protect and prevent against HIV infection and also provide care for the infected cases.

The project will compliment the HIV/AIDS prevention and treatment initiatives of Ministry of Health. The project will compliment the efforts of the SGBV initiatives of IMC in the same project area and with the active participation of the community and key stake holders; the project is expected to achieve the goal of reducing the incidence and prevalence of HIV/AIDS in the project area. The HIV/AIDS task force with representation of refugees will continue to play a key role in monitoring progress and assessing impact of the project.

The project continues to provide educational and nutritional support to 770 registered OVCs but this support is still inadequate, with only one uniform per OVC provided to all school-going OVCs and seedlings and tools provided to the OVC's families. The program still does not cover other aspects of the OVC program such as legal, care and support and palliative care to those who test positive. This is because of the lack of pediatric care at the Bujubuli Health facility. IMC will continue to seek ways that these groups of OVC can receive the full complement of OVC care. . The HIV/AIDS Counselor will continue to handle the emotional needs for the OVC while those with severe psychological problems will be referred to the Psychiatric nurse resident in Kyaka II. IMC will continue to strengthen OVC program using a family centered approach where OVCs are targeted within their families to ensure adequate monitoring, support and, ownership of program. To address the psychosocial needs of these OVC and their families/caregivers, a refresher training will be conducted for 10 volunteers trained in child counseling during FY09 and IMC provide ongoing supportive supervision to these individuals. The Counselor will be responsible for providing psychosocial care directly to those OVC with particular needs when referred by the 10 trained counselors. Existing child rights committees at zonal level will be trained to integrate OVC care in their child rights education programs in the communities as well as monitor the conditions of OVC in their zones.

IMC will also continue to provide scholastic materials to 518 OVC in school. However the materials will be distributed at household level to reduce stigma associated with distribution in schools. This will be complemented by an awareness-raising campaign coordinated by the Community Educators aimed at changing the attitudes of families/care givers to promote children's right to education, particularly those younger girls currently undertaking traditional 'female roles' in the household.

The HIV Counseling and Testing (HCT) program has grown tremendously; the current project has been able to reach out to 3,422 new individuals with HCT services so far. The outreach program has however been constrained by inadequate transport (vehicle) facilities. Secondly, the project has two counselors who are normally overwhelmed by the turn of people demanding for HCT. Disclosure of test results to sexual partners for the few who test presents a key challenge to addressing partner sero-discordance. Existing Post test clubs have been supported to raise awareness on the benefits of HCT and this has contributed to the increased demand for HCT however these clubs need to be further supported to effectively to promote positive living and reduce stigma.The services at this center will continue to be operated.. Health staff will continue to receive refresher trainings on HIV counseling as well as ethical issues associated with RTC and routine counseling and testing (RCT). Selected individuals will be trained as Counseling Assistants to support the HVCT unit to better the counselor-client ratio and improve the quality of HVCT provided, especially at outreach sites where many people turn up demanding for counseling and testing services. HIV test kits and related materials will be obtained from the health sub-district but IMC and GTZ will procure some to prevent stock outs. In addition to promoting the available services, periodic community awareness campaigns especially around key international events like World AIDS Day December 1st, will address issues related to disclosure of status to partners and families and the need for couple counseling and testing. Couple counseling will be promoted through training of Counselors in couple counseling and also tokens in the form of T-shirts, fast services, refreshments etc. will be provided to couples that turn up for HVCT. Community Educators will emphasize the importance of testing for children at risk of infection as part of this campaign. Children about 12 years can access VCT at the different outlets or outreaches.

IMC had been providing HIV awareness campaigns in Kyaka II, expanding the programs to cover all the zones in the settlement. Knowledge of the basic HIV facts increased, covering over 90% of the refugee population. However, comprehensive HIV knowledge is still a challenge across all age groups. In addition, there is need to focus on social change to create environments that support positive behavior change among young people and adults since increased knowledge does not entirely translate into safe behaviors and practices. To implement this objective, IMC will continue raising awareness on AB as well as focus on translating existing HIV Knowledge into the desired behavioral change using the health belief model within the context of HIV/AIDS targeting segments of the community as well as in and out of school youth. The model involves providing comprehensive HIV knowledge, assessing risk for HIV and consequences and identifying alternatives to risky behavior and drawing action plans to reach desired behavior. Life skills training for the youth (in and out of school) is also a key component of this model. The model will be tailored to promote abstinence and marital fidelity. IMC will continue to promote the use of the PIASCY (Presidential Initiative For AIDS Strategy on Communication to youth) in order to provide comprehensive HIV/AIDS knowledge for the youth especially those in schools. In each school, life skills clubs were implemented. . In addition, door to door visits will be conducted by community educators targeting families to improve communication between parents and children hence motivating positive and responsible behaviors. Behavioral change campaigns will be conducted around World AIDS Day, Day of the African Child and World refugee day. These campaigns will also provide avenues to provide public information about HCT, OVC care and ART. HIV counseling and testing will be conducted at the celebration sites. IMC will support establishment of another group of PHA building on the experiences and activities of the one formed last year and train them to carry out HIV/AIDS awareness. IMC will also continue to work with faith based institutions to create awareness on abstinence and promote marital fidelity. The existing GBV program implemented by IMC will provide an opportunity to promote girl child education and also create awareness on gender and gender based violence to facilitate the creation of more stable homes. The community centers will be furnished with games to reduce idleness of the out of school youth. IMC will recruit and train 20 new community educators to work among the refugee and host populations. HIV/AIDS talks will be organized in schools, using guest speakers from the church, other health centers, district and, NGO staff.

From 2007-2009, the project focused on raising awareness on the benefits of condoms and making them available in the community via the establishment of condom dispensers installed at or near the bars. Notwithstanding the increased knowledge levels among communities about condoms as a key HIV prevention strategy, a continued robust condom promotion campaign will be vital to promote correct and consistent condom use especially among the high risk groups. Operational research to assess condom use needs to be undertaken to inform further interventions in this area. IMC will continue with condom promotion, integration of RH and STI management, prevention with positives activities and, promotion of HCT as a prevention strategy. IMC will launch a rigorous condom promotion campaign in addition to ongoing door to door sensitization by community educators. The condom outlets will support additional condom outlets from the existing number. IMC and GTZ will continue to monitor the use of these outlets and will increase the number based on the demand by the community. STI prevention and treatment will be strengthened through outreach testing, community sensitization, training of community workers, training of health staff in syndromic management of OIs, IEC materials and provision of a broad spectrum of antibiotics. Adolescent friendly reproductive services will be instituted at one health center through the training of health staff, providing related supplies and materials, school talks and providing straight talk newspapers. Another group of PHAs will be formed and trained on positive living and prevention of STIs including prevention of re-infection building on the activities of the group formed last year. They will also be encouraged and supported to carry out HIV/AIDS awareness including condom use. During public information campaigns, HCT will be promoted as a prevention strategy. During HCT and condom awareness, communities will be informed about discordance and the need for discordant couples to use condoms consistently. Awareness on male circumcision within the context of HIV will be done through door to door sensitization by community educators, IEC materials and routine health education. Those in need of circumcision services will be referred to Kyegegwa HC III. The existing Gender Based Violence Program will implement interventions aimed at changing unequal decision making powers at household level and other gender norms. This will provide an opportunity to discuss issues around negotiation for safer sex among couples. Alcoholism is a major impediment to practicing safer sex and accelerates sexual coercion. The project will therefore raise awareness about the linkage between alcohol, HIV and GBV in the communities through drama, community meetings and impromptu discussions conducted by educators. IMC will also work with the OPM and the refugee welfare leaders to enact and enforce by-laws regulating drinking hours and operations of bars in order to reduce alcohol consumption.

Continued sensitization will remain instrumental in increasing the number of women attending antenatal care services and accessing PMTCT services. Over the past years, there has been an improvement in the number of pregnant women who were tested under PMTCT setting. In the last year, 1639 were tested and out of that number 46 were positive. These mothers were enrolled in the program to receive support and care from other mothers and also to receive counseling on how to protect their unborn children from being infected. The mothers were also encouraged to attend PMTCT meetings with their partners who provided support for them and encouraged them to attend. Increased uptake of PMTCT services is highly linked to the husband's participation, and while this has improved more outreach needs to be done to change both expecting mothers and husbands attitudes. Some mothers who enroll in the PMTCT program dropped out before their delivery dates due to the distances they have to travel to reach the Health Centers. To be able to support mothers in this category a Home based PMTCT program was tried and started implementation during the latter part of the year. IMC will monitor the success of this program in countering the absence of mothers to deliver at the health facility. IMC expanded PMTCT services to one other health center II in Mukondo as well as improved the quality of PMTCT services outlined below. Incentives like t-shirts and mosquito nets will be used to motivate couples who attend antenatal care services as part of the process of increasing men's enrolment into the PMTCT program. In addition, a special antenatal clinic day will be set aside to attend to couples.

Specific services provided to HIV positive expectant mothers will include HIV specific infant feeding education, provision of micro nutrient supplements like iron, OI management, nutrition counseling, education on good hygiene practices, personal and home care. Reproductive health services such as treatment of sexually transmitted disease, family planning / child spacing, intermittent preventive treatment of malaria, and postnatal care will be integrated into PMTCT programs through education and provision of services. HIV positive mothers will also be provided with preventive ARVs (basic regimen, combined regimen or HAART using MOH PMTCT guidelines). In addition IMC will support HIV positive mothers by taking their blood samples to the JCRC in Fort Portal where CD4 counts can be conducted. Follow up care and support for mother and baby will be done after delivery in order to increase uptake of PMTCT services.

IMC will conduct a rigorous PMTCT campaign using film vans, IEC materials and door to door sensitization. The PMTCT awareness campaign will highlight the benefits of PMTCT services to girls, pregnant women, their partners, parents and communities as well as the need for male partners to provide appropriate support. IMC and GTZ will conduct refresher trainings for existing Traditional Birth Attendants (TBAs) on PMCT to provide PMCT awareness and also to ensure that they refer HIV positive mothers to the health centers for delivery.

IMC will continue to run the home-based PMTCT program to follow up on expectant mothers not accessing ANC services and PMTCT clients who drop out. IMC will continue to monitor the success of this program in educating mothers of the need to attend to delivery at the health centres instead of delivering at home.

While a fully fledged pediatric care program is yet to be established at the Health Center, an early infant diagnosis (EID) and limited pediatric care program was established to cater for HIV positive babies. This program will continue to be operated, with support from Health personnel from Kyegegwa Health Center. HIV positive babies will be enrolled in the ART program. HIV specific infant feeding counseling to HIV+ mothers will continue after delivery and during further postnatal visits, soon after delivery and at 5 to six months when babies are expected to be weaned. IMC will continue to promote exclusive breastfeeding since it is the most viable option in this context. Awareness on early cessation of breast feeding and rapid weaning will be done during the home visits. IMC will continue to approach UNICEF and other partners for the supply of RUTF to children who become malnourished after the cessation of breastfeeding by their mothers. IMC will also contact other partner such as NULIFE to ensure that the children are enrolled in the nutrition program which provides food to people living with HIV. The families of HIV positive mothers will be supported to strengthen or set up income generating activities for purposes of raising money to manage complementary feeding.

IMC/GTZ will continue to implement TB/HIV interventions at the Mukondo HCII which had an effect of increasing the service outlets for clients To ensure a continuing high standard of care, IMC will undertake continous refresher training to 10 health professionals to provide clinical prophylaxis, TB diagnosis, treatment protocol and elements of Community based Directly Observed Treatment Short-course (TB-DOTS). Training will be conducted by TB staff from the district that have substantial knowledge on national TB and ACP programs. IMC will identify and train 18 community health workers as TB/HIV focal persons on CB-DOTS using national TB/HIV collaborative guidelines and provide them with relevant materials and logistical support to improve drug adherence and defaulter tracing. Communities will be sensitised about respiratory tract infections in general & T.B in particular issues related to indoor smoke pollution, over-crowding, and the risks of drinking partially boiled milk during community gatherings. A TB campaign will be conducted on World Tuberculosis Day (March 24) which will help to improve case finding, reduce stigma and defaulter rates as well as promote preventive and care aspects of tuberculosis. TB reagents and prevention therapy will continue to be accessed at Kyegegwa Health Sub district.