LIVING ON!

FIGHTING HIV/AIDS IN TURKANA

INTERNATIONAL RESCUE COMMITTEE RESPONDS TO THE WORLD’S WORST HUMANITARIAN CRISES AND HELPS PEOPLE SURVIVE, RECOVER AND REBUILD THEIR LIVES. WE RESTORE SAFETY, DIGNITY AND HOPE TO MILLIONS WHO ARE UPROOTED AND STRUGGLING TO ENDURE. THE IRC LEADS THE WAY FROM HARM TO HOME.

The IRC’s
Since

Impact
pandemic by providing

in Turkana

2005, the IRC has assisted the local and refugee populations of the Turkana region in Kenya in their response to
the HIV/AIDS

services, fighting awareness. As of August 2010, we have tested more than 110,000 people, provided access to free antiretroviral therapy for more than 1,500 patients, supported local partners with staff and equipment worth more than $3 million US , conducted more than 200 trainings for local target groups, mobilizers and advocates, supported more than 2,000 awareness outreaches and helped build institutional and response capacity through trainings , financial and expert support. We are effectively reaching out to more than half of the
population of Turkana.
COVER PHOTO Couple attending a session at a mobile voluntary counseling and testing (VCT) station in Nabute village, Lodwar.

basic clinical stigma and raising

IRC KENYA / LIVING ON! / COUNTRY DIRECTOR’S MESSAGE

3

MESSAGE FROM THE COUNTRY DIRECTOR

Dear Friends, Partners and Supporters, I am pleased to share our experiences from one of the IRC’s most successful and longstanding programs in Kenya. This publication introduces you to our work and our achievements in responding to HIV/AIDS in Turkana, and outlines the challenges we face in this fascinating region. With the support of the U.S. Centers for Disease Control and Prevention, the IRC has provided a coordinated response to HIV/AIDS in Turkana since 2005. We have a long and successful track record in the region, providing refugees and Kenyan communities with aid and medical services, including HIV/AIDS treatment, since 1992. Much remains to be done, but the IRC has significantly contributed to some major improvements in the fighting against HIV/AIDS in Turkana. Thanks to our efforts and engagement, the awareness of and the attitude toward HIV/AIDS have improved, although social stigma remains an undeniable problem. We were able to expand our focus on prevention activities that engage and empower local communities. Furthermore, we assisted in securing accessible, comprehensive and highquality HIV/AIDS treatment services through both IRC and partner facilities. Our approach is based on building local capacity, supporting homegrown structures and attaining long-lasting impact that goes beyond treating HIV/AIDS. A sustainable response to HIV/AIDS in Turkana will require further government leadership and coordination, continuous commitment from donors and, foremost, regional prioritization. Momentum is needed for the Turkana region to catch up with the rest of Kenya; improved transport, health, education and communications infrastructure will not only contribute to fighting HIV/AIDS but also improve the region’s general welfare. The IRC remains committed to helping the Kenyan government respond to the HIV/AIDS pandemic. We are thankful for the support of our donors, the Kenyan Ministry of Public Health and Sanitation, the Ministry of Medical Services and other governmental and local partners, and Kenyan communities where we work. We wish to express our special gratitude to our staff, whose dedication and perseverance makes the IRC successful in achieving our mission to assist those in greatest need.

CONTENTS
4 ACHIEVEMENTS 6 AIDS GLOBALLY, LOCALLY 8 TURKANA ESSENTIALS 16 IRC IN TURKANA 18 HIV/AIDS PROGRAM 28 BEST PRACTICES 49 LESSONS LEARNED 11 map 22 timeline 24 statistics 56 endnotes 57 acronyms and abbreviations 59 credits

theIRC.org
KELLIE LEESON, IRC KENYA COUNTRY DIRECTOR

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IRC KENYA / LIVING ON! / ACHIEVEMENTS

Since 2005, the IRC has persistently and systematically worked with local and refugee communities and with partner organizations to combat HIV/AIDS in Turkana, and it has significantly contributed to the following

ACHIEVEMENTS
ENSURED AVAILABILITY AND QUALITY OF HIV/AIDS SERVICES IN TURKANA
The IRC has been instrumental in raising the awareness of HIV/ AIDS in Turkana. It has helped create a demand for basic services by taking a lead in HIV-monitoring and providing voluntary counseling and testing services (VCT). Moreover, by operating medical facilities, establishing comprehensive care clinics and supporting the region’s main healthcare providers, the IRC has assured access to higher quality HIV/AIDS treatment in Turkana.

ENGAGED AND EMPOWERED COMMUNITIES
Local and refugee communities are the focus of the IRC’s response to HIV/AIDS in Turkana. Shifting from delivering services and information, the IRC now assists communities in targeting at-risk populations and individuals. Raising awareness, building communitytailored response capacity and assuming ownership and responsibility is central to the success of this strategy.

ABOVE Voluntary counseling and testing session in Lodwar District Hospital VCT center.

RIGHT Community outreach session in a village near Lokichoggio.

IRC KENYA / LIVING ON! / ACHIEVEMENTS

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RIGHT Awareness mobilization in a village near Lokichoggio.

IMPROVING AWARENESS AND FIGHTING STIGMA
The attitude towards HIV/AIDS in Turkana has notably improved and the IRC has played a crucial role in facilitating this change. HIV/AIDS stigma has decreased among local and refugee communities, which have access to basic information on its prevention and treatment. Although much remains to be done, this achievement is essential in engaging the community to take the lead in fighting HIV/AIDS and in generating hope for the future.

Through its support for local partners and authorities, the IRC has contributed significantly to building local capacity, improving basic healthcare services and creating better support structures in the region. By operating hospitals and clinics, supporting partners’ facilities with staff and equipment, and providing management training, planning and assessment assistance to local and provincial structures, our impact has gone beyond the HIV/AIDS response.

IMPROVED LOCAL CAPACITY, HEALTH AND SUPPORT STRUCTURES

RIGHT IRC-sponsored laboratory in Kakuma Mission Hospital.

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IRC KENYA / LIVING ON! / HIV/AIDS GLOBALLY, LOCALLY

HIV/AIDS GLOBALLY, LOCALLY
Nearly three decades after the first cases of AIDS were recorded, the disease remains a grave threat to health and development. It affects individuals, families, communities and societies worldwide. This modern plague has taken 34 million lives by 2010, making it one of the most destructive diseases in recorded history. According to the latest global statistics, the number of people living with HIV reached an estimated 33.4 million in 2008— a 20% increase from 2000. In 2008 alone, an estimated 2.7 million new HIV infections occurred and 2 million people died as a result of AIDS-related illnesses.1 The continuing rise of the population living with HIV clearly demonstrates that humankind is struggling in our efforts to stop the spread of the AIDS pandemic. But the growing numbers also reflect the beneficial impact of antiretroviral therapies (ARTs). The accessibility of antiretroviral drugs (ARVs) increased drastically in recent years, particularly in low– and middle–income countries. In times of increased global mobility, HIV/AIDS spares no continent, nation or society, but patterns of the AIDS pandemic differ considerably from region to region, afflicting some more severely than others. While the pandemic is spreading most rapidly in Eastern Europe and Central Asia, where the number of people living with HIV increased 67% between 2001 and 2008, sub-Saharan Africa bears the biggest AIDS burden in absolute numbers. The region currently accounts for two-thirds of HIV-infected individuals globally. High poverty levels, slow response and the underdeveloped health systems, along with cultural and behavioral habits, are commonly cited as causes for such high regional HIV/ AIDS prevalence rates. An estimated 1.9 million new HIV infections occurred in sub-Saharan Africa in 2008, bringing the total number of people living with HIV in the region to approximately 22.4 million.2 The rate of new HIV infections in sub-Saharan Africa has been declined by 25% in comparison to the pandemic’s peak in 1995, but the total number of people in the region living with HIV continues to climb. In 2008, the adult HIV prevalence in the region (ages 15 to 49) was 5.2%, resulting in an estimated 1.4 million AIDS-related deaths— a number representing an 18% decline in annual HIV-related mortality since 2004.3 Heterosexual intercourse remains the primary mode of HIV transmission in the region, followed by extensive ongoing transmission to newborns and breast-fed infants. The modes of transmission are more numerous than previously thought, however. According to recent research from East, West and Southern Africa, infection occurs among men who have sex with men and inject drugs.4

KENYA
Kenya did not avoid the early HIV/AIDS pandemic, although it was, at least partially, able to contain the disease’s drastic spread from 1990 onward. The country’s HIV prevalence peaked at 13% in 2000, when AIDS was declared a national disaster, and was dramatically reduced to 6-7% in the following years, partially due to an increase in education and awareness, but also high death rates.5 It continues to present a significant burden for Kenyan society despite institutional and policy responses from the government. Determining the HIV/AIDS prevalence rate in Kenya is challenging, with various estimates around 7%. Indicators for 20086 show a relatively stable HIV prevalence rate of 6.3% for adult Kenyans between 15 and 49, which is comparable to rates reported in 2003.7 But alternative studies have indicated an increased HIV prevalence of 7.4% in 2007, reversing the previously reported decline.8 The most commonly cited factor for this increase is the decline in HIV-related mortality, stemming from more rapid treatment and the availability of ARVs. AIDS-related deaths in Kenya have also fallen by 29% since 2002. However, an increase in risky sexual behavior may be playing a key role in the apparent reversal of epidemiological trends.9 HIV prevalence in Kenya is higher among women (8%) than men (4.3%) at both national and provincial levels,10 percentages in line with regional trends in sub-Saharan Africa. Women’s greater vulnerability to HIV stems not only from greater physiological susceptibility to heterosexual transmission, but also to severe social, legal and economic disadvantages.11 Girls and young women are particularly at risk of becoming infected in Kenya. Those aged 15 to 19 are three times more likely to be infected than their male counterparts, while those between 20 and 24 years are 5.5 times more likely to be living with HIV than their male counterparts.12 Epidemics in sub-Saharan Africa have matured and models suggest that the proportion of new infections among people in stable, so-called ”low-risk” partnerships is often high. In Kenya in 2006, heterosexual sex within a union or regular partnership

RIGHT The Kenyatta International Conference Centre, a symbol of modern Kenya and national unity. AIDS was declared a national disaster in 2001, with prevalence rates peaking at 13% the same year and dropping to 7% in 2009.

IRC KENYA / LIVING ON! / HIV/AIDS GLOBALLY, LOCALLY

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RIGHT Nairobi, Kenya’s capital, accounts for approximately 10% of all HIV infections in the country.

accounted for an estimated 44% of incident HIV infections compared to 20% of new infections caused by casual heterosexual sex.13 HIV prevalence in Kenya is higher in urban areas than in rural areas (7% vs. 6%), although the pattern differs by sex. Urban women have a considerably higher risk of HIV infection than rural women (10% vs. 7%), while rural men have a slightly higher level of HIV infection than their urban counterparts (5% vs. 4%).14 However, since approximately three-quarters of Kenyans live in rural areas, the majority of HIV positive people can be found there—

approximately one million individuals aged 15 to 64 compared to 400,000 in urban areas.15 There are significant differences in HIV prevalence rates within Kenya, which indicates regional heterogeneity of the country’s AIDS pandemic. Although numbers cited by different studies vary, the western parts of Kenya tend to have higher HIV prevalence rates than those in the east.16 Three provinces (containing half of Kenya’s population) have 65% of the country’s HIV infections: Nyanza province accounts for over one-third, Rift Valley province (where Turkana is located) one-fifth, and Nairobi province one-tenth.

TURKANA
HIV/AIDS has always been viewed as a pandemic of Kenya’s urban population17 and therefore not acknowledged as an issue in scarcely populated Turkana. Available statistics have indicated, however, that the region has not been spared the spread of HIV/ AIDS, consistently scoring above the national HIV prevalence rate. Accurately assessing HIV/AIDS impact in Turkana is a challenge due to the remoteness and vastness of the region, high mobility of the local population and security concerns. HIV awareness in Turkana has increased, with levels up to 98%, due to sustained national and regional HIV/AIDS information campaigns. However, the region has reported some of the highest HIV prevalence rates in the country in the last decade. In 2001 and 2002, HIV sentinel surveillance on antenatal mothers and patients with sexually transmitted infections showed HIV prevalence rate of 13% and 18%, respectively.18 According to a 2007 study carried out among the rural Turkana population, HIV prevalence was 4.1% in rural areas and 8% in urban centers.19 In the same year, data from the District AIDS and Sexually Transmitted Infections Coordinator (DASCO) in Turkana Central indicated a prevalence rate of 6.7%, increasing to 14% in some urban centers. Data from the 2009 Turkana Central District Ministry of Public Health and Sanitation puts the HIV prevalence

TURN THE PAGE TO LEARN ABOUT TURKANA
rate at 7%, close to the prevalence rates the IRC found during testing in the region.20 Access to ARVs in Turkana is greatly hampered by the isolation and mobility of the nomadic community. According to the National STI and AIDS Control Program (NASCOP) 2007 report, an estimated 2,883 people in Turkana were in need of ARVs in 2006, but this number could be higher because of increased access to HIV testing and counseling services in Turkana in recent years. Access to ARVs has increased from an estimated 300 people on treatment at the end of 2006 to about 1,500 in 2010.21 One of the leading causes of death among people living with HIV/ AIDS is tuberculosis (TB). Its presence is an important eligibility criterion for the initiation of ARV treatment. TB prevalence rates are high in Turkana among both pastoral and urban communities, and the co-infection rates are sometimes shockingly high. A 2002 study showed that 80% of TB patients in Lodwar District Hospital were HIV positive.22

TURN TO PAGE 19 TO LEARN ABOUT THE IRC HIV/AIDS PROGRAM

8 IRC KENYA / LIVING ON! / TURKANA ESSENTIALS

TURKANA ESSENTIALS

Turkana is one of the hottest, most arid and remote Kenyan regions, located in the Rift Valley Province in northwest Kenya. This scenic region of plains, broken by lava hills,23 is bordered by Uganda to the west, Sudan and Ethiopia (including the disputed Ilemi Triangle) to the north, Lake Turkana (with the Marsabit District on the lake’s opposite side) to the east, and the West Pokot, Baringo and Samburu districts to the south. It encompasses an area of nearly 77,000 square kilometers (30,000 square miles), similar in size to Scotland or South Carolina.

The region is an administrative part of the Rift Valley Province, also known as the breadbasket of Kenya, but such labels are misleading as the area hardly permits crop farming. The local economy, which relies on livestock, is regularly hit by droughts and famine. These rough conditions make Turkana one of the poorest regions of Kenya, with 74% of its population living in absolute poverty.24 The area is scarcely populated, with an estimated 539,263 people as of 2010,25 accounting for approximately 1.3% of Kenya’s total population. The region’s population is genderbalanced26 but

SETTLEMENTS AND INFRASTRUCTURE
The Turkana people traditionally did not occupy permanent settlements, despite their introduction during the colonial period. Following the droughts that hit the region in the 1980s, approximately one-half of Turkana’s population settled in or close to famine-relief camps. About the same number remain in or around settlements such as Lodwar or Lokichoggio, or in villages located along the region’s rivers and streams. Larger settlements suffer from limited investment and often lack basic infrastructure such as roads and transport services, sanitation, water, energy supplies and public lighting.
LEFT Traditional Turkana village, near Lodwar.

LEFT Entering Kalokol, a fishing village on the shores of Lake Turkana.

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ethnically diverse, due in part to its recent transitional and refugeehosting status following the establishment of Kakuma Refugee Camp in 1992. The majority of the region’s population is composed of the local Turkana, a Nilotic nomadic tribe that has, over the centuries, adapted to the arid environment by herding livestock and moving frequently. The Turkana are, in fact, one of the most mobile populations in the world. The Turkana depend on camels, cattle, sheep, and goats for subsistence; they use donkeys to transport household goods during migrations. They also engage in small-scale agriculture and basket weaving, products which can be traded along with livestock for grain and other necessities. Men are mainly responsible for herding, while women are in charge of watering and milking the livestock, feeding the family, household tasks and errands. Evidence suggests that in recent years, these pastoral communities have experienced rapid and unprecedented changes in their livelihood, exacerbated by recurrent droughts, the most recent of which occurred in mid-2010.27 Livestock numbers have remained stagnant over the last few decades and natural resources remain scarce. While their numbers are increasing, the Turkana have seen many of their tribe move to towns like Lodwar, Kakuma and Lokichoggio, settlements that have become areas of concentration for IRC services. In addition to persistent security concerns, the region’s population is afflicted by malnutrition and health issues. MALNUTRITION remains a serious problem in Kenya, where every fifth child under five is underweight and 31% of the total population is undernourished,28 even more so in arid and semi-arid areas like Turkana. Seasonal droughts, high poverty levels and limited infrastructure add to food insecurity in the region; 2009 numbers have shown alarming levels of global acute malnutrition (GAM) above 20% and severe acute malnutrition (SAM) at 3.5%.29 During the 2009 drought, 74% of Turkana’s population relied on food aid.30

BELOW Kakuma Refugee Camp (Kakuma I) and the typical Turkana landscape.

GEOGRAPHY AND CLIMATE
Much of Turkana is a broad low-lying plain, interspersed with lava hills. The plains are arid and lie at an elevation of 300-800 meters (980-2620 feet); the mountains receive more precipitation and rise up to 2,200 meters. The climate is hot and dry, with precipitation from April to June and occasionally during November. The mean annual rainfall in Lodwar (506 m / 1660 ft), the region’s main settlement, is 16.5 cm (6.5 in), with a high of 49.8 cm (19.6 in) and a low of 1.9 cm (0.74 in).

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RIGHT An IRC vehicle is part of a convoy, with security escort, traveling from Lokichoggio to Kakuma. .

IRC KENYA / LIVING ON! / TURKANA ESSENTIALS

SECURITY
The security situation in Turkana is often cited as one of the main causes hindering its development, but is also a consequence of its geographic location and economic situation. The reliance of traditional populations on livestock economy and the scarcity of resources have historically caused conflicts among the Turkana, and also with a number of local communities in Kenya that border the region and even some beyond these borders. Relative instability in the regions northwest of Kenya has hampered security in Turkana considerably over the past several decades, a period marked by civil wars in neighboring Southern Sudan, a major transport route to Sudan. The region was affected by firearms trafficking and used as a springboard for humanitarian operations in Southern Sudan. The signing of the Southern Sudan 2005 peace accords has opened up the transport corridor to a flurry of activity and prompted many nonindigenous peoples to settle in the region. However, limited road infrastructure and persistent poverty in the region foster banditry and looting and render travel difficult and dangerous, often requiring a security escort.

HEALTH CONCERNS in Turkana are numerous and aggravated by its remoteness, make the healthcare infrastructure additionally inaccessible and unaffordable for most of the population. The situation is worsened by high malnutrition rates, Turkana’s location in a malarial endemic zone, limited sanitation facilities and high prevalence rates of HIV/AIDS and TB. Limited investment and marginalization, the high mobility of the local population, its transitional location and the vastness of the region make it hard to obtain accurate demographic information, to provide muchneeded public services and to implement effective and accurate development policies. Turkana was previously administered as the largest district in Kenya. The region is now split into six districts: Loima, Central, South, North, West and East Turkana, which are further broken down into 17 administrative divisions. The region, which currently has three representatives in the Kenyan parliament, remains largely off the national political map with limited political participation at the local level. For 2007 elections, the region registered 138,223 voters (109,567 for the 2010 constitution referendum), accounting for less than a quarter of its total population.31

GO TO PAGE 12 FOR IRC PROJECT SITES GO TO PAGE 18 FOR HIV/AIDS PROGRAM

BELOW Kakuma.

Cattle graze near

FLORA AND FAUNA
The vegetation of the area is characterized by annual grasses and shrubs in the plains and perennial grasses and large trees in the highlands. The lowlands are crosscut with temporary streams and rivers. The larger of the river courses, the Kerio and the Turkwell, support dense gallery forests; acacia trees grow along the banks of smaller streams and river beds. Although the region is arid, Turkana benefits from numerous springs and underground water sources. Early travelers reported an abundance of wild animals in Turkana, but today most wildlife is restricted to the forested areas, and to the unoccupied areas that serve as a buffer between the Turkana and the tribal groups on their borders.32

IRC TURKANA PROJECT SITES (2010)
Sudan Ethiopia

KIBISH
Lokwanya

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Rift valley

Eastern
Somalia

Western Nyanza Central Nairobi

N. Eastern

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IRC TURKANA PROJECT SITES

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Map Doc Name: KE_IRC HIV/AIDS Map Creation Date: Projection/Datum: Web Resources: Nominal Scale at A4 paper size:

05 August 2010 WGS 1984 http://ochaonline.un.org/kenya 1:2,000,000

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Map data source(s): Administrative boundaries data is from Data Exchange Platform for the Horn of Africa 2006 Roads data is from Communication Commission of Kenya 2006 Towns data is from World Food Program 2006 Rivers data is from Data Exchange Platform for the Horn of Africa 2006 Disclaimers: The designations employed and the presentation of material on this map do not imply any opinion on the part of the Secretariat of the United Nations.

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IRC KENYA / LIVING ON! / TURKANA ESSENTIALS

IRC PROJECT SITES:

LODWAR
Located in Turkana Central District, Central Division, population 40,000. Administrative and commercial center of northwestern Kenya.
The town of Lodwar is located on the banks of the Turkwell River, 50 kilometers from Lake Turkana’s western shore. It is considered the capital of the region, housing local and governmental facilities, including Turkana’s biggest health facility and the main referral hospital, Lodwar District Hospital (LDH). The settlement was established in the 1930s by traders and soon became the seat of the Turkana district commissioner’s office, with a small medical clinic and a government prison. During the colonial period, Lodwar functioned as a transit point for British officials moving Kenyan political prisoners to the north. The town had developed a reputation as an isolated outpost removed from in the rest of Kenya, but in recent years, Lodwar has expanded and gained commercial and economic prominence. Lodwar is the seat of several of IRC’s Turkana operations, including the HIV/AIDS program.

LEFT IRC-supported VCT center in Lodwar District Hospital. ABOVE Entry to Lodwar from Kakuma (North). BOTTOM Lodwar seen from the closest hill. BOTTOM LEFT Villages surrounding Lodwar. Such villages, located in the outskirts of Turkana’s major towns, have grown in size and numbers during the recent decades. TOP OF THE PAGE The main street of Lodwar.

IRC KENYA / LIVING ON! / TURKANA ESSENTIALS

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IRC PROJECT SITES:

KAKUMA
Located in Turkana West District, Kakuma Division. Population 138,000, including roughly 67,000 refugees in Kakuma Refugee Camp. The largest settlement in northwestern Kenya.
Kakuma made it onto the map in the early 1990s after the establishment of Kakuma Refugee Camp, now the second largest refugee camp in Kenya. Following the influx of refugees from neighboring Sudan and the transfer of refugee populations from numerous Kenyan camps that began to close in 1992, Kakuma has turned into a multinational community. The camp currently provides a home to refugees from over 20 ethnic groups and 12 African countries— Burundi, Central African Republic, Democratic Republic of Congo, Eritrea, Ethiopia, Republic of Congo, Rwanda, Somalia, Sudan, Tanzania and Uganda. Somalis form the majority of the camp’s population (58%), followed by Sudanese (28%), Ethiopians (9%) and Congolese (3%). IRC is the exclusive provider of medical services in Kakuma Refugee Camp, where it operates a hospital and several clinics. It also supports Kakuma’s Mission Hospital, which is the main referral hospital for Turkana North and West districts.

LEFT VCT center in Kakuma Refugee Camp (Kakuma I). BOTTOM CENTER Children in Kakuma Refugee Camp. BOTTOM RIGHT Entry to Kakuma, refugee camp in background. RIGHT Kakuma Refugee Camp. ABOVE CENTER IRC-supported Kakuma Mission Hospital. ABOVE LEFT The main street of Kakuma town. TOP OF THE PAGE Kakuma Refugee Camp (Kakuma IV).

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IRC KENYA / LIVING ON! / TURKANA ESSENTIALS

IRC PROJECT SITES:

LOKICHOGGIO
Located in Turkana West District, Lokichoggio Division. Population 36,187. Former humanitarian hub for Southern Sudan.
The town of Lokichoggio, often referred to a Loki, is located about 30 kilometers from the border with Sudan. Daily temperatures frequently reach 40°C/100°F, and it is hot and dry year-round. Loki was established in 1992 as the base for the U.N.’s Operation Lifeline Sudan, a response to the humanitarian emergency in Southern Sudan in the wake of the prolonged civil war and famine. Loki became a transit center for refugees and and satellite location for international organizations and NGOs operating in Southern Sudan. At the height of operations, the IRC partnered with African Inland Church to offer comprehensive HIV prevention as well as support to aid workers. The partners opened the first stand-alone VCT center in town, expanding its services over the next few years. Due to its transitional location Loki became a vibrant commercial and multiethnic center— a temporary home for about 1,000 humanitarian workers who lived alongside the local urban and rural Turkana populations plus the Kikuyu, Luhya and Somalis. . The recent relocation of humanitarian operations to Juba in Sudan has downscaled and marginalized the importance of Lokichoggio, although the town remains the main entry point for Southern Sudan. The IRC has operational presence in Lokichoggio, working through and supporting the Africa Inland Church Medical Center, the main medical facility in the area.

TOP OF THE PAGE The main street of Lokichoggio. LEFT IRC-supported VCT center, located at AIC Health Centre, Lokichoggio. BOTTOM Abandoned aircraft at Lokichoggio airstrip that used to serve as the base for Operation Lifeline Sudan.

IRC KENYA / LIVING ON! / TURKANA ESSENTIALS

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IRC PROJECT SITES:

KALOKOL
Located close to the shores of Lake Turkana, in Turkana Central District, Kalokol Division. Population 29,000.

Due to the proximity of Lake Turkana, fishing is one of the main livelihoods in Kalokol, which even has a fish-processing facility. The area is windy, dusty, hot and dry— harsh even for local livestock such as goats and camels, allowing only limited pastoral activities and business development. The landscape is characterized by lowlands that stretch along the lake’s western shores. Africa Inland Church’s Kalokol Medical Center, which has been supported by the IRC since 2005, is the only medical facility in the area and on the western shores of Lake Turkana.

GO TO PAGE 49 TO MEET IRC PARTNERS IN KALOKOL AND LOKICHOGGIO

TOP OF THE PAGE Fishing is the main livelihood in Kalokol. ABOVE LEFT, RIGHT AIC Health Center Kalokol and the IRC-supported VCT center. BOTTOM LEFT View of Kalokol from the town water tower. BOTTOM RIGHT Kalokol main street.

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IRC KENYA / LIVING ON! / IRC IN TURKANA

IRC IN TURKANA
IRC Kenya operation is intimately linked to the Turkana region where the IRC has been working since 1992.

HISTORY
The IRC began working in the region by providing health-related outreach activities in Kakuma Refugee Camp, initiating a primary healthcare program and establishing a network of clinics. In 1995 the IRC’s services were expanded at the request of the community to include a small self-reliance program comprised of adult education and community-based rehabilitation. In 1997, the IRC took over the camp’s health services and became the sole implementing health-sector partner under the operational umbrella of the U.N. High Commissioner for Refugees (UNHCR). It then assumed responsibility for the camp hospital, bringing all preventative and curative health-sector activities under its management. Since 2001, the IRC’s activities have gradually expanded in scope and area, including Kenyan communities. The HIV/AIDS prevention and care program led the expansion of IRC’s activities across the greater Turkana region to Kakuma town in September 2001, Lokichoggio in 2004, Kalokol in 2005 and Lodwar in 2007. This was followed by the introduction of region-wide child health and nutrition programs, a water and sanitation program and a cross-border peace-building program operated with the IRC Uganda since 2009. The IRC also promptly responds to emergencies like the devastating 2006/2007 drought and 2009 cholera outbreaks. The IRC has been supported by the following donors in the implementation of its Turkana programs: BPRM, CDC, DFID, EU, Otto Family Foundation, RIJ, SV, UNHCR, UNICEF, USAID, WFP and WHO.

APPROACH
In the greater Turkana region, the IRC provides essential services through the implementation of its programs, which target two groups of beneficiaries: thousands of refugees who have fled conflicts in other African countries such as Somalia, Sudan, Ethiopia, Uganda and DRC, and Kenyan communities in need of humanitarian or development assistance. In order to assure maximum impact and effectiveness of its Turkana programs, the IRC bases its approach on thorough and continuous assessments of needs in the region; situating more programs in the same geography; integrated mainstreaming of new services through existing ones to reinforce results; and supporting and partnering with actors already present on the ground to avoid replication and build local capacity.

PROGRAMS

MATERNAL, NEONATAL AND CHILD HEALTH PROGRAM (KENYAN COMMUNITIES)
Since early 2009, the IRC has been running maternal, neonatal and child health programs for host communities, implemented through its partners, Diocese of Lodwar and African Inland Church Health Center in Lokichoggio. At facility level, IRC supports antenatal and postnatal care, maternity services, emergency obstetric care, immunization outreaches and malnutrition stabilization centers. At community level, the IRC offers support for the treatment of childhood illnesses and training of community health promoters, screens for malnutrition, promotes safe motherhood and conducts behavioral-change outreaches on hygiene and disease prevention.

CROSS BORDER PEACE BUILDING (KENYAN COMMUNITIES)
Together with IRC Uganda and partners, IRC Kenya aims to strengthen the cross-border capacity of civil society networks and organizations in the Karamoja, Turkana and Pokot regions to prevent and resolve conflicts between communities along the Kenya-Uganda border. The IRC assists civil society in building capacity to successfully lobby local representatives and authorities to prevent and mediate conflicts.

OPPOSITE PAGE AT RIGHT Somali refugee girl received by IRC clinicians at KRC Clinic 5. LEFT Local woman vaccinated against tetanus in Kakuma Refugee Camp Clinic 4. Although intended primarily for the refugee population, many locals use IRC-run medical facilities in the camp.

IRC KENYA / LIVING ON! / IRC IN TURKANA

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RIGHT Management of acute malnutrition at Kakuma Mission Hospital by the nutrition team.

NUTRITION (KRC, KENYAN COMMUNITIES)
In Kakuma Refugee Camp, the IRC runs a range of preventive and curative activities including growth monitoring, infant and young-child feeding, health and nutrition education, communitybased management of acute malnutrition, and hospital inpatient feeding services. In the local communities, the IRC operates a full community therapeutic program through partners’ health facilities—AIC health centers and Kakuma Mission Hospital— including supplementary feeding, outpatient therapeutic feeding and stabilization centers. Outreach centers have been set up at community level to ensure high coverage and accessibility to services. Main activities include food distribution, health and nutrition education, vitamin A supplementation, de-worming, and infant and young-child feeding practices.

RETURN AND EDUCATION PROGRAM (KRC)
Through this program, the IRC offered a curriculum in literacy and numeracy in English and Kiswahili, as well as courses in peace and reconciliation, gender and community development. The IRC also supported other programs through business skills and facilitators’ training courses, and prepared people who were scheduled for resettlement in the United States. The IRC handed over the program at the end of 2008.

CLINICAL SERVICES AND SUPPORT (KRC)
The IRC runs a 90-bed primary care hospital with a minor operating theater, outpatient department, male and female inpatient wards, a pediatric ward, an isolation ward, a tuberculosis ward, laboratory, pharmacy and a therapeutic feeding center. In addition, the IRC supports four outpatient clinics providing curative services, preventative health care, pre- and postnatal care, immunizations and family planning. The IRC also offers physiotherapy and rehabilitation for persons with disabilities.

COMMUNITY HEALTH PROGRAM (KRC)
The IRC focuses on preventive health care and education in the camp with a team of community health workers, traditional birth attendants, vaccinators, and reproductive and mental health workers. The program includes therapeutic feeding and supplementary feeding centers and a 24-hour emergency feeding center located in the pediatric ward of the hospital. Under the program, defaulter tracing and referral is undertaken, as well as hygiene education and birth supervision.
ABOVE Access to drinking water remains a major issue in Turkana. ABOVE CENTER Latrines at Kakuma Refugee Camp.

ENVIRONMENTAL HEALTH (KRC)
The community-based sanitation program in the camp covers solid, liquid and human waste control, vector control, food quality and animal slaughter inspection, and burial of the dead.

WATER PROGRAM (KENYAN COMMUNITIES)
From 2007 to 2008, after Turkana was heavily affected by droughts, the IRC implemented a comprehensive water program, providing towns like Kalokol or Nadapal with gravity flow systems or similar infrastructure projects that provided thousands with access to drinking water.

IRC KENYA / LIVING ON! / HIV/AIDS PROGRAM

IRC TURKANA HIV/AIDS PROGRAM

19 BASICS 20 PROGRAM OBJECTIVES 22 TIMELINE 23 IRC BCC STRATEGY: KAKUMA CAMP PILOT 24 STATISTICS 28 BEST PRACTICES 49 LESSONS LEARNED

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BASICS
HISTORY
The ORIGINS of the IRC’s HIV/AIDS program in Turkana date back to the 1990s, when IRC Kenya became the main provider of health services in Kakuma Refugee Camp under the operational umbrella of UNHCR. With HIV prevalence rates in Kenya rising and hitting remote areas like Turkana particularly hard, it became clear that there was a need to help the Kenyan government address the issue in a comprehensive manner. Relying on the support of individual donors and ultimately the U.S. Centers for Disease Control and Prevention (CDC), IRC Kenya started an HIV/AIDS prevention and care program in the Turkana region, beginning in Kakuma town (2001) and spreading to Lokichoggio (2004), Kalokol (2005) and Lodwar (2007). In implementing its HIV/AIDS program, the IRC must tackle the usual challenges associated with operating in Turkana. The region is vast and most areas remote, with limited or no healthcare facilities. Assuring ACCESS to HIV/AIDS-related CLINICAL SERVICES and information is vital for the successful implementation of the program. IRC facilities are spread throughout the region, covering hot-spots and major urban centers as well as surrounding rural areas. Whenever possible, the IRC helps build local capacity and supports partners and local structures. In Lodwar, Lokichoggio, Kalokol and Kakuma town, the IRC supports the clinical dimension of the HIV/ AIDS program with equipment and counseling, financing and training for its implementing partners: Diocese of Lodwar, Africa Inland Church and the Ministry of Health. In Kakuma Refugee Camp, the refugee population relies solely on IRC-provided healthcare and HIV/AIDS prevention and treatment.

ACCESS TO CLINICAL SERVICES

BEHAVIORAL CHANGE COMMUNICATION

The behavioral change communication (BCC) component of the program, the forefront of prevention, is managed and facilitated by the IRC. Poverty, lack of education and the prevalence of certain cultural practices increase the risk of HIV/AIDS contraction and transmission and underscore the BCC’s importance, but also make implementation a challenge. BCC activities target clusters of problems with direct or indirect link to HIV/AIDS which, when addressed, also spur development in local communities. These activities are attached to existing initiatives, networks and community structures as often as possible, generating individual inclusion and empowerment. Turkana has high malnutrition rates and is affected by droughts and insecurity, harsh living conditions the IRC tries to ameliorate through numerous other programs. In order to increase the scope of the HIV/AIDS program outreach and the effective use of resources, these programs are often used as a platform for MAINSTREAMING HIV/AIDS ACTIVITIES and providing a holistic approach to issues such as nutrition, child, maternal and community health, and water and sanitation.

PROGRAM MAINSTREAMING
LEFT Voluntary counseling and testing (VCT) session at Kakuma Mission Hospital.

IRC HIV/AIDS PROGRAM OBJECTIVES

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ASSURING IMPROVED ACCESS TO QUALITY HIV/AIDS PREVENTION, TREATMENT AND CARE SERVICES IN TURKANA, REQUIRES THE IRC TO...

Offering comprehensive services is crucial for successful care and treatment in underserved areas.

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INCREASE ACCESS TO A COMPREHENSIVE HIV/AIDS CARE PACKAGE AT ALL PROGRAM SITES
The IRC operates a Comprehensive Care Clinic (CCC) at the Kakuma Refugee Camp hospital and in Lokichoggio, supports and strengthens CCC in Kakuma Mission Hospital, provides a basic HIV care package in Kalokol and has introduced a basic care package for adult/pediatric ART at several other locations. The IRC provides Cotrimoxazole Preventive Therapy (CPT) to all eligible patients; strengthens links to care clinics and other services such as home-based care (HBC), voluntary counseling and testing (VCT), and prevention of mother-to-child transmission (PMTCT); and introduces nutritional support services to ART patients. The IRC facilitates training on HIV/AIDS care service provision for its staff and partners, and offers support in the provision of medical equipment. The knowledge of HIV/AIDS in the region is limited and the sources of information scarce.

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INCREASE ACCESS TO HIV PREVENTION EDUCATION SERVICES AT PROGRAM SITES
The IRC supports group-specific HIV/AIDS behavior change campaigns (BCC) that make use of media including film, drama, dance, song, community meetings, targeted education and promotional materials. This requires development and adaptation of culturally appropriate messages, refresher training and resource materials to help outreach staff and peer educators achieve their goals. Additionally, various awareness activities on HIV prevention are conducted in bars and video halls, and condoms distributed.

GO TO PAGES 28 TO 40 TO LEARN MORE ABOUT PREVENTION INTERVENTIONS
Knowing an individual’s status is a starting point for addressing HIV/AIDS issues and providing treatment.

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MAINTAIN AND EXPAND ASSESS TO HIGH-QUALITY HIV COUNSELING AND TESTING (CT)
The IRC provides high quality CT services at the six project sites, support for the creation of post-test clubs in all six sites, strengthening the institutional capacity to provide quality CT services in the six locations, and bolstering institutional capacity to implement routine quality assurance CT systems in the six locations.

IRC KENYA / LIVING ON! / HIV/AIDS PROGRAM
LEFT Awareness outreach in Kakuma Refugee Camp delivered through a dance skit.

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Sexually transmitted infections (STIs) increase the chances of HIV contraction and HIV/AIDS patients are more susceptible to TB infections.

4 5 6

INCREASE EXISTING TB/HIV CO-INFECTION AND STI CONTROL SERVICES
The IRC provides STIs and refers clients to HIV counseling and testing, monitors partner treatment rates, offers refresher training on STI syndrome management, provides systematic diagnostic counseling and testing of HIV for TB patients as well as treatment to TB/HIV-positive patients, and strengthens institutional capacity to manage TB/HIV infections.

Blood safety is a basic requirement for the prevention, control and treatment of HIV/AIDS.

CONTINUE TO EXPAND THE EXISTING BLOOD AND INJECTION SAFETY PROGRAM AT SERVICE DELIVERY POINTS
The IRC conducts training on universal precautions at all project sites, ensures that all blood for transfusion is screened for HIV, Hepatitis B and syphilis, and supplies health facilities with equipment to ensure blood safety.

Mother-to-child transmission remains a major concern in Turkana.

INCREASE ACCESS TO QUALITY PREVENTION OF MOTHERTO-CHILD TRANSMISSION (PMTCT) SERVICES AT ALL SITES
This is done by ensuring PMTCT services to pregnant women are integrated into the antenatal care package; by improving referrals of HIV-positive pregnant women for hospital delivery; by increasing institutional capacity to provide PMTCT services; by introducing early infant diagnosis; and by monitoring sero-status and growth of children born to HIV-positive mothers.

GO TO PAGES 46-48 FOR PMTCT BEST PRACTICE

Turkana is vast and its population extremely mobile, presenting a challenge for HIV/AIDS data collection.

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IMPROVE THE AVAILABILITY AND QUALITY OF HIV DATA IN TURKANA
The IRC undertakes continuing data collection and monthly reporting of client– and provider–initiated counseling and testing (CT), STI client CT, tuberculosis client CT, and prevention of mother-to-child transmission. The IRC also conducts training on HIV/ AIDS data management, disseminates information through reports and/or meetings with stakeholders and helps build the capacity of the Turkana Health Records Department on data management.

GO TO PAGE 43 FOR HIV/AIDS DATA MANAGEMENT
Home-based care is vital to assuring HIV/AIDS treatment for patients unable to access medical facilities.

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EXPAND THE COVERAGE OF THE EXISTING HOME-BASED CARE PROGRAM
The IRC provides home-based care services to HIV/AIDS patients and strengthens the capacity of its partner organizations to provide home-based care services.

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IRC TURKANA HIV/AIDS PROGRAM TIMELINE
P R O G R A M D E V E L O P M E N T
JAN 2001 Kakuma town Prevention and care program launched. 2007 KRC BCC training and BCC pilot strategy. 2008 program Induction and roll out of Families Matter program. Early Infant Diagnosis training and program. 2006 KRC Reproductive Health program changed to HIV program, safe motherhood transferred to Clinical Services program. HIV comprehensive care clinics data reconstruction. 2009 program “Prevention with Positives” at Clinical and Community levels. Integrated database development. Nutrition and Community programs mainstreaming.

2009 program Active participation in response to disasters and disease outbreaks. Advocacy for special food rations for PLWHA and TB patients at national and provincial levels.

2002 KRC VCT at MPC1 and MPC4.

2004 Lokichoggio Stand-alone VCT and BCC.

2008 Lodwar CD4 Machine installed (LDH).

2004 Kalokol Integrated VCT and BCC.

2009 Loki CSW involvement in HIV prevention. CD4 machine installed, AIC HC.

2008 Lodwar HIV/AIDS awareness through radio.

2010 Kakuma CD4 machine installed (KMH).

2001
D O N O R S & P A R T N E R S

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2006 Networking with MoH HIV/AIDS structures at district, provincial and national levels. 2006 Lokichoggio MoU with AIC – stand alone VCT and HIV/TB. 2006 Kalokol MoU with AIC to run HIV/ AIDS program. 2001 KRC UNHCR-funded Reproductive health program 2005 KRC CDC funding, integrated HIV/AIDS program. 2006 Kakuma MoU with KMH to run HIV/ AIDS program.

2007 Lodwar MoU with LDH to implement HIV/ AIDS program.

2010 Active membership in Technical Working Group at national level (NASCOP). Direct support to Provincial Health Management Teams. 2010 Expansion strategies through POA project and APHIA plus project. 2009 Participating in MoH Annual Operations Planning.

2007 KRC MoU with NCCK to implement life skills for youth.

2008 Lokiriama, St.Monica, St.Catherine, Lokori MoU with DOL.

2007 KRC GLIA funding.

2008 Organizational capacity assessment (OCA) exercise among partners.

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KAKUMA CAMP PILOT

DEVELOPING GLOBAL IRC BEHAVIOR CHANGE COMMUNICATION (BCC) STRATEGY
Kakuma Refugee Camp served as a pilot site for the development of IRC’s global behavior change communication (BCC) strategy in 2007. BCC interventions are crucial but challenging components of programming, as they need to take into consideration the specificities of the environment and audience to result in meaningful and lasting social change. IRC’s Kakuma operation was chosen as the pilot site because its health program and team are among the strongest in the IRC, providing for a positive environment to launch the 12-step approach to BCC. Additionally, the complex mix of ethnic groups, cultures and languages in a setting like Kakuma Refugee Camp requires a carefully planned and targeted communication strategy, particularly in relation to behavior change for culturally sensitive issues related to reproductive health, sexuality and HIV/AIDS. The IRC recognized the importance of a detailed, structured process in the design of an effective communications intervention and developed a 12–step approach to creating a BCC project. A thorough understanding of the audience and analysis of the context were the foundation of this approach. Community involvement and participation were crucial for the success of a BCC strategy that included: (A) identifying risky behaviors; (B) selecting the target group; (C) identifying communication activities and methods; and (D) facilitating commitment to and support for the BCC process. IRC’s BCC strategy was rolled-out in Kakuma Refugee Camp and across other IRC country programs in 2007.
IRC BCC FRAMEWORK

RIGHT BCC and awareness outreach in Kakuma Refugee Camp.

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HIV/AIDS PROGRAM IN NUMBERS
VCT SERVICES
The data demonstrates a gradual and consistent increase in the number of clients who have accessed voluntary counseling and testing services supported by the IRC, and a shift from static to mobile or home-based services. Acknowledging that access to medical services is one of the main problems in Turkana, the IRC adopted a multipronged strategy of proactively reaching out to the population and bringing HIV/AIDS treatment services closer to the people, either where they congregate, do business or live. In addition, mobile VCT services also targeted pastoralist populations in remote and rural areas with few or no medical facilities. Some locations were several days’ walk from the nearest hospital, clinic or dispensary. The overwhelming majority of clients accessing VCT stations use both, testing and counseling services. The total number of people reached by testing and counseling services, which combines VCT and all types of provider-initiated counseling and testing, is expected to reach 50,000 for year 2010 and has been increasing steadily every year. This clearly demonstrates that if these services are accessible, people’s health-seeking behavior will change.

PMTCT-RELATED TESTING
Prevention of mother-to-child transmission (PMTCT) is crucial to IRC’s HIV/AIDS intervention in Turkana. Identification of women in need of PMTCT treatment presents one of the major challenges in remote areas with limited healthcare facilities. Providing testing with antenatal care offers an ideal opportunity for identifying HIV-positive women. The number of women tested for HIV in IRCsupported facilities while attending antenatal care has risen since 2005.

GO TO PAGE 44 FOR PMTCT BEST PRACTICE

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ANTIRETROVIRAL THERAPY
The number of people initiating and adhering to the antiretroviral therapy in Turkana has traditionally been low for reasons of limited access to healthcare facilities and high ART costs. The IRC has provided ART available free of charge since the early stages of HIV/AIDS program’s implementation and increased the ARV coverage along with the expansion of its activities. ARV adherence remains a major challenge for various reasons, including the high mobility of local communities, their remote location and limited health knowledge. The data shows a gradual increase in the number of individuals who have newly initiated ARV treatment. The IRC data from 2007 to 2009 on ARV defaulters reveals that approximately 600 individuals discontinued their ARV treatment. About 15% were transferred to locations outside of IRC’s coverage and the rest ether defaulted or the IRC lost track of them. About 20% of the individuals died during the survey.

GO TO PAGE 43 FOR HIV/AIDS DATA MANAGEMENT BEST PRACTICES

HIV/AIDS AWARENESS
During the early stages of the HIV/AIDS Turkana intervention, the IRC expanded the scope of its HIV/AIDS awareness activities and channels. New and innovative ways to spread the message about HIV/AIDS, from radio to formal education, were introduced, a strategy intended to address one of the biggest challenges in the region— reaching out to and raising awareness among populations in the most remote and rural areas of Turkana. Since 2010, the awareness outreach is more targeted and focuses increasingly on specific groups at-risk.

GO TO PAGES 28-48 FOR AWARENESS BEST PRACTICES

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BUILDING LOCAL CAPACITY
Building local capacity through training and education is one of the cornerstones of IRC’s approach in the region. The variety of HIV/ AIDS-related training sponsored or supported has increased significantly, as well as the range of beneficiaries who now include medical staff, community health and development workers, teachers, public officials, parents, youth, at-risk groups and others. The increased frequency of these capacity building activities has also led to more comprehensive coverage, meeting the needs of the region more closely. Generally, building capacity through training of medical and community staff has beneficial effects beyond the HIV/AIDS program.

PROGRAM FUNDING (CDC/PEPFAR)
IRC’s HIV/AIDS program has seen an increase in funding since its start in 2005, which confirms the persistent need for HIV/AIDSrelated services in Turkana. During this time, the IRC has expanded the number of locations where VCT, care and treatment services are accessible, it scaled up its PMTCT activities and emphasized the prevention focus of its outreach. Accordingly, the funding for prevention activities has increased two-fold in absolute terms but decreased relative to other components. This indicates a more targeted approach to prevention; for example, funding for care, treatment and support, for which includes access to ARVs, has increased six-fold. Changes in relative numbers of program fund allocation demonstrate that the IRC reprioritizes in accordance with best interests and needs of the beneficiaries of its programs on the ground. Furthermore, the IRC has had to adapt to limited funding, a challenge that could negatively impact on the achievements of the HIV/AIDS program. As demonstrated throughout this document, the implementation of the IRC’s HIV/AIDS program in Turkana has had significant effects on the behavioral patterns related to HIV/AIDS in the region. It is essential to secure further funding to support program activities and local partners beyond the 2005-2010 program phase.

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Many lessons and best practices have been drawn from the IRC’s experience working with local communities and numerous local, national and international partners in Turkana for more than two decades, along with five years of coordinated response to HIV/AIDS. The IRC strives to reflect upon its experiences and apply them to its programs and activities. The IRC also shares them with partners and donors on a regular basis to contribute to the continuous improvement of development and humanitarian programs in Turkana.

28 COMMUNITY THEATER

BEST PRACTICES

32 TARGET-GROUP ADVOCATES 34 HIV/AIDS AWARENESS ON RADIO WAVES 37 PREVENTION WITH POSITIVES 40 FAMILIES MATTER! 43 HIV/AIDS DATA MANAGEMENT 44 VCT AND INTEGRATED OUTREACH SERVICES 46 PMTCT, EARLY CHILD DIAGNOSIS AND HOSPITAL DELIVERIES

49 THE IRREPLACEABLE POWER OF PARTNERSHIP

LESSONS LEARNED

51 NEED FOR ALTERNATIVE WAYS TO UNDERSTAND THE CONTEXT, REACH OUT TO THE POPULATION AND DELIVER THE HIV/AIDS MESSAGE 52 THE BENEFITS OF LINKING AND MAINSTREAMING HIV/AIDS THROUGH OTHER PROGRAMS 52 NEED FOR A STRONGER PUSH FROM THE GOVERNMENT ON THE HIV/AIDS FRONT 53 INSEPARABLE THREATS: HIV AND TB 54 MORE STRUCTURAL INVESTEMENT IN TURKANA

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COMMUNITY THEATER

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Raising HIV/AIDS Awareness and Engaging Communities in Turkana Through Youth Advocacy Groups
Raising general awareness about HIV/AIDS is at the core of the IRC’s strategy to prevent the disease’s spread and manage its negative social impacts, especially stigma. For the awareness activities to be as effective as possible, it is crucial that they be engaging, attractive and entertaining, which community theater groups supported by IRC in Turkana strive to achieve. Since many youth in Turkana are out of school but unemployed, the IRC seeks to engage them actively in HIV/AIDS awareness campaigns to reach out to their peers. Community theater groups are usually composed of local youth who have undergone voluntary HIV/AIDS counseling and testing and were then recruited to help with community outreach. The IRC supports seven groups that conduct outreaches six to eight times a month in the form of skits, dances, role-playing and short performances. These activities can be an integral part of a larger outreach event or a singular activity at community meetings or celebrations. The performances focus on delivering messages on HIV/AIDS or general health: They promote health services and facilities, inform on basic principles of hygiene, sanitation and care, challenge myths, stereotypes and attitudes, and try to break down barriers about sex and sexuality. The latter is especially important, given the taking

THIS PAGE Lodwar-based St. Augustine Youth Centre group performing a skit in Nabute village, Lodwar. Storyline: Young man returns to his village from Nairobi, has unprotected sex with his ex-girlfriend and contracts an STI. He visits a hospital, talks to a counselor and is advised by health workers and friends to use protection and know his HIV-status in the future. OPPOSITE PAGE Dance skit performed by a Community Theater Group in Kakuma Refugee Camp.

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into general reluctance among the population to address such issues in public settings. Performances are part of a larger HIV/ AIDS mobilization activity and take place in busy public places, such as markets or water wells, at different times of the day. Performances often attract the attention of the whole village or town. The audience is encouraged to participate and ask questions, but also to undergo voluntary HIV/AIDS counseling and testing at mobile counseling and testing stations located close to outreach venues. Community theater groups in Turkana present an innovative method of conveying HIV/AIDS-related messages and have proved successful in raising awareness among locals who often refer to these events as the source of their knowledge about HIV/ AIDS. Future plans to improve Community theater outreach include adaptations of the program for specific targeted groups, including through puppetry performances for children, touring performances and support for the establishment of similar groups in the region.

THIS PAGE Lokichoggio theater group performing skits on HIV/AIDS and stigma in Lokichoggio and surrounding villages.

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BANJUKA (Kalokol)
The theater group from Kalokol has been active since 2007. Lucy, Susan, Florence (below, first row from the left), Rose, Said, Jacqueline (second row) and their colleagues practice twice weekly and perform in the villages of Kalokol division at least six times a month. They say the best way to attract attention through theater is to make people laugh, even when topics are serious. They are proud of their work and believe they have influenced their audience—condoms, sexuality and STIs are topics that do not cause negative reaction anymore. Although they must travel to remote locations and have problems informing communities about upcoming performances, the group remains ambitious and wants to perform outside of the Turkana region.

PHOTOS ABOVE Banjuka group performing a skit in Kalokol. Storyline: After being tested and found HIV-postive, a girl (and her mother) is chased from their home by her father. They turn to a doctor for help. He talks to the father and provides him with basic information about HIV/AIDS, antiretroviral therapy and confronts disease-related myths. As a consequence, the father accepts his daughter and wife back into the home.

LEFT Theater group from Kakuma Refugee Camp performing during an HIV/AIDS community outreach. LEFT BELOW Dance skit in Kakuma Refugee Camp. BELOW Lodwar theater group performing during Families Matter! graduation ceremony in Lodwar.

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TARGET-GROUP ADVOCATES

The IRC has worked extensively with most-at-risk populations in Turkana, including commercial sex workers, truck drivers en route to and from South Sudan, and the fishing communities of Lake Turkana. Initially these groups were considered only as target groups for behavior change communication and HIV/AIDS-related messages. If properly educated, trained and supported, they can become an effective advocacy group for continued behavior change communication on HIV/AIDS and general health among their peers and in the local community. Young women and girls are particularly vulnerable to HIV, more so when frequently changing sexual partners or as a result of commercial sex activities. The IRC has designed outreach activities in Lokichoggio and Lodwar specifically for these groups. Initially the objective was to make them aware of the risks linked to such behavior and to encourage them to reach out to their peers, sexual partners and, in some cases, customers. After training 20 young women in Lokichoggio and attaining the initial objective of disseminating information through them to their peers, eight girls from the group were mobilized for further outreach. Their engagement is particularly valuable since they have privileged access to the local communities. They were also already trained on HIV/AIDS or issues of general health and know

who to turn to for additional information. The women work in pairs, reaching out to different villages and settlements twice a week. An initial outreach at a specific location is repeated, focusing on the same topic or addressing a new issue, depending on the needs. This approach has proven extremely efficient in addressing basic hygiene and health-related misconceptions persistent among the locals or in fighting HIV/AIDS and the related stigma. People are more ready to listen and trust the members of their own community, even more so when talking about personal matters such as health or sexuality. Even though the primary aim of such community outreach is curtailing the spread HIV/AIDS, such activities provide basic information on hygiene and nutrition, diseases such as diarrhea and pneumonia, and issues such as home delivery, referrals, antenatal and child care. Community members are encouraged to visit health facilities sooner rather than later, although financial considerations remain an important deterrent to seeking medical assistance. It often happens that locals do not go to the clinic for fear that they will need to pay for treatment, even if it is provided free, as in the case of HIV/AIDS antiretroviral or tuberculosis treatment. Frequent access to all communities, particularly the remote ones,

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Actively Engaging Most-at-Risk Populations in Response to HIV/AIDS
LEFT Fabulous, a group of young women and girls that provide awareness outreach, talking to villagers in Lokichoggio.

remains a challenge. Fabulous, as one group of young women from Lokichoggio have named themselves, are few in number and have privileged access to some villages and parts of Lokichoggio only, a common situation with similar outreach groups in other towns and villages. They emphasize that outreaches must occur on a more regular basis that in order for behavioral patterns and habits to change. This will require additional recruitment and training, but also a change in locals’ perception of their work, which is often stigmatized or misperceived because of the topic it addresses.

FACT BOX: GIRLS AND WOMEN AT RISK
Although HIV spares no one, the likelihood of contracting the virus is higher for some groups, particularly women. In sub-Saharan Africa, this stems not only from their greater physiological susceptibility to heterosexual transmission, but also from the severe social, legal and economic disadvantages they confront. The risk of becoming infected is especially disproportionate for girls and young women. In Kenya, young women between the ages of 15 and 19 are three times more likely to be infected with HIV than their male counterparts, while those between 20 and 24 are 5.5 times more likely to be living with HIV than men their age. Furthermore, due to economic hardship and limited livelihood activities, many women are forced to resort to commercial sex work for their own and their families’ survival. This is particularly the case in Turkana, significantly increasing the risks of HIV contraction. In Kenya, the data on modes of transmission suggest that sex workers and their clients account for an estimated 14.1% of incident HIV infections.33
BELOW Concepta, left, and Sura, members of Lodwar women’s target group, share their thoughts about outreach challenges among their peers, especially those practicing commercial sex work.

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Fighting Stigma and Raising Awareness with Help from Turkana’s Radio Waves

Radio is a popular medium in Kenya as demonstrated by the growing number of local-language radio stations.34 These stations play an important role in stimulating public discussion and provide a regular source of information for majority of Kenyans.35 In remote areas such as Turkana, where access to TV, print and internet is, at best, limited, radio is disproportionately important as a source of information. Several pockets still lack radio coverage, as was the case with Kakuma until recently. The IRC adopted radio in Turkana in 2008 as a platform to disseminate awareness of HIV/AIDS, partnering with stations in Lodwar and Lokichoggio soon after they began broadcasting. Radio outreach is based on weekly half-hour to one-hour shows, usually focused on one particular topic. Program hosts, community health workers, HIV/AIDS counselors and IRC program staff disseminate basic information or hold debates, sometimes introducing drama and skits by local groups and, when time permits, taking questions and comments from listeners. The programs are broadcast in Kiswahili and Turkana languages and are promoted at HIV/AIDS-related events, awareness activities and VCT centers. Without exception the response of the listeners has been overwhelmingly positive, demonstrating the demand for program time focusing on health and HIV/AIDS issues. The shows regularly run overtime, indicating a need for more frequent or longer broadcasting. The initial audience response also confirmed that knowledge of HIV/AIDS remains riddled with misconceptions and myths.

RIGHT By 2010, the IRC was airing HIV/AIDS-related programming on four Turkana-based radio stations: Radio Hossana (Lodwar), Biblia Husema (Lokichoggio), Radio Sayare (Lodwar) and Radio Akicha (Lodwar).

LEFT Eddy James Andebe, branch manager and on-air host at Lokichoggio's only radio station, Biblia Husema.

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BELOW An on-air host at Radio Akicha. Listeners desire for information is demonstrated by their frequent call-in questions at the end of the weekly HIV/AIDS program.

RIGHT Eregae, a presenter at Radio Sayare on 93.9 FM. Most of the programming on Sayare FM is prerecorded, although there is always a possibility for listeners to interact and ask questions at the end of the show.

Radio has proved to be one of the most valuable tools for behavioral change communication, reaching both literate and illiterate audiences, villages and remote areas. Broadcasting on four local radio stations, the IRC has, up to mid-2010, reached approximately 35% of potential listeners in Turkana and provided 17 hours of HIV/AIDS-related airtime per month. The IRC is the first NGO in the region to use mass media for HIV/AIDS awareness campaigns.

LEFT The IRC radio awareness outreach debuted in 2008 on Radio Hossana when it became evident that there is a vacuum in publicly available channels for communicating the message about HIV/AIDS and health in general. After launching the program, the IRC and Radio Hossana collaborated on alternative methods of HIV/AIDS awareness activities, including concerts for youth and mobile outreaches.

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PREVENTION WITH POSITIVES
Raising Awareness Through Empowered HIV-affected Community Advocates
Prevention with Positives (PwP) is an innovative way of spreading awareness of HIV/AIDS in the community and is based on the active involvement, reintegration and empowerment of those affected by the disease. People living with HIV/AIDS can and should play a significant role in the design and implementation of HIV/AIDS prevention and care programs. Because of their personal experience, they are unique advocates for reducing stigma associated with HIV/AIDS, promoting accurate self-risk perception and correct and consistent condom use. The first and crucial step of the approach is the engagement of HIV/AIDS-affected individuals. IRC does this through psychosocial support groups at its comprehensive care centers in the region, which provide support and counseling for individuals recently tested positive. Group facilitators help identify individuals who are recruited for prevention activities. They undergo a two-day training workshop on behavioral change communication focused on HIV/AIDS issues, positive living, disclosure of HIV/ AIDS status, opportunistic infections, stigma and discrimination and presentation skills.

MEET AN ADVOCATE: JOSEPH EPETET
Joseph is HIV-positive and has been a PwP advocate for six months, helping to spread information about HIV/AIDS in local communities. He comes from a village near Lokichoggio that was hard hit by AIDS— many people were sick or dying, including his wife and four children. When he finally sought medical assistance, he was extremely weak, weighing only 30 kilos (66 pounds), but his health has gradually improved since he began antiretroviral therapy. He is proud to say that he currently weighs 60 kilos (132 pounds). As part of IRC assistance to those testing positive, Joseph became involved in the activities of the psychosocial support group and was recruited to assist with HIV/AIDS outreach. He is now extremely happy and proud of his work, although he admits that the challenges are numerous. People are deterred from visiting medical facilities because they simply can’t afford to reach them or because they fear they will be charged for services provided. When it comes to HIV/AIDS, many are afraid to get tested, because they fear the results or because they are afraid that this information could be leaked to the community. “The attitude of the community towards me and my colleagues is sometimes still negative and based on a misunderstanding of HIV/ AIDS,” he says. “Women come and get tested with their kids, but many positives [persons living with HIV], especially men, don’t.” He revealed that it is often very hard to make people understand that life as an HIV-positive person is possible, but that it requires a healthy lifestyle, responsible behavior and strict, life-long antiretroviral therapy. Much of his work is therefore about identifying and counseling those who have disappeared or defaulted from their ARV therapy.

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MEET AN ADVOCATE: JOSEPH EMEJEN
Joseph is an HIV/AIDS and ex-tuberculosis patient who was not aware of the seriousness of his health problems for a long time. At the time he was admitted to the hospital, he could not even walk. After testing HIV-positive, he had a hard time accepting his status, his response complicated by the fact that he tested positive for tuberculosis as well. His family members and friends abandoned him and, although his health gradually improved, he stayed at home believing his life was over. After joining IRC-sponsored psychosocial support groups, Joseph experienced a change of attitude. “It was an eye-opener”, he says, “encouraging me to contribute to the benefit of my community with my own experience, to assist people who need help the same way I did and to spread the message about HIV/AIDS.” When approaching people in community outreaches, Joseph says that one needs to be informal, relaxed and willing to listen. People have many questions and some still challenge him when he speaks of HIV/AIDS, condoms or living with HIV. “Stigma in the communities is still very high, people are uncomfortable talking about those things or even say that HIV is not their problem—they ask why I didn’t rather bring some food.” He tends to begin his talk addressing issues of general hygiene, such as washing hands and cleaning nails, avoidance of sharing sharp objects and the importance of visiting hospitals when necessary. Joseph reiterates that the biggest hurdle he faces during his outreaches is persuading people to seek help. “People don’t do that either because they are afraid the information of their illness will leak or because they don’t have the money. If they are HIV-positive, facing reality is another big problem.” People are usually surprised when he shares that he is HIV-positive, but this is the best way to show that life can go on if one lives healthily and adheres to ARV therapy.

Once trained, PwP advocates are a powerful voice in HIV/AIDS prevention activities. They are a real-time example, confirming that HIV/AIDS can affect anyone, brothers, sisters and neighbor, with names and faces. PwP advocates relate their problems but also share positive aspects of their stories— how they continue with normal life, contributing to community health and fighting stigma and. PWP advocates reach out in many ways. They help spread HIV/ AIDS awareness and encourage testing at local events such as barazas, or public meetings organized by community chiefs, and in schools and at football matches and other public events. They conduct individual outreaches, targeting their own communities and speaking to men and women of all ages to promote behaviors that prevent new infections. They also play an integral role in the clinical dimension of the HIV/ AIDS program in Turkana by providing initial counsel to clients who have just tested positive at VCT clinics. It is extremely important to provide psychological support and counseling for HIVaffected clients as early as possible. PwP advocates assist them to overcome the initial shock and accept their HIV-positive status;

FACT BOX: HIV/AIDS STIGMA IN KENYA
HIV/AIDS-related stigma remains a problem in Kenya. Many Kenyans see HIV as a punishment for immoral behavior, which tends to encourage stigma against people infected with the virus. The 2010 study “Extent and Impact of Stigma and Discrimination on Women and Children Infected and Affected by HIV and AIDS,” conducted by ActionAid International and Women Fighting AIDS in Kenya, found that 74% of respondents in 430 households in three districts in western Kenya felt people with HIV deserved their positive status as a punishment for morally unacceptable conduct, while 70% believed people with HIV were promiscuous.36 The 2007 study in northern Kenya confirmed that stigma toward people living with HIV is prevalent in the region. There was widespread belief that HIV is a “foreign disease” affecting urban populations only, and few people knew the basics about the disease. People living with HIV were discriminated against and excluded from community support systems crucial for their survival, especially during periods of drought. They feared disclosing their status as this would lead to loss of social capital.

IRC KENYA / LIVING ON! / BEST PRACTICE they share their experiences, explain the availability of antiretroviral therapies, advise on prevention of further infections and the importance of a healthy life. IRC started the PwP program in 2010 and has so far engaged and trained 19 advocates who have reached out to approximately 5,800 individuals in Turkana project sites. Each advocate takes part in approximately eight outreaches per month and is on duty in the local comprehensive care center to provide post-test support. Although they occasionally encounter obstacles during their outreaches, mainly driven by the persistent social stigma linked to HIV/AIDS, their own empowerment has proven priceless. IRC aims to train more PwP advocates, providing each of its clinical project sites with their permanent presence and their integration in all HIV/AIDS outreach and mobilization activities.

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MEET THE ADVOCATES: JANE EKALE AND SIMON LOKOLONYOI
Simon and Jane are HIV-positive PwP advocates from Kalokol. They say that there is always more work than time, but they enjoy what they do and take pride in their efforts. Their work can be hard, and they had to get used to answering many questions, especially after revealing their positive status. People often do not believe them and their story of living positive, forcing them to show their ARV medication or their training certificates. Still, they emphasize that it is important “to build trust even before you start talking about unconventional topics like HIV/AIDS, or health in general.” The hardest thing to explain about HIV/AIDS treatment and positive living, according to Simon and Kane, is the individual’s lifelong fight against the disease and the necessity to embrace a healthy lifestyle. Much of their time is delegated to finding those who stopped their ARV treatment and HIV-positive, they say. But it is also important to talk about altering lifestyles regardless of one’s status. This includes practicing safe sex and general hygiene, and seeking medical assistance when needed.

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JAMII INAFAA! FAMILIES MATTER!

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Those Who Learn, Teach: Using and Strengthening the Home Link

Families Matter! interventions aim to encourage effective communication on topics such as sexual risk reduction by providing guidance to caregivers on the importance of talking with children and young adolescents (9 to 12 years old) about sexuality, as well as how best to approach such sensitive subjects. The Families Matter! approach is an evidence-based intervention that draws upon the Parents Matter! program devised by the U.S. Centers for Disease Control and Prevention. Families Matter! directly responds to gaps identified by the IRC during earlier stages of the HIV/AIDS program in Turkana, particularly addressing concerns that caretakers were left out when conducting sexuality and sexual risk reduction education. The approach was adjusted to provide support to parents and other primary caregivers so that they could convey their values and expectations about sexual behavior to their children and dependants. Additionally, they were given basic training on crucial messages related to HIV, STIs and pregnancy prevention. The intervention now empowers parents in their role as responsible and knowledgeable caregivers and raises their own awareness of HIV/ AIDS.

TESTIMONY OF AN ELDERLY MALE GRADUATE OF FAMILIES MATTER! “According to the Turkana tradition, these things are not discussed openly. Children usually get embarrassed and surprised when their parents try to talk to them about sexuality or diseases like HIV. Initially, I wasn’t open; I was not able to speak to my children about these things. Since I’ve started coming here, I’m able to talk to them.”

BELOW “You are the best teacher for your child!”, Families Matter program slogan.

LEFT Cover of the instruction manual for participants of the Families Matter! program. In the background, a program graduate is reviewing lessons learned during the five-week training course.

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IRC’s target outreach for Families Matter! is 25% of families with children between 9 and 12 in all IRC Turkana sites. To date, the IRC has trained 39 facilitators who take groups of parents and/or guardians, called “waves,” through five weekly sessions on sexual topics and sexual risk reduction. Participants graduate after the completion of their “wave,” and further participants and groups are recruited for new sessions. Fifteen waves have been completed by mid-2010, reaching roughly 517 parents and 813 adolescents. The next challenge will be expanding the program to other locations in the region and planning follow-up sessions with the waves of graduates.

TOP LEFT A program graduate in Lodwar is congratulated by an IRC staff member.

TOP RIGHT Program participant in Kalokol reviews the lesson with his class.

RIGHT Families Matter! helps parents and guardians talk with children about sensitive issues, including sexuality, which are not commonly discussed openly in traditional Turkana household.

ABOVE The Families Matter! program occasionally reaches out directly to children, as in a 2010 Kalokol “wave”. Here, young graduates who participated in the training course with their parents proudly pose at the graduation ceremony.

LEFT 2010 graduate waves from Lodwar (above) and Kalokol (below).

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HIV/AIDS DATA MANAGEMENT
Providing Reliable and Accurate Data on HIV/AIDS Care and Treatment

Vast and remote regions like Turkana, especially when inhabited by pastoralists, are particularly difficult to survey for accurate and reliable HIV/AIDS-related data. Apart from understanding regional prevalence rates and patterns, researchers must cope with particular date-management challenge of the ARV therapies (ART) themselves.. Individuals often begin a therapy only to default because after finding it difficult to access to healthcare facilities and services, or because they lacked knowledge or understanding about medication intake. These problems only compound the task of collecting and maintaining accurate information and data to monitor and run HIV/ AIDS response programs. Based on a recommendation from the Kenyan National AIDS/STD Control Program (NASCOP), the IRC has been systematically collecting accurate data in Turkana to assure quality of care, to monitoring patients undertaking ARV therapies and to provide reliable HIV/AIDS-related data for the region. Every patient has a personal file, a compilation of reports and information, which also allows for a conduct of cohort analysis if required. Every effort is made to assure strict confidentiality.

Possessing an accurate and reliable HIV/AIDS data system, available at all program sites, is particularly valuable when monitoring and tracking patients’ movements in the region, a common phenomenon in the Turkana region where nomadic lifestyles are common. Accurate information also allows for easier tracing of ARV defaulters. On the other hand, the need remains for trained data management staff to oversee data reconstruction, particularly reconstruction involving multiple databases. In order to be able to extract useful information for programming response, data must be collected systematically over long periods across the entire region, a task that requires consistent staffing, methodology and funding.

GO TO PAGE 25 FOR ARV STATISTICS

RIGHT Shadrack, a data clerk at the IRC-supported VCT center at Kakuma Mission Hospital, manages data at the VCT center and also participates at mobile VCT locations and villages around Kakuma like Uropui, Letea, Kalobeyei, and Lokorei.

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COUNSELING AND TESTING FOR EVERYONE!
Knowing an individual’s status is the foundation and starting point for any HIV/AIDS treatment or awareness activity. A successful HIV/AIDS program must allow community members to access testing and counseling instantly and affordably. The IRC is directly implementing or supporting several types of counseling and testing geared to the location and needs of the environment. Most testing in Turkana is conducted on a voluntary basis in mobile or static VCTs, encouraged by various outreach activities. Additionally, IRC conducts provider-initiated testing and counseling as well as diagnostic counseling and testing (DCT) through its and partners’ medical facilities. Because most of Turkana’s population resides outside of urban centers or in remote areas, a proactive approach in providing counseling and testing services through mobile CT-units is important. Mobile counseling and testing accounts for the majority of tested individuals in the region and is often supported by awareness outreach activities to attract and persuade individuals to get tested. From 2005 to 2010, the IRC organized or supported more than 1,800 mobile testing outreaches, which currently run at an average frequency of 60 per month. Although access to VCT services is assured for more than half of the population of Turkana, access for all of these services in remote rural areas remains challenging due to lack of roads, vehicles, personnel and financial resources.

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Providing a Comprehensive Package of Counseling, Testing and Integrated Outreach Services
RIGHT Local Turkana men approach IRC’s mobile VCT site in Lodwar to inquire about counseling and testing.

LEFT A Sudanese refugee attending a voluntary counseling and testing session held as a side event of an awareness outreach in Kakuma Refugee Camp.

ABOVE Mobile VCT site in Naqualele village near Lodwar.

RIGHT Mobile VCT site in Nabute village near Lodwar.

LEFT OPPOSITE PAGE IRC-supported static VCT center at Kakuma Mission Hospital. All HIV/AIDS-related services in Turkana are available free of charge.

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PMTCT, EARLY CHILD DIAGNOSIS AND HOSPITAL DELIVERIES
The chances of an HIV-positive pregnant mother transmitting the virus to her baby is as high as 30%, but can be significantly reduced with prevention of mother-to-child transmission (PMTCT) interventions. Mother-to-child transmissions account for most infections of children under the age of 15, 90% of which occurred in Africa in 2008.37 Following national and international guidelines, the IRC has been offering a comprehensive approach to PMTCT at all of its programs sites in Turkana. The approach includes prevention of HIV infection, family planning to prevent unplanned pregnancies, antiretroviral therapies, prophylaxis treatment, antenatal care, safe delivery, feeding options, and follow-up with mothers and babies who are tested for HIV six weeks after delivery. One of the biggest challenges of preventing mother-to-child transmission is identifying HIV-positive pregnant women. The IRC targets women of childbearing age through mass awareness, special target groups and maternal child health (MCH) clinics with reproductive health messages. The involvement of female community health workers is crucial in this process, as are women participating in the Prevention with Positives (PwP) program. Once identified, HIV-positive women are encouraged to join

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Fighting HV/AIDS from the Outset
LEFT A Somali Bantu refugee and future mother at Kakuma Refugee Camp, Clinic 5, taking part in the VCT session as part of the antenatal care program.

support groups for persons living with HIV/AIDS. Community health workers at maternal and child health clinics conduct special counseling sessions for them, discussing topics like HIV/ AIDS stigma, positive living or HIV treatment. These sessions are of crucial importance, giving hope to HIV-positive women and providing them with essential information on preventing virus transmission. Kenyan national PMTCT guidelines recommend formula feed for mothers who cannot exclusively breastfeed and who meet the AFASS criteria, recommending that the replacement feeding should not be used unless it is acceptable, feasible, affordable, sustainable and safe (AFASS). The substitute milk, expensive and often unavailable, is not provided free of charge.

RIGHT Aisha, a Somali Bantu HIV-positive refugee mother, takes part in the IRC-run prevention of mother-to-child transmission (PMTCT) program in Kakuma Refugee Camp. Her greatest concern is preventing the transmission of HIV to her newborn son, Muhina.

LEFT Young mothers from local communities in front of the IRC-sponsored Comprehensive Care Clinic at the Lokichoggio AIC Health Center. Such clinics help to identify women who are in need of PMTCT intervention.

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LEFT Young or future mothers in front of the VCT center at Lodwar District Hospital. One of the biggest challenges with PMTCT is to identify HIV-positive women who require intervention.

HOSPITAL DELIVERIES
Delivery presents a particularly risky event during which an HIV-positive mother is more likely to transmit HIV to her newborn. Providing professional pre-, intra- and post-delivery care to HIV-infected women is an effective way of minimizing the risks of such transmission, a goal easier achieved if delivery is performed in a medical facility in the presence of medical staff. This is particularly challenging in Turkana where, due to the remoteness of the area, lack of medical facilities and cultural habits, the rate of hospital deliveries is below 8%. In order to reduce maternal mortality rates, and scale up safe deliveries supervised by professional staff as a PMTCT intervention, the IRC has been actively advocating for hospital deliveries among pregnant women in Turkana, particularly those future mothers that will require a PMTCT intervention. Advocacy led to a significant increase in hospital deliveries at IRC-supported sites between July 2009 and June 2010 among PMTCT mothers. Half of them now give birth in clinical settings, compared to extremely low hospital delivery rates among the general population in Turkana.

Acknowledging that an average Turkana woman would not be able to afford substitute milk, the IRC provides formula milk free to women who pass the AFASS criteria. IRC-supported community health workers also try to ensure that HIV-positive pregnant women and mothers complete prophylaxis, deliver in health facilities and have their babies tested at six weeks. Many challenges are associated with successful prevention of mother-to-child transmission interventions. It is particularly hard to identify and retain women who need PMTCT services due to the distance of health facilities from their homes and low involvement and support of their partners. To bridge these gaps, the IRC is focusing on integrated outreach services supported by targeted and mass awareness campaigns.

LEFT Mohamed, a Somali refugee recruited to help conduct IRC/UNHCR’s behavioral surveillance survey in Kakuma Refugee Camp, interviews a young Somali refugee mother. Such surveys not only provide IRC with data to asses the situation on the ground, but also serve as one of the tools to identify young women who might be in need of PMTCT interventions.

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LESSONS LEARNED

THE IRREPLACEABLE POWER OF PARTNERSHIP
Working together with partners, a cornerstone of the IRC’s approach in the region, has proved instrumental for the achievements and implementation of the IRC’s HIV/AIDS program. Based on experience, this strategy has been most effective in building local capacity and achieving a sustainable regional HIV/AIDS response. When targeting local communities, the IRC partners with local faith-based organizations—the major providers of healthcare services in the region as well as with local nongovernmental organizations and community-based initiatives. Offering support in human resources has proved to be valuable and effective, as well as assistance with equipment and medical supplies, and management and technical expertise. In Kakuma Refugee Camp, the IRC finds strong partners in local and international governmental and nongovernmental organizations such as UNHCR, IOM, World Food Programme (WFP), National Council of Churches of Kenya (NCCK), Lutheran World Federation (LDW), Jesuit Refugee Service (JRS) and FilmAid.

AFRICA INLAND CHURCH’s health facilities were started by missionaries in the 1970s and handed over to the local community in the early 1990s. Government support has been extremely scarce or nonexistent, with the maintenance and provision of services almost exclusively funded by user contributions (in a region with high unemployment rate and extremely low incomes) until the CDC’s and IRC’s involvement in 2005. AIC Lokichoggio Health Center serves mainly local urban and transit populations but also encompasses communities from neighboring Southern Sudan. At the height of Operation Lifeline Sudan, which conducted major operations from Lokichoggio, the IRC partnered with AIC to offer a comprehensive HIV prevention and support package to the then high number of aid workers in Lokichoggio. Achievements included the first stand-alone VCT center in Lokichoggio, HIV treatment services at the health center and strengthened mobile outreach services for the pastoral community. Samuel Ikeny, the program administrator, and Bethwel Lochor, AIC’s rural health area supervisor, mentioned many challenges, including insecurity, inaccessibility, high staff turnover and frequent lack of basic supplies, but they also praised the IRC for its support with “staffing, expertise and with general local health system strengthening.”

AIC Kalokol Health Center is the sole static health post in the Kalokol Division on the eastern shores of Lake Turkana. Prior to 2006, IRC HIV/AIDS intervention activities did not exist in the Kalokol area, hard hit by tuberculosis. Samuel Losuru, the center’s administrator, says that challenges are numerous but that partnership with the IRC has been “exceptional and critical for delivering a comprehensive HIV/AIDS treatment package, as well as vital for providing other health services in the area.”

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IRC KENYA / LIVING ON! / LESSONS LEARNED LODWAR DISTRICT HOSPITAL (LDH), a government facility with a large clientele and outreach, is the main referral hospital of Turkana. The IRC partnered with LDH in 2007 to strengthen its systems capacity and improve the general clinical care for HIV/AIDS. This is an important part of an initiative to assist the Government of Kenya in response to HIV/AIDS, a crucial determinant of a successful response.

Gilchrist Lokoel, district medial officer of health, notes that Turkana is, slowly but steadily, catching up with the rest of Kenya in response to HIV/AIDS. The role of the IRC has been vital: “The IRC does not seek to establish parallel structures on the ground but builds on what is already existing or being implemented.”

THE CATHOLIC DIOCESE OF LODWAR (DOL) provides an extensive range of primary healthcare services and is supported by the IRC to increase HIV/AIDS outreach, particularly in rural areas. DOL is working through the Kakuma Mission Hospital (KMH), the main referral center for northern Turkana, including patients from the IRC-run Kakuma Refugee Camp Hospital. At the Kakuma Mission Hospital, the IRC assists with equipment, financial support, expertise and staffing. Through this partnership, which started in 2006, the IRC has supported an average of 17 employees every year. Sister Elizabeth Mwaniki, KMH administrator, mentions countless problems: cost-sharing, staff retention, high electricity costs and cuts, irregular supplies, lack of transport, floods of referrals and ineffective follow-up with patients. “Without the IRC support,” she says, “the hospital could not offer HIV/AIDS or other services at current levels!”

In reaching out to youth, DOL is supporting youth facilities such as the Bishop Mahon Youth Centre, in Lodwar where the St. Augustine Youth Friendly Services VCT station is located. This strategy has proven successful as many youth gather there in their free time.

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LESSONS LEARNED

NEED FOR ALTERNATIVE WAYS TO UNDERSTAND THE CONTEXT, REACH OUT TO THE POPULATION AND DELIVER THE HIV/AIDS MESSAGE
HIV/AIDS is a social problem with region-specific permutations. Turkana is no exception. It is a vast and heterogeneous region with many remote areas, high illiteracy rates and various cultural practices that influence modes of HIV/AIDS transmission, treatment and perception. The IRC has been gradually shifting from prevention intervention towards a comprehensive prevention, care and support program, increasingly relying on evidence-based prevention strategies and “out of the box” thinking. HIV/AIDS messages and response need to be locally tailored, relevant and acceptable to the community. Future programs should consider filling gaps through community support initiatives like care for orphans and vulnerable children (OVCs) and linkages to income-generating activities.

ABOVE Talking about HIV/AIDS and STIs during an awareness outreach in Kalokol. RIGHT IRC staff member talking about HIV prevention during life skills training for teachers in Lokichoggio. BELOW Primary school teachers attending life skills training in Lokichoggio. The IRC sponsors such trainings and provides instructors who conduct modules on HIV/AIDS awareness, prevention and treatment.

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LESSONS LEARNED

THE BENEFITS OF LINKING AND MAINSTREAMING HIV/AIDS THROUGH OTHER PROGRAMS
The IRC’s HIV/AIDS program in Turkana has made tremendous efforts to ensure and increase access to HIV/AIDS prevention, care and treatment services in the region. However, the region remains heavily afflicted by factors that demand other emergency interventions, particularly in healthcare and nutrition, and is often affected by cattle rustling and other incursions from neighboring communities. The achievements and success realized in one area can easily be eroded by complex emergencies. The implementation of the HIV/AIDS program in Turkana has shown that due to other pressing needs the importance of HIV/AIDS-related problems is too often scaled back by the local population. An integrated and holistic approach to healthcare programming is needed in areas like Turkana. Such an approach includes the integration of health systems and primary health, nutrition, HIV/AIDS and community health interventions, as well as water, sanitation and livelihood programs. The IRC has recognized the benefits of this approach compared to other competing health and social issues in Turkana and emphasizes specific interventions to mainstream health systems in order to increase access. The IRC also improved health outcomes by working in collaboration with the community using a mix of health promotion interventions. This not only leads to better long-term impact and results on the ground, but also provides for more cost-effective spending of donor funds.

LESSONS LEARNED

STRONGER GOVERNMENT PUSH ON THE HIV/AIDS FRONT
Fighting HIV/AIDS in Turkana will remain a challenge until a comprehensive Turkana-specific approach can be devised to reach out to both urban and rural regions. As much as community actors and nongovernmental organizations can assist in this outreach, it will be sustain only with strong, tailored regional interventions, and with the involvement of local authorities and coordinated leadership at all levels. An integral part of such a push by authorities will require more local capacity building. A concrete recent and immediate step toward improved local capacity was the revamping of the national HIV/AIDS training guidelines and curriculum, taking into better consideration the specific needs, background and potential of trained staff.

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ABOVE Young Turkana girl gets her tuberculosis medication at the AIC Health Center in Lokichoggio.

LESSONS LEARNED

INSEPARABLE THREATS: HIV AND TB
Tuberculosis remains a public health and social issue with a significantly negative impact in Turkana. Due to the intrinsic connection between TB and HIV/AIDS, the gains being realized in the fight against HIV/AIDS could be eroded or slowed if there is no commensurate investment in TB prevention and control. As much as the IRC has supported the Ministry of Public Health and Sanitation on TB/HIV collaborative activities, a great deal remains to be done.

RIGHT Tuberculosis ward at the IRC-run Kakuma Refugee Camp Hospital.

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LESSONS LEARNED

MORE STRUCTURAL INVESTEMENT IN TURKANA
Turkana is a region with vast cultural and economic potential, the realization of which depends on sufficient resources and investment, proper leadership, and local involvement in and ownership of development initiatives. Decades of sub-optimal regional development combined with a challenging environment will require a strong push and momentum for Turkana to catch up with the rest of Kenya in obtaining sufficient transport, health, education system and communications infrastructure. Focusing on specific improvements will accelerate the general development of the region. In remote underdeveloped areas like Turkana, the fight against HIV/AIDS should be treated as a health problem in an emergency, and not as an emergency of its own.

RIGHT Entry into Lodwar from Kitale. Turkana roads are few and ill-maintained.

OPPOSITE PAGE IRC medical supplies delivered to Turkana through Lokichoggio airport .

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ENDNOTES
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 UNAIDS. 2009 AIDS Epidemic Update. Geneva: UNAIDS, 2009; at 7. Ibid, 21. Ibid. Ibid, 29. NACC. United Nations General Assembly Special Session on HIV and AIDS, Kenya Country Report. Nairobi: NACC, 2010. KNBS. Kenya Demographic and Health Survey 2008-09. Nairobi: KNBS/NACC/NASCOP/MOPHS, 2010; at 210. 2003 Kenya Demographic Health Survey estimated prevalence rate among adults (15-49) at 6.7%. CBS. Kenya Demographic and Health Survey 2003. Nairobi: CBS/MOH/KMRI/NCPD/ORC/CDC, 2004. NASCOP. KAIS/Kenya AIDS Indicator Survey 2007. Nairobi: NASCOP/KMRI/NACC/KNBS/CDC/USAID/UNAIDS/, 2009. UNAIDS. 2009 AIDS Epidemic Update. Geneva: UNAIDS, 2009; at 29. KNBS. Kenya Demographic and Health Survey 2008-09. Nairobi: KNBS/NACC/NASCOP/MOPHS, 2010; at 215. UNAIDS. 2009 AIDS Epidemic Update. Geneva: UNAIDS, 2009; at 22. Ibid, 31. KAIS 2007 shows similar trends. Gelmon et al. Kenya: HIV Prevention Response and Modes of Transmission Analysis. Nairobi: 2009, NACC. KNBS. Kenya Demographic and Health Survey 2007. Nairobi: KNBS; at 216-7. NASCOP. KAIS/Kenya AIDS Indicator Survey 2007. Nairobi: NASCOP/KMRI/NACC/KNBS/CDC/USAID/UNAIDS/, 2009. Nyanza province has an overall prevalence of 14%, double the level of the next highest provinces—Nairobi and Western, at 7% each. All other provinces have levels between 3% and 5%, except North Eastern province where the prevalence is about 1%. KNBS. Kenya Demographic and Health Survey 2007. Nairobi: KNBS; at 217. Practical Action. Breaking the Siege - Mainstreaming HIV/AIDS in Peace Building. Practical Action PEACE Bulletin, December 2003, http://www.itdg.org. MOH/NASCOP. KAPB Survey, Central Division – Turkana. Nairobi: NASCOP, 2003. NASCOP/NACC. National HIV Prevalence Report June 2007. NASCOP/NACC, 2007. MPHS/MMS. 2009 Health report, Turkana Central and Loima Districts. MPHS/MMS, 2009; at 6. NASCOP/NACC. National HIV Prevalence Report June 2007. NASCOP/NACC, 2007. Owiti, J.A. Tuberculosis and HIV/AIDS are Like Co-Wives: The Conception of HIV/AIDS and Tuberculosis Among Urban Turkana population at Lodwar Township, Kenya. International Conference on AIDS, July 7-12 2002, abstract no. WePeD6409. McCabe, J.T. Encyclopedia of World Cultures. 1996. GOK. Turkana District Development Plan 2002-2008. Nairobi: GOK, 2002. Kenya National Bureau of Statistics website—http://www.knbs.or.ke. According to the 1999 Kenya national census 50.2% females and 49.8% males, respectively. Ibid. OCHA. Kenya Humanitarian Update, Vol. 61, 23 June-21 July 2010. Von Grebmer et al. 2009 Global Hunger Index. Bonn/Washington: WHH/IFPRI/ConcernWorldwide, 2009. IASC. Kenya Drought Alert, July 2009; and Malnutrition Crisis in Northwest, IRIN, July 16 2009, at http://www.irinnews.org/Report.apsx?ReportId=83003. Ibid. Kenya Interim Independent Election Commission, Regional Voter Registration Statistics As At Close Of Registration, 2010, at http://www.iiec.or.ke/sites/default/files/statistics-1_0.pdf . McCabe, J.T. Encyclopedia of World Cultures. 1996. UNAIDS. 2009 AIDS Epidemic Update. Geneva: UNIADS, 2009; at 22. Freedom House. Freedom of the Press 2009: Kenya. New York: Freedom House, 2009; also at http://www.freedomhouse.org/template.cfm?page=251&year=2009 Hannah Bowen. Information at the Grassroots: Analyzing the Media Use and Communication Habits of Kenyans to Support Effective Development. InterMedia/Africa Research, 2010. PlusNews. Kenya: HIV Carries Moral Stigma, at http://www.plusnews.org/Report.aspx?ReportId=89316. Okal, J. and Bergmann, T. HIV in Emergencies Case study: Northern Kenya. London: ODI, 2007; at 4-7. UNAIDS. 2009 AIDS Epidemic Update. Geneva: UNAIDS, 2009.

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ACRONYMS AND ABREVIATIONS
AFASS AIC AIDS ANC ART ARV BCC BPRM CBS CCC CDC CPT CHW CT DASCO DCT DFID DOL EID FMP HBC HCW HIS HIV HTC IOM Acceptable, feasible, affordable, sustainable and safe breastfeeding. Africa Inland Church Acquired Immune Deficiency Syndrome Antenatal Care Antiretroviral Therapy Antiretroviral Drug Behavior Change Communication U.S. Bureau of Population, Refugees, and Migration Central Bureau of Statistics Comprehensive Care Clinic Centers for Disease Control and Prevention Cotrimoxazole Prophylaxis Therapy Community Health Worker Counseling and Testing District AIDS and Sexually Transmitted Infections Coordinator Diagnostic Counseling and Testing UK Department Development for International PEPFAR PITC PMTCT PWHA PwP RIJ STI SV TB UNHCR UNICEF USAID VCT WFP WHO JRS KMH KMRI KNBS KRC LDH LWF MOH MOPHS NACC NASCOP NCCK NCPD Jesuit Refugee Service Kakuma Mission Hospital Kenya Medical Research Institute Kenya National Bureau of Statistics Kakuma Refugee Camp Lodwar District Hospital Lutheran World Federation Ministry of Health of Kenya Ministry of Public Health and Sanitation National AIDS Control Council National AIDS and STI Control Program National Council of Churches of Kenya National Council Development of Population and

President’s Emergency Plan for AIDS Relief Provider Initiated Testing and Counseling Prevention of Mother-to-Child Transmission People with HIV/AIDS Prevention with Positives Refugees International Japan Sexually Transmitted Infection Stichting Vluchteling Tuberculosis U.N. High Commissioner for Refugees U.N. Children's Fund U.S. Agency for International Development Voluntary HIV Counseling and Testing World Food Programme World Health Organization

Catholic Diocese of Lodwar Early Infant Diagnosis of HIV Families Matter Program Home-Based Care Health Care Workers Health Information Systems Human Immunodeficiency Virus HIV Testing and Counseling International Organization for Migration

ABOUT IRC
The International Rescue Committee (IRC) responds to the world’s worst crises and helps people to survive and rebuild their lives. Founded in 1933 at the request of Albert Einstein, we offer lifesaving care and life-changing assistance to refugees forced to flee from war or disaster. At work today in over 40 countries and 22 US cities, the IRC restores safety, dignity and hope to millions who are uprooted and struggling to endure. The IRC leads the way from harm to home.

IRC KENYA Strategic Objectives 2010-2015

Urban Programming: To foster a stable environment for vulnerable urban populations (poor and refugees) by boosting household viability, strengthening the voice of the urban poor and refugees, as well as increasing government accountability. • Governance: To increase IRC’s programmatic impact and sustainability through institutional capacity strengthening, accountable use of resources and greater political and conflict analysis. • Disaster Risk Reduction: To optimize IRC’s impact through targeted programming that minimizes vulnerability and increases capacity to proactively mitigate and reactively address disaster impacts for sustainable development. • Refugees: To maintain IRC’s high quality refugee program and amplify its impact through appropriate research and advocacy to influence global and national refugee policies and practices.

theIRC.org
INTERNATIONAL RESCUE COMMITTEE KENYA P.O. Box 62727-00200 Nairobi, Kenya +254 20 272 0064 ircnbi@kenya.theirc.org INTERNATIONAL RESCUE COMMITTEE 122 East 42nd Street New York, NY 10168-1289, USA PUBLICATION CREDITS
WRITING, EDITING, PHOTOGRAPHY and PRODUCTION DESIGN: Matija Kovac
BACK COVER PHOTO “Moonlight” voluntary counseling testing (VCT) session in Lodwar. and

COMMENTS, CONTRIBUTIONS and REVIEWS: Peter Mutanda, Kizito Mukhwana, Lizzy Masila, Prafulla Mishra, Felister Nekesa, Geoffrey Luttah, Kellie Leeson, Sophia Mwangi, Katherine Sarkis, Gretchen Larsen, Melissa Winkler, Steven Manning, Symon Wambugu, Kenneth Sisimwo, Jemimah Khamadi, Raphael Lokol, Paul Wasike and other IRC staff members COPYEDITING: Rex Roberts MAPPING SUPPORT: UN OCHA Kenya, Information Management Unit LAYOUT and PRINTING: Ecomedia DESIGN based on prototype by Radley Yeldar, London. CONSENT HAS BEEN SOUGHT AND SECURED FROM ALL INDIVIDUALS WHO APPEAR IN THE PHOTOS FEATURED IN THIS PUBLICATION. This publication was made possible by financial support from the U.S. Centers for Disease Control and Prevention.

SEPTEMBER 2010

IRC TURKANA HIV/AIDS PROGRAM
Since 2005, the IRC has assisted the local and refugee populations of Turkana, Kenya, in their response to the HIV/AIDS pandemic by providing basic clinical services, fighting stigma and raising awareness. As of August 2010 we have tested more than 110,000 people, provided access to free antiretroviral therapy to more than 1,500 patients, supported local partners with staff and equipment worth more than $3 million US, conducted more than 200 trainings for local target groups, mobilizers and advocates, supported more than 2,000 awareness outreaches and assisted in building institutional and response capacity through training, financial support and expertise. We are effectively reaching out to more than half of the population of the Turkana region.

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