When Mary tested HIV-positive at the hospital where she had sought care for frequent illnesses during her pregnancy, she was sure there had been a mistake. A second test confirmed the result. "It was difficult to absorb the shock," she said. "I was worried about my baby."

Local health workers could not provide much assistance. They referred the 27-year-old expectant mother to Kenyatta National Hospital in Nairobi, almost 400 kilometers from her home in Kenya's Western Province.

What followed was intensive counseling on positive living with HIV. The information and encouragement she received from counselors at Kenyatta helped Mary accept her HIV status and face the challenges ahead, including the death of her husband a few months later and raising her children alone.

This kind of support will soon be available closer to home at a new HIV voluntary counseling and testing center at St. Mary's Hospital in the Western Province town of Mumias. Family Health International's Implementing AIDS Prevention and Care (IMPACT) program in Kenya is providing technical assistance to establish this center, with funding from the United States Agency for International Development (USAID).

Through the Mumias center and 11 other voluntary HIV counseling and testing centers, FHI/IMPACT will link interventions to reduce the risk of HIV/AIDS among vulnerable populations with community-based care and support for those already infected or affected by the virus. Outreach workers and volunteer peer educators will refer people to the centers and help them change the behaviors that put them at risk of infection. Those who test positive for HIV and their families will be referred to community-based teams of caregivers and other nearby sources of support.

Such linkages are one of the hallmarks of a new generation of programs responding to the challenges of HIV/AIDS prevention and care in areas with high HIV prevalence, according to John McWilliam, the FHI country director in Kenya.

"Many programs are working on prevention in one part of the country and care and support in another part of the country -- hence the target community does not see the connection," McWilliam said. "IMPACT is addressing the needs of the uninfected through prevention and clinical service interventions, the infected through care and palliation, and the affected through psychosocial support interventions in a given target community."

Priority Communities

Almost everyone in Kenya knows about AIDS and how deadly it is. A recent IMPACT study carried out by the Program for Appropriate Technology in Health (PATH), however, found that there is widespread misunderstanding of the relationship between HIV and AIDS. The National AIDS and Sexually Transmitted Disease Control Programme (NASCOP) estimates that 2.2 million Kenyans will be living with HIV by the end of the year 2000 and 3 million, or 15 percent of the total population, will be infected by 2005.

Reversing this trend calls for strategies that incorporate lessons from past interventions and intensify proven approaches. FHI's experience with its USAID-funded AIDS Control and Prevention (AIDSCAP) program in Kenya from 1992 to 1997 showed that targeting groups whose activities and settings expose them to a higher risk of HIV/AIDS can contribute significantly to halting the spread of the epidemic.

FHI and the 22 nongovernmental organizations (NGOs) and other local and international groups that are its partners in IMPACT/Kenya have used such lessons to design a targeted intervention strategy for the program. The design combines intensive prevention and care activities in selected regions with activities at the national level to help create an environment that supports sustained behavior change.

To have the greatest possible impact on HIV with the resources available, the IMPACT design focuses on eleven "priority communities" in three provinces -- Western, Rift Valley and Mombasa -- which were selected based on HIV prevalence, the presence of high-risk situations and settings, and programmatic needs and gaps. The high population densities in the chosen communities further justify the investment.

The largely rural Western Province has a population density six times the national average and high rates of HIV infection among those tested in prevalence studies. In the town of Busia on the Kenya-Uganda border, for example, prevalence among women at antenatal clinics has approached or exceeded 30 percent. Before FHI/IMPACT started activities in this province, the region had few HIV prevention programs.

More than one out of four adults are estimated to be infected with HIV in Nakuru, Kenya's third largest city and capital of Rift Valley Province. Nakuru is surrounded by small towns dominated by agricultural industries, military bases and truck stops, where the practice of high-risk behaviors has fuelled the epidemic.

In the coastal town of Mombasa, a major port, numerous industries and tourism have attracted Kenya's highest immigrant worker population after that of the capital city of Nairobi. Some 2,000 women serve commercial sex clients in Mombasa's port, rail, trucking and tourism businesses, and half of all the sex workers tested in prevalence surveys have tested HIV-positive.

Five priority communities in these three provinces were originally targeted for IMPACT program interventions. Additional funding from the U.S. government's Leadership and Investment in Fighting an Epidemic (LIFE) Initiative enabled IMPACT/Kenya to expand from five to 11 communities. It also gave the program, whose original mandate had primarily been HIV prevention, an opportunity to help people cope with the impact of HIV/AIDS on their families and communities.

Collaboration and Participation

To facilitate collaboration among the IMPACT partners, FHI established field offices in Mombasa and Nakuru. FHI also holds monthly meetings that bring together an "implementation team" of representatives of all the IMPACT partners in each province to review progress, plan future activities, and discuss opportunities and constraints.

These kinds of regular interaction have helped the program achieve a unique degree of collaboration, according to Dr. Elizabeth Ngugi, co-director of the University of Nairobi's Strengthening Sexually Transmitted Disease (STD)/AIDS Control in Kenya Project. Under IMPACT, University of Nairobi staff members help train clinicians at clinics managed by the Family Planning Association of Kenya and collaborate with Artnet Waves Communications on community outreach.

"Each one of the implementing partners is contributing an aspect in the prevention-to-care continuum, and we all feel as members of a family," Dr. Ngugi said.

Community Involvment

In all the priority communities, FHI/IMPACT promotes behavior change and a more supportive social environment for reducing HIV risk. The program also strengthens or helps establish the services necessary to support behavior change, such as accessible, effective diagnosis and treatment of sexually transmitted infections (STIs).

Interpersonal approaches are at the core of IMPACT's intervention strategy. Peer education in the priority communities targets sex workers, men at workplaces, adult women in low-income neighborhoods, and students. Outreach through performances by youth drama groups is primarily aimed at youth, but also speaks to parents and other community members.

"These interventions make it possible to bring HIV and AIDS into daily living room discussions among families in the priority communities," says Peter Mwarogo, field operations manager for FHI/Kenya. "The man gets the same message from his peers at the workplace, so does his wife from neighborhood peer educators, and the children from the school and the youth theater outreaches. Issues brought out through these various sources can trigger discussions at dinner time, thus making HIV/AIDS an everyday agenda in the home."

Peer educators across the priority communities initially receive one week of training, which is updated at regular meetings with IMPACT field coordinators. During the meetings, participants discuss the questions they've received and how to respond to them. They also develop and practice the use of participatory approaches to peer education.

The standard curriculum for peer educators emphasizes interpersonal communication skills and participatory techniques. For example, "picture codes," or illustrations depicting various risk situations, are used to provoke spirited discussion and individual and group reflection. Participatory games capture audiences' attention and make learning fun.

"One does not feel like you are put in a corner to receive education," observed Stephen Mukare, who has participated in peer education sessions at the Kenya Ports Authority. "We contribute as much as we receive the information."

Ask Me

FHI and its partners knew that IMPACT needed an innovative communication strategy to help move Kenyans beyond awareness of HIV/AIDS to action. "It is well known that the usual messages about HIV and AIDS have perhaps outlived their shelf life and lost their edge and power to trigger reflection and behavior change," said C.Y. Gopinath, creative director for PATH/Kenya.

The theme of the IMPACT strategy, executed by PATH and the rest of the partners in all sites, is "question your relations and take charge of your life."

"AIDS is a consequence of fractured relations, just like violence and other social problems," Gopinath explained. "This strategy encourages inquiry into the quality of relationships that dominate within communities -- between husband and wife, young man and woman, CSW [commercial sex worker] and her client, infected and uninfected."

Such inquiry, captured in the Kiswahili slogan "Niulize" ("Ask me"), is intended to create a more positive view of what these relationships could be, and thus lay the foundation for optimism and change. Peer educators and outreach workers provide information in response to questions from community members, and the issues raised become more complex as people's ability to reflect on their own situations deepens.

The concerns and themes that arise within the communities will be amplified to a wider public, mainly through a 30-minute interactive radio show that will be broadcast nationwide. The program will include a soap opera called Pendo's Story, a panel discussion, news, interviews and song.

Reaching Youth

Discussions about sexual relationships and the Kenyan HIV/AIDS epidemic often turn to the relations between girls or young women and older men. "In Kenya, like in many other African countries, older men are targeting younger girls who they believe are 'clean,'" said Theophil Orangi, a teacher and Girl Guide leader. "It is attitudes such as these that have led to an increase in HIV among girls."

Studies in Kenya have identified youth, and particularly girls, to be at high risk of HIV infection. National statistics indicate that the highest HIV prevalence rates are found among women ages 20 to 24 and men ages 30 to 39. Studies from Nyanza Province show that 22 percent of young women in the 15- to 19-year age group are already infected with HIV, compared with just 4 percent of their male counterparts.¹

One IMPACT project uses the national network of the Girl Guides to bring HIV/AIDS prevention education to girls. This peer education initiative, carried out by the Kenya Girl Guides Association with technical assistance from FHI/IMPACT, includes contests and a merit badge that Girl Guides can earn through work and study.

"Our youth usually influence each other to do negative things," said Margaret Ochieng of the Kenya Girl Guides Association in Mumias. "In this case, we are empowering the youth to influence each other in a positive way."

Young people also influence their peers through the popular theater program run by Artnet Waves Communications. Artnet trains members of local youth groups in basic theater production skills, and other IMPACT partners educate them about HIV/AIDS so they can stage short performances with HIV/AIDS messages.

Schools are also part of the effort to reach youth with potentially lifesaving information and support. FHI/IMPACT is working with the Centre for British Teachers (CfBT), which has enlisted teams of parents and teachers from 100 schools in Nakuru to determine how to integrate HIV/AIDS messages into subjects such as home science, music, languages, arts and crafts, and drama.

Empowering Women

In its work with sex workers, FHI/IMPACT has adopted the model developed by the STD Project of the University of Nairobi in Nairobi and Nakuru. By mobilizing sex workers to use condoms, seek prompt treatment for STDs and form support groups through which they were empowered with negotiating skills, the project helped the women take measures to protect themselves from HIV. As a result, the annual incidence of HIV among 4,000 sex workers in the project sites dropped from nearly 50 percent in 1987 to approximately 10 percent in 1997.

The project paid dividends for other community members: a 15 percent decline in the number of pregnant women testing positive for HIV. This result illustrates how interventions targeting groups at high risk -- a common strategy in areas with low HIV prevalence -- can also have a dramatic impact in high-prevalence settings.

"By reducing STD in sex workers, we are reducing STD in men and, by extension, we are reducing STD in the men's spouses," said Dr. Ngugi.

FHI/IMPACT is expanding the work of the STD Project to all of its priority community sites, involving other organizations in the effort, and incorporating more participatory methods. Laura Wangari, a project coordinator attached to the International Centre for Reproductive Health, which is an affiliate of the University of Ghent in Belgium and an IMPACT partner in Mombasa, says the approach is proving effective.

"Many of the women did not believe in condoms and some were initially hostile when approached," she said. "But once the peer educators were trained and starting using condoms, the demand for condoms shot up."

Rose Wambua, a sex worker in Mombasa, appreciates the negotiating skills she has learned and the caring attitudes of program staff. "In a community with a lot of negative attitudes towards female sex workers, the program has made us feel someone values us as human beings and is interested in our health and welfare," she said.

Still, Wambua notes, it takes time and patience to convince men to use condoms. Sometimes solidarity with other women helps. "In some groups, the women have blacklisted clients who still insist on not using condoms," Wangari reported.

Involving Workers and Employers

Members of another important audience -- men -- are reached on the job. In Mombasa, for example, IMPACT supports four large workplace HIV/AIDS projects. As part of one of these projects, 200 peer educators hold weekly meetings and informal talks with their coworkers at the Kenya Ports Authority (KPA), which has about 7,000 mostly male employees.

Qualitative evaluation suggests that such workplace programs are beginning to affect norms of social behavior and that they have stimulated demand for HIV prevention services such as STI treatment and condom social marketing. Most programs, however, have been donor-driven, and only a few businesses are directly funding HIV/AIDS prevention activities.

In Western Province, the Mumias Sugar Company is emerging as a model of what companies can do. During a recent launch of the IMPACT program in Mumias, the company's chief executive officer, Errol Johnstone, announced that the organization would set aside funds for a comprehensive HIV/AIDS program and request technical assistance from FHI.

To encourage other companies to respond as Mumias Sugar Company has, FHI is collaborating with the Regional AIDS Training Network at the University of Nairobi to develop a package of HIV prevention services that employers can purchase. FHI/IMPACT is also working at the national level to heighten management and employee awareness of the need for workplace-based interventions. The aim is to institutionalize sustainable, high-quality workplace HIV/AIDS programs funded primarily by employers.

"We know many companies are trying to find ways to address the problem," said McWilliam. "We'd like to help them find ways to assist their workers in prevention, care and support for HIV and AIDS."

Linking Prevention and Care

Voluntary HIV counseling and testing (VCT) is seen as the linchpin in the prevention-to-care continuum that local organizations and communities are building with the help of FHI/IMPACT. Through a referral network of peer educators, field coordinators, counselors, healthcare staff and community caregivers, HIV VCT services will help link prevention efforts with the newer care and support interventions made possible by the LIFE Initiative.

HIV VCT can be an effective behavior change intervention in its own right, as the findings of a multicenter randomized study conducted in Kenya, Tanzania and Trinidad confirmed.² Mary, the young HIV-positive widow from Western Kenya Province, knows this link between VCT and prevention all too well. An active volunteer in the Society of Women Against AIDS in Kenya (SWAK), one of IMPACT's partners, she has taken her role in HIV prevention very seriously since learning of her status.

"Men sometimes try to seduce me, but I resist their advances," Mary said. "If I was careless, I would have spread the disease to many people."

Mary also knows how important the psychological support she received from Kenyatta Hospital counselors was in giving her the will to survive. She believes that better access to such services is essential for reducing the stigma associated with HIV/AIDS.

"Counseling, especially in rural areas, should be increased," she said. "This will help people come out in the open and speak about AIDS."

Assessments of HIV VCT services in Kenya have shown that few services are available, and most sites offering counseling and testing provide poor service. Confidentiality may not be guaranteed, the quality of counseling is variable, and linkages between HIV VCT and HIV/AIDS care and support services are often non-existent. One study conducted by FHI and the Population Council found only one site in Nairobi offering walk-in counseling and testing services in 1999.³

FHI/IMPACT's vision is to bring quality HIV VCT services to the community. The program is working with a variety of partners to establish voluntary counseling and testing centers in each of the priority communities, usually by adapting and equipping existing health centers to provide such services. Lab technicians are trained in HIV testing and quality assurance, and counselors receive training in pre- and post-test counseling.

LIFE Opportunities

VCT center staff will refer HIV-positive clients to sources of AIDS care, psychological and social support, and diagnosis and treatment of tuberculosis and other opportunistic infections. LIFE Initiative funding will enable FHI/IMPACT to complete the continuum from prevention through care by working with Kenyan health services, NGOs and communities to improve such services.

For example, FHI/IMPACT is collaborating with the public health system to strengthen the capacity of medical facilities to offer diagnosis and treatment of TB, which has reached epidemic proportions in communities with high rates of HIV. Even in countries with successful TB control programs like Kenya's, AIDS-related TB is overwhelming existing resources. As a result of rising HIV infections, Kenya has experienced a 600 percent increase in its TB caseload over the past 11 years.

FHI/IMPACT will also help forge an often-missing link in the continuum of care by preparing a number of health centers to serve as HIV clinical care centers. These centers will offer much-needed medical support to the family members and volunteers who provide home-based care to a growing number of people living with HIV/AIDS.

FHI is working with ICROSS (International Community for Relief of Starvation and Suffering), a local NGO, and Kenya's district AIDS committees to improve home-based care. Collaboration with district AIDS committees enhances sustainability because staff salaries are paid by the Kenyan government.

The district AIDS committees will form home care teams of government health personnel and community volunteers to provide individualized care and support services to HIV/AIDS-affected households. The services offered may include counseling, nutrition, infection prevention and palliative care, depending on the needs identified by families affected by HIV/AIDS through participatory assessments.

Once the ICROSS home care program is underway, a similar participatory process will help mobilize communities to support orphans and other vulnerable children. Peer educators, support group members, home care teams and other community members will be involved in identifying children in need of support and the community resources available to support them.

A Beginning

Before they began implementing IMPACT projects, the partner NGOs mapped out their communities together, highlighting areas where HIV risk behavior was prevalent, as well as existing prevention and care services in their communities. Mapping the communities and dividing them into zones assigned to different field coordinators and peer educators helped the IMPACT partners ensure that their communities were covered and that high-risk areas were adequately targeted by interventions.

"With this intensity, we are covering everyone in each of our priority communities," explained Stella Kilalo, a field coordinator for the Mkomani Clinic Society, an IMPACT partner in Mombasa.

The experience of Mariam Abdalla, a resident of the IMPACT priority site of Kisauni, illustrates how such intensive community-based prevention and care activities can have a pervasive influence. The wife of a driver at Bamburi Portland cement factory, one of the IMPACT workplace sites, Abdalla says these days she discusses AIDS issues with her family and is impressed that her daughter, son and husband are equally well informed. Her neighbor, Rukia Mohamed, has been trained as a community caregiver by another USAID partner, Pathfinder International, and Abdalla has referred people to her.

Of late, Abdalla says, the health workers at the Kisauni clinic are very friendly. Every time she visits the clinic, the providers talk to her about HIV/AIDS and STIs. Abdalla has not yet decided to go for HIV testing but thinks she will as soon as the services are introduced at the Kisauni health center. Only time will tell.

-- George Obanyi and Lee Pyne-Mercier

George Obanyi is a Kenyan freelance journalist. Lee Pyne-Mercier is a program officer in FHI's HIV/AIDS Prevention and Care Department.

References

1. The Study Group on Heterogeneity of HIV Epidemics. Differences in HIV Spread in Four Sub-Saharan African Cities: Summary of the Multi-site Study. Geneva: Joint United Nations Programme on HIV/AIDS, August 1999.
2. The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial. The Lancet 2000, 356(9224): 103-112.
3. Population Council and Family Health International. HIV/AIDS Counselling, Testing, Care and Support Services in Nairobi, Kenya. Nairobi, Kenya: Population Council and Family Health International, 1999.