PEPFAR Angola will initiate a comprehensive, multi-faceted prevention program to promote normative change and adoption of safer sexual behaviors, with the aim of reducing new HIV infections among general population adults, youth and high-risk groups. The program will align with GRA priorities and directly support the Prevention Thematic Area of the Partnership Framework, especially as outlined in Goal 2. Reduce the spread of the HIV epidemic, objective 4: Increasing number of people adopting safe sexual behaviors.

Specifically, the USG prevention portfolio in Angola will seek to:

- Reduce risk behaviors such as early sexual debut, multiple concurrent partners (MCP), transactional, commercial sex, inconsistent condom use, gender-based violence (GBV), and sexual risk associated with alcohol use.

- Use gender-sensitive approaches to reach high risk groups such as youth and adults engaged with multiple concurrent partners, including, mobile population (e.g. truckers, military and police), and areas of high concentration of sex workers.

- Target geographic areas/hotspot venue including areas of high population density such as Luanda, border areas such as Cunene, and transportation corridors such as from Cunene to Luanda.

Angola has a mixed HIV/AIDS epidemic. HIV/AIDS data available show a slightly higher prevalence among women than men, with a principal transmission method being heterosexual sex, as described in the sexual prevention TAN. There are an increased number of cases in provinces near the borders and cities with high population density, such as in Luanda. This trend is associated with the population mobility, poverty, the limited access to primary health care, as well as sexual practices (UNGASS 2007).

The prevention program will require concerted attention to the general population while simultaneously concentrating on specific targeted populations such as youth (<15, 15-24) who represent 60 percent of the population, and the highest risk populations. Considering that the main mode of transmission is heterosexual sex; and the common practice of multiple concurrent partners (MCP) is an important driver, though data needs to be strengthened to improve the understanding of the dynamics of the epidemic. Additional key drivers of the epidemic include: high rates of unprotected sex, either low and or inconsistent condom, or low perception of risk. Commercial sex workers, their clients and mobile workers (including truck drivers, miners, military personnel and the police) are assumed to be the most at risk populations in Angola. HIV prevalence among sex workers was reported at 23.l percent (UNAIDS 2008). Little is known about men, who have sex with men (MSM) in Angola, but studies are planned, and there is government support for this work. Although there is little data on prisoners they are a population of concern, as are most vulnerable youth. IDUs are not known to be a MARP in Angola.

In Angola's PFIP, there are three main Prevention packages outlined: prevention package for the general population, prevention package for youth and prevention package for MARPs. To avoid vertical programming and in order to achieve the maximum results on an epidemic with limited amount of data, it is important to focus efforts in an efficient, comprehensive and integrated manner. In terms of implementation of these three packages, USAID's prevention efforts will be split into two main projects and a targeted intervention, one geared towards general population and youth in the community, one reaching Angola's MARPs/highest risk-groups and one geared towards higher-risk general population at hot spots. A gender lens will be integrated into all activities, recognizing that some cultural and gender norms reinforce key drivers of the epidemic such as multiple and concurrent partners, gender based violence and transactional sex.

Well-structured prevention interventions will be directed to difficult and hard-to-reach locations in the country. For each of these specific populations a distinct prevention package is needed. Each package will contain the components of condom promotion, procurement and distribution, tailored messages on prevention, expansion of HIV voluntary counseling and testing, STI prevention and treatment, stigma reduction for people living with HIV/AIDS, gender equity, and reduction of gender-based violence. Although the proportion of people using male and female condoms rose in recent years, the uptake is still low, and efforts to increase correct and consistent condom use will be strengthened. People living with HIV in these targeted communities are a further priority. Interventions will be customized for different risk groups based on their respective needs.

The overall goal of this project is to ensure delivery of a comprehensive package of services for MARPs: There is substantial evidence for the effectiveness of a comprehensive package of interventions for populations most-at-risk for HIV, including commercial sex workers, their clients and other high risk populations.

The program will also incorporate linkages to "MARP-friendly" health services, especially referrals to HIV care and treatment which is provided by the GFATM and GRA, given high prevalence in these populations. These linkages may also include referrals substance abuse services, PMTCT (including family planning), and post-exposure prophylaxis as available and appropriate to meet the needs of each vulnerable group as appropriate. Sensitization of health care providers to provide MARP-friendly services will also be a critical part of the package. The program will explore opportunities and linkages with other implementers to bring mobile HIV testing services to locations that are convenient to MARPs.

Due to stigma and discrimination, and a lack of data on MARPs in Angola, thus far HIV-related services have not focused significantly on most at-risk populations. Existing data on HIV in Angola and anecdotal evidence from organizations serving MARPs and other prevention efforts indicate that commercial sex workers, clients of sex workers and mobile men are at significantly increased risk for HIV infection. Although there is a clear need for more systematic data on these populations, the limited data available suggests a mixed epidemic, with various geographic hotspots and MARPs bridging into the general populations. Additionally, due to limited data, there are no reliable estimates of the size of these MARP/high risk populations or mapping of their locations.

Anecdotal evidence suggests that sex workers continue to have unprotected sex, usually at the paid request of their clients. Because MARPs often have sexual contact with the general population, neglecting the prevention needs of MARPs spurs a continual reservoir of new HIV infections in the country. In order to effectively address the HIV/AIDS epidemic in Angola, it is essential to address both the needs of the general population at risk of HIV and those of specific MARP groups.

In FY 08 and FY09 USG supported NGOs that brought BCC and condoms to CSW and truckers in particular. TraC studies were implemented after some years of intervention and show only little change. More in-dept studies were planned and executed to come to more effective interventions that really will lead to behavior change and not only to more knowledge. The National Network of PLWHA was supported to advocate for better services for PLWHA and interventions (PwP) were planned. All involved local NGOs received institutional capacity building to improve their management and M&E.

Plans for FY 10 will include a continuation of existing MARP focused activities. These existing activities will continue to focus on CSWs, their clients and truckers. Strengthened and expanded activities that reach additional MARPs both in the groups defined above and new key MARPs will be defined and designed, in line with the Prevention strategy in the next five years. Project interventions are likely to be targeted in year one, in order to conduct all of the planned and critical data collection efforts. Based on the results of the data collection and studies, the MARP program will be further defined and expanded and will collect additional data including mapping exercises if needed to inform the design of MARPs activities.

Specifically this project will work to scale-up the delivery of this package to MARPs in priority prevention areas in selected geographic areas through collaboration with local MARP focused organizations. The program will use data and information derived from current and planned studies and program monitoring to strengthen service delivery and to propose additional innovative approaches to reach MARP with prevention services.

Key objectives of this prevention project for MARP/high risk populations include:

Objective 1

Reduce risk of HIV among MARPs and bridge populations by increasing consistent condom use and the adoption of safer sexual behaviors.

The project will expand and increase quality of interpersonal communication and outreach to promote essential elements of HIV preventionbehavior change, products and servicesthat targeted populations require to protect themselves from new infections (or, given their higher rates of infection, to prevent others from being infected.)

Objective 2

Expand and increase uptake HIV counseling and testing targeted to hard-to-reach populations, and strengthen linkages to other HIV and health services.

The emphasis will be on expanding demand creative and innovative approaches to providing CT for populations who may not access services, due to stigma discrimination reasons, at mainstream clinics; strengthening screening and treatment of sexually-transmitted infections (STIs); and referral for HIV care and treatment and other services.

Objective 3

Continue to improve targeting and uptake, efficiency and sustainability of condom social marketing (CSM) and provision of and access to public sector condoms.

Support and link to existing CSM activities to ensure continuity in the supply of condoms, with increased focus on condom promotion and sales in high-risk populations and communities. Support linkages and distribution of free condoms through peer education and outreach components.

Objective 4

Strengthen capacity of government, civil society and the private sector to deliver comprehensive HIV services for high-risk populations and to create an enabling environment for service expansion.

In the Angolan context, where sex between men and commercial sex remains taboo and stigmatized and possibly punishable by law, HIV/AIDS programs must enlist the explicit cooperation of law enforcement, health authorities, and the political and religious communities, to reduce the fear of arrest and stigmatization that cause MARPs to avoid health seeking behaviors. Critical advocacy efforts will focus on mobilizing key stakeholders, including government, civil society and members of targeted populations, to create a legal, political and social environment where MARPs can be reached with effective prevention programming. The project will help strengthen government coordination of programming for MARPs, and enable local NGOs and community-based organizations (CBOs) to advocate and mobilize resources for, and to deliver appropriate services to targeted populations in close collaboration with GFATM (through a possible extension of round 4).

The program will look to partner with commercial sex workers, MSM and human rights organizations and networks, in order to spearhead advocacy for policies to reduce barriers for the delivery of services. A range of local, national and regional stakeholders will be encouraged to assume leadership for advocacy efforts, so that this policy work is sustainable beyond the life of the project. The program will support stakeholders by ensuring timely and accurate use of data for policy work and advocacy, and for evidence-based decision making.

This project will provide sub-grants and capacity building to a variety of CBOs, CSOs, networks and other key stakeholders related to MARPs. The transfer of knowledge and skills required to operate efficient, cost-effective, accountable and transparent organizations is essential to managing integrated interventions for MARPs and high-risk populations. Moreover, solid organizational performance is fundamental to the short and long-term success of the provision of and scaling up of interventions. Capacity building efforts should work to meet the particular organizational development needs of target organizations. Capacity-building will cover a broad range of substantive areas, ranging from advocacy to administration and finance, governance, leadership, management, networking, and strategic planning. Particular attention will be given to monitoring and evaluation, supportive supervision and quality assurance, given the importance of the quality of interventions to achieving successful behavior change.

In program activities, PROACTIVO will prioritize CSWs, truckers, other clients of sex workers (mobile populations, men with money, and security personnel) and MSM. CSWs and MSM will be reached through peer-education and other interpersonal approaches, while truckers and other clients of sex workers will be reached through "hot zone" activities in bars and nightclubs and through targeted community and mass media. Gender sensitive communications with CSWs, truckers and MSM will include messages about the importance of correct and consistent condom use with all clients and non-casual partners.

Since many CSWs would not self identify as sex workers, activities will also target transactional sex where appropriate. Male sex workers and MSM are also hidden, vulnerable and hard to reach populations, requiring increased attention and tailored programming. Given that different MARPs, such as CSWs and truckers, face different challenges and have various needs, prevention initiatives targeted to MARPs need to be evidence-based and tailored to each MARP sub-population and context, and linked to behavioral outcomes.

Under this program, the PROACTIVO project will support the combination HIV prevention approach advocated by the GRA by delivering and coordinating evidence-based behavioral and structural interventions, while supporting biomedical interventions such as referrals to HIV counseling and testing and STI treatment. Behavioral interventions will include a broad range of communications with a primary focus on community outreach and mobilization. PROACTIVO is supporting structural interventions by addressing stigma and discrimination against MARPs and advocating for an environment supportive of healthy sexual behaviors and gender norms. PROACTIVO supports biomedical interventions by promoting uptake of services, addressing behavioral and structural barriers to use of services and establishing strong referrals.

The PROACTIVO strategy prioritizes evidence based activities that will link MARPs and their sexual partners to a core package of interventions that reach target populations at the individual, sexual networks, community and societal levels.

Specific key activities include:

Promotion of MARP friendly services is a very important to reduce stigma and discrimination. Promotion of and linkages to 'MARP-friendly' healthcare services includes VCT, referrals for post-exposure prophylaxis, male circumcision, family planning/reproductive health including PMTCT and antiretroviral services etc and to build capacity in staff to appropriately respond to the special needs of MARPs.

Conducting a mapping exercise within the selected geographic zones building upon the findings of the forthcoming BSS and PLACE/MAP studies conducted by other organizations. The mapping exercise will identify and list all project hotspots in the targeted zones; gather more reliable, recent estimates of specific MARP; identify health service providers (STI, VCT, FP, ARV) in and around major transport hubs and ports; and facilitate monitoring of project intervention coverage. This will allow the project to work with the GRA to finalize strategies that are responsive to each MARP's specific needs.

Support the GRA in its effort to take mobile VCT to national scale. This approach will be consistent with the MOH's current policy that only trained health staff should implement or manage care and treatment activities such as VCT; and it will also support the INLS' work to expand access to VCT in fixed sites and to ensure that each province has at least two mobile VCT clinics.

Support GRA in the establishment of a National MARP Working Group. PROACTIVO will seek to establish a MARP Working Group within the broader multi-sectoral HIV coordination committee linked to INLS. PROACTIVO will work with GRA, INLS and other stakeholders on national level to develop a basic terms of reference and structure for the MARP Working Group in the first three months of the project.

Provide sub-grants to local NGO/CBOs to implement prevention activities focused on MARPS. These organizations will be selected through a competitive process to fill gaps in coverage and to ensure that MARPs' unique needs are met, to contribute to an increased capacity in civil society to respond to MARPs and decrease stigma and discrimination.

Interpersonal communications. PROACTIVO proposes two approaches to IPC: 1) Trained outreach workers (known locally as activists) implement small group sessions with targeted messages that can have an impact. These can include drama activities at a truck stop and followed up by a 'question and answer' session. 2) Peer educators. Recruiting and retaining peer educators is extremely challenging in Angola. However, peer education is a very effective means of encouraging behavior change and, despite its challenges; it will remain a key approach under this project.

Alcohol and bar initiative to address alcohol and HIV risk among MARPs. Activists conduct one-off outreach sessions in popular bars and clubs in hotspots. PSI/Angola and its local partners will broaden bar and club work through a concerted effort to build relationships with owners, servers and other employees of nightclubs, bars and brothels and recruit them for condom promotion and IEC material provision.

Guerilla Marketing. Guerrilla marketing techniques use unconventional marketing approaches in nontraditional venues. Guerrilla marketing is designed to create a memorable experience that generates "buzz" and spreads in viral fashion through word-of-mouth.

Targeted IEC materials. PSI/Angola will work with the INLS and other government partners to create a comprehensive national strategy for targeted IEC materials for each MARP population. These will include materials used by peer educators and outreach workers when conducting IPC activities, as well as low literacy materials for direct distribution to target populations. To ensure the success of these materials, representatives from communities and MARP will be involved in their development and pre-testing.