Angola is considered having a mixed HIV/AIDS epidemic with an official national prevalence of 2%. The research and evidence base in Angola is growing; available data indicate the main mode of transmission is unprotected heterosexual sex. The common practice of multiple concurrent partners is an important driver, though data need to be strengthened to improve understanding of the dynamics of the epidemic. Commercial sex workers (CSWs) and mobile workers (including truck drivers, miners, military personnel and the police) are assumed to be the most at risk populations (MARPs) as they are in other sub-Saharan countries. Little is known about men who have sex with men (MSM) in Angola. HIV prevalence among sex workers was reported at 23.1% (UNAIDS, 2008). An estimated 77 percent of young people aged 15-24 in the general population did not correctly identify ways of preventing sexual transmission of HIV, and up to 32% of youth initiated intercourse before the age of 15 (UNAIDS, 2008).

Condom use rates in Angola are low. A study conducted by Population Services International (PSI) indicates that only 55% of youth used a condom with their last casual partner, 37% with a non-married permanent partner, and 19% with a marital partner. Data collected from clients at voluntary counseling and testing (VCT) centers also indicate low condom use rates. More than half of VCT clients reported not using a condom in the last three months, 35% reported sometimes using a condom, and 7% reported always using a condom. Reported condom usage at last sex was 20%, condom use with a regular partner was slightly lower at 15%, while use with a casual partner (among those reported having a casual partner) was 30%.

The PEPFAR program Angola is initiating comprehensive, multi-faceted prevention programs to promote normative change and adoption of safer sexual behaviors, with the aim of reducing new HIV infections among general population adults, youth and most at risk populations (MARPS). To meet the overall goal of improved health status in Angola, the integrated Social Marketing for Health project will scale up the access of health products, including condoms, bed nets, contraceptives and water purification tabs, in Angola and will build on lessons learned and achievement from previous similar USAD supported interventions. The HIV/AIDS component of the project aims to ensure the availability of both commercial and generic brands of condoms nationally, for prevention interventions, specifically targeted for prevention activities in areas considered as hot spots.

USAID also supports an integrated health system strengthening project and Community Based Prevention and MARPs projects. The Social Marketing for Health Project will leverage with all other interventions and cater to all sites and activities, as well as building links and cooperation with GRA and other stakeholders.

A gender lens will be integrated into all activities, recognizing that cultural and gender norms may reinforce key drivers of the epidemic such as multiple and concurrent partners and transactional sex. Gender inequality and social and cultural norms that put both men and women at increased risk of HIV is one of the key drivers of the HIV epidemic in Angola. Typically, men have the negotiating power in heterosexual relationships and women have little influence over sexual and reproductive decision making, including condom use. This exemplifies how harmful gender norms put both men and women at risk of HIV and needs to be addressed in marketing and communication campaigns with target group specific messaging. A gender lens will be integrated into all activities, recognizing that cultural and gender norms may reinforce key drivers of the epidemic such as multiple and concurrent partners and transactional sex, and also address gender based violence (GBV) and alcohol use etc.

The Social Marketing for Health project will additionally include a research component to provide a better evidence base for programming for distribution and marketing of condoms. Research will also feed into programming of the prevention projects in the overall portfolio. In FY10 USAID started implementing Priorities for Local AIDS Control Efforts (PLACE) studies in Angola through MEASURE Evaluation. The purpose of this venue based rapid assessment is to identify geographic areas where HIV transmission is likely to be high and where condom distribution and marketing and prevention programs should be focused. PLACE provides critical information, including a list of venues where people meet new sexual partners, a description of characteristics of the venues and their patrons, and information to monitor youth-focused and general HIV/AIDS prevention programs at these venues, including information about sexual behavior. The study will provide quantitative data that will inform future strategic programming for PEPFAR Angola, especially HIV prevention programs, condom promotion and behavior change interventions.

In FY 2010, two initial PLACE studies were conducted in Luanda. The first, a full study in the municipality of Rica Pinto; a slum in with high population concentration, high presence of mobile population such as truckers and a commercial hub in the city. The second study in Luanda aims to provide 'snapshots' from all of Luanda's nine municipalities and from the estimated total population of about seven million. Preliminary results are forthcoming in the beginning of FY11.

In COP FY11 funds will include PLACE studies, with a local TBD partner, in the key provinces Cunene and Huambo and cover both rural and urban areas; specific locations and number of studies will be decided in consultation with GRA and local partner organizations and be based on the results from the two initial studies. Maps produced and data collected as part of each study area will be disseminated broadly to facilitate participation and intervention development from various stakeholders and local implementing partners.

An important component of this activity will be to increase the local capacity for conducting studies such as PLACE. Capacity building efforts include intensive analysis and report writing, a stakeholder's workshop to decide locations of subsequent studies, and a data use workshop for local stakeholders to generate interest in PLACE and train stakeholders in using data to inform interventions. Another objective of this approach is the training of a pool of Angolan social researchers and interviewers who can expand this initiative over the whole country in the coming years, linking research to action.

Distribution systems and product availability are key areas of focus. Male condoms should be affordable and readily available wherever people need them; products should be in places where people meet sexual partners to increase the probability that people will use them, particularly for high-risk populations and in targeted geographic areas. It's specifically important that condoms are available in 'Hotspots' such as "luncheonettes" and bars, stores, clinics and VCT. Products should be in places where people meet sexual partners to increase the probability that people will use them, particularly for high-risk subgroups and in high-density areas. Condom social marketing will also be linked to outreach. All activities promoting consistent condom use and realistic risk perception and partner reduction should be coordinated with other relevant communications campaigns targeting both men and women.

USAID is looking to the Social Marketing for Health project to dramatically scale up the accessibility of social marketed products, with an initial focus on male condoms, and have a significant and sustainable impact on the use of quality, essential products. Impact may not be defined solely as the sheer number of condoms distributed and purchased, rather, how product use is affecting health issues in Angola, such as including condom use and behaviors by at-risk target audiences, use during higher-risk sexual acts, and the proportion of coverage within a given sub-population.

Social marketing is a strategy to promote the healthy behaviors of the Angolan population and as such, this intervention will be more clearly aligned to behavioral outcomes than previous marketing interventions. The Social Marketing for Health project will focus on effective social marketing to significantly expand coverage, access, and demand. Future communication campaigns needs to be based on clearly defined public health issues and behaviors, and respond to the needs, desires, and requirements of specific target audiences. In regards to HIV prevention, social marketing needs to respond to the drivers and dynamics of the HIV/AIDS epidemic throughout Angola. Social, cultural and gendered norms affecting the choice to use condom or not need to be considered and addressed in all marketing and promotion of correct and consistent condom use to all target populations by tailored messaging.

In addition, the project will coordinate with Civil Society, private sector and GRA and provide technical assistance and support to the INLS throughout the life of the project in strengthening the positioning, distribution, marketing, and promotion of non-branded public sector condoms and female condoms for distribution in clinical settings.