Additional Funds JSI is requesting $380,413 additional funds to cover this shortfall and allow for the continued implementation of project activities. Below is a calculation of the funds required to maintain activities at the FY07 level: Program activities for the 12-month period of FY07 (Oct 06 - Sept 07) were budgeted at $664,104, a monthly burnout rate of $55,342. However, since no FY07 funds were released to MMIS, the project could only allocate $217,663 for program activities over the 9-month period June 07 - Feb 08. To continue activities, MMIS would require the additional $280,413 ($664,104 - 217,663) for the 9-month period June 07 - Feb 08. In preparation for expansion, an additional $100,000 will be required for equipment, materials and supplies.

Planned activities include j. Consolidating of the achievements made in the 4 districts to ensure that the skills and competencies to achieve injection safety and infection prevention and control. k. Scaling up its activities (except for the distribution of retractable syringes which requires MOH's decision due to budget implications) to ten new districts and Botswana Defense Force Health Corps. The targeted PEPFAR goal was to train 5,000 new healthcare workers in the current and new districts.

Table 3.3.05: Program Planning Overview Program Area: Condoms and Other Prevention Activities Budget Code: HVOP Program Area Code: 05 Total Planned Funding for Program Area: $ 2,763,695.00

Program Area Context:

Statistics

Among young people in Botswana, sexual activity tends to start in the 15-19 year range. While a large number of Batswana youth are abstinent, those who are not often have multiple partners. Condom use is reported to be fairly high among sexually-active youth. Intergenerational sex appears to be placing young women at higher risk of HIV than their male counterparts.

Among adults, having multiple sexual partners is also a serious concern. A survey from 2003 found that 20% of adults age 15-49 had had sex with someone else while in a relationship with one of their recent partners. The percentage of men reporting sexual concurrency was higher than that among women: 31% vs. 16%. Reported condom use at last sex is relatively high among adults as well, though significantly lower among married or cohabiting men and women, compared to those in other kinds of relationships. To date, there are no published data from Botswana about the sexual behaviors of people who know they are infected with HIV or on ARV treatment.

Alcohol abuse is reported and viewed as a key facilitating factor in HIV transmission in Botswana. A 2005 population-based survey (Physicians for Human Rights, abstract) found that 31% of men and 17% of women met criteria for heavy drinking. Forty-five percent of participants identified alcohol use as the most important factor that makes men and women vulnerable to HIV in Botswana, and risky drinking was associated with various behaviors that increase the risk of HIV (e.g. inconsistent condom use, multiple partnerships).

There are few data about the prevalence of transactional sex, but qualitative research suggests this is not uncommon in some parts of Botswana. Virtually no respondents to BAIS II Survey (2004) reported exchanging money or gifts for sex, but sex work is available and evident in many parts of the country. Fortunately, injection drug use does not seem to be a significant factor of the epidemiology of HIV in Botswana. Homosexuality is not acceptable behavior across most parts of Batswana society. Therefore, Men who have Sex with Men (MSM) are difficult to identify, and only one functioning gay, lesbian, bisexual advocacy group is known to exist.

With the expansion of effective treatment services, bacterial sexually transmitted infections (STIs) have declined significantly in the last decade in Botswana. Viral STIs now comprise the majority of infections seen in clinics; for example, in a recent study 59% of Genital Ulcer Disease was found to be caused by HSV-2. A small minority of men (~15%) are circumcised.

Services The Government of Botswana (GOB) provides free condoms through a large distribution network, reaching many workplaces, entertainment centers, and health care sites. Condoms are available for sale in the market as well, at subsidized prices. The Government of the Netherlands now supports a large share of condom social marketing in Botswana through a regional agreement with Population Services International (PSI).

There are few organizations that openly cater to sex workers or their clients, or MSM.

The Government has supported the development of a national alcohol policy, which is still in development with the leadership of the alcohol industry, but alcohol, and its linkages to HIV in particular, are not yet a standard part of the health care system or public health messages in the country.

The provision of post-exposure prophylaxis (PEP) to rape victims is part of the Ministry of Health's (MOH) policies, and many police and health care workers have been sensitized to the policy. However, little is

known about how the policy is being implemented.

In FY07, funding in this program area includes support for comprehensive HIV prevention interventions to sexually-active youth, women, and men nationally and locally. Specifically, we are combining funds from abstinence and be faithful (AB) Prevention with those from Other Prevention for a number of programs: Family Health International (FHI)'s youth intervention, Pathfinder's male-focused activities, the national Ipoletse information and counseling hotline; and the Makgabaneng behavior change program. These programs serve their audiences' information and service needs, particularly in the areas of family planning, condom use, and referral/utilization of critical other HIV/AIDS services.

We also will continue support for two interventions focused on alcohol-HIV intersections. One targets health care workers (HCW) and settings for simple alcohol screening and brief interventions, while the other targets drinking establishments for dual alcohol and HIV risk reduction messages. Support for expanding prevention activities on the district and village level, with additional technical and administrative support from National Alliance of State and Territorial AIDS Directors (NASTAD), will continue. Also, we will continue to work with the Botswana Defense Force (BDF), to implement peer education and localized media campaigns in support of HIV prevention among recruits and officers.

In FY07, we propose a new initiative to fund and strengthen civil society groups that target sex workers and/or MSM in their work, as well as a rapid assessment of the HIV prevention needs of MSM. We are also increasing our work to strengthen prevention interventions in clinical settings for people living with HIV/AIDS (PLWHA), with complementary funding from Counseling and Testing Program Area. An assessment conducted with FY06 funds will inform that effort considerably. Finally, with FY07 funds, we will follow up work from an FY06 assessment of the health care sector's readiness to provide expanded male circumcision services, We anticipate that that exercise will raise numerous other questions that will need to be answered, and the results from the trials in Kenya and Uganda should be available by then, to further guide our work in this area.

Referrals and Linkages The relatively widespread availability of HIV testing in Botswana - through both free-standing voluntary counseling and testing (VCT) centers and the routine HIV testing (RHT) program - facilitates the promotion of HIV testing to high risk populations. The same may be said for antiretroviral (ARV) therapy and other care and treatment service referrals, though individuals are rarely monitored to see if they follow through on any referrals they might receive. USG is supporting assessments of these referral networks, to better identify ways to strengthen them. We will focus FY07 efforts on strengthening prevention services within existing HIV-related clinical and community programs, beginning with Tebelopele and other VCT delivery centers. Other programs ready for engagement on this level will be identified in the course of the Prevention with Positives (PwP) assessment that will begin shortly.

Policy The USG plan in this program area includes few activities that focus on policy related issues. Some policy barriers for the Other Prevention work include the illegality and low acceptance of homosexual behaviors and identity; MSM, gay, lesbian, and other sexual minority groups are largely underground and unorganized and thus difficult to work with directly for HIV prevention. As in many places in the world, sex work is also illegal. High taxes on public health advertising hinder condom social marketing, as does the continued lack of a national alcohol policy or a strong national body dedicated to reducing the public health burden associated with alcohol abuse.

Challenges and gaps Please refer to the challenges noted in the Abstinence/Be Faithful program area context, which also apply to USG work in this program area. In particular, the civil sector of the country needs strengthening to expand the effectiveness of its HIV prevention efforts.

Program Area Target: Number of targeted condom service outlets 920 Number of individuals reached through community outreach that promotes 59,052 HIV/AIDS prevention through other behavior change beyond abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention through other 1,290 behavior change beyond abstinence and/or being faithful

Table 3.3.05: