Transactional sex (exchange of sex primarily motivated by material gain) is one explanation for the large number of people living with HIV in Africa and for the disparity in the levels of HIV infection between men and women. This exchange of money or resources for sex often involves age mixing between older men and young women and/or multiple or concurrent partners. Transactional partnerships may particularly facilitate the rapid spread of HIV and other STIs when the sexual relations involve complex chains of interconnected partners that place an entire social network at risk. Transactional sexual relationships differ from those traditionally defined as commercial sex as well as from the material and monetary transfers to express affection or otherwise solidify and enhance affective dimensions of a relationship. HIV researchers, practitioners, and academicians have offered varied explanations for these relationships of sexual exchange (i.e. socioeconomic and power imbalances, opportunities to foster social mobility and economic security, social "safety net" and sustaining or enhancing social relationships). It remains unclear how these factors interrelate or vary depending on age, sex, or the cultural, economic, and environmental context.

To better understand the role of transactional sex in the transmission of HIV, CDC/PEPFAR began initial work developing a two-phase project with COP 2009 funding for prevention of sexual transmission, complementing strategic priorities developed through the Prevention of HIV among Persons Who Engage in High Risk Behavior (PHPEHRB) Headquarters Operation Plan (HOP). Phase 1 of the project aimed to leverage country-level engagement and implement a protocol to examine the social, sexual, economic, and environmental networks of women and men engaged in transactional partnerships; describe attitudes toward, motivations for, determinates of, and social relations of persons in these networks; and document the community context in which they operate. The assessment will examine the relations and interdependence of individuals with multiple network-based contexts and situations that influence the involvement in, occurrence or absence of transactional sex. In collaboration with CDC, experts in the areas of research on transactional sex, network analysis, qualitative research, and diffusion of health-related ideas and behaviors through informal networks are conducting the assessment and developing recommendations for intervention-related activities, messages, and modes and levels of delivery.

Based on the findings of the formative assessment, Phase 2 (beginning in 2010) will focus on the design, development, and pilot of an intervention (or module for potential inclusion in other ongoing prevention activities) to prevent transmission of HIV related to high-risk transactional sexual behavior. The activity will include both process and outcome monitoring to determine feasibility, acceptability, and effectiveness of the intervention and the revision of the intervention based on findings. In addition, an intervention protocol manual, intervention materials and tools, and program monitoring and evaluation guidance and tools will be developed that can be disseminated for use in other contexts and settings. The intervention design and development of subsequent materials will consider the potential role or absence of other interventions; cultural, environmental, and epidemiologic factors; and policies.

The anticipated cost for Phase 2 is Redacted per year for two years. This will fund partners to implement the programmatic activities and participate in the program evaluation (Redacted per year). The designated implementer for Phase 2 (Redacted per year) will provide training and on-site support for piloting the intervention and will be responsible for process and outcome M&E activities and revision of intervention materials as needed. The anticipated period of performance of the implementer for Phase 2 is 24 months.

This activity supports the PEPFAR II legislative objectives of 1) developing evidence-based prevention strategies that are tailored to country and community needs, 2) targeting those most at risk and, in particular, addressing the heightened vulnerability of women and girls to HIV, and 3) facilitating the application and integration of operations research findings into prevention programming to support an effective national response by countries. This activity also aligns with the PHPEHRB TWG focus to strengthen programming and to ensure that rigorous assessment and studies become the basis for implementing prevention programs for most-at-risk populations.

Transactional sex (exchange of sex primarily motivated by material gain) is one explanation for the large number of people living with HIV in Africa and for the disparity in the levels of HIV infection between men and women. This exchange of money or resources for sex often involves age mixing between older men and young women and/or multiple or concurrent partners. Transactional partnerships may particularly facilitate the rapid spread of HIV and other STIs when the sexual relations involve complex chains of interconnected partners that place an entire social network at risk. Transactional sexual relationships differ from those traditionally defined as commercial sex as well as from the material and monetary transfers to express affection or otherwise solidify and enhance affective dimensions of a relationship. HIV researchers, practitioners, and academicians have offered varied explanations for these relationships of sexual exchange (i.e. socioeconomic and power imbalances, opportunities to foster social mobility and economic security, social "safety net" and sustaining or enhancing social relationships). It remains unclear how these factors interrelate or vary depending on age, sex, or the cultural, economic, and environmental context.

To better understand the role of transactional sex in the transmission of HIV, CDC/PEPFAR began initial work developing a two-phase project with COP 2009 funding for prevention of sexual transmission, complementing strategic priorities developed through the Prevention of HIV among Persons Who Engage in High Risk Behavior (PHPEHRB) Headquarters Operation Plan (HOP). Phase 1 of the project aimed to leverage country-level engagement and implement a protocol to examine the social, sexual, economic, and environmental networks of women and men engaged in transactional partnerships; describe attitudes toward, motivations for, determinates of, and social relations of persons in these networks; and document the community context in which they operate. The assessment will examine the relations and interdependence of individuals with multiple network-based contexts and situations that influence the involvement in, occurrence or absence of transactional sex. In collaboration with CDC, experts in the areas of research on transactional sex, network analysis, qualitative research, and diffusion of health-related ideas and behaviors through informal networks are conducting the assessment and developing recommendations for intervention-related activities, messages, and modes and levels of delivery.

Based on the findings of the formative assessment, Phase 2 (beginning in 2010) will focus on the design, development, and pilot of an intervention (or module for potential inclusion in other ongoing prevention activities) to prevent transmission of HIV related to high-risk transactional sexual behavior. The activity will include both process and outcome monitoring to determine feasibility, acceptability, and effectiveness of the intervention and the revision of the intervention based on findings. In addition, an intervention protocol manual, intervention materials and tools, and program monitoring and evaluation guidance and tools will be developed that can be disseminated for use in other contexts and settings. The intervention design and development of subsequent materials will consider the potential role or absence of other interventions; cultural, environmental, and epidemiologic factors; and policies.

The anticipated cost for Phase 2 is Redacted per year for two years. This will fund partners to implement the programmatic activities and participate in the program evaluation (Redacted per year). The designated implementer for Phase 2 (Redacted per year) will provide training and on-site support for piloting the intervention and will be responsible for process and outcome M&E activities and revision of intervention materials as needed. The anticipated period of performance of the implementer for Phase 2 is 24 months.

This activity supports the PEPFAR II legislative objectives of 1) developing evidence-based prevention strategies that are tailored to country and community needs, 2) targeting those most at risk and, in particular, addressing the heightened vulnerability of women and girls to HIV, and 3) facilitating the application and integration of operations research findings into prevention programming to support an effective national response by countries. This activity also aligns with the PHPEHRB TWG focus to strengthen programming and to ensure that rigorous assessment and studies become the basis for implementing prevention programs for most-at-risk populations.