While HIV prevalence rates in the Caribbean militaries are unknown, most of the military population falls within the vulnerable or at risk population for STIs and HIV. With FY08 PF funds, DoD PEPFAR will identify TBD partners to support partner militaries in Barbados, Antigua, St. Kitts & Nevis, Bahamas, Jamaica, Suriname, Trinidad & Tobago, and Belize in the implementation of HIV prevention activities with military members and their families.

TBD partners will provide technical assistance to support military capacity to administer and manage HIV program activities in Sexual Prevention and Testing and Counseling. Emphasis will be placed on expansion and enhancement of existing military-specific HIV prevention programs using a combination based prevention approach targeting recruits, enlisted, officer groups and their dependents, and addressing issues related to specific known and suspected stressors that influence HIV risk behaviors, such as substance abuse, mobility and prolonged deployments, as well as address issues related to gender norms, stigma and discrimination. Military members will be provided the necessary skills to change behaviors, engage in safe sex practices, decrease other risk behaviors and know ones status. By targeting military personnel, activities will support the Partnership Framework prevention goal of reducing HIV prevalence among persons engaged in high-risk behaviors (PEHRBs) and their clients. The support of prevention programs leveraging the existing military institutional structures will lay the foundation for sustainable programs in militaries in the region.

TBD partners will also support Laboratory, Strategic Information, and Health Systems Strengthening efforts for the partner militaries. Laboratory efforts will support the Partnership Framework objective of improving the capabilities and quality of HIV diagnostic and laboratory services and systems by strengthening the capacity of military laboratories in the diagnosis of STIs, TB and malaria, in addition to ensuring quality provision of HIV rapid diagnostics in the lab, clinical and non-clinical settings. Laboratory SOP development, logistics management and QA/QC activities will be coordinated with national and regional endeavors to avoid creating parallel systems. In addition, military lab workers will receive TA in the biosafety, management of sample collection and documentation and results reporting in accordance with national health management information systems to provide clinical providers data for clinical decision making.

In order to support the Partnership Framework objective of strengthening the capacity of partner countries to strategically generate, collect, interpret, disseminate, and use quality strategic information, HIV and other STI bio-behavioral surveys will be carried out in the Defense Forces of Barbados (in conjunction with the Defense Forces of St. Kitts & Nevis and Antigua), Bahamas, and Suriname in order to improve evidence-based programming and the understanding of the HIV risk factors in these populations. Military officials will be trained in HIV surveillance, data collection and analysis, and use of data to improve the quality and cost-effectiveness of HIV prevention, treatment, care and support services in militaries. Technical assistance to partner militaries will strengthen monitoring and evaluation and data collection systems for health to ensure effective utilization of data for programming and policy formulation.

Health Systems Strengthening activities will support the development and implementation of military HIV policies and strategic plans addressing issues related to HIV testing (recruit and periodic), retention and promotion of identified HIV-positive individuals. Technical assistance for system and institutional strengthening will encourage addressing issues related to access and availability of prevention, care, treatment and support programs. These efforts will support the Partnership Framework objective in Sustainability by improving the capacity of Caribbean militaries to effectively lead, finance, manage and sustain the delivery of quality HIV prevention, care, treatment and support services for militaries.

Cost efficiency and quality will be improved by increasing capacity of military healthcare workers to conduct trainings internally, leveraging partnerships with local organizations, and sharing best practices across militaries in the region.

Program monitoring and evaluation will be carried out according to national standards, utilizing mechanisms provided or recommended by the Ministries of Health.

Cross-Cutting Budget Attribution: Gender

Prevention outreach activities will address male norms and address issues related to sexual violence and coercion.

Cross-Cutting Budget Attribution: Human Resources for Health

TBD partners will support the human capacity development of military personnel (health care providers, program/clinic managers, administrators, and community members) through the provision of TA in HIV prevention, adult care and treatment, the implementation of laboratory SOPs and utilization of laboratory equipment and diagnostics, HIV and STI surveillance and data analysis, and policy development. These efforts will support the Partnership Framework objective of Human Capacity Development.

TBD partners will support the militaries of Barbados, Antigua, St. Kitts & Nevis, Bahamas, Jamaica, Suriname, Trinidad & Tobago, and Belize with Adult Treatment training. This activity will support the Human Capacity Development objective of the Caribbean Partnership Framework through the training of military health care providers and clinicians in the provision of multidisciplinary clinical services, such as antiretroviral therapy, prevention, diagnosis and treatment of opportunistic infections (OIs), assessment and management of pain and other symptoms. Training may also include prevention with positives activities to improve health care providers' abilities to effectively counsel military members on healthy living, reduction of risk behaviors, partner notification, and adherence to ART. Efforts will be made to address stigma and discrimination by promoting accepting attitudes toward people living with HIV/AIDS.

With FY09 PF funds, activities will strengthen the capacity of the militaries of Barbados, Antigua, St. Kitts & Nevis, Bahamas, Jamaica, Suriname, Trinidad & Tobago, and Belize to provide accessible, confidential, and quality testing and counseling services. Activities will build on previous FY09 funded initiatives implemented through PSI with the Jamaica Defense Force and the Trinidad and Tobago Ministry of National Security, and implemented through Charles Drew University with the Belize Defense Force and the Jamaica Defense Force, to expand testing and counseling services for military personnel and their families.

Efforts will be made to integrate Testing and Counseling services into existing medical health services and routine medical care through provider-initiated testing and counseling (PITC). Testing & Counseling opportunities for military personnel will be expanded (i.e. on bases, on deployment, temporary assignment). TC activities will link with prevention sensitization activities to educate participants and access other support services. The feasibility of mobile services will be explored as a means to reach military personnel assigned in areas away from military health facilities and urban testing sites.

Local resources and referral systems will be utilized to ensure appropriate linkages to prevention, treatment, and care and other health services. As militaries increase their capacity for managing TC activities, couples TC will be promoted among military personnel and their partners in order to identify serodiscordant couples and encourage safe sex practices and other preventive behaviors. Couples TC will promote gender equity and facilitate safe, mutual disclosure of HIV test results. The militaries will procure rapid test kits or work with national supply chain mechanisms to ensure all sites have sufficient supply, adequate and secure storage facilities, as well as inventory monitoring and tracking systems for HIV test kits.

TA in the provision of quality HIV TC services will be provided to military TC providers. Building on previously funded trainings, training and refresher training of counselors will begin to focus on management and supervision and advanced TC skills such as couples counseling. Counseling will be performed in accordance with national guidelines and will include targeted prevention messages, emphasizing the reduction of risk behaviors, and address issues surrounding stigma and discrimination. Mechanisms to maintain confidentiality of those tested will be put in place. A monitoring and evaluation system will be implemented through i.e. standardized logbooks, client data forms, monthly reporting forms, and other methods that comply with the national reporting systems and requirements.

With PF FY10 funds, this activity will support increased capacity within the militaries of Barbados, Antigua, St. Kitts & Nevis, Bahamas, Jamaica, Suriname, Trinidad & Tobago, and Belize in the areas of surveillance, monitoring and evaluation (M&E), and analysis and utilization of strategic information. Activities will encourage partner militaries to review and utilize data to improve the military healthcare system, direct policies, and improve the quality and cost-effectiveness of HIV prevention, treatment, care and support services in militaries.

Activities will build on previous FY08 and FY09 funded SI activities to identify HIV risk behaviors, indicate where gaps in health services exist, and inform HIV prevention programming through behavioral and bio-behavioral surveillance.

Data from the bio-behavioral surveys carried out in the Defense Forces in the region will be reviewed and utilized for evidence-based programming using known HIV risk factors in these populations. Military leadership will be engaged with review of survey results and recommended for broader dissemination to inform policy and strategic decision making. TA will be provided to healthcare providers (HCP) and policymakers to analyze and use collected data to streamline HCPs workflow in HIV services, monitor quality, and facilitate the identification of gaps in HIV services.

Continued support for building capacity will be provided in the areas of monitoring and evaluation and use of strategic information. Short term technical assistance and periodic on-site mentorship will be provided in data collection, utilization of program monitoring data, and complimenting the goals of the national strategic plans for HIV/AIDS. Strategic Information activities with all partner militaries will also inform policy. Military personnel will be trained in M&E of military-specific HIV operational plans to identify needs and gaps related to programs.

Improvements will be made to the militaries health information management systems enabling them to provide strategic, data-based decisions in a timely manner. Capacity will be built among defense force personnel to conduct operations research to evaluate the effectiveness of program implementations (e.g. behavioral intervention assessments).

TA will be provided for the timely and accurate collection of national HIV indicators within military HIV programs and facilitate data flow mechanisms for linkage to national and regional systems. National resources will be leveraged to improve strategic information systems and capacity in militaries.

This activity will strengthen the capacity of partner militaries in Barbados, Antigua, St. Kitts & Nevis, Bahamas, Jamaica, Suriname, Trinidad & Tobago, and Belize to plan, manage, and implement HIV programs. Activities will build on previous DHP FY08 funded Health Systems Strengthening efforts with the Belize Defense Force, the Suriname National Army, and the Trinidad and Tobago Ministry of National Security to strengthen their leadership and capacity to manage HIV programs, improve the policy environment to reduce stigma and discrimination, and ensure access to HIV care and treatment services among military members.

With PF FY 08 funds, referral networks and service integration will be strengthened for HIV/STI/TB care and treatment. Strategies for improving partnerships with other governmental organizations, NGO, and private entities working on HIV and health will be emphasized. Program activities will seek to secure military leadership endorsement and support of interventions addressing gender norms, substance abuse, confidentiality, among others.

Opportunities to strengthen pre-service and in-service training will be expanded and improved for military health care providers in multidisciplinary fields, including STIs, and ART management, psychosocial counseling, substance abuse will be pursued. Military personnel will be trained on how to use HIV surveillance to improve HIV prevention programming. Opportunities for military to military exchange training programs and professional exchanges to share program best practices and foster regional collaborations will be explored. TA will be provided for the development of strategies to encourage staff retention, performance and promotion for healthcare staff providing HIV/AIDS related services.

Military HIV policy and strategic plans will be drafted, reviewed and implemented, addressing issues related to HIV testing, retention and promotion of identified HIV positive individuals. Policies and protocols will also address systems and institutional strengthening to address issues related to access and availability of prevention, care, treatment and support programs. Efforts will be made to strengthen military protocols that reduce stigma and discrimination and strengthen military commitment to support HIV-positive members and HIV programs.

With PF FY10 funds, DoD PEPFAR will identify TBD partners to support partner militaries in Barbados, Antigua, St. Kitts & Nevis, Bahamas, Jamaica, Suriname, Trinidad & Tobago, and Belize in the implementation of HIV prevention activities with military members and their families. Partnership Framework activities will support continuation and expansion of previous FY08 and FY09 funded sexual prevention initiatives focusing on training of master trainers and peer educators, distribution of military-specific information, education, and communication (IEC), sensitization on the importance of partner reduction and correct and consistent use of condoms, and behavior change communication activities promoting responsible behavior among military personnel.

PF FY 10 BCC activities for HIV prevention and risk reduction will target recruits, enlisted, officer groups and their dependents. Training and technical assistance will be provided in evidence based interventions in areas such as increasing consistent and correct use of condoms (including minimizing the stigma surrounding accessing condoms), promoting condom negotiation skills with partners, decreasing sexual risk behavior, mitigating the influence of alcohol on sexual risk taking behavior, improving knowledge and attitudes about testing, decreasing HIV-related stigma, decreasing gender-based discrimination and violence, and addressing the influence of mental health factors on risk behaviors. Prevention activities will also promote partner reduction by communicating the risks associated with overlapping or concurrent sexual partnerships. Prevention counseling will be integrated into TC services and will link with HIV testing and care and treatment services. Health seeking behaviors and access to services will be promoted. Analysis of structural changes that may decrease vulnerability will be conducted with community participation to promote their adoption.

Interventions will be delivered through individual one on one and small group sessions, campaigns, and through trainings integrated into the military institutions. Peer educators will be trained in risk reduction counseling and equipped with risk reduction supplies (i.e. penile models, condoms). Master trainers will train others on how to implement educational outreach and community mobilization activities, implement activities themselves and provide supportive supervision of peer educators. Selection criteria will be established for peer educators, and retention and incentive strategies will be developed with militaries to encourage sustainability of activities. Refresher trainings will also be regularly provided and as needed.

Efforts will be made to integrate STI screening and treatment into existing medical health services and routine medical care for military personnel. Technical assistance for the diagnosis and treatment of STIs will be carried out. STI awareness will be incorporated into educational outreach and other prevention activities. STI services will link with HIV testing, care and treatment services.

Operations research will be conducted to determine the efficacy of these interventions on key behavior and health outcomes. Interventions will be compared across and between countries to refine intervention efficacy.

With PF FY08 funds, this activity will support the training of lab personnel and necessary support for equipment and commodities to develop and strengthen laboratory systems and facilities in order to support STI, TB, OI, and HIV diagnosis and improve the capacity of the militaries of Barbados, Antigua, St. Kitts & Nevis, Bahamas, Jamaica, Suriname, Trinidad & Tobago, and Belize to provide clinical care to HIV-positive military members. Support will be provided for laboratory specimen collection and transport, including procurement of infection control materials.

Activities will build on previous DHP FY08 funded initiatives, such as an assessment conducted by the Belize Defense Force on the requirements for the provision of VCT and procurement of needed supplies and previous collaboration between the US Military HIV Research Program (USMHRP) and the T & T Ministry of National Security to provide technical assistance, train lab personnel and provide assistance related to other national lab referral systems to strengthen laboratory efforts in T & T.

Laboratory personnel will be trained in laboratory SOP development, logistics management, QA/QC activities, utilization of laboratory equipment and data management. This activity will link with CT, TB, and care and treatment services by providing ancillary support for rapid HIV testing and diagnostics for STIs, OIs and TB. Military laboratories will be strengthened to provide referral systems to civilian sector labs where resources limit diagnostic and treatment service provision within the military health system.