In March 2010, USAID will launch a Request for Activities (RFA) that will be awarded to start activities in September 2010. The new instrument will cover prevention activities in Central America, with additional bilateral funding to support activities to be managed by USAID/Mexico, and will have a life of 5 years. The program, through the regular budget assigned to USAID, will continue to support core activities that are being implemented through the current prevention instruments, targeting Most At-Risk Populations (MARPs). With the limited supplementary Partnership Framework (PF) funds coming from FY09 and FY10, additional activities will be included in the new instrument.

"Combination prevention- a combination of behavioral, structural, and biomedical approaches based on scientifically derived evidence with the wisdom and ownership of communities- offers the best hope for successful prevention" (Merson et al, Lancet 2008)

Due to the highly concentrated nature of the HIV epidemic in Central America and Mexico, the most effective use of regional prevention resources will be to continue focusing on reducing high risk sexual behaviors among MARPs. MARPs include Commercial Sex Workers (CSWs) and their clients, Men who have Sex with Men (MSM), partners of People Living with HIV/AIDS (PLWHA,) and certain ethnic groups (Garifuna and other indigenous populations). Within these MARP categories are individuals who are harder-to-reach and/or have special needs, including: bi-sexual MSM, MSM who do not identify as homosexual or gay, transgender, transvestite, MSM adolescents, partners of PLWHA who do not know their status or their partner's status, and highly mobile populations.

The cost effectiveness of targeting MARPs in concentrated epidemics is well documented. The World Bank publication, "HIV/AIDS in Central America: an Overview of the Epidemic and Priorities for Prevention" shows the results of an analysis of various resource allocations using the "Allocation by Cost-effectiveness Model". The Central America analysis concluded that an investment of $1 million in MARPs interventions would yield a prevention rate of between 11%- 19% among expected primary and secondary infections at a cost of $84 -$196 per infection prevented. This is in contrast to resource allocations for prevention measures such as blood safety or prevention from Mother to Child Transmission (PMTCT), which would only "prevent a few hundred infections at a cost of several thousand US dollars per infection prevented."

In addition to being cost-effective, the Central America prevention strategy also aims to ensure a comprehensive approach including secondary vulnerable groups, defined as those who interact with high-prevalence populations and/or have increased vulnerability to infection due to their social/economic status. These groups may include: potential clients of sex workers, partners of sex workers, mobile populations, transport workers, seafarers, and persons involved in uniformed service.

In order to reach these groups effectively for maximum impact, prevention resources must focus on locations where MARPs congregate socially, where they meet as groups to advocate for favorable policies and access to services, and where they frequent health service providers/facilities. Networks of MARPs, self-help groups, and NGOs in the region are still very weak and in need of institutional strengthening in a number of areas. An effective network of MSM groups, for example, does not exist in any of the countries in the region. Regional program experience shows that sex workers do tend to frequent public sector health facilities, but that MSM are more likely to access health services through private providers and/or NGOs. PLWHA often receive their ARVs, if they are on treatment, through the public sector, but also use private providers for more comprehensive care and follow-up.

Within MARP categories, three groups have often been neglected in prevention programming (design, implementation, and monitoring): 1) PLWHA, and especially adolescent PLWHA; 2) MSM who also maintain heterosexual relations and prefer to remain anonymous; and 3) adolescent MSM. The new program will intensify efforts to design and implement prevention activities that involve these groups either directly or through more accessible MARPs and motivate them to access prevention services.

In addition to identifying and reaching MARPs through the groups and services they use, an effective HIV prevention strategy must also take into account the concept of self-preservation in the context of the individual's health and well-being. Two key challenges in promoting healthy behaviors to combat HIV/AIDS concern the amount of risk to which an individual is willing to expose him/herself and the level of vulnerability to which s/he is subject through interaction with high risk sexual partners or through social/economic factors.

To more fully understand the role that these two challenges demand and the nature in which they contribute to the epidemic, it is important to understand their definition. UNAIDS has defined risk as, "the probability that a person may acquire HIV infection. Certain behaviors create, enhance, and perpetuate risk. Examples include unprotected sex with a partner whose HIV status is unknown; multiple unprotected sexual partnerships, sharing syringes and needles among injecting drug users, etc&"

Vulnerability, on the other hand, 'results from a range of factors that reduce the ability of individuals and communities to avoid HIV infection. These may include: (i) personal factors such as the lack of knowledge and skills required to protect oneself and others; (ii) factors pertaining to the quality and coverage of services, such as inaccessibility of services due to distance, cost, and other factors (iii) societal factors such as social and cultural norms, practices, beliefs and laws that stigmatize and/or reduce the empowerment of certain populations, rendering them unable to refuse participation in high risk sexual relations. '

The overall objective of the new cooperative agreement (CA) will be to support the USG/USAID Regional Prevention Strategy that focuses on providing cost effective, sustainable interventions designed to achieve "Increased Access to HIV Prevention Interventions by Most-At-Risk Populations in Central America and Mexico". The ultimate goal is to provide universal access to these interventions by MARPs in collaboration with host governments, other donors, and civil society.

The Recipient of this CA will implement a minimum package of prevention activities designed to effectively reach MARPS, especially those groups identified above as critical to reach in stemming transmission among the highest prevalence groups. The concept of prevention with positives should be an integral part of new prevention activities as well as ensuring that PWLHA are linked to treatment, care, and support services.

The three components for prevention interventions under this CA will draw on resources to be allocated in the following areas: 1) evidenced based models for behavior change; 2) structural approaches to reduce stigma, discrimination, and homophobia that create barriers to access of services and violate human rights of PLWHA; and 3) essential health services (voluntary testing and counseling, referrals for STI diagnosis and treatment, opportunistic infections (OIs) among PLWHA) including promotion of condom and water-based lubricant distribution.

The four main components that this project will cover are:

Component 1: Behavior Change Communication (BCC) designed to reduce high risk behaviors and vulnerability to HIV/AIDS transmission including a range of interventions addressing gender norms- male, female, and transsexual- as well as understanding the determinants of behavior and develop appropriate interpersonal communication (IPC) methodologies.

Component 2: Structural Approaches to increase the implementation of policies/laws against stigma and discrimination and address such factors as physical, social, cultural, organizational, community, economic, laws, and policies that affect HIV infection. The structural approaches to HIV prevention seek to change social, economic, political, or environmental factors determining HIV risk and vulnerability. In particular, societal norms that lead to homophobia and homophobic behaviors will be given greater attention and emphasis under the new program. A recent meeting on MARP programming (December 2009) in Antigua, Guatemala highlighted the need for understanding the role of homophobia in prevention, care, and treatment and how it affects access to services. The new program will take a step-wise approach to analyze the constraints to prevention of HIV among MARPs in light of social norms that promote homophobia, and propose strategic approaches to reaching decision makers who have a critical impact on creating an enabling environment for prevention.

Component 3: Expanding Access and use of prevention services including voluntary testing and counseling, STI diagnosis and treatment, promotion of condoms and water-based lubricants, and referrals for PLWHA requiring care and support services. The recipient will coordinate with Ministries of Health throughout the region, Global Fund grantees and other public, private, CBO and NGO partners to upgrade the quality and promote a sub-set of VCT and STI providers who are most accessible to high-risk groups. Referral linkages with sources of ARV treatment, psychosocial support, and other related services will also be strengthened.

Cross-Cutting Component 4: Monitoring and evaluation/Strategic Information will include special studies (e.g. ethnographic research on the behavior and practices of specific MARP sub-groups), formative research in the design of interventions under all three of the above components, quantitative and qualitative studies in different geographic locations for program design and implementation, as well as account for differences in prevention needs across the region. The recipient will monitor activities and carry out periodic evaluations to continually assess program efforts. Improved management systems will be used to monitor quality as well as quantity of interpersonal BCC. The recipient will systematically interpret monitoring and evaluation findings to identify actionable program implications and revise implementation strategies accordingly.

The project will improve access to VCT among at-risk groups in the region by continuing to implement mobile VCT programs in El Salvador, Guatemala and Nicaragua. These services will be complemented by promotional activities designed to increase client uptake of VCT services.

In all three countries, the implementer will work in collaboration with national Ministries of Health (MOH) and local partners to implement mobile VCT strategies that ensure the quality of services while responding to local needs. In each country, the project will engage professional counselors, trained in client-centered techniques, who help clients to develop personalized risk-reduction plans during pre- and post-test counseling sessions. Clients who test positive are referred to local health care facilities for follow-up care and support services. Additionally, the recipient will works within each country's regulatory framework for HIV counseling and testing services to ensure quality control in its provision of mobile VCT. The project's VCT provision reflects a coordinated effort between the MOH and the project. The project will provide pre- and post-test counseling, and the MOH will provide the test. As such, these services are registered as provided by the MOH, which helps the MOH to increase coverage and motivates them to collaborate with the recipient.The project will include individuals from the network of private sector providers in relevant training workshops to build their capacity and linkages with the formal health sector, improving the number of friendly services targeted to MARPs.

In addition to counseling for HIV, the recipient will also continue support for STI counseling and referrals. USAID recognizes the critical need to refer clients to STI services. While the project will not conduct diagnosis and treatment for STIs, it does ensure that counseling for STIs and referral to STI treatment facilities are a routine part of VCT services. Counselors supported by the project are trained to identify symptoms and risk factors for the most common STIs among FSW and MSM. Clients who may be at risk for STIs are referred to local health facilities to access appropriate diagnostic and treatment services. Referrals for STIs are conducted in close collaboration with local MOH and project partners.

In each country, the project will support BCC activities targeting FSW and MSM to promote services and raise general awareness about the importance of VCT. The recipient will look into including clients of FSW and other high risk groups. Promotional messages will be based on the perceived benefits and barriers to HIV testing amongst these populations, including publicizing the dates during which the mobile VCT teams will be available to offer services and distributing reminder cards, where appropriate.

The current project has already witnessed a high demand among the target populations for counseling and testing services. However, often there are not enough HIV tests at the health centers, and those that are available are prioritized for pregnant women. While the new project will not have the resources to purchase HIV tests, it will coordinate with MOH health centers where tests are available, to create demand among the target groups, to provide pre- and post-test counseling, and to improve the access of tests to the target groups.

The role of the private sector in this objective will be essential, in particular to improve the access to services for MSM. The creation of appropriate and accessible services for MSM will be part of the core activities developed by the new instrument. Trainings and sensitization as well as promotion of the services will also be part of the specific interventions that will be needed to improve access and achieve greater demand for services for MSM.

Following a routine research and monitoring regime, the project will conduct behavioral studies every two years with specified target groups and by country. With FY10 funds, (in 2011), the new project will carry-out a new round of these studies. Target populations to be included in this new round of behavioral studies will be MSM, FSW and PLWHA. Specific drivers of risky and unsafe sexual behaviors will be identified based on the results of the studies. In addition, the survey will also be useful in monitoring the coverage of the program, including the mass media and IPC activities. Other key projects, like GFATM can also be monitored through this process.

Besides the quantitative research, qualitative research will also be conducted in order to identify dynamics and characteristics of the populations included in the program. Different approaches and methodologies will be used for this purpose.

The new prevention project will complete the next round, subsequent to previous rounds in the former project, of measuring and mapping access to condoms for high-risk groups for all the Central American countries covered under this program. To complete this specific study, some of the activities include:

Develop Terms of Reference and select a research agency for data collection activities for the next round, and sign contract

Conduct field work in the countries

Analyze and prepare report

Disseminate results of the study with local governmental agencies, Global Fund, NGOs and other organizations / stakeholders from private and other sectors.

A series of research dissemination meetings in each country will be organized to share the results of the surveys, specific studies and qualitative research conducted in each country.

The project wil support the national response targeted to MARPS in the region. Due to the innovative and based evidence methodologies, the activities, materials and workshops developed by the project will be use across the region for the MOH staff as well will be adopted by GFATM projects. The activities developed by the project, will address not just issues related to behavior change, also will include topics such as gender, stigma and discrimination reduction, references to national system for STI diagnosis and treatment. In order to achieve this objective, different training sessions and workshops will be conducted for MOH staff, NGO staff and GFATM projects.

In FY10, the project will implement interpersonal communication (IPC) activities with MARPs across the region; the project will focus on reaching new participants by visiting new venues and by extending the geographic reach of the prevention interventions and strengthening partner NGOs more heavily than before.

Depending on the recipient of the cooperative agreement, the project may continue to utilize existing or adapted methodologies that have demonstrated efficacy. Use of existing materials would be adapted to reflect the results of the last behavioral surveys, and to better focus on relevant messaging for specific target groups. Using mass media, the project will air some key campaigns: such as partner reduction and abstinence. The project will also work with its C/FBO partners to incorporate these promotional spots in their work where appropriate.

The course of the HIV/AIDS epidemic in Central America underscores the importance of addressing the issues of abstinence, being faithful and the issues around stigma and discrimination in Central American countries. Although C/FBOs are prevalent throughout the Central American region, they have frequently been overlooked as a potential venue through which HIV prevention messages can be provided.

C/FBOs, however, are in a unique position to encourage community awareness and mobilization against the HIV epidemic. Religious leaders have the power to shape opinions and influence behaviors in their communities. Accordingly, C/FBOs, backed by the authority of traditional leaders, churches, or other religious institutions can have a far-reaching impact on the HIV/AIDS pandemic by delivering compelling messages about prevention as well as providing spiritual and social support for those living with and affected by the virus.

The project will focus its C/FBO efforts on three primary program areas including:

1) Stimulating broad discourse on healthy social norms and risky sexual behaviors;

2) Addressing stigma and discrimination toward people living with HIV; and

3) Supporting the idea of knowing your HIV status.

One of the primary objectives to the prevention program is to reduce stigma, discrimination, and homophobia through national, local, and institutional policies that key decision makers, health care providers, and other target groups will implement as part of a multi-sectoral response to the HIV/AIDS epidemic. This objective will seek have an impact to:

- Influence policies and budgets at the national and municipal level

- Create more favorable attitudes towards behaviors conducive to health and well-being

- Increase perception of risk and confidence to take action

- Influence positively social and subjective norms related to homophobia, stigma and discrimination.

- Increase intentions to act

In addition to the efforts realized with BCC activities, the project will also support the following activities

- Maintain and expand distribution of water-based lubricants in high-risk outlets, outlining the benefits of their use with a condom for HIV/AIDS prevention, using innovative strategies

- Male condoms will continue to be distributed under social marketing techniques.

- Expand distribution in Garifuna communities in any business establishment located in these communities in Honduras

- Continue assessing and piloting the current mix of delivery channels - commercial distributors, wholesalers, and NGOs - for condoms distribution and water-based lubricants in terms of their feasibility, appropriateness and cost-efficiency.

- Continue efforts from the previous project to implement National Condom Distribution strategies by using total market approaches and involving participants from public, social marketing and private sectors. Develop a national condom strategy document. Organize a forum with all participating agencies.

In FY10, the project will implement interpersonal communication (IPC) activities with MARPs across the region; the project will focus on reaching new participants by visiting new venues and by extending the geographic reach of the prevention interventions and strengthening partner NGOs more heavily than before, through a training program to improve the technical skills of the NGOs staff.

Depending on the recipient of the cooperative agreement, the project may continue to utilize existing or adapted methodologies that have demonstrated efficacy. Use of existing materials would be adapted to reflect the results of the last behavioral surveys, and to better focus on relevant messaging for specific target groups. Using mass media, the project will air some key campaigns: such as partner reduction and abstinence. The project will also work with its C/FBO partners to incorporate these promotional spots in their work where appropriate.

The course of the HIV/AIDS epidemic in Central America underscores the importance of addressing the issues of abstinence, being faithful and the issues around stigma and discrimination in Central American countries. Although C/FBOs are prevalent throughout the Central American region, they have frequently been overlooked as a potential venue through which HIV prevention messages can be provided.

C/FBOs, however, are in a unique position to encourage community awareness and mobilization against the HIV epidemic. Religious leaders have the power to shape opinions and influence behaviors in their communities. Accordingly, C/FBOs, backed by the authority of traditional leaders, churches, or other religious institutions can have a far-reaching impact on the HIV/AIDS pandemic by delivering compelling messages about prevention as well as providing spiritual and social support for those living with and affected by the virus.

The project will focus its C/FBO efforts on three primary program areas including:

1) Stimulating broad discourse on healthy social norms and risky sexual behaviors;

2) Addressing stigma and discrimination toward people living with HIV; and

3) Supporting the idea of knowing your HIV status.

One of the primary objectives to the prevention program is to reduce stigma, discrimination, and homophobia through national, local, and institutional policies that key decision makers, health care providers, and other target groups will implement as part of a multi-sectoral response to the HIV/AIDS epidemic. This objective will seek have an impact to:

- Influence policies and budgets at the national and municipal level

- Create more favorable attitudes towards behaviors conducive to health and well-being

- Increase perception of risk and confidence to take action

- Influence positively social and subjective norms related to homophobia, stigma and discrimination.

- Increase intentions to act

In addition to the efforts realized with BCC activities, the project will also support the following activities

- Maintain and expand distribution of water-based lubricants in high-risk outlets, outlining the benefits of their use with a condom for HIV/AIDS prevention, using innovative strategies

- Male condoms will continue to be distributed under social marketing techniques.

- Expand distribution in Garifuna communities in any business establishment located in these communities in Honduras

- Continue assessing and piloting the current mix of delivery channels - commercial distributors, wholesalers, and NGOs - for condoms distribution and water-based lubricants in terms of their feasibility, appropriateness and cost-efficiency.

- Continue efforts from the previous project to implement National Condom Distribution strategies by using total market approaches and involving participants from public, social marketing and private sectors. Develop a national condom strategy document. Organize a forum with all participating agencies.