Most Central American countries, with the exception of Belize, are characterized by a concentrated epidemic (i.e., HIV prevalence of less than one percent in the general population and greater than five percent among specific subgroups) focused among men who have sex with men (MSM), transgender, male and female sex workers (SW), SW clients and partners, certain ethnic groups (e.g. Garífuna), and mobile populations.

One of CDC primary partners is Del Valle University of Guatemala (UVG). The Centre for Health Studies is an academic unit within the Institute for Research at UVG. Its vision and mission is to become a center of excellence by conducting science and training contributing to the improvement of health in Guatemala and the region, in collaboration with strategic partners. During the last 29 years, CHS has developed the capacity to conduct studies in response to public health needs and to translate results into public health programs and policies. Major investments, have yielded important gains in research-based knowledge and applied public health programs, such that it is fair to say that the program has played a critical role in the advancement of public health in Guatemala and Central America. The knowledge produced has been the basis for the improvement of the prevention and control of the major public health threats in the region. Some new areas that have been developed in the last five years include: HIV/AIDS, Tuberculosis and sexually transmitted diseases surveillance and operational research carried out in collaboration with the US Centres for Disease Control and Prevention. The UVG has had the ability to integrate laboratory science into field studies. The UVG laboratory capacity includes modern equipment and personnel for entomological, parasitological, bacteriological, virological, immunological and molecular biology activities. Currently, the UVG is recognized as a centre for excellence in research and training in health science, with more than 300 publications and the completion of over 100 grants.

SI Capacity Building The UVG will strengthen the capacity in the Central American region through provision of technical assistance, capacity building and coordination. The UVG will provide support for planning processes and implementation of plans, including national strategic plans, regional surveillance plan, national surveillance plans and monitoring and evaluation plans. TA to select and harmonize national core indicators will be provided, as well as TA for the establishment of one national body that will be the repository of all/most of M&E and surveillance information.

BSS+ in Guatemala The UVG will provide technical assistance for the preparation for and implementation of the BSS+ study in Guatemala. Several qualitative studies will be conducted to inform the BSS+ study and prevention activities such as the VICITS strategy and other prevention interventions for MSM. Population size estimation exercises will be linked to BSS study in Guatemala. Capacity building for analytic interpretation of BSS+ and other M&E instruments for program planning will be provided and help increase the use quality, collection, analysis and use of data .

M&E for MSM Prevention It is essential to monitor and evaluate the impact of the interventions being implemented in the region for the groups at highest risk of infection. The UVG will support the implementation of programmatic evaluation of coverage and impact of interventions and costing of strategies. This programmatic evaluation will improve the programs and the heath of the participants covered by the strategies. Protocols will be developed for the evaluation of prevention strategies for MSM in one TBD country.

Training & Communications- CDC, through UVG, will strengthen human resources for health in the areas of HIV, STI, TB, surveillance and reproductive health. UVG will contribute to a Regional Training Center with an interdisciplinary team of epidemiologists, behavioral scientists, physicians, public health specialist, economists and policy makers. The UVG will also support curriculum development, training materials, and technical assistance. The Center's mission will be to expand human capacity in the region for the implementation of effective, sustainable and context-specific HIV strategic information processes which enable evidence-based development of HIV prevention, care and treatment in the region. The Center will be implemented as a collaborative effort between the UN agencies,the University of North Carolina and Del Valle University of Guatemala (UVG) where it would be based in Guatemala City. The UVG has had a longstanding relationship with the US Centers for Disease Control (CDC), Stanford University, King's College in London, and the Institute for Tropical Diseases. The Center will assist in training of key personnel in the region to develop human capacity for the implementation of strategic information. Scholarships will be provided to a number of regional resources to fill gaps in local expertise.

CDC and UVG will also support implementation of the communications strategy to assist in dissemination of lessons learned and best practices in the region.

VICITS VICITS (Vigilancia y control de VIH, ITS y comportamiento sexual en poblaciones vulnerables HIV/STI/ surveillance and control among most at risk populations) is a comprehensive HIV and STI prevention program linked to the analysis of surveillance data in Central America. VICITS is an HIV prevention strategy that combines sexually transmitted infections (STI) diagnosis and treatment among most at risk populations, condom promotion, bahavioural change and an information system to monitor the impact of the project. Due to high infection rates and a high number of sexual partners, sex workers (SW) and men who have sex with men (MSM) have been identified as a core group in HIV transmission in Central America. The presence of sexually transmitted diseases and difficulty in safe-sex negotiation makes this group more sensitive to acquire, and more prone to transmit, HIV. Evidence supports that timely treatment of STIs may reduce HIV transmission, especially in concentrated epidemics and in groups with a high rate of bacterial infection - such SW and MSM.

The UVG will continue to support an STI control for HIV prevention intervention among sex workers, MSM and PLHA in Guatemala known as the VICITS strategy. The intervention will include strengthening STI etiologic and syndromic management through training of health personnel, strenghthening counseling for risk reduction and condom promotion, improving laboratory STI and HIV diagnostic capacity through training and provision of equipment and reagents. The project will support provision of reproductive health services and outreach activities to improve coverage and compliance with follow-up visits. An information system to monitor HIV, STI and condom use trends will allow evaluation of the project's impact. The strategy is designed with the participation of the Ministry of Health and implemented in government facilities and selected NGOs.

UVG will also support diagnosis, treatment and control of STI among people living with HIV in two major treatment centers in Guatemala where nearly 70 percent of all PLWH are followed for ARV care.

MSM: Men traditionally do not access health services in the Central American regions, since they are mainly tailored towards women and children. MSM have greater barriers to health services due to homophobia, unfriendly service hours, and lack of standardized guidelines. Strategies in the US that combine STD and HIV prevention for MSM have achieved higher levels of condom use with casual partners and increases in HIV testing (such as Many Men, Many Voices). In Latin America, Peru has successfully launched HIV and STI services for MSM in public facilities since the 1990`s, and in 2009 they were able to reach more than 70,000 MSM in 70 facilities (Jorge Sanchez and JL Sebastian personal communication). A qualitative study conducted in Honduras in 2009, in preparation for the HIV prevention strategy for MSM, reported that participants preferred services to be established in public facilities to ensure sustainability. The major NGOs working with MSM directed a letter to CDC in 2009 requesting that the VICITS strategy be implemented for MSM immediately.

Data from the 2009 Integrated Behavioral and Biological Survey (IBBS) in El Salvador showed that most MSM access STI and VCT services through public facilities, with nearly 80% of those with an HIV test in the last year having done it in a public health facility (ECVC, EL Salvador). Similarly, data from Honduras in 2006 showed that 76% of MSM had their HIV test done at a public facility. Based on OGAC guidelines on strengthening health systems and assisting Ministries of Health in planning and managing health programs effectively, prevention activities for MSM, PLHA and FSW will be implemented in close coordination with the MOH and in both public and private clinics. Working with public facilities is of utmost importance to ensure sustainability. Through VICITS, access and quality will be improved for STI, VCT, and referral for HIV care and risk reduction counseling at public health facilities for the MSM community. This is based on the WHO/PAHO recommendations on increasing access and quality to MSM and it addresses the push towards combination prevention. CDC has conducted BSS studies in Honduras, El Salvador that show that MSM are equally reaching pharmacies, public health services and private services for STI treatment. There is no objection by the MSM community to access public health services-- on the contrary on a qualitative study conducted in 3 cities in Honduras, MSM requested the VICITS strategy be implemented such facilities.

PLHA: Currently there is NO structured intervention for PLHA in the Central American region that aims to increase healthy behaviors. VICITS for PLHA will combine risk reduction counseling, partner testing and STI diagnosis and treatment for this population. Co-infection of HIV and other STIs has been shown to increase HIV viral load in plasma and genital secretions. Testing STIs among HIV positives can lower genital viral load and therefore reduces the risk for HIV transmission. PEPFAR I & II encourage the focus on PLHA.

Provide assistance to National laboratories for them to participate in the regional laboratory network.

CDC and UVG will assess the national laboratory infrastructure and expertise required to support the STI and TB program improvement, monitoring and evaluation from 1 country.

CDC and UVG will provide TA to improve quality control and enable participation in external quality control programs.

CDC and UVG will enable participation of national laboratories in the global/regional HIV/STI laboratory harmonization and standardization initiatives through supporting travel and meetings

CDC and UVG will assess the national HIV algorithm in Honduras and Belize, to promote the use of rapid test for a more efficient HIV diagnosis and implement new national algorithms based on assessment findings.

HIV/TB Lab Capacity Evaluation - An assessment of the national laboratory system is the initial step toward improving laboratory services on TB/HIV to establish the strengths/weaknesses/needs of two countries. Evaluate potential sentinel sites and choose 3 per country for HIV/TB sentinel surveillance in Guatemala and Honduras and the laboratory capacity for HIV and TB diagnosis at sentinel sites. Purchase equipment and reagents to strengthen local laboratories. Train laboratory staff in biosafety, quality control and diagnostic procedures.

PROVIT is a program that aims to improve detection of HIV among TB patients, TB management and strategic information for TB and HIV. PROVIT was designed by the Regional Office for Central America and Panama of the Global AIDS Program of the Centers for Disease Control and Prevention. This Program will be implemented in at least three countries: Guatemala, Honduras and Nicaragua. Each country will have three sites. Technical assistance will be provided by CDC and Del Valle University of Guatemala.

Del Valle University will support training through the provision of technical experts. Training will include HIV and TB diagnosis, clinical management of TB/HIV, laboratory biosafety and quality control, and TB/HIV recording and reporting system. Del Valle University will help establish an information system through ETR.net, a Microsoft.netbased computer software (not currently web enabled) that uses WHO and IUATLD core surveillance variables. Epidemiological advantages of electronic TB recording and reporting systems are significant, and include: (1) time-efficient data entry and reduction in transcription errors; (2) timely data transmission; (3) real-time data quality checks and more extensive data validity testing; (4) improved data analysis capability; (5) more timely generation and availability of reports; (6) marked decrease in the laborious task of cross-referencing information between TB and HIV programs; and (7) flexibility to adapt to changing needs. This system will allow us to monitor the programs impact on increasing detection and follow-up of TB cases and HIV testing.