While HIV prevalence rates in the Central American militaries are unknown, most of the military population falls within the vulnerable or at risk population for STIs and HIV. With FY09 PF funds, DoD PEPFAR will identify TBD partners to support partner militaries in El Salvador, Guatemala and Nicaragua 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 one's status. By targeting military personnel, activities will support the Partnership Framework prevention goal of increasing healthy behaviors among MARPS and their clients to reduce HIV transmission. 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 the Health Systems Strengthening, Strategic Information, and Policy Environment efforts for the partner militaries in El Salvador, Guatemala, Nicaragua and Belize. Health Systems Strengthening efforts will improve 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. Activities will expand and improve in-service training for military health care providers in multidisciplinary fields, including the diagnosis and management of STIs, OIs, TB, and mental health disorders, as well as training in the provision of antiretroviral therapy, the assessment and management of pain and other symptoms impacting HIV co-infected individuals.

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 El Salvador, Guatemala and Nicaragua in order to improve evidence-based programming and the understanding of the HIV risk factors in these populations. Results from the HIV bio-behavioral survey in the Belize Defense Force (BDF) will be analyzed with specific risk factors incorporated into the design of a specific prevention program for the BDF. Military officials will be trained in HIV surveillance, data collection and analysis, and data use to improve the quality and cost-effectiveness of HIV prevention, treatment, care and support services in militaries. Technical assistance to partner militaries in El Salvador, Guatemala, Nicaragua, and Belize will strengthen monitoring and evaluation and data collection systems for health to ensure effective utilization of data for programming and policy formulation.

Partnership Framework 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 systems 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 objectives in Policy Environment and Health Systems Strengthening by improving the capacity of Caribbean militaries to effectively lead, 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, leverage partnerships with local organizations, and share 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, National AIDS Programs, and the regional Central America PF plan.

PF FY10, activities will strengthen the capacity of the militaries of El Salvador, Guatemala and Nicaragua to provide accessible, confidential, and quality testing and counseling services. Activities will build on previous Defense Health Program (DHP) funded initiatives implemented through Nicasalud in Nicaragua and PASMO in El Salvador to expand as well as initiate in Guatemala HIV testing and counseling services for military personnel and their families.

Efforts will be made to integrate Testing and Counseling (TC) services into existing medical health services and routine medical care through provider-initiated testing and counseling (PITC). TC opportunities for military personnel will be expanded (i.e. on bases, pre/post deployment, temporary assignment) and activities will link with other prevention activities as well as provide access to other support services.

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. 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.

Militaries will work with national supply chain mechanisms to ensure TC sites have sufficient supplies, 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. 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. 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. Mechanisms to maintain confidentiality of those tested will be established. 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 El Salvador, Guatemala, Nicaragua 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 DHP FY09 funded SI initiatives, including a bio-behavioral survey carried out by Ciccatelli Associates with the Belize Defense Force.

When data collection for the baseline bio-behavioral surveys in El Salvador, Guatemala, and Nicaragua funded using PF FY 09 funds has been completed, data will begin to be analyzed in order to improve evidence-based programming and the understanding of the HIV risk factors in these populations. Data analyses and findings will be presented to military leadership and recommended for broader dissemination to inform policy and strategic decision making. TA will be provided to health providers and policymakers to analyze and use data to streamline healthcare providers' 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 El Salvador, Guatemala and Nicaragua to plan, manage, and implement HIV programs. This activity will also support policy efforts in Belize. Activities will build on previous DHP FY09 funded Health Systems Strengthening efforts in Nicaragua and Belize through Charles Drew University 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 10 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. Financial management mechanisms will be improved and training will be provided for military leadership in financial management for HIV programs. The development of mechanisms for leveraging resources and creating greater resource efficiencies will be encouraged.

Opportunities to strengthen in-service training will be expanded and improved for military health care providers in multidisciplinary fields, including STIs, ART management, psychosocial counseling, and substance abuse will be pursued. TA will be provided to improve treatment adherence, psychosocial support services and diagnosis and treatment of mental health problems for the HIV + personnel and civilians receiving treatment and care at military health sites. Service guidelines will be developed or disseminated and quality assurance mechanisms will be established. Military personnel will also be trained on HIV surveillance and strategic information.

FY 2010 funds will support the provision of quality HIV treatment and care for HIV positive military personnel in El Salvador, Guatemala and Nicaragua. Basic care provided by military health services to HIV-positive personnel includes clinical staging and baseline CD4 counts for all patients, CD4 cell count monitoring, prevention, diagnosis and treatment of opportunistic infections (OIs), psychosocial counseling, and referrals for people living with HIV/AIDS (PLWHA) to community-based basic care and support services based on their individual needs. Technical assistance will also be provided to the military to strengthen linkages to community-based HIV care services and support groups. In order to support the Health System Strengthening objective of the Partnership Framework, this activity will build the capacity of the health workforce by training military health providers at the facility level in the diagnosis and treatment of STIs, OIs, and mental health disorders. Training will 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.

TBD partners will also support the militaries of El Salvador, Guatemala, Nicaragua and Belize with Adult HIV treatment training. This activity will support the Health System Strengthening objective of the Partnership Framework through the training of military health care providers and clinicians in clinical services, such as antiretroviral therapy, prevention and treatment of opportunistic infections (OIs), assessment and management of pain and other symptoms, and nutritional support. Training may also include prevention with positives activities to improve health care providers' ability 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.

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. If necessary, activities will support the retention of healthcare personnel and uptake of clients by improving the workplace environment through minor refurbishment of work sites, including counseling and testing centers, labs and clinic settings.

With FY10 PF funds, DoD PEPFAR will identify TBD partners to support partner militaries in El Salvador, Guatemala and Nicaragua in the implementation of HIV prevention activities with military members and their families. The overall goal is to focus on the drivers of the epidemic specific to the military and address knowledge, attitudes and practices related to HIV prevention. Technical assistance will build internal capacity of partner militaries to direct and maintain HIV prevention efforts.

Partnership Framework activities will build on previously-established sexual prevention initiatives with the Salvadoran Armed Forces (SAF), the Guatemalan Armed Forces (GAF), and the National Army of Nicaragua (NAN), funded with FY 08 and/or FY 09 Defense Health Program (DHP) funds. Current programs implemented through PASMO (PSI) in El Salvador, and Nicasalud in Nicaragua focus on the training of military enlisted and officer personnel in HIV education, sensitization on the importance of partner reduction and correct and consistent use of condoms, behavior change communication activities promoting responsible behaviors among military personnel.

PF FY 10 BCC activities for HIV prevention and risk reduction will target recruits, enlisted, officer groups and their dependents. Technical assistance will be provided for the provision of evidence based interventions in areas such as increasing correct and consistent condom use (including minimizing the stigma surrounding accessing condoms), promoting condom negotiation skills with partners, decreasing sexual risk behaviors, mitigating the influence of alcohol on sexual risk taking behaviors, HIV testing and counseling (TC), 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 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 to HIV and other STIs 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 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 implement and train others on how to implement educational outreach and community mobilization activities 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 sustainable programs. Refresher trainings will also be provided.

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 with STI awareness and incorporation into educational outreach and other prevention activities will be conducted. 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 FY10 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 to support STI, TB, OI, and HIV diagnostics and improve the capacity of the militaries of El Salvador, Guatemala and Nicaragua 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.

FY10 PF funds will support training and support for HRH strategies and improved supply chains for the delivery of quality HIV related services. 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. Funds may support minor refurbishment and infrastructure support for outlying bases supporting the military in order to facilitate service delivery.

With PF FY10 funds, this activity will support coordination between TB and HIV programs in El Salvador, Guatemala and Nicaragua. Technical assistance will support the Health System Strengthening objective of the Partnership Framework by building the capacity of the health workforce in TB services. Military medical personnel will receive training on TB case identification, diagnosis and appropriate referral for treatment. The partner militaries will implement HIV testing and counseling for all TB patients and TB screening of all HIV-infected personnel. Necessary equipment and laboratory supplies will be purchased to support program area activities. This activity will link with laboratory infrastructure activities to strengthen TB diagnostic capabilities.