There is limited data on HIV prevalence rates in Central American militaries, and most of the military population falls within the vulnerable or at risk population for STIs and HIV. With FY12 funds, the DoD will support efforts in Health Systems Strengthening, Strategic Information and Policy Environment for the partner militaries in Belize, Guatemala and Nicaragua. Programs in El Salvador and Honduras will be supported utilizing pipeline funds.Efforts in HSS will improve capacity and quality in the delivery of HIV diagnostic and laboratory services and systems. 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, as well as training in the provision of antiretroviral therapy, the assessment of alcohol use, medication adherence and provision of Positive Dignity Health and Prevention (PDHP) interventions in both clinical and non-clinical settings.

These efforts link to the PF goals by improving the capacity of Central American militaries to effectively lead, manage and sustain the delivery of quality HIV prevention, care, treatment and support services for military members and their families.

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. The program will incrementally increase the financial and human resource responsibility of the host country militaries. Program monitoring and evaluation will be carried out to inform program planning and efficacy.

Military laboratory capacity will be strengthened in the diagnosis of HIV in the lab, clinical and non-clinical settings, other STIs, TB and malaria and disease and program surveillance that will inform military leadership of resource requirements (training, human and material resources) and inform the program of necessary corrective measures for continuous improvement. Previous and continuing initiatives in the area of clinical laboratory enhancement have yielded significantly improved laboratory services available for military and related civilian populations. This program has enhanced the provision of primary medical care in the areas of HIV diagnosis and treatment as well as diagnosis and treatment of STIs and TB. In addition, host militaries will be called on to incrementally increase cost sharing on provision of counseling and testing laboratory commodities.

With FY12 funds, DoD Naval Medical Research Unit NAMRU 6 will support improved technical proficiency of laboratory personnel in laboratory procedures used in HIV/AIDS-related diagnoses and treatment monitoring. Specifically, HIV rapid testing and quality evaluation and assurance measures will be emphasized in addition to training military health providers in the screening, diagnosis and treatment of STIs and opportunistic infections (OIs). A system of sustained support supervision for trainees in the implementation of accurate diagnostics and laboratory management will be strengthened. Focus will be provided on strengthening the equipment and commodities systems to support STI, TB, OI, and HIV screening and diagnostics in the militaries of Belize, Guatemala and Nicaragua. Similar activities in El Salvador and Honduras will be supported using pipeline funds.Laboratory personnel will be trained in the development of standard operating procedures (SOP) for laboratory logistics management (i.e. laboratory specimen collection and transport), quality assurance and quality control activities, infection control materials, utilization of laboratory equipment and data management. This activity will link with HTC, 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.Provision of technical assistance in the areas of training and support for human resources for health (HRH) strategies and improved supply chains for the delivery of quality HIV related services will be supported.

With FY12 funds, increased capacity building in the areas of surveillance, monitoring and evaluation (M&E), and analysis and utilization of strategic information within the militaries of Guatemala and Nicaragua will be supported. El Salvador and Honduras will be supported utilizing pipeline funds. Activities will encourage partner militaries to collect, 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. Disease and program surveillance systems will be initiated such that the Central Military Health Unit and HIV/AIDS Program office have the means necessary to analyze data from the numerous decentralized locations of military bases to inform the status of activities, and any areas of concern requiring investigation or further action. This system will be established within the military system, with the ease of sending the required reporting data to the MOH. Technical assistance will be provided for the timely and accurate collection of national HIV indicators within military HIV programs and to 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. 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).Data from baseline bio-behavioral surveys that will be conducted in Guatemala and Nicaragua will be analyzed to improve evidence-based programming and deepen our understanding of the HIV and other STI 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. Technical assistance 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 capacity building will be provided in the areas of M&E and use of strategic information for program evaluation. Short term technical assistance and periodic on-site mentorship will be provided in data collection, utilization of program monitoring data, and complementing the goals of the national strategic plan for HIV/AIDS. Formative assessments and operational evaluation will be planned to provide data to inform interventions and identify best practices to scale. 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.

This activity will strengthen the capacity of partner militaries in Belize, Guatemala and Nicaragua to plan, manage, and implement HIV programs. Programs in El Salvador and Honduras will be supported utilizing pipeline funds. Continued efforts to improve the policy environment to reduce stigma and discrimination, and ensure access to HIV prevention, care and treatment services among military members will be addressed. 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 FY 12 funds, referral networks and service integration will be strengthened for HIV/STI/TB care and treatment. Strategies for improving partnerships with other governmental organizations, NGOs, 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, and 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, psychosocial counseling, and substance abuse. Technical assistance will be provided to improve treatment adherence, psychosocial support services for HIV positive 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. Support will be provided for participation of military representatives in military HIV conferences as well as in regional meetings for Central American militaries to share best practices across technical areas.Provision of quality HIV treatment and care for HIV positive military personnel will be supported in these countries. 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), and referrals for people living with HIV/AIDS (PLWHA) to community-based basic care and support services based on their individual needs.The Health System Strengthening objective of the Partnership Framework is supported through the training of military health care providers and clinicians in adult HIV treatment and other clinical services, such as prevention and treatment of OIs, assessment and management of pain and other symptoms, and nutritional support. Training may also include PDHP 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.Technical assistance will be provided for the development of strategies to encourage staff retention, performance and promotion for healthcare staff providing HIV/AIDS related services.

With FY12 funds, DoD will support the Belize and El Salvador militaries in the implementation of HIV prevention activities with military members and their families. The goal is to focus on the drivers of the epidemic specific to the military and addresses knowledge, attitudes and practices related to HIV prevention. Military members will be provided the necessary skills to change behaviors, engage in safe sex practices, decrease other risk behaviors and learn HIV status. By targeting military personnel, activities will support the Partnership Framework prevention goal of increasing healthy behaviors among MARPS to reduce HIV transmission. Technical assistance will build internal capacity of the partner military to direct and maintain HIV prevention efforts. Technical assistance will be provided for the provision of evidence based interventions in areas such as correct and consistent condom use (including minimizing stigma surrounding accessing condoms), promoting condom negotiation skills with partners, decreasing sexual risk behaviors, mitigating the influence of alcohol on sexual risk taking behaviors. Prevention activities will promote partner reduction by communicating the risks associated with overlapping or concurrent sexual partnerships. 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.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.