The Global AIDS Program (GAP) in Central America and Panama region focuses its assistance activities primarily on improving the capacity of Central American countries to plan for, implement and evaluate surveillance programs, with a special emphasis on second-generation surveillance. Given the mix of resources available to the Program, the GAP regional office has initiated work at different levels in order to implement its assistance activities. CDC/GAP-CAP through its implementing partner Tephinet/TaskForce, supports the Central American MOHs with resources for key personnel, strategic information activities and support to the national HIV/AIDS Laboratories. The Tephinet/Task Force's mission in Central America and Panama is to provide technical and program management expertise, coupled with collaboration skills, to transform public health practice and significantly improve outcomes. Tephinet/Task force has demonstrated its commitment to assist the CDC/GAP Central America office in meeting its goals and objectives. Tephinet/Task force has adapted well to the various needs expressed by the region, and has identified mechanisms to provide appropriate technical assistance as needed, and has efficiently mobilized to respond to the dynamic and demand-driven commitments of the regional office.

Tephinet will continue to support the implementaiton of an MSM HIV/STI multilevel combination prevention intervention in Guatemala. Tephinet will continue to support an STI control for HIV prevention intervention among sex workers and MSM in Honduras, Nicaragua and a TBD country. The pilot for provider initiated testing in Guatemala and a country TBD will be completed and results disseminated to stakeholders. Tephinet will continue to facilitate the implementation of regional (Panama, Guatemala, Honduras, Nicaragua, Costa Rica, El Salvador, Belize) workshops on strategic information and the travel of consultants and workshop attendees. Tephinet will continue to support the implementation of a BSS+ study in Honduras and Panama. Data from qualitative studies in Honduras, Nicaragua, Belize, Panama, and El Salvador will be analyzed and reports disseminated to inform prevention strategies and the BSS+ implementation. Population size estimation studies will continue in Honduras, and Panama. Tephinet will continue to support the creation and implementation of a national system to monitor the care of patients living with HIV/AIDS is in Panama and Honduras.

Health systems strengthening is a cross-cutting issue for all Tephinet activities. Treatment, counseling, laboratory, and other guidelines are prepared together with National HIV Programs. Prevention services are provided through public facilities and staff is trained, equipment provided, and infrastructure development is provided through this mechanism. Information systems developed either to monitor the impact of prevention interventions or to support surveillance, monitoring, and evaluation are integrated into the national health systems.

There is currently unequal access to primary health services for men and women in the Central American region. Health services-- in general-- are mainly tailored to serve the needs of women and children. MSM have greater barriers to accessing health facilities due to homophobia, stigma, and discrimination. Tephinet will work towards equalizing access for men, and especially MSM. Previous studies have documented high rates of gender-based violence for MSM, male and female sex workers. Prevention programs will document levels of gender-based violence and include counseling and referral services to address these problems. Data from BSS+ and other special studies will help design strategies to reduce discrimination towards MSM, male and female sex workers.

Provider-Initiated Testing Expansion of provider initiated testing to additional sites in Guatemala and a country TBD will be conducted. This strategy will assist in increasing coverage on HIV testing for the following groups: TB patients, STI patients, SW and MSM. For STI patients, SW and MSM counselling and testing will be done as part of VICITS, for TB patients it will be linked with PROVIT. Activities will include provision of needed supplies and equipment, evaluation of coverage and acceptance and expansion to other sites and countries.

BSS+ and Special Studies Tephinet will continue to support the implementation of a BSS+ study in Honduras and Panama, and will provide technical assistance for BSS+ studies in Belize and Costa Rica. 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 studies. 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 . Tephinet will also assist in evaluating different recruitment methodologies (Respondent driven sampling, time location sampling, cluster sampling, etc) in order to identify the best strategy in terms of cost, precision and feasibility and provide informed recommendations to countries. Activities will include, stakeholder meetings, protocol development, IRB approvals, data analysis and report preparation and dissemination of findings.

MoniTARV- HMIS to Monitor HIV Care Tephinet will continue to support for a national system to monitor the care of patients living with HIV/AIDS is in Panama to achieve the best possible health services for HIV-positive patients especially in the provision of antiretroviral therapy. MoniTARV is a system which will provide the necessary information to monitor compliance with standards of care at the patient, clinic, and national level. The electronic software tool that is part of the information system will be developed on OpenMRSa community developed, open-source, enterprise electronic medical record system platform. Support for a national system for patients on HIV care will also continue in Honduras.

TA for Strategic Information Tephinet will continue facilitating the implementation of regional workshops on strategic information and the travel of consultants and workshop attendees. Tephinet will also implement a strategy to facilitate the dissemination of lessons learned and best practices including meetings, bulletins and web exchanges.

STI/HIV Prevention for SW & MSM 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, behavioral 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.

Tephinet will support an STI control and HIV prevention intervention among sex workers and MSM in Honduras, a TBD country and other countries as requested. The intervention will include strengthening STI etiologic and syndromic management through training of health personnel, strengthening 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 was designed with the participation of the Ministry of Health and implemented in government facilities and selected NGOs.

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). 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

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 a qualitative study conducted in 3 cities in Honduras, MSM showed openness to the VICITS strategy be implemented such facilities.

EVALUATION OF AN MSM COMBINATION PREVENTION INTERVENTION CDC and Tephinet will conduct an evaluation of a multilevel combination prevention intervention directed towards MSM. This activity will include protocol development, translation and adaptation of behavioral change materials for the Central American context, piloting of the combination prevention strategy, implementation of the evaluation, analysis of data and dissemination of results. As year one activities will mainly include development of the protocol and obtaining IRB approval, year 2 activities will include piloting of the strategy, recruitment of participants, and implementation of the evaluation. The evaluation will require an intervention and control sites and will combine biological and behavioral change interventions; and will take place at the individual group and community levels. The behavioral change strategy will be based on interventions that have been evaluated and shown to be effective for MSM and recommended by CDC as evidence-based interventions. It will be adapted through extensive formative work to the Central American context and will employ activities at the individual, group and community levels. The evaluation will be based on the diffusion of innovations theory and the power of peer influence aimed at mobilizing the MSM community. We anticipate that this peer driven, community-building strategy will reach MSM who would otherwise not be likely to receive prevention services, by relying on social networks. Our previous work using respondent driven sampling (RDS) as part of HIV prevalence studies among MSM has shown that it is possible to reach, and sample, hidden populations such as non-gay identified MSM and men who do not attend public venues by relying on social networks to recruit participants.

The biological component will be linked to the VICITS strategy and will include STI management, diagnosis of HIV and early initiation of HIV treatment. Patients diagnosed with HIV will be referred for appropriate care and treatment. Early initiation of therapy at 350 cells/mm3 will be provided to patients referred from the project (country guidelines require initiation of ARV treatment at 200 cells/mm3). It provides training for providers to improve the quality of STI management among MSM and reduce homophobia.

This project aims to evaluate and identify a locally adapted model of combination prevention that is culturally appropriate for the Central American context and that shows impact on healthy behaviors in a controlled design. The combination prevention approach has been chosen following the IAS Mexico Conference recommendations, The Lancet Special Series on HIV Prevention recommendations, and the WHO new guidelines on HIV prevention and services for MSM. The initial phase of this project will be evaluated by the Prevention Technical Working Group to incorporate the latest recommendations on HIV prevention for MSM and ensure that this evaluation complements current USG prevention programs.