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.

BSS+ in Guatemala The UVG will provide technical assistance for the preparation for and implementation of the BSS+ study in Guatemala and Panama. 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 through the Field Epidemiology Training Program (FETP).

If there is regional stakeholder interest and commitment in a Regional Training Center, UVG will contribute 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.

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, 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.

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). 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 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.

EVALUATION OF AN MSM COMBINATION PREVENTION INTERVENTION

CDC and UVG 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. Year one activities will mainly include development of the protocol and obtaining IRB approval 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.

None