The Combination Prevention Program of PASMO/PSI reduces the spread of HIV among MARPs in Central America, a Partnership Framework priority. PASMO's targeted MARPs include FSWs, their clients, MSM, transgendered persons, PLHIV and their partners, Caribbean populations, and men in uniform. Within these are harder-to-reach MARPs, including bi-sexual men, MSM who do not identify as homosexual and highly mobile populations. An increased focus for FY2012 will be on transgendered and PLHIV, the two groups who appear to be the drivers of the epidemic in the region.

The overall objective is to provide cost effective, sustainable interventions designed to achieve increased access to HIV prevention interventions for MARPs. The expected results are reduced prevalence of high risk behaviors among MARPs; decrease stigma and discrimination related to sexual orientation, occupation or status; increased access by MARPs to a minimum package of essential prevention services; and strategic information obtained through research and monitoring to improve activities. Activities work to improve gender equity through masculinities and stigma and discrimination studies based on gender norms. Results are incorporated into design and implementation of behavior change and health service activities. PASMO will be the main implementer of Gender Challenge Fund activities and will address Sexual Violence, Exploitation and TIP targeted to MARPs starting with a pilot project in Guatemala. PASMO coordinates with local NGOs and governments to maximizing funds.

Sustainability: The program uses existing NGOs and private sector health providers to implement activities and strengthens the NGO and provider capacity to deliver high quality interventions.

A goal of the PASMO/PSI Combination Prevention Project is to build capacity of local NGOs, civil society groups and health service providers. The program works with other partners in this area such as the USAID/PASCA project and the Global Fund. However, all projects struggle with the high rotation of personnel, the lack of coordination across training organizations and the lack of follow up with the trainees that affect long term results. To sustain the impact of these trainings and truly build capacity, the program is developing, in conjunction with other USAID partners and the Global Fund, an integrated plan for institutionalizing these activities.

A combination of locally-available short courses and technical assistance is being used to address specific capacity gaps within the NGO partners and health professionals that PASMO/PSI works with. In addition to building local managerial and technical skills, PASMO/PSI will strengthen financial and administrative systems to ensure adherence with sound management practices. Coordination mechanisms will be established, in conjunction with other projects and institutions (UNAIDS, Global Fund, Ministry of Health) to avoid duplication and to make sure that the beneficiaries incorporate these efforts in their own plans. A variety of needs have been identified, including gender, strategic planning, writing proposals, the use of the PASMO/PSI Unique Identifier Code and financial/budgets. To complement this effort, a database of training participants is in development.

PASMO/PSI will train a total of 538 health care workers, including counselors and community workers, in outreach with MARPs and testing and counseling to improve MARP-friendly services at IPPF clinics, private laboratories and NGOs. This will result in services free of stigma and discrimination, including homophobia. Journalists and decision makers will be sensitized. PASMO/PSI will also review existing curricula and manuals on stigma and discrimination. Cyber-educators will continue their training program, as they lead social media efforts in each country platform. Online trainings tools will be set up.

PASMO/PSI will continue to carry out planning, interventions and prevention activities in close coordination with other key partners, such as USAID partners in health, other USG agencies, other donors, and regional and local working groups.

Program target populations for VCT activities include TRANS, FSW and their partners, MSM, Men at Risk and Caribbean Populations. The average HIV prevalence rates in the region is between 2-6% for FSW, between 10-12% for MSM and around 20% for Trans. The program aims to test approximately 22,500 individuals in FY12. Studies have shown that FSW testing rates range from 68%-94% and MSM testing rates range from 52%-75% in the last 12 months in the region.

In order to increase access to VCT/STI services among MARPs, the Program will continue implementing a mobile VCT approach that includes STI screening and references for STI diagnosis and treatment. Mobile outreach services will be conducted by first generating demand through educational outreach activities at places where the target groups gather. These mobile VCT teams are part of prevention teams that will offer the minimum package of services including behavioral, biomedical and structural interventions. PASMO/PSI also supports national efforts in Guatemala and El Salvador during National Testing Week or National Testing Day (the only two countries in the region with these campaigns). A Unique Identifier Code will help track referrals and linkages and will provide evidence if the people reached with CT can complete the full combination prevention cycle.

VCT efforts includes working with private sector (private laboratories), public sector (MoH facilities), IPPF affiliates and any NGOs that offer these services; PASMO/PSI will explore how to integrate them into a network of MARP friendly service outlets. The protocols and algorithms used by the program, are approved by MOH. Training certifications will be offered in provision of VCT (approximately 90 individuals will be trained among the region) and educational materials will be developed for these trainings. The communication strategy and new materials for VCT promotion will be developed, including a variety of print materials such as VCT/STIs brochures and a list of references. When appropriate these materials will be tailored to specific target populations.

The program will also purchase rapid tests. These rapid tests will be purchased according to local guidelines and regulations for the provision of HIV testing services, in compliance with USAID Environmental Regulations for the disposal of medical waste, including needles and syringes.

Mystery client surveys and HIV service provider surveys will be used to measure quality at provider sites. The program, through its IPPF partner, will also use client intake data to measure client satisfaction and target program activities more effectively.

VCT Working Group will continue working in Guatemala and will be established in other countries. These are spaces where the social marketing, private and public sectors meet regularly to coordinate activities, discuss shared strategies, and analyze pertinent research related to these services.

PASMO/PSI will increase access to a minimum package of prevention services for MARPs in Central America. Program target populations for are Trans, FSW and partners, MSM, PLWHA, Men at Risk and Caribbean Populations , with a focus on Trans and PLWHA. The three main components that make up the combination approach are: a) Behavioral interpersonal communication activities, correct condom and lubricants use promotion. b) Biomedical interventions that improve access to condoms and lubricants, STI screening and treatment, referrals to VCT through both the public and private sector. Biomedical services are funded by PASMO/PSI and their sub-partner IPPF affiliates in the private sector and the in for the public sector. c) Structural interventions that will provide support to prevention actions adopted by individuals. These include family planning counseling, referral to support groups for legal support, violence, self-acceptance, nutrition, and referral to alcohol/drug treatment centers. The program further works to change social norms, reduce stigma and discrimination related to sexual orientation, occupation and serostatus, and address cultural, organizational, community, and economic factors that increase the vulnerability of MARPs. An integrated masculinity and anti-stigma/discrimination campaign will be developed. Journalists and decision makers will be sensitized.

A specific package of services with tailored materials and activities has been developed for each target population but all incorporate a minimum package of services. This package includes 3 behavior change communication activities, one HIV test or STI diagnosis and treatment and one structural level intervention. For one person to be counted as reached they must pass through this minimum package. Of the total people reached, at least 15% will be reached with the full package 3 times a year, the rest will pass through the services once a year.

Examples of specific approaches to reach MARPs include a strategy for implementing social media activities and implementation of a website for PLWHA and their family and friends, the creation and implementation of an interactive cellphone telenovela for FSW, materials to promote human rights education among MSM, and specific educational materials and methodologies for Trans populations. All activities and services will take into account gender considerations, in particular the need for a change of social norms related to male and female roles in society.

The program is going to spend $290,952 to reach 8% of FSW population (or 5,824 women), $484,920 to reach 9% of MSM population (or 15,500 men), $606,150 to reach 61% of Trans population (or 1,290 trans), $727,380 to reach 7% of PLWHA population (or 9,500 people), $242,460 to reach 21,015 men at risk and $72,738 to reach 735 of the Caribbean populations targeted with the full package of services at least once. Costs are higher for Trans and PLHWA due to the programs increased focus on these two populations and the need to create new materials.

Quality Control includes monthly monitoring plans, data collection and analysis, site visits, and a vouchers referral system. A Unique Identifier Code will be implemented, allowing the program to track the number of individuals reached with the minimum package. PASMO/PSI will conduct TRaC studies with MSM and FSW in each country and with TRANS and PLWA at a regional level to monitor and evaluate the impact of the overall program.