This is a continuing mechanism which serves PF Goal I: Prevention - reduce new HIV infections in Malawi and PF Goal II: Treatment, Care and Support - improve the quality of and access to treatment and care for Malawians impacted by HIV. These contributions directly support National Action Framework (NAF) Objective 1.1 (reduce the sexual transmission of HIV), NAF Objective 2.2 (increase access to a continuum of HIV care and treatment services) and NAF Objective 2.1.3 (strengthen referral systems within and between health facilities and community). The Evidence-Based Targeted HIV Prevention (EBT-Prev) Project focuses on implementation of HIV prevention activities in settings and populations with high-risk behaviors. The project will: conduct research to build a body of evidence that supports targeted adult prevention interventions; develop partnerships and interventions beyond PSI's mass communication strategies to address underlying issues for HIV prevention in high risk settings; develop linkages, networks and referral systems to support HIV prevention service provision in those settings; and use PSI's communications and condom social marketing (CSM) expertise to build new partnerships with local NGOs to address issues of concurrency, transactional sex, prevention with positives, discordance, improved CSM and appropriate support for male circumcision (MC) with selected MARPS. PSI will ensure that these targeted activities dovetail with general population HIV prevention activities thereby building synergy. In partnership with Banja La Mtsogolo (BLM) and with collaboration from national stakeholders, PSI will work to package MC as a health intervention that targets the general population, as opposed to promoting MC as a stand alone HIV prevention intervention, thereby assisting PEPFAR lay the foundation to launch further MC interventions, at a later stage, once the policy environment is conducive. EBT-Prev is designed to reach most at-risk populations (MARPs), populations that are identified as being at elevated risk of HIV infection because: (i) they are members of a group with high risk behaviors; (ii) they frequent known high risk settings; or (iii) a combination of these two factors. By implementing an extensive research agenda that utilizes an innovative combination of research methods (PLACE, GIS mapping and TRaC), EBT-Prev will identify populations and settings with high risk behaviors. In FY10, EBT-Prev will conduct an intensive baseline assessment to identify, segment and profile populations and settings (Priority Prevention Areas, or PPAs) with high risk behaviors. Specific target groups will be identified using research findings and may include CSW, migrant workers, truckers, MSM, men with money and women engaging in transactional sex.

In FY10, EBT-Prev will continue to deliver integrated behavior change communications (iBCC) interventions to populations with high-risk behaviors in existing 'hot spots' while research progresses in 5 pilot PPAs. In FY 11, these activities will be linked into HIV service provision networks, to be established under EBT-Prev, providing a 'point of entry' to the HIV continuum of care thereby fostering and expanding access to HIV prevention services and reducing HIV risk by targeting behavior change in these high risk

settings. In FY11, PSI will identify additional PPAs by utilizing the research findings, in conjunction with latest district-level HIV prevalence data, to give the project national coverage in a targeted manner.

EBT-Prev will sustain and refine PSI's general population marketing and distribution of male and female condoms to increase availability, including generic and branded communications. A family planning male condom will be introduced to the general population which will, additionally, provide an opportunity to develop a new CSM approach for discordant couples and PLHIV, including marketing and distributing male and female condoms in care and treatment settings and PLHIV groups in identified PPAs.

EBT-Prev will become more efficient overtime by partnering with Pact Malawi to build local NGO capacity to deliver project activities at PPA level. By utilizing a 'hub and spokes' model, PSI will form a research, communications and CSM 'hub of expertise' with Pact sub partners creating an extensive network of local NGOs acting as delivery 'spokes'. These NGOs will receive both technical and administrative capacity building from PSI and Pact throughout the project. This model will build project sustainability as knowledge and expertise is built at the local level and ensures integration with existing activities by partnering with local NGOs. Through Pact, PSI will also partner with MACRO, a renowned HTC local NGO in Malawi which has numerous testing sites that will be utilized as points of entry for linking into the continuum of care in identified PPAs.

EBT-Prev will address gender as a cross-cutting issue with iBCC interventions developed to address existing gender, sexuality and power constructs that increase both women's and men's vulnerability to HIV in different ways. The service provision network will be developed to be cognizant of the different needs of women and men and to include services to meet these needs accordingly.

Budget Summary PFIP Year 1 Funding - $3,228,511 PFIP Year 2 Funding - $4,394,372

IV. Budget Code: HVCT

$915,354 - Year 1 $1,054,843 - Year 2

With PF Year 1 funds PSI will implement the following activities:

In FY10, PSI will focus on completion of the research baseline assessment to identify PPAs and key behavioral determinants for target groups in support of HTC activities. PSI will also conduct pilot activities in Dwangwa sugar plantation to design and develop a HTC service provision network by local sub partners that will be replicated in additional PPAs in FY 11 to strengthen HTC uptake among the target groups. The promotion of HTC services among identified target populations will be achieved by utilizing a range of communication and interpersonal activities and by linking such activities to local healthcare services. The geographic coverage of HVCT activities will be determined by the identification and distribution of PPAs.

With PF Year 2 funds PSI will implement the following activities

A network of service providers will be established in 7 PPAs to support and promote increased access and uptake of services by populations with high risk behaviors. An integral activity in establishing these networks is to build effective referral networks in and around PPAs to ensure appropriate linkages to care, treatment and prevention services. To build robust referral networks, four specific activities will be undertaken in FY 11, as follows;

1. Identification and development of Strong Network Coordinators. These providers will have the credibility and infrastructure to support clients with chronic conditions and the capacity to provide some integrated services, conduct regular follow-up and refer clients to services outside their own scope, as required. Pact's partners that implement integrated HIV/AIDS programs will be critical to the development of this important role.

2. Build a HIV service provision network within and around PPAs. Using qualitative research to understand provider needs and barriers and how best to position the network to ensure provider participation in the network, tools, materials and training will be developed to recruit and motivate providers to network with one another, including development of a Service Directory.

3. Network Branding and Identification. A network brand will be explored and developed to unify communication materials, identify service points and build teamwork and commitment among providers.

4. Develop, disseminate and promote tools for effective referral and tracking. In collaboration with NGO partners and providers, PSI will develop mechanisms to facilitate referrals among providers and address the challenges of "back-referrals". Experience shows that vouchers, coupons and other referral documentation may aid clients to find recommended services and provide raw data to measure the breadth and depth of referral activity. EBT-Prev partners and providers will seek out sustainable, community-based solutions to address the issue of client transportation, a key barrier to successful referrals.

III. Budget Code: CIRC

$140,000 - Year 1 $172,775 - Year 2

With PF Year 1 funds PSI will implement the following activities:

PSI in partnership with Banja La Mtsogolo (BLM) and in collaboration with national stakeholders will explore how to motivate for and support the uptake of MC services as a health intervention to prevent various health risks for men and women including HIV transmission. Pending the development of policy and guidance from the Malawi MOH on MC for HIV prevention, it is envisioned that this partnership will

capitalize on BLM's existing network of clinics and their clinical expertise in undertaking medical MC and benefit from PSI's expertise in behavior change communications, quality assurance support and social marketing for MC.

In FY10, PSI will focus on the development of PSI-BLM strategic partnership document to guide development of MC services as a health intervention in Malawi following which PSI, in partnership with BLM, will commence supporting MC services by providing training and designing quality assurance and social marketing tools for MC in Malawi. Further to this, PSI will establish a target and report on the number of locations providing safe MC surgery as part of the minimum package of MC services within the reporting period (P5.3.D). Geographic coverage of MC activities will be in line with distribution of PPAs.

PSI will undertake activities to promote the uptake of health services such as HTC, STI and FP as essential components of quality HIV programming; successful communication regarding these services will lead to increased demand for these services which will serve as 'points-of-entry' for MC services. PSI will develop a HIV Service Directory for each PPA which will also include locally available MC services.

PSI will support high quality MC services by visiting MC providers to assess capacity and service quality. PSI will draw upon existing protocols, Quality Assurance checklists and technical personnel from other PSI platforms with experience in social marketing of MC to ensure that MC services in PPAs follow established best practice.

With PF Year 2 funds PSI will implement the following activities:

PSI will continue to implement activities to promote the uptake of health services as essential components of quality HIV programming and the successful communication on, linkages to and referrals to these services will lead to increased demand for these services which will continue to serve as 'points- of-entry' for MC services in the absence of a supporting policy environment. PSI will continue to promote the use of the HIV Service Directory in each PPA including locally available MC services.

PSI will continue to support high quality MC services in and around PPAs through support and supervision visits to MC providers. PSI will use evidence generated from implementing MC activities to influence policy support for MC at national level.

I. Budget Code: HVAB

$963,799 - Year 1 $1,223,037 - Year 2

With the generalized AIDS epidemic in Malawi, multiple and concurrent partners (MCP) connects large numbers of people into a few, large sexual networks that put many individuals at risk of HIV. A person can be linked into a sexual network and at high risk of HIV infection even if that individual has only one partner, if that one partner is currently linked into sexual network or has been linked into one in the past. MCP with low condom use is a key driver in the HIV epidemic in Malawi. 27% of men and 8% of women reported having sex with a non marital, non cohabiting partner in the year prior to the survey and condom use was less than 50% (MDHS 2004). Therefore to effectively address the HIV epidemic it is critical to have a strong appreciation of why individuals engage in MCP and to address these realities in a consistent and appropriate manner.

PSI will deliver Abstinence/Being faithful (HVAB) activities, including training, aimed at preventing HIV transmission by delivering messages/programs to promote reduction of (MCP) and transactional sex and other related social and community norms that impact these behaviors. The geographic coverage of HVAB activities will be determined by the identification and distribution of PPAs. It is envisioned that over the life of the project approximately 25 PPAs will be established nationally.

With PF Year 1 funds PSI will implement the following activities:

Targeted Outreach Communication (TOC) - Existing PSI TOC teams will continue to conduct interpersonal communications (IPC) educational events and interactive audiovisual shows that focus on risk awareness and promote adoption of safer sexual behaviors, including partner reduction, in 'hot spots' by raising awareness of key risky behaviors and issues such as MCP, transactional sex and discordance respectively.

Interpersonal Communication (IPC) - IPC activities are divided into two components: IPC Outreach activities that engage less specific, less readily identifiable target groups (e.g. men with money, etc.) and Peer Education (PE) activities that work with more readily identifiable risk groups (e.g. FSW.) IPC Outreach activities will promote adoption of safer sexual behaviors, including partner reduction, by conducting individual and group level interventions through local NGO partners.

Mass Media - such campaigns will center on increasing risk perception and raise awareness of the risks of MCP, transactional sex and discordance while promoting strategies that will support adoption of safer

sex behaviors, including partner reduction. Campaign materials will be developed with broad stakeholder involvement and will be rigorously pre-tested to ensure that messages are appealing, appropriate and understood by target groups.

Links to local healthcare services - Activities to reduce MCP will include messaging on linkages to local health services, including public sector facilities, CHAM, BLM clinics and private health care providers to raise awareness and encourage utilization of support services such as STI and HTC.

Positive Prevention - EBT-Prev will contribute to HIV prevention with positives by communicating and implementing messages, through mass media and appropriate IPC channels, on PwP issues including: personal risk perception, discordance, safer sex, Family Planning (FP), PMTCT, linkages to PLHIV support groups and the benefits of HTC and pre-ART program activities.

MSM - Research shows that 67% of men who engage in MSM activities in Malawi are married. Given this fact and the very high risk associated with MSM activities, it will be very important to work with MSM on the risks associated with MCP - both within the MSM network and outside the MSM network into the heterosexual population. Working with CEDEP, a local partner NGO, PSI will develop and pretest appropriate messages and interventions for this target group to promote adoption of safer sexual behaviors, including partner reduction.

With PF Year 2 funds we expect to implement the following activities;

Using evidence generated from research in the five pilot PPAs, PSI will expand implementation of the above mentioned HVAB activities into 7 new PPAs to address key issues including MCP, transactional sex and discordance among identified target groups. In FY11, PSI will also develop and implement community-level interventions and referral systems between services, through Pact sub partners located in the PPAs, to deepen the scope and quality of PSI's communications and IPC activities.

II.Budget Code: HVOP

$1,665,009 - Year 1 $1,943,717 - Year 2

PSI will deliver Other Sexual Prevention (HVOP) activities aimed at preventing HIV transmission by implementing communication and interpersonal (individual and group level) activities to complement HVAB activities. HVOP activities will be designed in a manner that will address MCP, transactional sex and discordance among identified target groups.

With PF Year 1 funds we expect to implement the following activities:

Targeted Outreach Communication (TOC) - Existing TOC teams will continue to conduct IPC educational events, interactive audiovisual shows with emphasis on correct and consistent condom use in the targeted areas. Activities will include promotion of both male and female condoms and raising awareness of the risks of MCP, transactional sex and discordance.

Interpersonal Communication (IPC) - IPC Outreach activities will include individual and group level discussions and interventions that will address risk perception, promote efficacy to reduce risk at individual or group level and promote condom use. Interventions and messages will focus on promoting the uptake of HIV prevention services, including HTC and other health services, such as FP, STI, PMTCT, and risk reduction counseling.

Mass Media - such campaigns will center on increasing risk perception and addressing myths and misconceptions about condom use, benefits of knowing one's HIV status and seeking HTC as well as the benefits and availability of HIV prevention and care services for those who are HIV-positive. Campaign materials will be developed with broad stakeholder involvement and will be rigorously pre-tested for appeal, appropriateness and understandability.

Links to local healthcare services - All HVOP activities will raise awareness of linkages to local health services, including public sector facilities, CHAM, BLM clinics and private health care providers. TOC staff, IPC Outreach Workers and Peer Educators will receive training on existing services to encourage and promote service utilization for STI, HTC, MC, FP, PMTCT and GBV.

Positive Prevention - EBT-Prev will support prevention for HIV positive persons, their partners and their children by consistently communicating through mass media and appropriate IPC channels on key issues including: promotion of HTC for couples; condom promotion to discordant couples using the introduction of a FP male condom targeting established couples; and behavior change communication for positive prevention, including messaging on personal risk perception, self-efficacy, discordance, safer sex, FP, PMTCT and PLWHA support groups.

MSM - By working with CEDEP, the scope and extent of MSM communities in and around PPAs will be

identified. CEDEP will guide PSI and local NGO partners to appropriately engage with existing MSM networks and disseminate information on the risks faced by MSM and adoption of safer sexual behaviors, including condom use. Opportunities to introduce MSM peer education activities, incorporating use of condoms by MSM and development of MSM-specific HTC counseling modules, will be investigated.

Condom use and social marketing (CSM) - Activities aimed at sustaining and refining CSM to the general population will include: generic mass media communications to increase condom use; Chishango branded activities, including the re branding of the current Chishango packaging (with no change to the actual product) and the subsequent evidence-based development and launch of a Chishango scented variant targeting the more urban market with the original product repositioned to target the rural market. In addition, a FP male condom will be launched targeting couples and PLHIV. It is anticipated that this condom market segmentation will result in increased overall condom use. With UNFPA co-funding, EBT Prev will continue to sell CARE female condoms to pharmacies, drug stores, clinics and hair salons. PSI will expand the current CARE female condom program activities to target FSW and women engaging in transactional sex. Using a proven method from the region, PSI will identify, recruit and train FSW 'Queens' - older, less mobile and respected FSW - who will be trained to sell CARE female condoms to their colleagues and customers.

With PF Year 2 funds PSI will implement the following activities:

PSI will expand implementation of the above mentioned HVOP activities into 7 new PPAs to address key behavioral issues including MCP, transactional sex and discordance, among the identified target groups using the evidence generated from the research in the five pilot PPAs. In FY11, PSI will develop, implement and strengthen community level interventions and referral systems between services, through Pact sub partners located in the PPAs, to deepen the scope and quality of PSIs communications and interpersonal activities. Pact Malawi will put out an APS that will identify additional local partners to implement community level activities in the PPAs.