The EBT-Prev project focuses on implementation of HIV prevention activities in settings and populations with high-risk behaviors. Using a robust research approach with at-risk populations, the project implements combination prevention (CP) interventions designed to increase adoption of safer sexual behaviors under the branded campaign: Tsankha Lingalira Sankha -Think about It, Its your Choice.

EBT-Prev works with vendors, fishing communities, plantation workers (all male & female, 20-49), Men who have Sex with Men (MSM), and Female Sex Workers (FSW) in 20 Priority Prevention Areas (PPAs) distributed geographically throughout Malawi. PPAs are in the Northern Region: Karonga boma, Mzuzu City, Nkhatabay boma; Central Region: Dwangwa, Lilongwe Old Town, Likuni, Mchinji boma, Salima boma; and Southern Region: Thyolo, Mulanje, Nchalo, Bangwe, Ndirande, Lunzu, Mwanza, Cape Maclear, Zomba, Liwonde, Makanjira, Maldeco.

In line with national strategic priorities, including: 1) support for effective rollout of the integrated ART/PMTCT program (FP, couples HTC, male involvement, PMTCT, GBV, and partner reduction) within high prevalence settings and among key populations, 2) scale out of VMMC as part of risk reduction activities, and 3) increased attention to womens vulnerability to HIV, EBT-Prev delivers a package of mutually reinforcing interventions, including behavior change communications, condom programming and access to HIV service across the continuum of care. In addition, EBT-Prev will provide comprehensive VMMC services within two targeted districts building on existing communications and referral activities.

In FY12, PSI will provide voluntary medical male circumcision (VMMC) services in Thyolo and one urban district (Blantyre) at scale. PSI will ensure that VMMC services follow established best practices from the region, utilizing dedicated resources, dedicated staff, outreach approaches and other approaches that maximize volumes and efficiencies. Quality assurance activities, including development of protocols, quality assurance checklists, and other appropriate measures will be addressed. PSI proposes to establish six dedicated teams that operate on an outreach basis from tented mobile facilities to provide 9,000 VMMCs over the first three months, offering HTC and condoms onsite. An existing referral network to HIV treatment and care services will be offered to HIV+ men. PSI will work in close partnership with BRIDGE II to provide technical leadership around VMMC communications planning, as well as training support to partners on the ground. Immediate priorities are finalization of the national communications strategy, materials, and branded VMMC services. All existing BCC interventions (TOC, IPC, peer education, and mass media) will integrate VMMC messages into existing communications activities within all priority prevention areas (PPA) with targeted community mobilization activities implemented for saturation districts. VMMC services will be integrated into the already established referral networks in each PPA and will provide specific VMMC training to service providers to encourage uptake of services, as required. All undertaking associated with VMMC service provision will be implemented as directed by MOH, as appropriate. In FY13, PSI will continue to deliver VMMC services and associated quality assurance and communications activities to provide 36,000 VMMCs. PSI will continue to collaborate with BLM and others to ensure adequate future VMMC service delivery capacity to enable Malawi to achieve established VMMC targets as more funds become available. PSI will clear, store, and distribute centrally-procured commodities to lead partners within targeted districts. Warehouse capacity will be assessed and upgraded to meet standards for storage of commodities.

PSI will use FY12 and FY13 funds to implement a combination of prevention interventions with vendors, fishing communities, plantation workers (male & female, ages 20-49), MSM, & FSW in 20 targeted priority prevention areas (PPA). Interventions are designed to address underlying behaviors and social norms that support concurrency and low condom use -- taking into consideration prevailing gender dynamics that influence men and womens participation in such behaviors -- and link populations to service uptake (couple HTC, PMTCT, FP, ART, VMMC, and GBV.)

Targeted outreach communications will intensify interpersonal communication educational events and interactive audiovisual shows to focus on risk awareness and to promote adoption of safer sexual behaviors in PPA. Sessions will explore risks of MCP and discordancy to promote condom use and couples HTC, and align with available SRH and HIV services. Gender-specific challenges are addressed through same sex sessions and community wide discussions of GBV. Messaging will promote uptake of PMTCT, VMMC, FP, and couple HTC services as part of the existing branded communications campaign to provide a consistent and recognizable communications vehicle with messages rotating over time. Members of all target groups will receive two evidence-based interpersonal communication (IPC) sessions per quarter for small-group skills-based education. IPC messages will be packaged as part of the ongoing branded communications campaign. The campaign will use radio to reinforce BCC messages delivered through other activities. EBT prevention communication activities are linked to referral network activities to increase access to HIV services among target groups.

Quality assurance is a priority. Messaging will be developed centrally and disseminated by trained staff with quarterly support and supervision. Standardized materials are developed centrally and used at PPA level.

Access to services across the HIV continuum of care, with particular emphasis on access to HTC services is a critical component of a combination prevention approach to HIV. As such, PSI will continue to deliver improved access to such services through the referral networks developed in each PPA for vendors, fishing communities, plantation workers (all male & female, ages 20-49), MSM, and FSW who engage in concurrent partnerships and low condom use.

With FY12 funds, PSI will implement the following activities: with PPA referral networks established in previous fiscal years, PSI will focus HVCT activities on the support and supervision of the referral network with particular emphasis on the monitoring and evaluation of the referral process, as well as a determined focus on quality assurance of services provided. The promotion of HTC services among identified target populations will be achieved by utilizing a range of communications activities and by linking such activities to local healthcare services and by strengthening local HTC provision through a PACT Malawi partner, MACRO, with dedicated responsibility to provide HTC services within PPAs under EBT prevention. Targeted teams will conduct quarterly HTC community mobilization activities with MACRO to create demand for HTC services and to supply HTC services respectively.

Referral networks will address the needs of survivors of gender-based violence (SGBV) by training service providers to screen for GBV and to refer SGBV to appropriate services, including Post Exposure Prophylaxis (PEP) as needed. Effective referrals within established networks will maximize opportunities for MARPs to access a range of required services, including VMMC, FP, PMTCT, GBV-related services, as well as HTC services.

With FY12 PEPFAR funds, PSI will implement the following activities: PSI will continue to work with local structures and partners to support and supervise improved access to HIV services with particular emphasis on tracking referrals through the effective M&E processes. The key roles of couple HTC, VMMC, FP and PMTCT services will continue to be highlighted through BCC activities.

Targeted outreach communication teams will intensify BCC activities with target groups in PPAs to promote couples HTC, PMTCT, FP and VMMC services. IPC activities will reach members of all target groups with two evidence-based IPC sessions per quarter for small-group skills-based education. Messaging on correct condom use, male involvement, discordancy and service uptake will be delivered as part of the branded campaign which provides a consistent and recognizable communications vehicle with messages rotating quarterly. Radio spots will be used to reinforce messages delivered through other activities. Peer-based FSWs interventions will be revamped to address holistic needs including risks around sex with a trusted partner and access to comprehensive PMTCT services, including family planning. Peer queens are trained for female condom promotion and links to focused HTC, GBV screening and referral. MSMs, reached through trained peer IPCVs, will address MSM-specific needs including condom and lubricant distribution and access to trained MSM-friendly services. Condom use promotion includes maximizing the number of socially marketed condom outlets in PPAs; working with local DHOs to facilitate adequate supplies of free public sector condoms; procuring an improved male condom to meet consumer needs; and with UNFPA co-funding, promote and sell CARE female condoms. Consistent condom use will also be part of the VMMC service package. To streamline the existing referral system, IPC volunteers will be trained as referral agents using a central facility hub to track referrals. Specific activities will focus on improving the quality of counseling by health service providers to enhance access to GBV, VMMC and PMTCT services within PPAs. Quality assurance is promoted by standardized materials developed centrally and disseminated by highly trained staff with quarterly support and supervision in each PPA. For population targets, see HVOP Budget Code Narrative Table in the document library.

Most at risk womens broader SRH needs are often forgotten in spite of high HIV prevalence in their communities. Female sex workers, women engaged in MCP and transactional sex in estates, fishing communities, and markets, are at high risk for unintended pregnancies, and mother to child transmission. With the scale out of the new PMTCT/ART treatment guidelines, these populations need to understand the benefits of family planning (FP), and if pregnant, early ANC, HIV testing with partner, and preparedness of life-long treatment for HIV+ mothers.

In FY12 and FY13, PSI's EBT prevention strategy will integrate key PMTCT messages and ensure referrals to FP and PMTCT services into all communications activities under the branded campaign within the targeted PPAs. Quarterly messages will promote uptake of PMTCT services, address male involvement in family planning, and promote uptake of services as a couple. Community HTC events will emphasize the importance of couples testing, and ensure efficient referrals for all women that test positive. Promoting disclosure and adherence support will be part of communications activities with referrals to community based care and support services.

EBT prevention will strengthen linkages with PMTCT services in all PPAs through its developed referral network activities. Service providers will be trained on the importance of HIV+ pregnant women, being referred for and accessing PMTCT services.

With leveraged funds, EBT prevention, will expand access to their social marketed family planning methods within PPAs. This will provide opportunities to complement informed choice about family planning with community based FP distribution. Peer-based female sex workers interventions will integrate messages about family planning options and PMTCT services and linked to focused HTC, GBV screening and referrals to HIV services.

Quality assurance is promoted by messaging being developed centrally and disseminated by trained staff with quarterly support & supervision.