Although the majority of new HIV infections in Mozambique occur in the general population, some population sub-groups are at significantly elevated risk, including persons engaged in sex work; clients of persons engaged in sex work; drug-using populations; men who have sex with men (MSM); military/police and other uniformed services; men and women engaging in transactional sex; incarcerated persons; mobile populations (e.g. migrant workers, truck drivers); street youth; and persons who engage in alcohol- associated HIV sexual risk behaviors.

In general, these most-at-risk populations (MARPs) and bridge populations have not been priority groups for prevention activities in Mozambique. Related USG Mozambique support to date has included training with focus on innovative behavior change communication (BCC) strategies. Peer education for female

sex workers (FSW) is being implemented, and with the full participation of FSW a video tracing their life stories was produced to support BCC messaging with their peer sex workers and, another is being produced for drug users.

In this context, the goal of this project is to improve HIV prevention activities among MARPs and ultimately impact HIV transmission rates in Mozambique. An effective program for MARPs and bridge populations in Mozambique will require a combination approach building on available information, existing activities, addressing gender related vulnerabilities and innovative approaches to expand the scope and coverage of interventions for key populations. Priority groups include, but are not limited to, FSW and clients; MSM; and drug users (IDU and NIDU including alcohol abuse). Recipients (grantees) will be expected to collaborate closely with the GOM and implementing partners to continue the implementation of existing services, based on achievements in Mozambique and seeking to improve interventions and scale up access to services. The geographic focus of this activity will be in Cabo Delgado, Nampula, and Inhambane Provinces.

There is substantial evidence for the effectiveness of a core set of interventions for populations at high risk for HIV. These interventions illustrate a minimum package of services for MARPs. Activities should focus on MARP populations that represent the most significant burden of disease, based on population size estimate and impact of HIV. Activities should be conducted as part of comprehensive programming that includes a minimum package of services: implementing, monitoring, and improving comprehensive HIV prevention programs for MARPs and other vulnerable populations. These programs include core public health components of outreach, HIV counseling and testing (CT), risk reduction counseling, condom distribution, education and promotion, screening and treatment of sexually transmitted infections (STI), and for those who are HIV-infected, referral to prevention of mother to child transmission (PMTCT) services and HIV care and treatment. For sex workers, more comprehensive programs can also include referral to family planning and other reproductive health services, psychosocial and legal services including substance abuse treatment, and linkages to income generation programs for those wishing to quit sex work. Activities will be designed to include gender equity programming as well as information and screening for gender-based violence interventions.

Activities are expected to help build capacity in Mozambique for sustainable implementation of relevant interventions, through close work with non-governmental organizations (NGOs) and community-based organizations (CBOs) reaching higher risk populations that advocate for and provide targeted services to marginalized, clandestine and mobile populations. All activities are to be pursued in coordination with the USG team, the GOM, and other implementing partners. New activities will build upon and replicate successful MARP programs currently supported.

Activities will also include design and implementation of a surveillance system at designated STI night clinics established for FSW, to provide much needed qualitative and quantitative information around specific MARPs groups. These activities will be conducted in additional provinces where STI night clinics are currently operational.

This activity support Partnership Framework goal 1, to Reduce new HIV infections in Mozambique (Objective 1.1: Reduce sexual transmission of HIV through comprehensive prevention interventions, including activities with MARPs).

Activities will be conducted at central level with GOM, and in three provinces: Cabo Delgado, Nampula, and Inhambane. Activities will include detailed mapping of MARP/bridge population interventions in relevant geographic areas; elaborated/adapted curricula for IEC, BCC, risk reduction, etc.; approved and disseminated policy and materials for MARP interventions, either at national level or individual provincial level; and demonstrated strengthened linkages of MARPs with care and treatment facilities (referral

charts, monitoring instruments), establishment of moonlight clinics, etc.

Measurable outcomes of the program will be based on number of individuals trained to implement MARP interventions; number of individuals reached with MARP interventions; and capacity building for sustainable interventions, including demonstrated evolution of organizational capacity of local organizations.

Activities will also include design and implementation of a surveillance system at designated STI night clinics established for FSW. This surveillance system will be implemented in order to provide much needed qualitative and quantitative information around specific MARPs groups in a clinical setting. Such data collection is considered a critical SI activity in that data around MARP populations in these settings has been a traditionally difficult data set to collect. As part of the need to move towards more evidence- based intervention programs, more quantitative and qualitative information around specific MARP groups is critical in the scaling-up of MARP evidence based interventions and programs. In addition, it is expected that this surveillance activity will begin to assist both the MOH and the NAC in developing more comprehensive datasets around MARPs. Such surveillance should also provide information about the effectiveness of MARPs oriented activities and interventions supported by the USG.