Including HIV-infected individuals in the effort to prevent new HIV infections ensures the prevention needs of HIV-infected individuals are incorporated into HIV responses and recognizes that changes in the risk behaviors of HIV-infected individuals are likely to have a greater impact on the spread of HIV than comparable changes in the risk behaviors of HIV-negative individuals. The objectives of prevention efforts with PLHIV, referred to as prevention with positives (PwP), are to prevent the spread of HIV to sex partners and infants born to HIV infected mothers, as well as to protect the health of infected individuals as part of a comprehensive HIV prevention approach.

The rapid scale-up of HIV care and treatment in resource limited settings has provided an opportunity to reach many HIV infected individuals with prevention messages and interventions within HIV settings. While behavioral interventions effective for HIV negative persons may be adaptable in some ways to interventions for HIV infected persons, the needs and motivations for HIV infected persons are likely to be quite different. These differences include disclosure to partners, preventing transmission to partners or unborn children, stigma of HIV infection, and negotiating sexual relationships as an HIV infected individual. In addition, community based services for PLHIV are integral for accessing PLHIV who are not treatment eligible and who do not receive clinical services. Community based services can provide an opportunity to reinforce messages that PLHIV receive from their providers.

However, in both clinical and community settings, HIV prevention is rarely incorporated into services for PLHIV, resulting in missed opportunities to reach PLHIV with programs to reduce HIV transmission to others. The purpose of this activity is to support a comprehensive PwP strategy that incorporates all relevant interventions to prevent the onward transmission of HIV. Interventions will also protect participating PLHIV against possible HIV re-infection, acquisition of sexually transmitted infections, and unintended pregnancies which could lead to mother-to-child transmission. Relevant evidence based interventions that comprise a comprehensive PwP strategy include STI management, family planning counseling and services, adherence counseling, alcohol reduction counseling, HIV counseling and testing for partners and families, education for correct and consistent condom use, condom promotion and distribution and disclosure counseling and support. Appropriate referrals should also be part of the strategy, including linkages to care and treatment services for HIV-infected individuals, as well as linkages to HIV prevention services (e.g. male circumcision) among HIV-negative individuals. Related wrap- around programming, such as income generation and food support, should be considered to maximize programmatic impact.

Currently, USG is supporting a PwP demonstration project that targets providers in facility and community based settings in Maputo and Sofala Provinces, including physicians, nurses, counseling and testing staff, home-based care staff, adherence support staff, support groups, and other site staff who were trained using country specific materials. PwP training materials have been adapted to represent the context of risk and HIV care in Mozambique, including the following eight modules: (1) Course overview and introduction to PwP; (2) Introduction to prevention counseling; (3) risk reduction and prevention messages; (4) Discussing disclosure; (5) Sex and sexuality, negotiation, and family planning; (6) Prevention of vertical transmission; (7) Living positively; and (8) Conclusion.

The overall goal of this activity is to implement a PwP program that will address the prevention needs of PLHIV and ultimately impact HIV transmission rates in Mozambique. In FY 2010 the PwP program in Mozambique uses three key approaches towards attaining this goal: 1) Provide training and technical assistance on PwP to HIV service providers, including USG clinical services partners. Service providers can include healthcare workers, testing and counseling staff, and peer educators; 2) Integrate HIV prevention into existing HIV program activities, including facility-based (antenatal care, care and treatment facilities, home based care, TB treatment settings, etc.), and community-based settings (community HIV counseling and testing, peer support programs, etc); 3) Work closely with the GOM to support planning, implementation, and monitoring and evaluation of PwP interventions.

FY 2010 activities will focus on scale up access to PwP (e.g. through integration of PwP services in existing HIV activities, and expansion in both geographical and technical scope) in addition to maintaining existing USG activities in Mozambique, in line with GOM and USG Mozambique goals. Training activities will be expanded to build skills and increase capacity and sense of responsibility among service providers to address HIV prevention needs with HIV infected clients. All activities will be conducted in provinces supported by CDC clinical services partners in Maputo City and the Provinces of Maputo, Gaza, Inhambane, Zambézia, Nampula, and Cabo Delgado. Ongoing activities in Sofala Province will continue as well.

These activities are linked to the Parnership Framework goal 1, to reduce new infections in Mozambique. Prevention is a high priority for both USG and GOM, and PwP is one of the key areas to be expanded and integrated within the national care and treatment program.

In FY 2010 training and implementation activities will be expanded. Key approaches will be to provide training and technical assistance on PwP to HIV service providers, including USG clinical services partners; to integrate HIV prevention into existing HIV program activities, including facility-based (antenatal care, care and treatment facilities, home based care, TB treatment settings, etc.), and community-based settings (community HIV counseling and testing, peer support programs, etc); and to work closely with the GOM to support planning, implementation, and monitoring and evaluation of PwP interventions.

Activities will focus on scale up access to PwP (through integration of PwP services in existing HIV activities, and expansion in both geographical and technical scope) in addition to maintaining existing HHS/CDC activities in Mozambique, in line with GOM and USG goals.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR: 1) Number of individuals (healthcare providers and counselors) trained to implement PP interventions; 2) Number of individuals reached with minimum package of PP interventions.

Other measurable outcomes will include approved and disseminated policy and materials for PP interventions, either at national level or individual provincial level; and capacity building for sustainable PP interventions.

In FY 2010 training and implementation activities will be expanded. Key approaches will be to provide training and technical assistance on PwP to HIV service providers, including USG clinical services partners; to integrate HIV prevention into existing HIV program activities, including facility-based (antenatal care, care and treatment facilities, home based care, TB treatment settings, etc.), and community-based settings (community HIV counseling and testing, peer support programs, etc); and to work closely with the GOM to support planning, implementation, and monitoring and evaluation of PwP interventions.

Activities will focus on scale up access to PwP (through integration of PwP services in existing HIV activities, and expansion in both geographical and technical scope) in addition to maintaining existing HHS/CDC activities in Mozambique, in line with GOM and USG goals.

Measurable outcomes of the program will be in alignment with the following performance goals for PEPFAR: 1) Number of individuals (healthcare providers and counselors) trained to implement PP interventions; 2) Number of individuals reached with minimum package of PP interventions.

Other measurable outcomes will include approved and disseminated policy and materials for PP interventions, either at national level or individual provincial level; and capacity building for sustainable PP interventions.