This new program is designed to contribute directly to USG and the GOM goals in HIV and health, as articulated in the Partnership Framework, to reduce HIV transmission and mitigate the epidemic's impact. It is also designed to support the national Strategy for Accelerated Prevention of HIV Infection. HIV prevention has proven most challenging, particularly since there is still no one single fully effective intervention that can reduce transmission. An approach that combines different prevention interventions is likely to be better suited to address the complexity. This project's overall goal is to reduce HIV acquisition and transmission by increasing the adoption of safer sexual behaviors and addressing social, economic and cultural factors that facilitate high risk of HIV transmission. Since the majority of new HIV infections in Mozambique are sexually transmitted in the general population, this activity will strengthen prevention interventions that address behavioral, structural and biomedical factors, increase their intensity and ensure they are tailored to resonate with, and motivate behavior change among, general adult and youth populations, including PLHIV, and to stimulate social and normative change more broadly.

This new activity aims to achieve three mutually reinforcing results: 1) Increased access to and use of effective and quality combination HIV prevention services among the Mozambican general population in the three highest prevalence provinces of Gaza, Maputo and Maputo City; 2) Increased technical leadership and coordination to develop strategic combination HIV prevention at the national, provincial and district levels ; 3) Strengthened capacity of Mozambican public institutions, civil society organizations, and the private sector to implement combination HIV prevention programs.

Ethnographic research in Mozambique reveals that the practice of multiple concurrent partnerships (MCP) is widespread and includes several types of transactional sex, with gender issues intricately woven into the practice. Condom use has been among the lowest in Africa (2003 DHS), although it has increased in recent years due to ongoing social marketing and free distribution. Both of these behaviors take place in the context of a poor understanding and perception of the risks involved. In accordance with USG's strategic prioritization, implementation efforts will begin in the more densely populated urban and peri- urban areas of the three highest prevalence provinces where high risk behaviors are widespread.

Programmatic emphasis will be on intensifying and expanding HIV prevention using complementary and reinforcing behavioral, biomedical and structural interventions to reduce risk of HIV transmission among the general adult and youth populations, including PLHIV, their partners and families. Primary emphasis

will be on assessing and addressing the sensitive behavioral and structural factors that underlie the practice of MCP, including alcohol abuse, gender and social norms and economic factors; increasing the perception of associated risks among individuals and communities; reaffirming the benefits of mutual fidelity between partners of known HIV status; and ensuring strong referrals and linkages to clinical services especially for CT, PMTCT, positive prevention, screening and treatment for STIs and TB, and AIDS treatment as necessary .

The project will support prevention programs for youth 15-19 years of age, both in and out of school , and will complement activities for younger youth aged 10-14 supported by other donors such as UNICEF and UNFPA. Activities to reach vulnerable youth with prevention messages and skills will be coordinated with the ROADS program interventions along transport corridors and hot spot venues which can draw young girls in particular. Community activities under this program will emphasize prevention of HIV transmission to uninfected partners and family members in discordant couples, and will stress protecting the health status of the HIV infected person and generally promoting positive living. Strong ties will be established with USG supported clinical partners to ensure that prevention needs of PLHIV are met and appropriate care received.

The project will provide technical leadership to strengthen the quality and robustness of behavior change interventions, ensuring that they incorporate evidence-based approaches and established best practices, and that they are designed to provide sufficient dose and intensity. The new partner will ensure consistency of behavioral change messages across the USG portfolio, to maximize synergies between mass media and interpersonal communication, and minimize duplication and overlap.

This program will enhance the technical and organizational capacity of GOM institutions such as the MOH and NAC, at central, provincial and district levels, as well as that of local organizations and partners in the private sector to build effective combination prevention programs. The new partner will implement both process and outcome evaluations to track progress in implementation and achievement of results.

The goal of the prevention interventions supported through this activity is to achieve normative change that will result in more responsible, less harmful attitudes and behaviors related to sex and gender in the adult population. Primary emphasis will be on discouraging the practice of MCP, increasing the perception of associated risks among individuals and communities and reaffirming the benefits of mutual fidelity between partners of known HIV status. The project will support the GOM in launching and implementing a comprehensive three-year national campaign to address MCP featuring reinforcing mass media and interpersonal communications at the national, provincial and district levels in the three highest prevalence provinces. Special emphasis throughout the campaign will be on addressing the social, cultural and gender norms and attitudes that perpetuate the practice of MCP among both men and women. Constructive male engagement to alter these norms will be a key thrust of the campaign. Concerted effort will be made to develop and expand workplace prevention programs and supportive HIV-related workplace policies to reach men, including coordination with programs that target mobile populations and men, such as the ROADS program.

Behavioral interventions will feature mass media (TV, radio, print), local media usually produced in local languages (community radio, theater groups), community education with existing groups (e.g., traditional councils, schools, civic organizations, religious congregations) and person to person communications for behavior change. National mass media campaigns will be supported directly by community-based activities.

Prevention programs for youth 15-19 years of age, both in and out of school, will be supported by this program. Special interventions will be designed and developed to address young girls who are out of school and are among the most at risk segments of the young population. Life skills-oriented programs will address peer pressure and other social factors that influence a young person's behaviors.

This project focuses on sexually active adult men and women and discordant couples as key populations

for prevention of sexual transmission in Mozambique's generalized epidemic. In such epidemic

situations, reaching individuals who engage in multiple concurrent partnerships, including transactional

sex, and those who are HIV positive, represents important opportunities to reduce or prevent

transmission of HIV to negative partners and spouses. As a result, this funding will focus on

comprehensive programming of behavioral interventions among these population segments. As both

individual perception of risk and condom use are very low throughout the country, this activity will

combine effective communication for behavior change, especially interpersonal communication and

counseling for risk reduction, with increased condom availability and promotion to improve currently

prevalent negative attitudes, and to increase consistent and correct condom use among sexually active

adults, and discordant couples in the three highest prevalence provinces of Maputo, Maputo City and

Gaza. The project will identify and design interventions to address alcohol use, widely prevalent in the

country, and is associated with increased risky sexual behavior and instances of gender based violence,

all of which heighten the probability of HIV infection. All behavioral interventions to reduce the risk of

HIV transmission will be linked to counseling and testing services, and will emphasize the importance of

disclosure of HIV status between sexual partners, taking into consideration the potential need to mitigate

issues of violence that may arise within a couple, as a result of disclosure. When MOH policies evolve

toward approval of medical male circumcision (MMC), the project will provide expertise on the behavioral

aspects that surround this highly effective prevention intervention, by explaining its benefits and

limitations, promoting the service, improving the availability of correct information among providers and

interested men, and by implementing behavior change communication to deter risk compensation.