This is a new implementing mechanism which is a follow-on to the Population Services International (PSI)/Social Marketing Association (SMA) Corridor of HOPE program which comes to an end in March 2010. During the end of COP09, PEPFAR Namibia will competitively award a new program to strengthen HIV prevention services for the following most-at-risk populations (MARP): men who have sex with men (MSM), sex workers (SW) and clients of sex workers including truckers, seafarers and miners.

This new mechanism has three main components: 1) increased access to a comprehensive package of

prevention services leading to reduced risk of HIV transmission among MSM, SW and clients of sex workers; 2) creation of an enabling environment for the provision of HIV services for these populations; and 3) increased organizational capacity of local stakeholders to develop, manage, and evaluate effective HIV prevention interventions for the target population.

This mechanism will fill an important gap in MARP programming in Namibia. Although commercial and male-to-male sex are not the source of most new HIV infections in Namibia, available data suggest that SW and MSM have some of the highest rates of HIV prevalence of any population sub-groups and remain important target audiences for prevention efforts. However, to date most prevention efforts have focused on awareness creation among youth and adults in the general population. The primary activity related to addressing higher-risk populations to date has been the SMA activity, but SMA also lacked a sharper focus on these most-at-risk groups.

The activity supports the prevention priorities of the Government of Namibia (GRN) as articulated in the draft National Strategic Framework for HIV/AIDS. The partner will participate in the Prevention Technical Advisory Committee (TAC) and work under the National Prevention Strategy currently under development. This program contributes to the draft USG Partnership Framework through the objective "Increased prevention programming for most at risk and vulnerable populations (MARP), including youth, sex workers, men who have sex with men, prisoners, truck drivers and other mobile populations."

Geographically, the new activity will, in collaboration with the GRN, establish selected high-risk areas in which to operate, specifically, those with a high density of MARP, high HIV prevalence and a thriving commercial sex industry.

A key focus of the program will be to identify and capacitate local organizations representing and serving MARP to operate in a cost-effective and accountable way and to develop the capacity of these groups and civil society to advocate for increased commitment by government and other stakeholders for improved HIV prevention, care and treatment services for MARP. By transferring technical knowledge and skills required to establish, operate and sustain these interventions to qualified indigenous organizations, and working with the GRN and stakeholders to create an enabling environment, USG will increase the likelihood of sustaining HIV prevention interventions with MARP in the future.

The program will address gender issues, recognizing that food insecurity, poverty and unemployment are among the reasons why women join the sex trade, and that power imbalances make it difficult for SW to insist on condom use with clients during paid sex.

During COP10, the USG will conduct research and surveillance regarding MARP including geographical

mapping, size estimations, biomarker and behavioral surveys. The current Global Fund (GFATM) proposal includes support to NGOs working with MARP to collect qualitative and quantitative information to assess the size and behaviors of these groups. The USG will coordinate with these efforts and incorporate data in program design, planning and implementation. The mechanism will undertake additional formative and quantitative assessment to fill information gaps as needed.

The USG will work closely with the recipient to build M&E capacity of local partners and the GRN for program management of prevention for MARP, disaggregating beneficiary-level indicators by sex and category of MARP, and tracking data on planned coverage of interventions. Limited indicators exist to effectively monitor key accomplishments in the areas of policy development, organizational capacity building and creation of an enabling environment. The program will utilize indicators additional to the required PEPFAR indicators to monitor key accomplishments in these areas, based on global standards.

This is a new activity. This new activity has three major areas of activity that parallel the overarching objectives outlined in the Implementing Mechanism narrative: 1) Delivery of a comprehensive package of services to MARP, 2) Policy and advocacy to create an enabling environment for the provision of HIV services to MARP, and 3)

Building the organizational capacity of local stakeholders to develop, manage and evaluate effective HIV prevention interventions for the target populations.

Despite increases in service delivery to Namibians, current GRN policies criminalize specific MARP and impede HIV programs that work with MARP. There is a risk that MARP remain marginalized and do not universally access available HCT and other HIV and AIDS services available.

1) Delivery of a comprehensive package of services to MARP: There is substantial evidence for the effectiveness of a comprehensive package of interventions for populations most-at-risk of HIV, including MSM, SW and SW clients. The program will roll-out a comprehensive package for MARP including the following core components: • Targeted condom and lubricant promotion • Peer education and outreach • HIV counseling and testing • Risk reduction activities and counseling • Use of data for evidence-based programming

The program will establish and strengthen innovative and tailored models for delivering HCT testing in "MARP-friendly" settings to sex workers, clients and MSM, which may include mobile services, etc. in addition to different testing models including VCT, PITC and couples testing. Referral approaches for MARP populations to HIV counseling and testing in addition to care and treatment, given the high prevalence in these populations, should be further considered and strengthened. These linkages may also include referrals for circumcision, substance abuse treatment, PMTCT (including family planning), and post-exposure prophylaxis, tailored to the needs of each vulnerable group as appropriate. Sensitization of health care providers to provide MARP-friendly services will also be part of the package. The program will explore opportunities to bring mobile HIV testing services to locations that are convenient to MARP.

The new program will scale-up delivery of this package to MARP in priority program areas through collaboration with local organizations, including MARP-led organizations. The program will use information derived from program monitoring to strengthen service delivery and to propose additional innovative approaches to reaching MARP with prevention services.

HIV counseling and testing service delivery points will be sensitized to work with MARP populations appearing for HCT services. The partner will establish M&E systems to track referrals to HCT from IPC activities. Qualitative and quantitative reviews of where MARP access HCT services will be conducted to better focus technical assistance.

2) Policy and Advocacy: Namibia maintains policies and legislation that criminalize MARP and impede HIV prevention activities with MARP. Mobilization of key stakeholders is critical to create a legal, political and social environment where MARP can be reached with effective prevention programming. In the Namibian context, where sex between men and commercial sex remain illegal, HIV/AIDS programs must enlist the explicit cooperation of law enforcement, health authorities, and the political and religious communities, to reduce the fear of arrest and stigmatization that cause MARP to avoid health seeking behaviors.

The program will partner with MSM, SW and human rights organizations and networks, in spearheading advocacy for policies to reduce barriers to delivery of services. A range of local, national and regional stakeholders will be capacitated to assume leadership of advocacy efforts, so that this policy work is sustainable beyond the life of the project. The program will support stakeholders by ensuring timely and accurate use of data for policy work and advocacy, and for evidence-based decision making.

3) Organizational Capacity Building: The transfer of knowledge and skills required to operate efficient, cost-effective, accountable and transparent organizations is essential to managing integrated interventions for MSM, SW and their clients. Solid organizational performance is core to the short and long-term success of scaling up interventions. The program will focus on meeting the particular organizational development needs of specific target organizations. Capacity-building will cover a broad range of substantive areas, ranging from advocacy to administration and finance, governance, leadership, management, networking, and strategic planning. Particular attention will be given to monitoring and evaluation, supportive supervision and quality assurance, given the importance of the quality of interventions to achieving successful behavior change.

Regular supportive supervision, distribution of standardized materials and monitoring visits will be undertaken by USG and prime recipients to ensure that outreach activities are being conducted to standards established by the GRN and USG, that linkages are strengthened to biomedical interventions available and that data reporting is accurately reflecting progress against PEPFAR indicators. Sustainability components will include capacity building of local civil society and regional administrations to better coordinate and implement evidence-based HIV prevention strategies.

This is a new activity.

This new activity will support a comprehensive package of prevention services for most-at-risk populations (MARP), including supportive policy development, capacity building of local organizations and the GRN in addition to ensuring risk avoidance as a component among clients. This narrative links to other narratives in HVAB, HVOP and HVCT. MSM and clients of sex workers are among the key populations targeted by this program. As one component of a comprehensive package for MARP, AB prevention funds will support outreach and education efforts to reduce multiple and concurrent partners among sex work clients and MSM.

1) Outreach and education to reduce multiple partners Because many clients of sex workers have regular partners in addition to commercial partners, they act as a 'bridging' population to continually spur new HIV infections in the general population. Clients of sex workers in Namibia are frequently individuals who have migrated for work or are in occupations requiring that they spend long periods of time away from home. Seafarers, truckers, and miners especially are thought to be occupational groups that frequently purchase sex from SW; rough estimates suggest there may be 2,600 truckers and 2,000 seafarers in Namibia at any point in time. The risk factors for HIV among these migrant populations include unprotected sex with paid and casual partners, multiple concurrent partnerships, and low risk perception. While men in some occupations are easily identified as likely to engage in paid sex, other clients of sex workers are less readily identifiable as a risk group. MSM in Africa often have frequent concurrent partnerships with both male and female partners, as well as high turnover of partners. The regular or noncommercial partners of sex workers are another important core group. Both MSM and other populations practice lower rates of condom use within stable relationships.

Little formative research on male clients of sex workers exists in Namibia, but studies elsewhere indicate that the decision to pay for sex often begins at entertainment establishments such as bars and beer gardens that are frequented by sex workers. This decision is often influenced by peer pressure from friends and business partners, and by the loss of control owing to the influence of alcohol. Apart from their contact with sex workers, clients routinely report intercourse with wives, girlfriends, and casual acquaintances. In some countries, HIV interventions have reduced the proportion of men who visit sex workers, as well as the frequency of visits by those who continue to engage in commercial sex.

The new program will conduct formative research to develop a profile of sex work clients in targeted areas and to identify entry points for program intervention, since vulnerabilities relating to HIV are often specific to each industry and sector. For men belonging to easily identified occupational risk groups, the program will identify relevant organizations such as truck and mining companies and port authorities and help them to develop and implement targeted prevention interventions for their workers. Innovative

interpersonal communications (IPC) tools and materials will be used to increase risk perception and understanding of the potential impact of risky sexual behavior on their families, and to build skills needed to adopt responsible decisions and behaviors. The program will also emphasize the role of alcohol as a facilitating factor for risk behavior. Strategies for reaching clients of sex workers who do not form a visible, coherent social group will include support to local community organizations for outreach in bars and entertainment establishments and other venues where men who frequent sex workers are to be found. The project will develop IPC interventions to engage target audiences in these settings, supported by educational materials about HIV. The program will develop mechanisms for supportive supervision of outreach staff, and will periodically undertake assessments to monitor trends in behavior among target populations. Messages about reducing partners and patronage of sex workers for these high-risk men will be integrated within a comprehensive approach to risk reduction, and will at all times be accompanied by condom promotion, demonstration and distribution. Regular supportive supervision, distribution of standardized materials and monitoring visits will be undertaken by USG and prime recipients to ensure that outreach activities are being conducted to standards established by the GRN and USG, that linkages are strengthened to biomedical interventions available and that data reporting is accurately reflecting progress against PEPFAR indicators. Sustainability components will include capacity building of local civil society and regional administrations to better coordinate and implement evidence-based HIV prevention strategies.

This is a new activity. This activity will have three major areas that parallel the overarching objectives outlined in the implementing mechanism narrative: 1) delivery of a comprehensive package of services to MARP, 2) policy and advocacy to create an enabling environment for the provision of HIV services to MARP, and 3) building the organizational capacity of local stakeholders to develop, manage and evaluate effective HIV prevention interventions for the target populations.

1) Delivery of a comprehensive package of services to MARP: There is substantial evidence for the effectiveness of a comprehensive package of interventions for populations most-at-risk of HIV, including MSM, SW and SW clients. The program will roll-out a comprehensive package for MARP including the following core components: • Targeted condom and lubricant promotion • Peer education and outreach • HIV counseling and testing

• Risk reduction activities and counseling • Use of data for evidence-based programming

The program will incorporate linkages to "MARP-friendly" health services, especially referrals to HIV care and treatment, given high prevalence in these populations. These linkages may also include referrals for circumcision, substance abuse treatment, PMTCT (including family planning), and post-exposure prophylaxis tailored to the needs of each vulnerable group as appropriate. Sensitization of health care providers to provide MARP-friendly services will also be part of the package. The program will explore opportunities to bring mobile HIV testing services to locations that are convenient to MARP.

The new program will scale-up delivery of this package to MARP in priority program areas through collaboration with local organizations, including MARP-led organizations. The program will use information derived from program monitoring to strengthen service delivery and to propose additional innovative approaches to reaching MARP with prevention services.

2) Policy and Advocacy: Namibia maintains policies and legislation that criminalize MARP and impede HIV prevention activities with MARP. Mobilization of key stakeholders, including government, civil society, and members of targeted populations is critical to creating a legal, political, and social environment where MARP can be reached with effective prevention programming. In the Namibian context, where sex between men and commercial sex remain illegal, HIV/AIDS programs must enlist the explicit cooperation of law enforcement, health authorities, and the political and religious communities, to reduce the fear of arrest and stigmatization that cause MARP to avoid health seeking behaviors.

The program will partner with MSM, SW and human rights organizations and networks in spearheading advocacy for policies to reduce barriers to delivery of services. A range of local, national and regional stakeholders will be capacitated to assume leadership of advocacy efforts, so that this policy work is sustainable beyond the life of the project. The program will support stakeholders by ensuring timely and accurate use of data for policy work and advocacy, and for evidence-based decision making.

3) Organizational Capacity Building: The transfer of knowledge and skills required to operate efficient, cost-effective, accountable and transparent organizations is essential to managing integrated interventions for MSM, SW and their clients. Moreover, solid organizational performance is core to the short and long-term success of scaling up interventions. Given the variable capacity among MSM and SW groups, the program will focus on meeting the particular organizational development needs of specific target organizations. Capacity-building will cover a broad range of substantive areas, ranging from advocacy to administration and finance, governance, leadership, management, networking and strategic planning. Particular attention will be given to monitoring and evaluation, supportive supervision

and quality assurance, given the importance of the quality of interventions to achieving successful behavior change.

Regular supportive supervision, distribution of standardized materials and monitoring visits will be undertaken by the USG and prime recipients to ensure that outreach activities are being conducted to standards established by the GRN and the USG, that linkages are strengthened to biomedical interventions available and that data reporting is accurately reflecting progress against PEPFAR indicators. Sustainability components will include capacity building of local civil society and regional administrations to better coordinate and implement evidence-based HIV prevention strategies.