FY08 Collaborative Ugandan PHE- UG.08.0203: Multi-country PMTCT How to Optimize PMTCT

Effectiveness (HOPE) Project

The FY08 - 09 Collaborative Multi-Country Public Health Evaluation for PMTCT, HOPE (How to Optimize

PMTCT Effectiveness), will be implemented in Uganda through CDC This PHE will be conducted in two

phases. First, a line list of all PMTCT sites in the country will be created, along with key variables, such as

patient volume, HIV prevalence, and PMTCT coverage. Second, from this list, PMTCT sites will be

randomly selected for inclusion. From selected sites, more detailed data will be collected, including site

characteristics, PMTCT program implementation, data collection and data quality, and PMTCT indicators

and infant outcomes. Associations identified through bivariate and multivariate analyses will be used to

improve PMTCT programs. As part of this PHE, PMTCT Monitoring and Evaluation and local capacity for

PMTCT M&E and PMTCT implementation, will be improved.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $17,887,816

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The Government of Uganda (GOU) finalized its 2007-2012 National Strategic Plan (NSP) for HIV/AIDS. The plan is grounded in

epidemiological data from the 2004/5 Ugandan HIV/AIDS Sero-Behavioral Survey (UHSBS), cross-sectional and longitudinal

studies identifying drivers of the epidemic, and surveillance trends. The NSP emphasizes the stark realization that the steady

decline in HIV prevalence (from 20% to 6.4% during the first 20 years of the epidemic) attributed to early prevention efforts has

reached a plateau, and that HIV incidence is back on the rise (an estimated 126,100 new infections and 70,300 deaths in 2007).

The NSP therefore highlights HIV prevention as a cornerstone of HIV/AIDS programming to alter the course of Uganda's mature

generalized epidemic.

UHSBS and other studies suggest that sexual transmission accounts for over three-fourths of all new infections (marital sex 42%,

commercial sex work 21%, and casual sex 14%). Mother-to-child HIV transmission (MTCT) is the second largest source

accounting for over one-fifth (22%) of new infections. Fuller analysis of the UHSBS data also suggests that the epidemic has

shifted into the general population and the older age groups, for which there has been little prevention programming in recent

years, since the Zero Grazing campaign waned. The UHSBS data highlight that whereas knowledge of HIV is high,

comprehensive knowledge (knowledge of transmission and rejection of misconceptions), which may influence behavior change

and risk perception, is still below 50% for both men and women. Based on these findings, the MOH has developed Policy

Recommendations that complement the NSP to guide implementation of prevention priorities. Recommendations particularly

relevant to HIV prevention stress the need to increase comprehensive knowledge and risk perception through use of

communication channels, particularly radio; to strengthen behavior change for risk reduction and risk avoidance among young

people; and to promote protective social norms. The USG Prevention Working Group is well represented on the National HIV

Prevention Committee, which provides a channel for coordination of prevention programming across GOU agencies, NGOs and

the AIDS development partners. Since FY07, the USG Prevention Working Group has thus supported a prevention program and

strategies that are in line with epidemiological findings and national priorities.

USG Prevention Programming

The USG portfolio includes comprehensive ABC programming approaches that are balanced differently as they are applied and

tailored to specific groups, behaviors, and underlying factors, in line with OGAC's ABC guidance and principles, and the NSP's

ABC+ approach.

Comprehensive Prevention Programming

In FY09, USG will continue to devote priority attention to prevention programming which is comprehensive, and includes

appropriate emphasis on adults, youth, at risk groups, risky behaviors and norms. USG partners will strengthen behavior change

approaches among youth, including educational counseling and communication efforts, to reflect results of ongoing evaluations

(e.g., AB/Y; PIASCY; Be a Man) and incorporate state of the art practices. USG partners will continue to heighten self-perception

of risk among youth and within the general population; and will support prevention strategies that address social and gender

norms that underlie risky sexual behavior. Correct and consistent condom use will be promoted among sexually active populations

and social marketing programs will ensure distribution and availability. In FY09, behavior change efforts will likely be bolstered by

two national crosscutting communication campaigns. One will deal with issues of stigma and discrimination, as they underlie

prevention, care and treatment practices. The other, "Know your status" will promote counseling, testing and disclosing. It is

expected that such intensified efforts will create more of an enabling environment for positive behavior change that increases self-

perception of risk and promotes protective behaviors.

Personalized Risk

In FY08 a particular effort was made across all USG partners to focus messages and activities on heightened risk perception,

which seems to have waned across all population segments and all age groups. It is of particular concern that risky sexual

behaviors were highly prevalent in the UHSBS, and were shown to be on the increase compared to the late 1990s. Yet most

people who engaged in risky behaviors, such as having multiple sexual partners, did not perceive themselves to be at high risk of

HIV infection. Only 21% of female and 23% of male respondents to the UHSBS believe it very likely that (s)he will contract HIV,

with variations by age, gender, and residence. With the strong feeling in GOU circles that there is increased disinhibition among

population groups, it is important that USG and its partners refocus messages explicitly on personalized risk. Approaches to

heighten personalized risk will be linked to HIV counseling and testing initiatives, and the Know Your Status campaign.

Programming for Youth

USG partners will build on the positive trends and behavior change noted among youth. Young women for example, are

increasingly delaying the age at first sex. This trend is not as clear among young men, however. Data also show that 50 percent of

never married men and 64 percent of never married women aged 15-24 have never had sex. In view of these positive trends and

the reality that young people will always need information and motivation as new cohorts enter the 10-20 age groups, USG

partners will continue to consolidate and strengthen their youth programming toward the goal of ensuring an "HIV-free

generation". A particular effort will be made to ensure the soundness of existing abstinence programs among young people 10-14

years old, through a combination of school-based and out of school programs, media, and community approaches. Programs will

continue to support the Ministry of Education and Sports to reach more students in primary and post primary schools, through

President Museveni's PIASCY initiative with a strong teacher training component, and age appropriate comprehensive prevention

messages, skills, and activities. In addition to this curriculum-based approach, USG will continue to support a large number of civil

society and faith-based organizations working at community level to reach out of school youth through peer education,

information, education, and communication approaches, drama, and local radio programming. Initiatives such as "Young

Empowered and Healthy (YEAH)", the "Something for Something Love" campaign, the radio series "Rockpoint 256", and its

reinforcing materials and interpersonal approaches have created a positive "buzz" among the youth. Such initiatives represent

intensive programming, combining media and interpersonal approaches, thus working at multiple levels to create conditions

required to foster behavior change. In FY09, USG will continue to support such efforts and encourage those that are innovative

and appealing to young people. USG will also support implementing partners and counterpart organizations to improve

programming and linkages across prevention for youth and OVC prevention needs. The prevention needs of young positives are

being addressed with a combination of general and tailored communication and education efforts both at facility and community

level.

High Risk Sex

High risk sex, defined as having multiple concurrent partners and unprotected sex, is the main driver of the generalized Ugandan

epidemic. Analysis of sexual behavior over the last decade shows that among persons having sex since the late 1980s, risky

behaviors are on the rise, including an increase in casual sex, sex with multiple partners, and a decrease in condom use. Sex

among discordant couples seems to account for the largest number of new infections. USHBS found that among cohabitating

(married or living together) couples, 91% of partners were both HIV negative; 3% were both HIV positive, and 5% were

discordant. The fact that there were more cohabitating couples discordant for HIV than cohabitating couples that were both

infected represents a critical unmet prevention need. The vast majority of cohabitating couples do not mutually know their HIV

status, and are therefore not empowered to take action to prevent transmission. It is, however, unknown what proportion of

infections that arise among discordant couples are due to transmission between these couples. Transmission may also arise from

concurrent sexual relations that the couple may be engaging in outside their primary relationship. Prevention counseling and

messages targeting discordant couples therefore need to stress faithfulness as well as correct and consistent condom use within

discordant relationships. Knowing HIV status and disclosing it within couples is also critical. At least two key factors contribute to

low non-disclosure rates among discordant couples: stigma, and fear of violence, particularly by men against women. Therefore,

USG will expand FY09 support for these themes as part of overall programming, and also as part of the Stigma and Know Your

Status campaigns. USG has increased its procurement of condoms, in response to the data on high risk sex.

High Risk Groups

In addition to focusing on decreasing risk behaviors in the general population, USG partners have targeted high risk, vulnerable

and mobile populations with renewed interest, as they remain sources of new infections within Uganda's "mixed" epidemic. These

populations include commercial sex workers, internally displaced persons (IDPs), truck drivers and fishermen. These groups

share risk behaviors. They are more prone to have many sexual partners, to use condoms inconsistently, and consequently

increase the risk of acquiring and/or transmitting HIV to several partners, including their cohabiting spouses. A USG supported

HIV prevalence and risk behavior survey is underway to identify modifiable risk factors among most at-risk populations, including

fishermen, prisoners, men who have sex with men, and commercial sex workers.

Sex Work

USG will continue to support innovative work targeting low-income women, who often supplement their income through

commercial sex with "boda boda" (motorcycle) drivers, long distance truck drivers, and the communities they serve. Commercial

outlets existing within a specified radius of lodges, nightclubs and bars will be targeted for condom distribution and risk behavior

avoidance messages. Partner activities that focus on sex workers include providing access to drop-in centers where they can

receive peer education targeting HIV prevention and sexual violence mitigation, counseling and testing services, and income-

generation activities.

Herpes Simplex Virus Type 2 (HSV-2)

UHSBS found that genital herpes is a strong driver of the HIV epidemic, with close to 50% of Ugandans being infected (49% of

women; 38% of men aged 15-49). Among HIV-infected UHSBS participants, 85% were co-infected with HSV-2; among HIV-

negative participants, 44% were infected with HSV-2. To better understand risk factors for recently acquired (within 150 days)

HIV infection, USG conducted a secondary UHSBS analysis that included testing of all HIV positive participants using the

serology-based HIV incidence (BED) assay. The BED analysis found that compared to persons sero-negative for HSV-2

infection, persons sero-positive for HSV-2 had four times the risk of acquiring recent HIV infection. In FY08, USG supported the

MOH to develop a public health prevention campaign emphasizing education, targeted prevention, promotion of HIV and HSV-2

testing prior to marriage, and promotion of condom use among HIV and HSV-2 discordant couples these efforts may help prevent

new infections. In addition, the STD clinic in Mulago was be upgraded to provide diagnostic services for selected STIs and staff

were trained. The STD clinic is mandated with the provision of diagnostic, care, and treatment services for selected sexually

transmitted infections, including HIV.

Focus on High Prevalence Areas

In FY09, USG will target high prevalence regions identified by UHSBS for integrated support in HIV programming, including

prevention. Support to IDPs in Northern Uganda will continue, and USG support to prevention programming among members of

the Uganda People's Defense Force (UPDF) will be increased. USG will strengthen prevention programs for service members

and their families through behavioral change and communication interventions, counseling and post-test clubs. Private security

companies, police and prison staff will be new populations for targeted prevention programming.

Substance Abuse

Alcohol consumption is associated with an increase in high-risk sexual behavior, and with violence, particularly by men against

women. Excessive alcohol consumption and its link to HIV will be addressed by further strengthening projects and alliances with

Ugandan breweries initiated in FY06 and FY08. In addition, alcohol messages will be fully integrated into media programs

targeting men, and outreach programs with vulnerable youth.

Gender Norms

The recently conducted trend analysis (1985-2005) shows that certain positive behaviors are sliding backward from the late

1980s. In particular, there is an increase in casual sex, an increase in multiple partners, and a recent decrease in men's condom

use with casual partners. Clear gender disparities emerge from these analyses and cut across risky behaviors: men more

commonly engage in sex earlier and with more partners than women do. USG objectives within prevention programming to

reduce sexual transmission include a strong focus on the critical role of partner reduction, faithfulness, and the underlying gender

inequalities that sanction this behavior. Recognizing the importance of the data on male behavior, particularly multiple partners,

several of the USG partners have coordinated with the male oriented campaigns (e.g., Be a Man), sharing similar approaches,

materials and messages for training group facilitators, and working with men to challenge accepted gender norms. Several

partners are addressing gender-based violence in relation to sexual prevention, counseling testing and disclosure, and alcohol

abuse.

Table 3.3.02: