The aim of this program is to support more effective prevention of HIV infection over the next five years, relying on a "comprehensive" or "combination" Zambian-led, community-based prevention approach that incorporates biomedical, behavioral, and structural prevention interventions in community settings to a much greater extent than previously. Ongoing national clinical and media-based prevention efforts will be reinforced in the community, where the evidence suggests that most people initiate, practice, establish and maintain positive behavior change.

The awardee will submit a more detailed narrative, describing its approach more specifically, and possibly revise targets slightly based on award negotiations. The more detailed partner narrative will be entered in place of this overview after competition is completed and the award is signed.

This project is intended to support the Zambian National HIV/AIDS Prevention Strategy, as well as that of PEPFAR, including new guidance for 2010 on Prevention with Positives (PWP). The four main prevention-related program/technical areas will be: Abstinence/Being faithful (AB) prevention programming (including partner reduction) and Other Prevention (OP), Prevention of Mother to Child Transmission (PMTCT), and Testing and Counseling (TC). The program will also promote male circumcision (MC), but will not provide clinical MC services. In addition, the following cross-cutting issues will be aggressively addressed: alcohol and substance abuse, gender-based violence, and social norms that contribute to acquisition and transmission of HIV.

The specific goal statement is: "Building on the success of prevention efforts to date, further reduce the acquisition and transmission of HIV through higher quality, more effective, and increasingly sustainable prevention, TC, MC, and PMTCT services."

The proposed objectives are to: 1) Ensure that individuals, households, and communities affected by HIV/AIDS access more effective, gender-sensitive, higher-quality HIV prevention and TC, MC and PMTCT; 2) Strengthen the continuity and coordination of, as well as commitment to, effective, efficient and sustainable HIV prevention, TC, MC, and PMTCT; and 3) Improve the efficiency, sustainability, and local capacity of the response to HIV/AIDS, including greater engagement with the private sector.

One of the largest community-based prevention efforts of the USG Zambia, this project will link to other clinical, media, workplace and community-based prevention efforts. It will align closely with and support the National HIV Prevention Strategy, and adhere to PEPFAR ABC prevention guidance and technical considerations. Working closely with GRZ structures and initiatives, the scope, coverage and effectiveness of prevention efforts will increase significantly nationwide.

The specific target number and location of districts is TBD through competition. Primary target populations include the 85% of Zambians who are HIV-negative, especially those most at-risk, as well as at-risk OVC and youth, and other vulnerable groups (PLWHA and the discordant/uninfected spouses/partners of PLWHA), women affected by gender-based violence (GBV), and their families and communities. Lastly, it targets Zambians whose risk of infection is increased by abuse of alcohol and other substances, and behaviors influenced by social norms promoting risky sexual activity.

While this project will not support formal strengthening of the government health system, informal contributions to system strengthening include closer linkages between community-based prevention efforts with those of government, including clinical and community prevention efforts of the GRZ.

Cross-cutting program elements of this project include: closer alignment of USG prevention efforts with those of the GRZ; greater continuity and integration of prevention efforts with Care and Treatment interventions; basing prevention on evidence-based approaches including reduction of multiple and concurrent partners; gender integration of prevention efforts; and addressing alcohol as a risk factor. More details on the cross-cutting aspects are found below.

Strategies to become more cost efficient include: use of existing trained community volunteers, peer educators, and health workers to reduce the cost of initial training; retention of volunteers, peer educators, and caregiver volunteers from previous projects in order to expedite start-up and avoid interruption of services; and expanding prevention efforts through as many existing prevention "channels" as possible.

Efforts of this project will be closely tied to the community-based prevention, care and support RFA; the two activities will develop and follow a joint work plan. Where possible, efforts will be combined such as conducting joint training and monitoring and evaluation activities as appropriate. This project will also link closely to other USG Zambia activities, to optimize use of USG resources.

In addition, the emphasis on linking to the private sector and increasing sustainability implies that these activities will require less external donor funding in the future and be community-owned to a greater extent.

Monitoring and evaluation plans include greater integration with national M&E plans and structures with a greater emphasis on outcome and impact measures in addition to outcome measures.

Another mechanism, the USAID TBD RFA for prevention, care and support will provide the bulk of community-based OVC essential care and support service delivery.

The Prevention RFP is designed to provide expert technical assistance and support for the design of evidence-based interventions and the training of paid staff and volunteers who actually implement prevention with OVC and at-risk youth to the TBD RFA and other mechanisms. The aim is to improve community-based prevention efforts with OVC and youth. As this activity consists primarily of technical assistance and training support, there are no OVC targets per se.

Prevention training will incorporate recommendations from joint CDC-USAID technical assistance visits in August 2009 regarding overall Prevention as well as Prevention with Positives (PWP). OVC prevention efforts will begin at the earliest opportunity in the community, in school settings and elsewhere, in accordance with national guidelines for schools.

PWP efforts will focus on OVC who range from early adolescence to 18 years of age, those who are already sexually active, or those who indicate they may soon become active. PWP seeks to prevent them from re-infecting themselves or infecting others.

Narrative (2250 characters) Community-based prevention, care and support TBD will provide adherence support to adults (and under PDCS, to children) receiving ART. It will include compliance with ARV drug regimens, and support for regular and timely return to clinic visits. In some cases this might include transport assistance as funds permit and client circumstances require. The project will also promote Prevention with Positives (PWP) for adults and sexually-active pediatric clients (roughly, adolescents to 18 years old), to reduce the risk of re-infection to them, or of transmission of HIV to others.

It will promote Positive Living and behavior change in terms of reducing the intake of alcohol or abuse of other substances which might interfere with ARV drug action. The TBD will seek and incorporate expert guidance on early warning signs of ARV drug resistance and incorporate it into training of community volunteers and health workers to monitor clients for signs of its emergence. Food and Nutrition Support for malnourished pre-ART and ART patients will follow Zambian draft Food by Prescription guidelines developed by the National Food and Nutrition Commission, as well as adhering to OGAC Food and Nutrition guidance on nutrition assessment, counseling, and support, to ensure better standards of client care. National guidelines on Integrated Management of Acute Malnutrition (IMAM) may soon require diagnosis and treatment of malnutrition in all clinical settings, including ART.

The expected outcome of extending this Testing and Counseling (TC) project is to reach a combined level of community and home TC clients of the two community-based programs it follows, which was about 41,000 in 2008 (this may increase for 2010). The solicitation will accomplish this through direct TC provision, and joint TC conducted with the large number of volunteers and peer educators expected to work for the community-based prevention, care, and support RFA, under a joint work plan.

TC will determine the HIV status of clients, and take on two new aims: 1) Identifying at-risk youth and adults before they are infected, and provide more in-depth counseling, to help them protect themselves through appropriate messages and behavior change services; and 2) Identifying PLWHA in the home or community as early as possible, in order to help them change their behaviors so that they do not infect others, as well as to link them proactively and immediately to existing care and treatment services.

There will be two TC "add-ons." First, for the over 85% of Zambian clients who test HIV-negative, the will be screened for HIV risk, and HIV risk profiles will be developed. Prevention activities will be designed and implement targeting those with high risk profiles. Additionally, HIV-positive clients will not simply receive a "passive paper referral", but rather an efficient, effective means to link clients immediately and pro-actively to relevant services will be devised and implemented. Through better coordination and continuity between the Prevention RFP individuals will be linked to other HIV services such as PMTCT, MC, FPP, and ART as well as behavior change activities.

The project will implement effective, comprehensive behavioral prevention methods (relying on evidence-based approaches, PEPFAR AB guidelines, and the current state of the art), to protect vulnerable and at-risk groups while reducing HIV transmission. Drivers of the epidemic, including reducing multiple concurrent partners will be a primary focus. Methodologies to reduce HIV transmission at two critical time periods will be included. The first is the viral load spike at initial infection, and the second is the viral spike when the immune system, after resisting HIV for some time, finally collapses (on its own in the absence of ART) or at the time of treatment failure. This will require new strategies, methods, and possibly also new technologies to reduce risk at these two critical times.

AB prevention efforts will work across a range of at-risk and infected youth and adults, engage them with comprehensive approaches, and include effective client referral and linking systems. Prevention for at-risk youth and adults will include appropriate interventions and services by age and level/type of vulnerability. Approaches used reflect sensitivity to gender, HIV-status, and socio-economic vulnerability levels. AB activities, as with other prevention activities shall initiate PWP activities for the spouse or partners of any HIV positive clients, and link them to community or clinical TC services for discordant couples. Targets include the 85% of Zambians who are HIV-negative, at-risk OVC and youth, and their discordant/uninfected spouses/partners.

Community-based AB prevention promotes social mobilization around prevention, stimulate participation, and elicit commitment of community leaders and members. They also encourage establishment of open and regular community-based "prevention dialogue", including discussions on GBV prevention, social norms that drive HIV, goals and accountability in communities.

The project will: support GRZ leadership and coordination; maintain large-scale, nationwide coverage; make improvements in quality and continuity of prevention; maintain a high level of community mobilization; and increase sustainability and Zambian ownership over five years.

The project will implement effective, comprehensive behavioral prevention methods (relying on evidence-based approaches and PEPFAR AB guidelines), to protect vulnerable and at-risk groups while reducing HIV transmission. Drivers of the epidemic, including reducing multiple concurrent partners will be a primary focus. Methodologies to reduce HIV transmission at two critical time periods will be included. The first is the viral load spike at initial infection, and the second is the viral spike when the immune system, after resisting HIV for some time, finally collapses

OP prevention efforts are expected to work across a wide age range of at-risk and infected youth and adults and engage with complex, multi-sectoral systems, including effective referral and linking systems. Prevention for at-risk youth and adults will include appropriate interventions and services by age and level of vulnerability. The approaches used reflect sensitivity to gender, HIV-status, and socio-economic vulnerability levels. OP activities, as with other prevention activities shall initiate PWP activities for the spouse or partners of any clients found to be HIV positive, and will link them to community or clinical CT services for discordant couples.

Community-based prevention promotes social mobilization around prevention, to stimulate participation and commitment of community leaders and members, and to encourage establishment of prevention dialogue, goals and accountability in communities. OP activities will target reduction of alcohol intake as a risk factor in HIV transmission, offering community and individual interventions, ranging from mobilizing the community to promoting more responsible use of alcohol, to offering those with drinking problems access to behavior change service options such as alcoholics anonymous or recovery services.

The aims of this project will support GRZ leadership and coordination; maintain large-scale, nationwide coverage; make improvements in quality and continuity of prevention; maintain a high level of community mobilization; and increase sustainability and Zambian ownership over five years.

The program will counsel and test at least 15,000 pregnant women, and refer them to clinical PMTCT. (TC will be provided to spouses or partners of pregnant women). Through community-based TC, HIV-positive women will be identified early in their pregnancies, such that they may initiate PMTCT early. Community-based prevention and TC workers will also seek out women who desire family planning/reproductive health services, and link them, helping HIV positive women and couples to plan, space, and manage births, and avoid unwanted pregnancies. PMTCT will initiate Prevention with Positives (PWP). It will link the woman, and her spouse or partner, to care and support for ongoing PWP.

First, the project is expected to achieve a reduction in the drop-off from initial counseling, to testing, to prenatal prophylaxis, and to participation in safe infant feeding. Second, the project will coordinate with other USG and GRZ nutrition activities which promote safe infant feeding options. Following national PMTCT and Infant and Young Child Feeding (IYCF) guidelines, as well as PEPFAR Food and Nutrition guidelines, the project will support PMTCT nutrition and prioritize exclusive breast feeding to six months. The goal of infant feeding is long-term HIV-free survival; maternal nutrition support will help ensure maternal health and a healthy birth. Nutrition support will be preventive first, and then curative. Community-based PMTCT activities will link to OVC services to ensure long-term continuity of follow-up and support for HIV-exposed or HIV-positive infants.

Clinic-to-community linkages between VCT/PMTCT/HBC will reduce PMTCT loss-to-follow up from HIV diagnosis, and provide support for exclusive breast feeding. Replacement feeding may be used in special cases, such as the death or incapacity of the mother due to HIV/AIDS or other illness, but it will be used with caution and under close support and supervision. The risk of diarrheal disease is high, and can result in acute infant malnutrition/death. The project will link to and receive technical assistance from a food and nutrition support TBD contract.

Family food security needs of PMTCT clients/infants, and other family income or livelihood needs, will generally be referred to other providers, such as WFP.