The Community Compact project is an attempt to address gaps in current HIV prevention activities. Its aim is to increase the number of individuals and couples who know their status and who receive information and services that will help avert new infections in Kanyama township in Lusaka and Kalabo district in Western Province. The Community Compact is a community sensitization and mobilization project that develops and supports community-led HIV prevention strategic plans. Prevention program activities are developed in collaboration with community teams in Kanyama and Kalabo.These teams have been trained in HIV/AIDS basics and prevention with positives core messaging. Teams have also been trained in key messaging on male circumcision, treatment and adherence, pediatric care, Prevention of Mother to Child Transmission, voluntary counseling and testing (CT) and TB.CT is provided by trained lay counselors. As an integral part of the project, the community teams work with staff at health centers to improve referral to HIV treatment and care for those who test positive. Improvements have been identified to reduce clinic-based barriers that prevent those that test positive from accessing treatment.The project provides CT for couples in the community and provides support for discordant couples. Therefore, it is crucial to promote CT integration with other care and prevention services and provide condoms and safer sex messages to discordant couples.The Community Compact will also include aspects of health systems strengthening. The project will try to improve coordination between community teams and the staff at the health centers and between the various departments in the health centre itself, e.g., PMTCT and antiretroviral therapy clinics.

HRH - Like many developing countries, Zambia is suffering from a severe shortage of health staff to deliver services. This is not only prevalent in rural areas, where many health posts do not even have a trained staff, but is also commonplace in urban areas like Lusaka. Kanyama Clinic provides most care for a population of more than 170,000 but has only one doctor. This translates into severe congestion and long waiting times for all services. The congestion at the clinic is often the reason provided by those who do not access counseling and testing services, treatment and care, maternal and child health, etc. As much of the information on HIV prevention and treatment services is disseminated at health centers, this means that a large percentage of people are missing out on these important messages.The Community Compact is strengthening existing community structures in Kanyama and Kalabo. CIDRZ will train and empower the 100 community team members, transfer knowledge to them, and build their capacity. Once established, these teams will be a source of HIV prevention and information in their communities. Community team members will identify community forums whereby HIV prevention information can be disseminated. By using lay counselors trained in psychosocial and rapid testing services that were once only available at the clinic are now brought to the home or other local access points. The Community Compact will also train community health workers (CHWs) in Kalabo district, to combat the lack of trained health staff. Thirty-six CHWs will be trained using a MOH-approved curriculum that will be specifically adapted for the project and will integrate HIV prevention programs.Ideally it would be useful to bring prevention and treatment services to the community, e.g., pharmacy refill points in Kanyama or mobile MC outreach for Kalabo. However, these are costly and would be dependent on available funding.Through capacity building, the Community Compact Program will strengthen existing community structures in Kanyama and Kalabo and position them as leaders in HIV/AIDS prevention information in their communities following the end of the project.

Male circumcision, as part of a comprehensive HIV prevention package, reduces the risk of heterosexually acquired HIV infection in men by approximately 60 percent. For men that test negative, CIDRZ will promote male circumcision services. These services are provided in Kanyama by Marie Stopes. In Kalabo, CIDRZ will work with the District Health Office to provide mobile male circumcision services several times each year. CIDRZ also hopes to increase male participation in HIV prevention activities, particularly in the area of prevention of mother to child transmission.

The overall aim of the Community Compact is to increase the number of individuals and couples who receive information and services that will avert new infections in Kanyama and Kalabo. CIDRZ already has significant experience providing counseling and testing (CT) in the home and through mobile outreach services with structures already in place in Kanyama and Kalabo. In 2012, using these structures, the project will test and counsel couples in the community and provide support for discordant couples. In many instances, one individual in a couple knows their status but fails to disclose to their partner. In Zambia, a significant number of new infections occur within marriage or in cohabiting relationships. Therefore, there is a specific focus on couples CT and mutual disclosure. Couples CT is the most effective way of achieving accurate and timely disclosure and promoting couple specific prevention. For couples who are discordant, CIDRZ will promote safer sex messages, distribute condoms, promote treatment as per national guidelines, and provide information to minimize the risk of infection for the seronegative partner in the relationship.CIDRZ will also promote CT integration with other care and prevention services in a manner consistent with national guidelines for confidentiality and work to reduce the stigma and discrimination that is associated with HIV testing. The project will also improve referral to HIV treatment and care for those that test positive and integrate prevention with positive services. We will track how many people the community teams have referred to all the service areas, including those that test positive and are referred to ART.

Prevention is a key component of the Community Compact program as it seeks to avert new infections of HIV by increasing the number of individuals and couples who know their status and access information and services. This is a community-led prevention initiative. Once the community teams have been trained in HIV/AIDS basics and prevention with positives core messaging, they sensitize the community on HIV prevention information and services. This includes information on infant and adult male circumcision, Prevention of Mother to Child Transmission, cervical cancer, TB, treatment and adherence, and voluntary counseling and testing.In 2012, prevention education will occur through HIV prevention messages provided during door-to-door outreach and testing. Dissemination also occurs through distribution of information, education and communication materials as well as through drama performances. The program uses trained drama groups that use specific CIDRZ-sanctioned scripts that address the key issues.The community teams also distribute condoms. During the establishment of the program, community mapping identified local and external resources, as well as risk areas. Condoms and IEC materials are distributed at these key points within the community.To ensure the success of these prevention measures, the Community Compact program will distribute 40,000 IEC materials, 80,000 male condoms and 40,000 female condoms in Kanyama and Kalabo in FY 2012. In 2013, 50,000 IEC materials will be distributed, along with 100,000 male condoms and 50,000 female condoms.Although participation in the Community Compact is voluntary, there will be incentives provided. Whilst the aim of the project is to avert new HIV infections, it will also be an analysis of incentives and whether their use affects the level of engagement by the community and improve desired outcomes. There will be process and service uptake indicators, which will measure the level of participation of the community teams. Incentives depend on the achievement of specific benchmarks. If these targets are reached, incentives must be used for health-related activities that will benefit the community as a whole.

Gender - In Zambia, 16 percent of women are HIV positive, compared to 12 percent of men. Gender inequalities are a key driver of the HIV epidemic. Norms around masculinity encourage intergenerational sex, which contributes to higher infection rates among young women aged 15-24. Norms around femininity prevent some women, particularly young women, from accessing HIV prevention information and services. In most cases, women are willing to use condoms but find it difficult to introduce the topic of condom use to their spouses for fear of being stereotyped as promiscuous. Generally, women tend to defer decision-making to their husbands or partners. This means that for the most part, it is men who decide if counseling and testing will occur or whether to use condoms.As part of the project, community teams will sensitize women in the community to access prevention services. Women are encouraged to ask their husbands to participate in couples CT. If they are unable to approach this subject, they can make arrangements for a lay counselor to come to the home to speak to their husband or partner.The community teams also distribute female condoms and work to dispel stereotypes that only promiscuous women access reproductive health services.The community teams also disseminate information on cervical cancer. In Zambia, which has the worlds second highest annual cervical cancer incidence and mortality rates, the HIV epidemic has contributed to the high incidence of cervical cancer. Women infected with HIV are thought to be three to five times more likely to develop cervical lesions that can become cancerous. CIDRZ has done extensive research in this area and community-based education has improved uptake of cervical cancer prevention services in Zambia.The Community Compact project will strengthen male involvement in reproductive services, especially in PMTCT. Generally women who test positive are afraid to disclose to their partner as they fear abandonment or violence. Male partner involvement in PMTCT may increase the likelihood of service uptake, behavior change, and improve adherence to PMTCT measures.