While scale-up of HIV care and anti-retroviral treatment (ART) has been rapid, with nearly 250,000 Zambians currently on ART, HIV prevention has not shown the same success, with continued increases in infections. The most recent population-based surveys found an adult prevalence of 14.3% in 2007. Women have higher prevalence than men (16.1% vs. 12.3%), and rates in urban areas are double that of rural (19.7% vs. 10.3%). While declines in HIV prevalence are substantial in the 20-29 year age groups in women and the 25-34 year age groups in men, young people make up the majority of new cases of HIV.

Addressing this incidence of HIV requires new programs that encourage community engagement and leadership and successfully change social norms that promote HIV spread. I n the DHS, only 45% of infected women and 28% of infected men had ever been tested for HIV; only one-fourth of HIV negative adults had ever been tested in 2007. Overall, 11.2% of cohabiting couples are discordant for HIV, including 6.6% of couples where the man is positive and the woman negative, and 4.6% of couples where the woman is infected. With low general testing rates, the vast majority of Zambians do not know the HIV status of themselves or their spouse. While over 80% of pregnant women were tested in 2008, only about 10% of their partners are tested, resulting in high incidence of infection among women and their infants (and also among the negative male partners in discordant relationships).

The proposed program will develop, implement, and scale-up community based agreements or "compacts" to decrease HIV incidence in Zambian households. Applicants are encouraged to utilize a range of approaches at the local level aimed at increasing HIV awareness and preventive behaviors resulting in an invigorated community environment where risk of HIV acquisition is clearly understood at all levels resulting in real behavior change.

"Community compacts" represent a different approach to HIV prevention, aimed at engaging directly with target communities and entering into a process whereby leaders and individuals alike are all involved in decreasing the number of new HIV infections while maintaining and/or enhancing the communal environment. The term "community" requires definition and could illustratively include the physical boundaries of a village or township ( ward, etc.), the catchment area surrounding a clinic, a church group or congregation, a grouping of individuals ( university students) or a school setting (students and teachers), or a subset of clinic attendees pregnant women attending ANC/PMTCT services and their families. Communities will be defined with appropriate outcome objectives. A key ingredient to success will be the approach taken by awardees to engage community leadership to mobilize communities to protect themselves collectively from HIV spread. Participatory dialogue with community stakeholdersincluding traditional chiefs, religious leaders, local government, and civil society will be critical to the development of community compacts and local government structures may be involved in project design, implementation, and monitoring.

The three objectives of these compacts are to:

1. Identify target communities and build bridges to develop community compacts or partnership activities for HIV prevention interventions;

2. Transfer skills to communities through Zambian partners to sustain HIV prevention activities; and

3. Develop and implement measurement frameworks to track progress of community prevention activities.

Initial and intermediate outcome measurements may be utilized that are part of the compact agreement, including achieving high rates of community testing, especially of couples, as an initial qualification for a compact agreement. Other measures will evolve based on the "community" being served and how measures of accomplishment are determined during program design and implementation. Overall, the expectation is to see decreased risk taking behaviors leading to decreased numbers of new HIV infections.

Changes in social norms that are anticipated include acceptance of testing for HIV and communication among couples about HIV status (best achieved through couples testing), and the unacceptability of high risk behavior (multiple concurrent partnerships, early sexual activity, sex with someone whose HIV status one does not know), and improved health-seeking behavior. The greatest long-term benefit will come through achieving lower rates of HIV incidence in communities.

Chiefs, local leaders, and other "community" members develop a community compact that includes individual testing and counseling as well as active prevention programs. Under these community activities a paradigm shift will be instigated whereby negative status is "rewarded" through the compact, while individuals who are positive will still receive support, the community at large may lose eligibility for its incentive. Similar to focusing on the negative status, testing and counseling will be focused on the 85% of Zambians who are negative, providing them, their partners, and community at large the information and tools necessary to maintain an HIV free life.

The challenge in geographic communities is developing incentives that are valued by the community and have secondary benefits. A school bursary fund administered by the community, a community center, or other improvements that promote health could be considered. Overall activities will promote knowledge of ones HIV status, with a particular focus on couples or partner counseling as a way of bringing HIV information into the household and thereby allowing for prevention interventions to be appropriately targeted.

Ideally, individuals will avail themselves of repeat testing as a means to determine whether HIV incidence has changed. However, other proxy measures may be required in order to allow for meaningful measurements across the determined time period.

Illustrative indicators:

? Number of people receiving testing and counseling services (esp., couples, men, adolescents, etc.)

The focus of this approach is to identify discordant couples and other high risk individuals (including those with multiple partners) and provide them with prevention training, including condoms, in order to prevent transmission.

These communities could include religious organizations, workplace environments, out of school adolescents/young adults or other types of organizations and communities. Leadership within these "communities" will develop a compact that includes education and support for individual and couples testing, and support for those already infected to reduce stigma related to HIV. For example, a compact could be designed with a secondary school that would include HIV prevention information, along with testing and counseling and including condom distribution. The exact interventions would be determined with the community (school) but would be designed to provide a framework for integrating HIV prevention information and behavior change interventions. This would be followed up by rigorous monitoring to evaluate program impact.

Incentives will be designed by the community themselves but could include institutional improvements for "structure" based communities, or inputs into a community or other setting. The geographic location of activities will vary depending on the definition of community. It could include a defined living area, a school or health facility, or other demarcation. What is key is the ability to reach the community with defined interventions such that measured outcomes can be determined.

Illustrative indicators:

? Number of youth (10-24) reached with community prevention programs

? Number of condoms distributed