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 and more adults become infected each year than are placed on ART. HIV prevalence in pregnant women was highest in 1994 at 20%, but declined only to 19% in 2004 and 17% in 2007/8. Two population-based DHS+ surveys have been completed, with HIV prevalence in the general adult population of 16.3% in 2001/2 and 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. In 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 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. Using a competitive process applicants will be 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 (e.g. ward, etc.), the catchment area surrounding a clinic, a church group or congregation, a grouping of individuals for example university students or a school setting (students and teachers), or a subset of clinic attendees pregnant women attending ANC/PMTCT services and their families, etc. 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 compact 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. This will have the secondary benefit of increasing referrals to care and treatment and identifying discordant couples. Programs may use approaches including repeat testing for HIV which could measure incidence in a confidential manner. The risk of increased stigmatization of HIV infection will be mitigated by systems which protect confidentiality while linking individuals and identifying the communities to which they belong. Aproaches may include, but are not limited to, those which use the Smart Care medical electronic records system. Appropriate and agreed upon incentives with input from the community for successful reduction in incidence may have secondary health and development benefits, such as improvements to health facilities, water and sanitation, school programs or scholarships, or address other community development needs.

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, unprotected sex with someone whose HIV status one does not know), and improved health-seeking behaviors. The greatest long-term benefit will come through achieving lower rates of HIV incidence in communities.

Chiefs, other local leaders, and health officials develop a community compact that includes door-to- door testing and counseling as well as active prevention programs and condom distribution in discordant couples and also making condoms easily accessible for HIV negative members of the community. 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 (such as clinic improvements as described under PMTCT) could be considered. The amount of incentive could be calculated based on a proportion of the amount saved per year in reduced HIV care and treatment costs. This level of testing might require one year in most community programs, so that seeing results will come slowest in geographic communities. Participation in SmartCare would also allow the capture of this information from other sites across the country and would confidentially track testing in a nationally acceptable way.

Initial targets:

1. 80% testing rates of all adults in the community, including a high proportion (at least 60%) of married people tested as couples.

Intermediate targets:

1. 80% retesting rates at least 12 months after initial tests.

2. Low rates of teenage pregnancy

Final outcome:

1. Transmission in discordant couples is less than 2% (minimum 40 discordant couples)

2. Overall transmission less than 0.2% or 2% of measured prevalence (whichever is higher).

Students, parents, faculty and school administration enter into a compact in an HIV-free generation approach. Parents and students (at least 80%) give permission and or consent for students to be HIV tested at the beginning and end of a school year, with a Testing and Counseling program independently maintaining confidential records, not accessible to school leadership or parents (part of the consent/compact). Such an approach will allow appropriate individual and private counseling of sexually active students and promotion of secondary abstinence and safer sexual practices. The incentive could be computers or books, refurbishment of the library, or support for an educational program that provides a secondary benefit.

Intermediate targets could include:

1. Reduction in school pregnancy rates

2. Reductions in those reporting sexual activity [subject to bias]

3. Final rate of testing at end of year [or two]

4. Successful completion of school year

Outcome target: Incidence less than 0.1%, minimum community size 500.

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

These communities could include religious organizations, workplace environments, or other organizations. Leadership of these organizations and faith-based communities will develop a compact that includes education and support for couples testing, support for those already infected and reduction in stigma related to HIV.

Initial targets include:

1. 80% of married couples test as a couple

2. 80% of singles over age 18 test

3. Stigma reduction program is included in the church educational program

4. Discordant couples enroll in program to reduce transmission that includes testing at least twice in the first year [recommended after 3 months]

5. 90% of couples and individuals retest after at least 12 months [except those individuals who are infected and couples who are both infected]

Outcome target:

1. Transmission in discordant couples is less than 2% (minimum 40 discordant couples)

2. Overall transmission less than 0.2%

Incentives for religious organizations will need to be consistent with US regulation. Since discordant couples will be identified in this approach, partnerships with organizations providing testing, counseling and other prevention services will help to maintain confidentiality and independence and that the reporting of results will not compromise this individual confidentiality.