Prevention of Sexual Transmission in the General Population (Updated February 2008)

President George W. Bush's Emergency Plan for AIDS Relief is the largest commitment ever by any nation for an international health initiative dedicated to a single disease-- a five-year, $15 billion, comprehensive approach to combating the disease around the world. U.S. Department of State U.S. Agency for International Development U.S. Department of Defense U.S. Department of Commerce U.S. Department of Labor U.S. Department of Health and Human Services Peace Corps Mailing address: SA-29, 2nd Floor 2201 C Street, NW Washington, DC 20522-2920 www.PEPFAR.gov

Prevention of Sexual Transmission in the General Population  The U.S. President’s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR) supports the rapid scale-up of prevention education and services. More than four million people were infected with HIV in 2005. PEPFAR recognizes that effective prevention efforts are essential both to prevent the continued spread of HIV, and to mitigate an expanding and increasingly unsustainable need for treatment and care. Despite the continuing large number of new infections globally, several countries have had some success in reducing HIV infection rates, associated with the adoption of “ABC” prevention behaviors. The “ABC” approach tailors behavioral messages to the local epidemic context: “A” behaviors include abstinence, including delay of sexual debut for youth; “B” includes faithfulness to one partner or reducing the number of sexual partners; “C” emphasizes correct and consistent condom use, where appropriate. PEPFAR, in partnership with host countries, seeks to build on these successes by establishing local programs and partnerships that support the uptake of these key prevention behaviors. Among the greatest challenges to mounting effective prevention programs is the diversity of epidemic contexts and prevention needs across countries. In most concentrated low-prevalence epidemics, HIV is concentrated among sub-groups within the population that engage in high-risk behavior, such as people in prostitution or injecting drug users. In contrast, in most generalized high-prevalence epidemics, new infections frequently result from multiple, often concurrent, sexual partnerships within the general population, among individuals who often do not see themselves as engaging in risky behavior. PEPFAR HIV prevention programs in countries that are experiencing generalized epidemics take a comprehensive approach that includes: Increasing individual risk-perception and equipping individuals with the information and skills they need to adopt safer behaviors, through structured, interactive behavior change approaches such as curriculum-based and peer education. These programs also provide information about and access to condoms and other HIV services.   Mobilizing community leaders and other influential groups to promote culturally-appropriate social norms and values that promote delay of first sex and fidelity, and discourage the multiple overlapping sexual partnerships that drive generalized epidemics. Such initiatives help to create an enabling environment in which communities support individuals in adopting and sustaining key prevention behaviors.   Supporting community and mass media that are linked to efforts to change individual behaviors and social norms in order to reinforce healthy values and behaviors.

The Power of Partnerships: In fiscal year 2007, the Emergency Plan allocated $601.3 million to support prevention in the 15 focus countries. As of September 30, 2007 in the 15 focus countries, nearly 197.8 million people were reached by community outreach programs promoting ABC and other related prevention strategies with PEPFAR support since the inception of the Emergency Plan. Since the inception of PEPFAR, the U.S. has supplied nearly 1.9 billion condoms in support of comprehensive ABC approaches based on the unique epidemiology of each country from January 2004 through December 2007. PEPFAR also recognizes that gender inequality and some existing social norms often raise powerful barriers to the adoption of “ABC” behaviors and increase vulnerability to HIV. PEPFAR-funded prevention programs seek to mobilize local communities to address norms, attitudes and behaviors that contribute to HIV risk and vulnerability, including stigma and discrimination; cross-generational and transactional sex; sexual coercion and exploitation; and alcohol and substance abuse. With a focus on both individuals and the social context, the Emergency Plan seeks to ensure that local and political leadership, mass media, churches, schools, workplaces, and other community structures all contribute to national prevention efforts through mutually reinforcing prevention strategies. Addressing the Vulnerabilities of Women The Emergency Plan recognizes the critical need to challenge gender inequities, including male behaviors that often place female partners at greater risk of infection. PEPFAR prevention programs also focus on giving women and girls skills, information, and support they need to protect themselves. PEPFAR-supported ABC programs address gender issues, including violence against women, poverty, cross-generational sex, and transactional sex. The Emergency Plan at Work The following examples illustrate how the Emergency Plan is working under national strategies and in partnership with host nations to support HIV prevention programs for the general population: In South Africa, the Men as Partners program challenges gender-related attitudes, addresses norms of masculinity, and discusses the risks of multiple sex partners. Men as Partners supports ABC prevention approaches through workshops, community education, media advocacy, and policy development. The program also coordinates a network of community, faith, and non-governmental organizations that collaborate to bring about the social change necessary to prevent HIV.   In Ethiopia, International Orthodox Christian Charities and the Ethiopian Orthodox Church address HIV prevention and stigma reduction in 20 dioceses. Their approach integrates HIV/AIDS training modules into the core pre-service training curriculum of eight clergy training institutes and three theological colleges. Clergy also perform a community outreach-focused internship. Mainstreaming HIV in the curriculum prepares priests to deliver HIV prevention messages upon completion of theological college, and creates a sustainable model within the Ethiopian Orthodox Church and the communities it reaches.   In the Dominican Republic, Haiti, Nigeria, Ukraine, Vietnam and Zimbabwe, the SMARTWork program conducts workplace programs to reach adults and their families with HIV prevention and to protect the rights of those affected by HIV/AIDS. SMARTWork builds partnerships with businesses, labor representatives and government. It employs a variety of approaches to address employees with prevention programs in the workplace, where adults spend much of their time.   In Botswana, the Partner Reduction and Fidelity Campaign uses mass media activities to address “trusted partner” myths, promote fidelity and HIV testing, and increase risk perceptions related to mixing alcohol and sex. It also uses a range of community-based outreach approaches such as “edutainment” and peer educators and community role models who sensitize the community to these issues.