IV. Critical Interventions in the Focus Countries: Prevention

“We will train doctors and nurses and other health care professionals so they can treat HIV/AIDS patients. Ourefforts will ensure that clinics and laboratories will be built or renovated and then equipped. Child care workers willbe hired and trained to care for AIDS orphans, and people living with AIDS will get home-based care to ease theirsuffering . . . And we’re developing a system to monitor and evaluate this entire program, so we can be sure we’regetting the job done.” President George W . Bush, July 2, 2003

The 2003 UNAIDS AIDS Epidemic Update offered a set of stunning statistics – last year, 3 million people died of AIDS. At the same time, 5 million more were infected with HIV. Despite two decades of focused attention on prevention, we have yet to achieve widespread success, as evidenced by the 14,000 people who each day join the ranks of those infected. Clearly, HIV/AIDS cannot be defeated unless the number of new infections is dramatically reduced and eventually eliminated.

It is time, however for new thinking and approaches. Past and current prevention messages have often failed to achieve the widespread behavior change that is necessary to end the pandemic. Prevention efforts are further hampered by the stigma surrounding HIV/AIDS and gender inequality that increases the vulnerability of women and girls.

Of the approximately 40 million people infected with HIV worldwide, it is estimated that as many as 95 percent do not know their status. Without knowledge of their status, people continue to spread the disease unwittingly and do not seek treatment. Given the sheer numbers of people who do not know their status, this factor alone represents an enormous challenge to turning the tide against HIV/AIDS. Limited testing strategies, insufficient testing services, and a lack of enabling policies have thus far proven inadequate for making sufficient progress against the disease.

Overstressed and poorly functioning health care systems also contribute to the spread of disease. Medical transmission of HIV continues to be a problem, spread through unsafe injections, unnecessary medical procedures, and use of unscreened blood supplies. Rates of sexually transmitted infections (STIs) remain high, and, when untreated, contribute to the spread of HIV. Health care systems, understaffed and inadequately supplied, have been unable to close this entry point for HIV infection.

In 2001, an estimated 720,000 children globally were infected via mother-to-child HIV transmission. U.S. Government programs such as the President’s International Mother and Child HIV Prevention Initiative, as well as those implemented by other partners, have proven that the administration of a short course of antiretroviral (ARV) drugs and improved breastfeeding practices can dramatically reduce the number of mother-to-child infections and thus the number of new infections overall. Such programs also provide a critical link to HIV/AIDS treatment programs that offer ARV and other treatment to HIV-infected women and their families, thus helping to preserve the family unit.

Finally, the limited availability of treatment and care, and its effects of extinguishing hope and fueling fear and stigma, presents its own barriers to prevention efforts, as denial continues to bolster inaction.

The President’s Emergency Plan is specifically designed to address these challenges and capitalize on the opportunities outlined above in achieving its goal of preventing 7 million new HIV infections. In its use of evidence-based prevention programs such as the “ABC” – Abstinence, Be faithful, and as appropriate, correct and consistent use of Condoms – approach, proven successful in Uganda, Zambia, Senegal, and elsewhere, the Emergency Plan will target prevention funds to methodologies that are effective in helping people avoid behaviors that place them at risk of contracting HIV. Identified best practices such as increased testing; appropriately tailored interventions for specific populations including women, men, and high-risk groups; the involvement of people living with HIV/AIDS, parents, and leaders from all sectors of society; and stigma reduction will be aggressively promoted to achieve real results in reducing the number of new infections. At the same time, these interventions must strengthen existing indigenous responses to the epidemic, be discerning and responsive to the culture, and build on community structures that influence social and community norms in order to reduce risk behaviors.

Furthermore, in keeping with the Emergency Plan’s health care approach, specific interventions to strengthen health care services to reduce HIV transmission are another cornerstone of prevention activities. The President’s Emergency Plan will help build the health infrastructure necessary to strengthen infection control programs, reduce medical transmission of HIV, and build the capacity of health care workers to treat STIs and prevent mother-to-child infection. Last, the fundamental principle of the President’s Emergency Plan – to integrate prevention, treatment, and care – is intended to stimulate a cycle that will reduce stigma and fear, create incentives for testing, and thus amplify prevention efforts.

Prevention Objective:
Prevent 7 million HIV infections in the focus countries

Prevention Strategies:

1. Rapidly scale up existing prevention services

2. Build capacity for effective long-term prevention programs

3. Advance policy initiatives that support prevention of HIV infection

4. Collect strategic information to monitor and evaluate progress and ensure compliance with Emergency Plan policies and strategies

It is estimated that immediate action to implement comprehensive prevention programs could avert 60 percent of new HIV infections in resource-limited settings by 2010. A delay of only three years could reduce efficacy by nearly 50 percent. Thus, rapid scale-up of existing prevention services is an urgent priority of President Bush’s Emergency Plan. Much has been learned about effective strategies for prevention over the past two decades. While the President’s Emergency Plan seeks in the long term to develop sustainable national programs in each country, in the short term it will move quickly through the expansion of current activities. Faith-based and community-based groups, as well as many ministries of health, have established excellent prevention programs in the areas of abstinence promotion, behavior change, prevention of HIV infection from mother to child, and technical assistance for improved medical practices. These organizations offer innovative, effective, and accountable local programs, and have established relationships with national organizations and local communities. Such organizations provide the optimal foundation to build on best practices toward the development of comprehensive national prevention programs.

Organizations are poised to rapidly and accountably scale up programs in the following priority areas:

• Prevention of HIV infection through abstinence and behavior change for youth;

• Prevention of HIV infection through HIV testing, targeted outreach, and condom distribution to high-risk populations;

• Prevention of HIV infection from mother to child; and

• Prevention of HIV infection through safe blood, improved medical practices, and post-exposure prophylaxis.

Prevention of HIV infection through abstinence and behavior change for youth
In many of the countries hardest hit by HIV/AIDS, sexual activity begins early and prior to marriage. Surveys show that, on average, slightly more than 40 percent of women in sub-Saharan Africa have had premarital sex before age 20; among young men, sex before marriage is even more common. Moreover, a significant minority of youth experience first sex before age 15. Abstinence until marriage programs are particularly important for young people, as fully half of all new infections occur in the 15- to 24-year-old age group. Delaying first sexual intercourse by even a year can have significant impact on the health and well-being of adolescents and on the progress of the epidemic in communities.

Adolescent girls in high HIV-prevalence countries in Africa are at significantly higher risk of acquiring HIV. In some communities, as many as 20 percent of girls aged 15 to 19 are infected compared to 5 percent of boys the same age. These age differentials in HIV prevalence reflect a pattern of older men having sex with younger women. Young women involved in exchange relationships with older men are disadvantaged by gender, age, and economic power. Moreover, a substantial proportion of girls in Africa and the Caribbean experience coerced sex, including forced first sex.

Youth are subject to a variety of conflicting social messages and influences related to sex. Although many traditional social norms emphasize abstinence for youth, extramarital sexual activity is common among adults, especially men. While virginity is emphasized for girls, sexual activity is often seen as a sign of manhood for young men. Parents, religious leaders, teachers, and the media may each provide different information related to HIV/AIDS, adding to confusion in decision-making.
Comprehensive and effective prevention approaches reflect the complex influences on young people’s deci-sion-making and the need to address the broader social factors that shape their behaviors. Internationally, a number of programs have proven successful in increasing abstinence until marriage, delaying first sex, reducing the number of partners, and even achieving “secondary abstinence” among sexually experienced youth.

President Bush’s Emergency Plan recognizes the diversity of countries and the need to harmonize prevention messages at the community level. Correct and consistent information is vital to effective HIV prevention, and program partners thus should not disseminate incorrect information about any health intervention or device. In addition, national governments may appropriately seek to coordinate information or referral links to other services designed for high-risk populations.

Risk Elimination, Risk Reduction Basic public health approaches to disease prevention rely on both risk elimination and risk reduction. Risk elimination strategies are those that reduce exposure to disease, such as abstinence in the case of STIs. Risk reduction strategies are those that reduce the likelihood of transmission during any given exposure, such as the use of condoms or the provision of prophylactic ARV treatment for exposed newborns or health care workers. Risk elimination is a cornerstone of the President’s Emergency Plan. Approaches that are directed to behavior change, such as encouraging abstinence, testing, and faithfulness in sexual relationships, have proven to be successful and will be expanded. Knowledge of HIV status, fidelity in marriage, and monogamy for the sexually active are equally important goals of prevention programs. Evidence from Thailand suggests condom use is an important means of reducing, but not eliminating, risk. Working closely with local governments, nongovernmental organizations, and prevention experts, condom programs targeted to at-risk populations will be supported. In doing this, it will be important to disseminate clear messages that support, rather than confound, a core risk elimination approach.

The Emergency Plan supports the following categories of activities as part of its rapid scale-up of prevention programs for youth:

Scale up skills-based HIV education, especially for younger youth and girls.  Young people need to be reached early, before they begin having sex, with skills-based HIV education that provides focused messages about the benefits of abstinence until marriage and other safe behaviors. Activities should help young people develop the self-esteem to delay sex until mar-riage, make informed choices, and develop the communication skills to say “no” to sex (as well as to alcohol and drugs, which increase vulnerability to sexual pressure). Best practices suggest that communication skills and the ability to personalize risk can be achieved through curricula that use interactive methods to target specific risk factors for early sexual activity in the local context and help young people define values. Ideally, programs should go beyond sexuality to build on young people’s assets and encourage them to stay in school and plan for their futures. While these programs are most relevant to younger adolescents aged 10 to 14 years, especially girls, they are also appropriate for older adolescents. Suggested activities include:

• Developing and disseminating age-appropriate curricula that include clear messages about abstinence until marriage and other safe behaviors, and that address risk factors in the local context;

• Expanding skills-based HIV education through schools, working both at the national level with ministries of education and local schools at the community level;

• Strengthening HIV education delivered through after-school programs run by youth services networks, including faith-based networks; and 

• Strengthening programs in HIV education for children who are not in school.

Promote healthy norms and behaviors.  Communities need to mobilize to address the norms, attitudes, values, and behaviors that increase vulnerability to HIV, including multiple casual sex partners and cross-generational and transactional sex. To stimulate such mobilization, there is an urgent need to help communities identify and recognize the ways in which they contribute to establishing and reinforcing norms that may contribute to youth risk, vulnerability, and stigma. President Bush’s Emergency Plan will support groups that discourage harmful norms through a variety of media and other activities at both the community and national levels. Suggested activities include:

• Training local religious and other traditional leaders in HIV concerns and supporting them in publicizing the risks of early sexual activity, multiple partners, and cross-generational sex;

• Supporting youth-led community media to help youth, their parents, and the broader community personalize the risks involved in these behaviors; and

• Supporting media campaigns that reinforce and make abstinence until marriage, fidelity, partner reduction, and other safer behaviors legitimate options and standards of behavior for both youth and adults.

Reinforce the role of parents and other protective factors.  Parents are potentially the most powerful protective factors in young people’s lives; they have great potential to guide youth toward healthy and responsible decision-making and safer behaviors. In Emergency Plan countries, where many youth have lost their parents to AIDS, other adult caregivers and mentors also have an important role to play in providing guidance to youth. Many adults, however, find it difficult to communicate with teens, both on broader issues of regulation and discipline and in discussing sexuality and their own expectations and values about sex. The Emergency Plan will support efforts to reach out to parents and other adult caregivers to educate and involve them in issues relating to youth and HIV and to empower them by improving their communication skills in the areas of sexuality as well as broader limit-setting and mentoring. Suggested activities include:

• Holding parenting education workshops to improve parent-child communication on HIV, sexuality, and broader issues such as limit-set-ting, through parent-teacher associations, local social and civic clubs, and faith-based groups;

• Organizing special school and community events jointly for parents and teens to promote mutual communication about HIV and healthy behaviors; and

• Developing and training a cadre of volunteer mentors for youth who lack sufficient parental or other adult supervision, including training in messages for HIV prevention.

Address sexual coercion and exploitation of young people.  Adolescents need a safe environment where they can grow and develop without fear of forced or unwanted sex, which often precludes the option of abstinence. The Emergency Plan supports psychosocial and other assistance for victims of sexual abuse. Efforts to target men with messages that challenge norms about masculinity and that emphasize the need to stop sexual violence and coercion will also be important. Suggested activities include:

• Organizing campaigns and events to educate local communities about sexual violence against youth and strengthen community sanctions against such behaviors;

• Implementing workplace programs for older men and school-based programs for young boys to provide education about preventing sexual violence, with a special focus on men who have a higher propensity to become perpetrators;

• Training health care providers, teachers, and peer educators to identify, counsel, and refer young victims of sexual abuse for other health services; and

• Working with governments and NGOs to eliminate gender inequalities in the civil and criminal code.

Prevention of HIV infection through HIV testing, targeted outreach, and condom distribution to high-risk populations
Following the “ABC” model, and recognizing that condoms are an essential means of HIV prevention for populations who engage in risky behavior, rapid scale-up of activities that target specific at-risk populations with outreach, prevention messages, testing, and condoms will be undertaken. These groups include prostitutes, sexually active discordant couples, substance abusers, and others. In doing this, care will be taken to adhere to local guidelines and standards and to ensure that the key behavioral messages of abstinence, faithfulness, and partner reduction are not confounded.

Prevention of HIV infection from mother to child
The technology now exists to substantially reduce mother-to-child transmission (MTCT) using simplified interventions that international clinical trials have demonstrated can reduce risk of HIV transmission from mother to child by 30 to 50 percent. The interventions involve providing routine HIV testing for pregnant women, administering short-course ARV prophylaxis to HIV-infected mothers in the last weeks of pregnancy or during labor or delivery, and administering ARV drugs by droplet to infants within 72 hours of birth. The interventions also call for less invasive medical procedures during childbirth, improved breastfeeding practices, and prevention and treatment of malaria.

The President’s Emergency Plan will build on the significant work already accomplished under the President’s 2002 International Mother and Child HIV Prevention Initiative (now integrated into the Emergency Plan). President Bush’s Emergency Plan will support rapid expansion of these programs through the following suggested activities:

• Scaling up existing prevention of mother-to-child transmission (PMTCT) programs by rapidly mobilizing resources;

• Providing technical assistance and expanded training for health care providers (including family planning providers, traditional birth attendants, and others) on appropriate antenatal care, safe labor and delivery practices, breast-feeding, malaria prevention and treatment, and family planning;

• Strengthening the referral links among health care providers;

• Ensuring effective supply chain management of the range of PMTCT-related products and equipment; and

• Expanding PMTCT programs to include HIV treatment for HIV-infected mothers and other members of the child’s immediate family.

Prevention of HIV infection through safe blood, improved medical practices, and post-exposure prophylaxis
HIV transmission in medical settings, including through blood transfusions, is a significant contributor to the HIV pandemic. Thus, the rapid implementation of safe blood programs and precautions against medical transmission of HIV is a priority area for the President’s Emergency Plan. The World Health Organization (WHO) estimates that 5 to 10 percent of all HIV transmissions are attributable to unsafe blood transfusions. Transmission of HIV and other bloodborne pathogens via blood transfusion is preventable by establishing an adequate supply of safe blood through a systematized blood transfusion service and by minimizing unnecessary transfusions. According to WHO, however, in 2002 only 90 percent of blood donations in Africa were screened for HIV, only 40 percent for hepatitis C, and 55 percent for hepatitis B.

Much can be done to reduce the likelihood of transmission, improve infection control, and increase the quality of health care services overall. President Bush’s Emergency Plan will provide technical assistance and training to prevent medical transmission of HIV and improve the quality of services through the network model. Support will be provided to improve blood safety, increase the use of safe injection practices, ensure the practice of universal precautions, and increase the availability of post-exposure prophylaxis. Specifically, expert guidance, support, and assistance from organizations currently providing training and technical assistance will be provided to ministries of health and national transfusion services to develop and implement comprehensive national safe blood programs. Suggested activities include:

• Providing technical assistance for developing effective national, generic, and site-specific policies, protocols, guidelines, and practices related to blood donation; safe injections; obtaining, handling, storing, testing, transporting, distributing, and disposing of blood, sharps, other injection equipment, and medical wastes; and universal precautions for infection control and prevention and management of occupational exposure to HIV;

• Training health care staff in the use of protocols and guidelines – the Emergency Plan will support training, supervision, and other performance improvement measures for health care professionals in the areas listed above as well as education about alternatives to injection in primary care practice;

• Ensuring effective supply chain management of the range of products and equipment needed to prevent medical transmission of HIV; and

• Providing technical assistance, training, and products for post-exposure prophylaxis in health care settings and for other types of potential exposure (such as sexual violence) once protocols have been established and trained personnel and supplies are in place.

2. Build capacity for effective long-termprevention programs

At the same time that President Bush’s Emergency Plan is mobilizing the rapid scale-up of behavior change interventions and other prevention services, it will also be laying the foundation for sustainable and effective long-term local and national prevention programs. The President’s initiative will help build, strengthen, and improve the quality and sustainability of prevention programs by promoting evidence-based best practices, encouraging innovation and evaluation to identify effective new approaches, and improving program planning, implementation, management, and monitoring. The development of such comprehensive and sustainable programming will be accomplished through the following key operational strategies:

• Promoting the “ABC” model;

• Innovatively expanding HIV testing;

• Supporting interventions for those at high risk of infection;

• Reaching and engaging mobile male populations;

• Improving diagnosis and treatment of STIs; and

• Developing and strengthening institutional capacity of implementing organizations.

Promoting the “ABC” model
Evidence from Uganda, Senegal, and Zambia demonstrates the effectiveness of a balanced approach to behavior change that encourages the adoption of “ABC” behaviors – A for abstinence, B for being faithful, and C for correct and consistent use of condoms as appropriate.

The application of A, B, and C interventions will be balanced and targeted according to the needs and specific circumstances of different at-risk populations. Expanding the human resources necessary to implement this bold new prevention strategy will require engaging a wide range of partners, from women’s associations to faith-based organizations (FBOs), sports clubs to workplaces, parents to schools, and health workers to traditional healers. President Bush’s Emergency Plan will support efforts to build the capacity of local and national partners to strengthen ABC prevention messages and link them in their application to ongoing treatment and care programs.

The application of the ABC model will emphasize:

Abstinence for youth. The strategies for youth described in detail above encourage abstinence until marriage for those who have not yet initiated sexual activity and “secondary abstinence” for unmarried youth who have already engaged in intercourse. FBOs are in a strong position to help young people see the benefits of abstinence until marriage and support them in choosing to postpone sexual activity. Programs will help youth develop the knowledge, confidence, and communication skills necessary to make informed choices and avoid risky behavior. President Bush’s Emergency Plan will also support programs that reinforce parental involvement, as parents are the primary caregivers and have the responsibility of overseeing the upbringing of their children.

Being faithful. Some of the most significant results from Uganda resulted from changes in behavior related to fidelity in marriage, monogamous relationships, and reducing the number of sexual partners among sexually active unmarried persons. President Bush’s Emergency Plan will build on this success by supporting counseling, peer education, and community-based interventions to address social norms that increase vulnerability to HIV, such as the acceptance of men having multiple sexual partners outside of marriage, cross-generational sex, and transactional sex. Working through the media and community-based and faith-based institutions, interventions will deliver messages that promote abstinence until marriage and fidelity to one partner, encourage men to refrain from sexual promiscuity and to respect women, and encourage testing. Knowledge of HIV serostatus is especially important, and counseling and HIV testing of couples can be an effective strategy. Despite the fact that sero-discordant couples – couples in which one partner is HIV-positive and the other HIV-negative – may remain monogamous, the risk still remains high for the uninfected partner.

Correct and consistent use of condoms as appropriate. For those who are infected or who are unable to avoid high-risk behaviors (such as discordant couples), condom use is a critical risk-reduction intervention. The Emergency Plan will make condoms available to reduce the risk of the spread of HIV infection among those who engage in high-risk activity by strengthening public and private sector programs to create demand among those at high risk and by expanding the number of condom distribution outlets near areas where high-risk behavior takes place. Improved condom forecasting and supply chain management will be necessary to ensure condoms are available in these high-risk settings. Use of condoms will also be promoted for sexually active discordant couples. In doing this, every effort will be made to deliver a consistent “ABC” message so that the general population receives a clear message that the best means of preventing HIV/AIDS is to avoid risk all together.

Innovatively expanding HIV testing
Estimates indicate that at many as 95 percent of people living with HIV/AIDS do not know their status. Without knowing their status, individuals can neither access appropriate care service for themselves nor take steps to prevent transmission to others. HIV testing is a critical intervention that serves as a linchpin connecting prevention to care and treatment. When combined with counseling, testing can also be a powerful means of educating individuals and communities about HIV and preventing infection. Those who know their HIV-negative status can avoid future infection and be linked to community prevention activities. Those who know their HIV-positive status can live positively and start early prevention and treatment of opportunistic infection or STIs, begin antiretroviral therapy (ART), seek psychosocial support, and plan for their futures. A strong testing and counseling program helps to reduce stigma and enhance the development of care and support services. In addition, HIV testing programs that target couples can identify sero-discordant couples and create a critical opportunity for prevention interventions.

While it is anticipated that the hope generated by access to ART will increase demand for HIV testing, this is not sufficient. Innovative solutions must be found to dramatically increase the number of individuals who are tested and know their status. The Emergency Plan will increase the availability of HIV testing services through a number of key innovative strategies:

• Integrating testing with other health services, such as family planning, antenatal care, STI, tuberculosis, and malaria programs, and improving the referral links among all of these services;

• Expanding the range of settings in which confidential testing and counseling are offered, including at times of employment, school enrollment, military enlistment, and marriage registration, and ensuring that non-discrimination policies and practices are in place;

• Strengthening training of health workers, professional and lay counselors, laboratory technicians, and other support people necessary to rapidly expand services;

• Strengthening linkages between testing and counseling and post-test services;

• Focusing efforts to make HIV testing available to those at highest risk of infection;

• Strengthening of counseling and support to clients to encourage disclosure of status to others;

• Ensuring adequate supplies of HIV test kits and other essential products;

• Stimulating demand for services through innovative communications and social marketing approaches at the community and mass media levels;

• Providing support to women to mitigate potential violence or other negative outcomes of disclosing HIV-positive status to male partners; and

• Strengthening national guidelines for HIV testing and counseling, where appropriate; encouraging the adoption of routine testing policies; and ensuring regulatory support for maintaining confidentiality, service quality, and adequate procurement and supply chain management.

Supporting interventions for those at high risk of infection
Some of the populations most affected by HIV/AIDS are also the most difficult to reach through conventional health care programs. Prostitutes and their clients, men who have sex with men, and injecting drug users are among those who are most marginalized in society and have the least access to basic health care. Developing and implementing interventions with some of these groups is even more difficult because of stigma and discrimination. At the same time, these populations are generally at higher risk of infection and in greatest need of prevention services. First and foremost, the Emergency Plan will support approaches directed at ending risky behavior. In addition, the Emergency Plan supports effective new approaches to reach groups at high risk through a combination of:

• Interpersonal approaches to behavior change, such as counseling, mentoring, and peer outreach;

• Community and workplace interventions to eliminate or reduce risky behaviors;

• Initiatives to promote the use of testing and counseling services;

• Linkages through referral networks with other health services;

• Diagnosis and treatment of STIs;

• Promotion of condom use during high-risk sexual activity;

• Strengthened referral systems to link substance abuse treatment services with HIV testing and counseling;

• Promotion of substance abuse prevention and treatment services; and

• Mass media interventions with specially tailored messages.

Reaching and engaging mobile male populations
Workers engage in risky behavior, such as sexual relations with non-regular partners, more often when they are posted away from home or are required to travel for extended periods of time. Migrant workers, truck drivers, and members of uniformed services such as the armed forces and police face serious risks of HIV and other STIs and can serve as a bridge for transmitting infection to the general population. The uniformed services present unique challenges and opportunities for HIV prevention. The United States has played a leadership role in pioneering prevention approaches with the military. President Bush’s Emergency Plan will build on already initiated U.S. Government activities to reach the military and other uniformed services including:

• Peer education, interpersonal and group communication strategies, and local mass media to promote faithfulness, partner reduction, avoidance of commercial sex, and condom use during high-risk sexual behavior;

• STI and HIV testing and counseling services, linked to treatment and care;

• Basic workplace and in-service training on HIV/AIDS for employees, new recruits, and existing personnel; and

• Condom promotion and distribution for those who practice high-risk sexual behavior.

Improving diagnosis and treatment of STIs
An important link exists between STIs and the sexual transmission of HIV. Untreated, STIs can significantly increase the likelihood of both acquiring and transmitting HIV. President Bush’s Emergency Plan will support STI prevention, diagnosis, and treatment services, and the linking of these services through referral networks with HIV testing and counseling and other HIV services, through implementation of the following strategies:

• Increasing availability and accessibility of STI treatment services through the expansion of STI prevention and treatment services where appropriate;

• Integrating STI treatment services with other HIV/AIDS and reproductive health care services and improving the referral links between programs; and

• Improving national STI treatment protocols, training health workers in their use, and where needed, developing national evidence-based guidelines, protocols, and training curricula.

Developing and strengthening institutional capacity
Prevention programs are only as strong as the institutions that support them. Therefore, a strong organizational infrastructure is the foundation upon which the planning, implementation, and evaluation of effective behavior change interventions and prevention services are built. Many of the organizations that implement risk elimination and reduction interventions may need to enhance of develop the institutional capacity to support the rapid scale-up of prevention programs necessary to effectively address the epidemic.

The President’s Emergency Plan will invest in strengthening the institutional capability of implementing organizations by providing technical assistance, training, and funding to improve and expand the organizational capability of key partners – including FBOs, other community-based organizations (CBOs), and nongovernmental organizations (NGOs)
– as well as public and private facilities that deliverabstinence-until-marriage programs, HIV testing and counseling, and PMTCT and STI services. By looking at the institutional capacity building needs of partners within a network, and the linkages between them, support will be provided to:

• Equip health facilities and mobile units to provide testing and counseling and STI services;

• Strengthen public and private sector capabilities to design and produce behavior change materials;

• Upgrade routine health information systems to improve prevention services data management;

• Strengthen qualitative and quantitative research capability;

• Support effective product procurement, storage, and distribution, particularly for HIV testing and targeted condom distribution programs;

• Strengthen NGO/CBO financial and administrative systems; and

• Improve laboratory capacity to perform HIV testing.

3. Advance policy initiatives that support prevention of HIV infection

Many of the focus countries have elevated HIV/AIDS to national priority status. All promote a comprehensive approach integrating prevention, treatment, and care. Most have clear statements supporting the human rights of people living with HIV/AIDS and condemning stigma and discrimination related to HIV status. Several explicitly state the importance of greater involvement of people living with HIV/AIDS in program planning and policy. In an effort to address underlying factors that promote vulnerability to HIV, most of the focus countries have established policies to promote gender equality, improve women’s socioeconomic status, and address violence against women. Application of these policies is far from complete, however, especially at the community level.

A key priority of President Bush’s Emergency Plan will be to support implementation of good policies and effective legislation, particularly at the community level. Illustrative examples of policy issues that may be addressed through Emergency Plan technical assistance include:

• Protection against stigma and discrimination, particularly within key settings such as workplaces, schools, and the military;

• Use of routine testing while applying the principles of confidentiality;

• Human resources policies, including the broadening of responsibility for HIV testing and counseling to lower levels of care;

• Access to health information and care, including for traditionally underserved populations such as women, the poor, and the disabled;

• Policies to promote gender equality;

• Support for the review, revision, and enforcement of laws relating to sexual violence against minors, including strategies to more effectively protect young victims and punish perpetrators; and

• Programs that support abstinence until marriage and fidelity within marriage.

4. Collect strategic information to monitor andevaluate progress and ensure compliance with Emergency Plan policies and strategies

Measuring prevention activities and providing useful feedback to programs for accountability and quality improvement is a goal of strategic information for improved HIV prevention activities. Improved HIV sentinel clinical and population-based surveillance systems will measure the impact and outcomes of prevention programs. Program monitoring will enable the tracking of training, media, and community outreach activities, including interventions to promote abstinence. Targeted program evaluations will provide evi-dence-based information to improve prevention programs, and information management systems will facilitate data storage and data flow. Sets of internationally agreed upon prevention indicators developed by WHO, UNAIDS, and U.S. Government agencies will guide the Emergency Plan’s strategic information system.

The prevention goal of 7 million HIV infections averted over five years will, by necessity, be based on mathematical projections. A methodology will be established that will use estimates of new infections based on assumptions of rates that would occur without the Emergency Plan, estimates of numbers of new infections under the new program, measures of program intensity (such as numbers of persons receiving prevention services, numbers of workers trained, and numbers of programs supported), and expected levels of program effectiveness.

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