7th July Summary The 15th topic of the Bridge Project e-forum was ‘Combination HIV Prevention programs for MARPs’, which was open for discussion from 9th – 7th July 2014. This was an active discussion with 26 posts and experiences shared from Ethiopia, Ghana, Zambia, Uganda, Nigeria and India. We thank the guest moderator and expert for this topic, Dr. Endale Workalemahu Tilahun, Deputy Chief of Party/Programs MULU MARPs, PSI Ethiopia for his guidance and insights. As part of this discussion, the participants discussed the following questions: Q1: What are the key aspects of combination prevention programs for MARPs? Q2: What are the benefits of having combination programs? Q3: What are the challenges that have been faced? What could be the solutions? Q4: How do you monitor and evaluate combination prevention programs? The participants’ main discussion points and the resources shared are listed below: Background Prevention efforts have mostly focused on reducing individual risk with fewer efforts made to address structural factors such as socio-cultural, economic, political, legal and other contextual factors National prevention programmes sometimes remain disconnected, lacking clear milestones. “Combination prevention” offers the best prospects for addressing documented weaknesses in HIV prevention programming and for generating significant, sustained reductions in HIV incidence in diverse settings. Combination prevention relies on the evidence informed; strategic, simultaneous use of complementary behavioral, biomedical and structural prevention strategies. Combination prevention programmes operate on different levels (e.g., individual, relationship, community, societal) to address the specific, but diverse needs of the populations at risk of HIV infection. Main discussion points An article on combination prevention published in April 2014 in the Lancet was shared

with the group The guest moderator shared that combination prevention concepts emerged based on evidences generated during the 2008 international AIDS Conference. The combination

of behavioral, biomedical and structural factors is powered to address the barriers of HIV prevention and resilience to ensure the prevention and control of the epidemic. It was shared that most at Risk Populations being at the center of the program, deserved the evidence based, contextualized and tailored combination prevention approach to enough curb the spread and contain it. Criterion to identify MARPs was shared: o o o o o

Engage in high risk sexual and drug-related HIV risk behaviors Overlapping HIV risk behaviors Often illicit or socially stigmatized behaviors Hidden, harder to reach Decreased access to, or use of health services

The general framework for CP includes measurement approaches (size estimation, etc), creating enabling environment (policy, advocacy, strategy, etc), development of Combination prevention based minimum package of services, M&E, and scale up to see population wide impact. It was additionally shared that combination prevention gives the opportunity to have complimentary and interwoven interventions that can successfully help the community/individuals supported to reduce their risk of acquiring or transmitting the infection. A participant from Nigeria shared that the key aspects of combination prevention should equally be based on evidence of type of high risk the Key Population was exposed to as well as the dynamics of the group including other factors like societal perspective of the group. Other factors would include resource availability as well as enabling environment for implementation of the program. It was also added that a combination prevention program should be packaged to address specific needs of the target groups in identified locations recognizing their peculiarity and dynamics with social cultural and political nuances. Combination prevention has increased and popularized a rights-based model of prevention interventions. As a result, there are programs that consciously seek ways to reach the key population with programs that aim at the drivers of the epidemic including behavioral, biomedical and structural. A main challenge was felt to be the inadequate funding of local initiatives since local institutions were not strong A note on the challenges and opportunities of Combination prevention was shared by the guest moderator The guest moderator also shared that the meaningful involvement of MARPs was an important strategy. The USAID funded MULU/MARPs HIV prevention project in Ethiopia has used a clause to the sub-agreement with local implementing partners to ensure engagement of the MARPs as part of the key players and not just beneficiaries. The need for minimum package of services: the menu for combination prevention is so broad. Hence, country specific, if possible, further down the structure region specific

packages to have a standardized approach across various stakeholders. The coordination structures need to ensure the minimum packages are covered at a population, hotspot and town level which will definitely require the contribution of various players for broadening the package within the three pillars and for each MARPs groups grow over time. A multi-disciplinary team of behavioral, biomedical and structural should use a standard checklist of supervision to see coverage of minimum packages and quality assurance. In Ghana there is now greater local financing by the advocating of all decentralized Government Agencies to fund HIV work with a percentage of their annual budgets. This annual contribution is monitored and reported on at local and at national level. At the decentralized level in all the administrative regions, there are Representatives of the Ghana AIDS Commission ( Technical Support Units) who also engage the local private sector to support regional HIV and AIDS plans. The Ghana government has also committed over 5 years and began disbursement of 100 million USD of additional funding a couple of years ago to improve local ownership of their response. In Kenya, there are a few challenges in designing and executing combination HIV prevention programs as a result of a lack of funding. Structural interventions tend to siffer as donors expect these to be met through partnerships, e.g. mitigation of sexual violence among MARPs in the face of double stigma faced by the MARPs etc. It was then shared by the guest moderator that the gap between prevention and treatment has narrowed. ART plays an important role in combination prevention, with HIV treatment being considered as prevention – 96% reduction in transmissions with early treatment. He also shared two articles: a study on PrEP from University of Washington and an article presented on International AIDS Conference 2011. It was also shared that through PMTCT, 58 precent reduction of new HIV infections was seen in Zambia. A UNAIDS discussion paper on Combination Prevention was shared with the group. Another article was shared on ‘Combination HIV Prevention: Significance, Challenges, and Opportunities’ PMC 2011 (link given) Key Resources Lancet article (attached) A note on the challenges and opportunities of Combination prevention (attached) A study on PrEP from University of Washington (attached) An article presented on International AIDS Conference 2011 (attached) UNAIDS discussion paper on Combination Prevention (attached) Combination HIV Prevention: Significance, Challenges, and Opportunities PMC 2011 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036787/

Again, I would like to thank the resource person and the participants for this very active discussion. With this summary, we conclude the discussion on the topic ‘Capacity Building of HIV Prevention Project Staff and Peer Educators’. Our next discussion on the ‘Violence and harassment, violence addressing mechanism and country response’ will be moderated by UoM and initiated soon. I request all our forum members to take advantage of this opportunity and be actively involved in the sharing of experiences and lessons. Regards, Amrita Bhende