1. Comprehensive HIV Prevention Strategies for Most at Risk Populations (MARPs) Anne Goldzier Thomas, Ph.D. US Department of Defense/PEPFAR Ethiopia National HIV Prevention Summit Addis Ababa, Ethiopia April 6, 2009

2. Traditional Most-at-Risk Populations (MARP) Commercial Sex Workers – Clients of sex workers Men who have sex with men (MSM) Injecting Drug Users

3. Non-Traditional MARPS Populations Incarcerated populations Mobile populations (truckers, migrants, seasonal workers) Street youth Military and other uniformed Services Other groups as identified by country epidemiologic assessment

4. HIV Prevalence: Female Sex Workers UNAIDS,2006

5. HIV Prevalence: MSM CountrySampleMSMPopulation SizePrevalencePrevalence Senegal 442 21.5 (17.7–25.3) 0.99 Kenya 780 10.6 (8.6–12.8) 6.93 Sudan 713 9.3 (7.1–11.4) 1.67 Egypt 73 0.01 (0.00–4.0) 0.01 Source: Baral et al, 2007

6. Challenges for Providing HIV Prevention to MARPS Enabling environment – Legal barriers – Policy barriers – Stigma and discrimination – Community support – Hard to reach Access to medical services – Stigma and discrimination – Lack of professional training – Lack of MARP friendly services – Drug and alcohol abuse treatment Access to targeted prevention services – Understanding the community – Providing appropriate prevention services Data – Identification of country specific MARPs – HIV prevalence – Behavioral risk data – Size estimation

7. Combination HIV Prevention Structural Behavioral Cross-cutting Biomedical Ref: The Lancet, Vol 372, August 9, 2008

8. MARP: Structural Prevention Approaches Laws – Decriminalization of behaviors – Inheritance laws Policy – 100% condom use – Care settings – HIV testing protocols – Allocation of resources – Task shifting Community – Addressing stigma and discrimination – Empowering MARP groups Economic – Income generation activities

9. MARP: Behavioral Prevention Approaches Behavior change communication Community outreach Peer-based outreach programs Increased condom availability Increased condom use HIV counseling and testing Prevention for positives

10. MARP: Biomedical Prevention Approaches STI diagnosis and care Medical male circumcision HIV counseling and testing Referrals to substance abuse counseling and treatment Emerging technologies

11. MARP: Cross-cutting Prevention Approaches Collection and use of epidemiologic data – Behavioral risk – Size estimation Program Monitoring and Evaluation Laboratory – Mobile services – Rapid tests Care and treatment – Facility, community, and mobile services – Health care worker training to reduce stigma and sensitize to special needs

12. Commercial Sex Workers Target group participate in the development, implementation and monitoring of prevention programs Promote consistent and proper use of condoms with clients and regular non-paying partners Ensure consistent availability of male and female condoms and lubricant Ensure availability of comprehensive health care services Referral to other non HIV/AIDS services as appropriate. Integrate violence reduction (both social and structural) in prostitution settings Link with relevant social welfare services for the target group and their families Provide vocational training

13. Men who have Sex with Men Ensure participation of MSM in the development, implementation and monitoring of prevention programs Promote consistent and proper use of condoms with both regular and non-regular partners Ensure consistent availability of quality male and female condoms and lubricant Ensure availability of comprehensive health care services with linkages to HIV treatment and care services

14. Clients of Persons Engaged in Sex Work Ensure participation of target group in the development, implementation and monitoring of prevention programs Promote consistent and proper use of condoms with both clients and regular non-paying partners Ensure consistent availability of quality male and female condoms and lubricant Ensure availability of comprehensive health care services; provision of or linkages to HIV treatment and care services; and referral to other non HIV/AIDS services as appropriate. Integrate interventions addressing gender norms and violence

15. Military and Other Uniformed Services HIV/AIDS policy development and communication Leadership training and advocacy support Peer prevention programs Condom distribution and use training STI diagnosis and treatment HIV counseling and testing Positive prevention for PLWHA Alcohol use reduction programs Addressing male norms Medical male circumcision Family outreach, including spouse support groups

16. Scaling Up Estimate population(s) size Tailor prevention package for defined populations Plan services Monitor progress and refine activities

17. Summary MARP intervention will influence the future of HIV/AIDS epidemic in many mixed epidemic countries Combination prevention approach necessary Approaches must be tailored to the specific epidemic Content and coverage remain critical Prevention among MARPs works

18. Acknowledgements Roger Myrick, CDC Atlanta Billy Pick, USAID Linda Wright-Deguero, CDC Atlanta Naomi Bock, CDC Atlanta Karina Rapposelli, OGAC, PEPFAR DC Swarup Sarkar, Global Fund

19. THANK YOU!