PEPFAR’s prevention strategies must be responsive to the drivers of the epidemic and address the needs of most-at risk populations in both generalized and concentrated epidemics. Prevention messaging needs to educate populations about the way the virus is transmitted. Successful prevention interventions help individuals to acknowledge and identify risk factors in their lives and actions they can take to protect themselves. The following describes ways in which PEPFAR will support countries in implementing prevention programs for specific populations:
Vulnerable women and girls
Nearly 60% of HIV infections in sub-Saharan Africa occur among women. PEPFAR is working through its gender strategy to address the needs of women and girls, many of whom are vulnerable due to structural conditions that limit their ability to access or utilize prevention programming. It is especially important for PEPFAR and countries to address the needs of girls and young women in relationships with older men, as these types of relationship are often common in hyperendemic areas. More detailed information about PEPFAR’s work with women, girls, and gender activities can be found in additional annex documents available at www.pepfar.gov/strategy/.
Men who have sex with men (MSM)
Reaching MSM in both generalized and concentrated epidemic settings poses significant challenges. In several of the countries in which PEPFAR works, homosexual activity is defined as a criminal act, and may result in detention or arrest for those suspected of engaging in MSM activity. Governments are often reluctant to engage in outreach to these communities. Cultural mores and stigma may make MSM reluctant to disclose possible risks in a clinical setting. In addition, transgender populations face significant stigma and barriers to receiving appropriate health services. In order to address the health needs of these populations, PEPFAR is working with countries to engage in the following:
Identifying the need in the MSM community
Rates of HIV infection among MSM are often much higher than the general population. A major prevention priority for PEPFAR is helping governments to engage in the research necessary to map their epidemic and identify increased risk existing among subpopulations including MSM. This data-driven base makes it easier for public health programs to target prevention efforts.
Removing Stigma and Discrimination
PEPFAR will work to ensure that its prevention, care, and treatment programs are free from stigma and discrimination directed toward clients.
Supporting MSM access to prevention, care, and treatment
PEPFAR supports country government policies that ensure that MSM have equal access to health care, HIV/ AIDS information and supportive services, and do not face arrest or detention for seeking these services.
Persons in Prostitution
Individuals who engage in or procure transactional sex, even on an occasional basis, are at higher risk for HIV. The intersection of trafficking in persons and prostitution further complicates efforts to provide needed HIV services. Prostitution is associated with psychological and physical risks, and PEPFAR is working with countries to help persons in prostitution get the prevention, care, and treatment services that they need. PEPFAR supports countries in the following activities:
Engaging in targeted prevention, care, and treatment outreach
PEPFAR is supporting efforts to provide basic HIV prevention, care, and treatment services to persons in prostitution. In many countries, cultural norms contribute to stigmatization of sex workers, limiting their ability to seek or obtain care. PEPFAR is working with governments to ensure that access to health care and social services is not denied because an individual is a sex worker.
Helping governments to support alternatives to prostitution
From a public health perspective, it is important not only to reduce the overall risk to individuals who are engaged in transactional sex, but to prevent people from turning to transactional sex in an economic crisis. PEPFAR is working with governments to support programs that increase educational and economic opportunity for sex workers, and that keep at-risk youth in schools or vocational training. It is also important to ensure that prevention programs and personnel recognize the risks associated with occasional transactional sex.
Working to reduce demand
Through its gender programming, PEPFAR is working with countries to change behavioral expectations that promote transactional sex as “masculine” behavior. It also works to ensure that men who procure sex take measures to protect themselves and all their sexual partners.
Injecting drug users
Comprehensive prevention packages for IDUs not only reduce immediate risks of transmission, but enable this population to receive care to treat and end their addiction. In multilateral fora, the Obama administration has supported a package of prevention to injecting drug users that mirrors the prevention package supported by the UNAIDS/United Nations Office on Drugs and Crime (UNODC)/WHO Technical Guide on harm reduction programs in relation to HIV. The Technical Guide recommends that programs directed toward IDUs should include a comprehensive package of nine activities. PEPFAR is currently working with agencies across the U.S. Government (USG) to determine the best way forward in supporting this comprehensive package.
The categorization of “youth” is often misleading, as youth not only encompass multiple age ranges, but also face various types of risk. PEPFAR’s programming for youth is medically accurate, age-appropriate, and targeted to needs based upon behavior. Behavioral interventions include delaying age of sexual debut, discouraging MCP or intergenerational sex, and providing information about consistent and correct use of condoms. PEPFAR will work with countries to strengthen school-based programs. HIV prevention messages that address the needs of both girls and boys will be integrated into life skills curricula. PEPFAR will also encourage governments to involve youth as part of the civil society response to the epidemic, so that policies targeting adolescents and young adults are realistic and responsive.
While much of the focus on youth involves BCC, it is important to recognize the diversity of situations faced by the youth PEPFAR serves. Youth exist among most-at-risk populations. Given the rates of child marriage in some PEPFAR countries, there are a significant number of girls and young women in marriages who need information about how to protect themselves from HIV infection. Confounding these prevention interventions are the gender inequities that may limit the power of young women in these relationships. Youth who are out of school present particular risks, as do orphans and vulnerable children (OVC). These populations may need prevention messaging that is packaged along with vocational or other social support programming to address their economic needs. PEPFAR is working with countries to ensure that youth programming – including OVC programming – is responsive to the needs of out-of school youth.
Truck drivers, migrant workers, and the military all pose significant challenges for HIV prevention efforts. The transient natures of these populations often limit exposure to prevention messaging, and also may increase opportunities to engage in high-risk behavior. Involuntarily mobile populations, such as internally displaced persons or other refugees, can be at high risk for HIV, particularly due to increased risk of sexual assault. Given the fact that these populations are moving across borders, governments may be less aware of their needs. There is difficulty cataloging and documenting need among these rapidly changing communities. The cross-border nature of these populations and their related epidemics exemplifies the need for cross-border and regional programming for these vulnerable populations. PEPFAR is working with governments, regional institutions, and multilateral organizations to provide outreach to these populations and ensure that comprehensive services are accessible to them.
Prevention work with incarcerated individuals affords an opportunity to diminish risk of transmission within and outside the correctional facility. Governments often do not place an emphasis on the ways in which a revolving door of prison populations can amplify risk in the general population. PEPFAR is supporting governments to minimize transmission within correctional facilities, educate and involve law enforcement in prevention activities, and ensure that adequate HIV prevention, care, and treatment services are available within prison settings.
Health Care Workers
To date, PEPFAR has supported post-exposure prophylaxis (PEP) treatment for health workers who suffer needle-stick injuries. PEPFAR is continuing to work with countries in developing a health care infrastructure that follows internationally-accepted infection control protocols. PEPFAR supports implementation of universal precautions, and increased availability of basic medical supplies to limit the risks faced by these workers.
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