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Community	
  mobilization	
  and	
  the	
  UNAIDS	
  Investment	
  
Framework	
  
	
  
Trends,	
  gaps	
  and	
  opportunities	
  in	
  mobilizing	
  the	
  community	
  
response	
  to	
  HIV	
  
	
  
	
  
A	
  new	
  framework	
  for	
  the	
  global	
  HIV	
  response	
  
	
  
In	
  June	
  2011	
  a	
  policy	
  paper	
  published	
  in	
  The	
  Lancet	
  lays	
  out	
  a	
  new	
  framework	
  
for	
  investment	
  for	
  the	
  global	
  HIV	
  response.	
  It	
  was	
  developed	
  by	
  an	
  international	
  
panel	
  of	
  experts	
  and	
  is	
  intended	
  to	
  facilitate	
  more	
  focused	
  and	
  strategic	
  use	
  of	
  
scarce	
  resources.1	
  
	
  
The	
  investment	
  framework	
  takes	
  as	
  its	
  starting	
  point	
  a	
  human	
  rights	
  approach	
  to	
  
the	
  HIV	
  response,	
  and	
  makes	
  a	
  distinction	
  between	
  basic	
  programme	
  activities	
  
that	
  have	
  a	
  direct	
  effect	
  on	
  HIV	
  risk,	
  transmission,	
  morbidity	
  and	
  mortality;	
  the	
  
critical	
  enablers	
  that	
  are	
  crucial	
  to	
  the	
  success	
  of	
  HIV	
  programmes;	
  and	
  synergies	
  
with	
  development	
  sectors.	
  
	
  
Critical	
  enablers	
  fall	
  into	
  two	
  categories:	
  social	
  enablers	
  that	
  create	
  
environments	
  conducive	
  to	
  rational	
  HIV	
  responses,	
  and	
  programme	
  enablers	
  
that	
  create	
  demand	
  for	
  programmes	
  and	
  improve	
  their	
  performance.	
  Examples	
  
of	
  social	
  enablers	
  are	
  outreach	
  for	
  HIV	
  testing,	
  stigma	
  reduction,	
  human	
  rights	
  
advocacy,	
  and	
  also	
  community	
  mobilization,	
  which	
  has	
  been	
  recognized	
  as	
  a	
  
cornerstone	
  of	
  HIV	
  programmes.	
  	
  
	
  
	
  
The	
  crucial	
  role	
  of	
  community	
  mobilization	
  
	
  
In	
  the	
  UNAIDS	
  Investment	
  Framework,	
  community	
  mobilization	
  is	
  defined	
  as	
  
“…when	
  a	
  particular	
  group	
  of	
  people	
  becomes	
  aware	
  of	
  a	
  shared	
  concern	
  or	
  
common	
  need,	
  and	
  together	
  decides	
  to	
  take	
  action	
  in	
  order	
  to	
  create	
  shared	
  
benefits.”	
  Community	
  mobilization	
  is	
  a	
  key	
  element	
  of	
  the	
  investment	
  framework	
  
because	
  it	
  leads	
  to	
  improved	
  uptake	
  of	
  HIV	
  programmes	
  and	
  promotes	
  local-­‐
level	
  advocacy,	
  transparency	
  and	
  accountability.1	
  
	
  
Community-­‐based	
  organizations	
  are	
  uniquely	
  placed	
  to	
  address	
  scale-­‐up	
  of	
  HIV	
  
treatment	
  and	
  prevention	
  and	
  are	
  already	
  providing	
  many	
  services.	
  Indeed,	
  
community-­‐level	
  initiatives	
  are	
  widespread	
  in	
  every	
  area	
  of	
  the	
  global	
  HIV	
  
response.	
  
	
  
Recently	
  a	
  number	
  of	
  literature	
  reviews	
  have	
  examined	
  elements	
  of	
  community	
  
mobilization	
  in	
  the	
  context	
  of	
  the	
  UNAIDS	
  Investment	
  framework.2-­‐10	
  The	
  
common	
  themes	
  and	
  key	
  findings	
  of	
  those	
  reviews	
  are	
  summarized	
  here.	
  
	
  
1.	
  Community	
  mobilization	
  is	
  crucial.	
  Community	
  mobilization	
  as	
  a	
  critical	
  
enabler	
  can	
  be	
  sub-­‐divided	
  into	
  three	
  parts:	
  outreach	
  and	
  engagement,	
  support,	
  
and	
  advocacy.2,3	
  For	
  it	
  to	
  be	
  successful	
  as	
  a	
  critical	
  enabler,	
  community	
  
mobilization	
  requires	
  an	
  effective	
  and	
  strong	
  community	
  system	
  that	
  encourages	
  
a	
  broad	
  spectrum	
  of	
  community	
  members	
  to	
  participate.2,3	
  
	
  
2.	
  Communities	
  know	
  their	
  needs	
  best.	
  Community-­‐based	
  HIV	
  testing,	
  
prevention,	
  treatment,	
  care	
  and	
  support	
  can	
  be	
  highly	
  effective	
  but	
  there	
  is	
  no	
  
one-­‐size-­‐fits-­‐all	
  model	
  and	
  they	
  must	
  be	
  adequately	
  supported	
  and	
  resourced.2,4	
  
	
  
3.	
  People	
  living	
  with	
  HIV	
  play	
  a	
  special	
  role.	
  PLHIV	
  need	
  to	
  be	
  at	
  the	
  forefront	
  
of	
  community-­‐based	
  efforts,	
  both	
  as	
  in	
  civil	
  society	
  organizations’	
  traditional	
  role	
  
of	
  advocacy,	
  and	
  increasingly	
  as	
  service	
  providers.2,4	
  
	
  
4.	
  Community-­‐based	
  groups	
  are	
  for	
  advocacy	
  and	
  service	
  provision.	
  The	
  
monitoring	
  and	
  advocacy	
  role	
  of	
  communities	
  affected	
  by	
  HIV	
  is	
  just	
  as	
  
important	
  as	
  service	
  provision.	
  However,	
  there	
  is	
  also	
  an	
  inherent	
  tension	
  
between	
  the	
  two-­‐	
  it	
  can	
  be	
  difficult	
  to	
  openly	
  criticize	
  organizations	
  and	
  
institutions	
  that	
  are	
  also	
  a	
  source	
  of	
  funding	
  for	
  services.4,5	
  	
  
	
  
5.	
  Peer	
  groups	
  are	
  powerful.	
  Not	
  only	
  are	
  peer	
  groups	
  one	
  of	
  the	
  most	
  popular	
  
means	
  of	
  community	
  mobilization,	
  they	
  are	
  also	
  one	
  of	
  the	
  most	
  effective.2,3	
  For	
  
key	
  populations	
  at	
  risk	
  of	
  HIV,	
  only	
  community-­‐based	
  interventions	
  can	
  
effectively	
  reach	
  their	
  target	
  audiences,	
  be	
  they	
  men	
  who	
  have	
  sex	
  with	
  men,	
  sex	
  
workers	
  or	
  people	
  who	
  inject	
  drugs.4	
  
	
  
6.	
  Task-­‐shifting	
  in	
  needed.	
  Community-­‐based	
  organizations	
  and	
  community	
  
health	
  workers	
  can	
  play	
  a	
  key	
  role	
  in	
  task-­‐shifting	
  of,	
  for	
  example,	
  HIV	
  testing	
  
and	
  counseling	
  to	
  improve	
  efficiency	
  in	
  the	
  health	
  care	
  system	
  and	
  remove	
  
service	
  bottlenecks.4,5	
  
	
  
7.	
  Voluntary	
  does	
  not	
  mean	
  free.	
  There	
  is	
  extensive	
  use	
  of	
  volunteers	
  and	
  
unpaid	
  community	
  health	
  workers	
  for	
  HIV-­‐related	
  interventions.3	
  However,	
  even	
  
volunteers	
  incur	
  costs,	
  both	
  for	
  management	
  and	
  to	
  the	
  individual.	
  Using	
  unpaid	
  
community-­‐based	
  workers	
  is	
  fraught	
  with	
  challenges	
  (including	
  ethical	
  
challenges)	
  and	
  even	
  using	
  volunteer	
  workers	
  still	
  requires	
  an	
  investment	
  in	
  
training,	
  and	
  organizational	
  support.5,6	
  Women	
  predominate	
  in	
  the	
  voluntary	
  
sector,	
  with	
  voluntary	
  duties	
  often	
  undertaken	
  when	
  aged	
  30	
  to	
  49,	
  the	
  life	
  stage	
  
most	
  burdened	
  by	
  other	
  responsibilities.	
  Increasing	
  task-­‐shifting	
  to	
  volunteers	
  
has	
  implications	
  for	
  gender	
  inequalities.7	
  
	
  
8.	
  There	
  are	
  many	
  gaps	
  and	
  overlaps.	
  Community-­‐based	
  services	
  are	
  typically	
  
poorly	
  coordinated	
  between	
  themselves	
  and	
  with	
  other	
  organizations.	
  Coalitions	
  
of	
  community	
  groups	
  can	
  conduct	
  mapping	
  exercises	
  to	
  identify	
  areas	
  that	
  are	
  
over-­‐served	
  and	
  those	
  that	
  are	
  neglected.4	
  
	
  
9.	
  There	
  are	
  common	
  obstacles.	
  There	
  is	
  a	
  lack	
  of	
  resources	
  to	
  ensure	
  service	
  
community-­‐based	
  services	
  are	
  delivered	
  on	
  sufficient	
  scale,	
  particularly	
  core	
  
funding	
  that	
  is	
  not	
  restricted	
  to	
  specific	
  programmes.4	
  Community-­‐based	
  
interventions	
  can	
  be	
  undermined	
  or	
  even	
  completely	
  prevented	
  by	
  legal	
  and	
  
social	
  barriers	
  to	
  human	
  rights,	
  and	
  stigmatizing	
  behavior,	
  even	
  among	
  health	
  
care	
  workers.8	
  Gender	
  inequalities	
  are	
  a	
  pervasive	
  obstacle.4-­‐6	
  
	
  
10.	
  More	
  data	
  and	
  evidence	
  is	
  needed.	
  Although	
  there	
  is	
  much	
  anecdotal	
  
evidence	
  on	
  the	
  effectiveness	
  of	
  community	
  engagement	
  in	
  the	
  HIV	
  response,	
  
more	
  empirical	
  evidence	
  is	
  needed,	
  as	
  is	
  better	
  and	
  more	
  regularly	
  up-­‐dated	
  data	
  
on	
  HIV	
  prevalence	
  and	
  the	
  impact	
  of	
  interventions.4	
  	
  
	
  
11.	
  Community	
  mobilization	
  can	
  turn	
  synergies	
  into	
  partnerships.	
  Making	
  
use	
  of	
  synergies	
  with	
  other	
  development	
  sectors	
  is	
  a	
  key	
  component	
  of	
  the	
  
Investment	
  Framework.1	
  Community-­‐based	
  organizations	
  play	
  a	
  crucial	
  role	
  in	
  
exploiting	
  those	
  synergies,	
  in	
  particular	
  within	
  the	
  health	
  sector.2	
  Community	
  
mobilization	
  can	
  be	
  crucial	
  to	
  building	
  partnerships	
  and	
  links	
  with	
  service	
  
providers	
  in,	
  for	
  example,	
  sexual,	
  reproductive,	
  maternal,	
  newborn	
  and	
  child	
  
health.	
  	
  
	
  
12.	
  The	
  benefits	
  of	
  community	
  mobilization	
  go	
  beyond	
  HIV.	
  The	
  crucial	
  role	
  
of	
  community	
  mobilization	
  in	
  the	
  HIV	
  response	
  is	
  very	
  clearly	
  stated	
  in	
  the	
  
Investment	
  Framework.	
  However,	
  it	
  also	
  has	
  benefits	
  beyond	
  HIV,	
  such	
  as	
  
empowering	
  citizens	
  and	
  improving	
  economic	
  productivity	
  due	
  to	
  better	
  health.2	
  
	
  
	
  
	
  
Community	
  mobilization	
  and	
  the	
  six	
  programme	
  activities	
  of	
  the	
  
UNAIDS	
  Investment	
  Framework	
  
	
  
Programme	
  Activity	
  1:	
  Focused	
  programmes	
  for	
  key	
  populations	
  at	
  higher	
  
risk	
  	
  
	
  
Key	
  populations,	
  including	
  sex	
  workers	
  and	
  their	
  clients,	
  men	
  who	
  have	
  sex	
  with	
  
men,	
  and	
  people	
  who	
  inject	
  drugs,	
  are	
  engaged	
  in	
  a	
  wide	
  range	
  of	
  community	
  
mobilization	
  activities	
  at	
  all	
  levels,	
  from	
  interpersonal	
  and	
  group	
  levels	
  to	
  
community	
  structural	
  and	
  environmental-­‐level	
  interventions.5	
  These	
  include	
  
training,	
  peer	
  leadership,	
  outreach	
  behavior	
  change	
  activities.	
  At	
  a	
  community	
  
level	
  interventions	
  are	
  typically	
  delivered	
  at	
  drop-­‐in	
  centres	
  and	
  include	
  
community-­‐based	
  HIV	
  testing,	
  counseling	
  and	
  treatment.	
  	
  Community-­‐level	
  
activities	
  engaging	
  key	
  populations	
  are	
  not	
  necessarily	
  small-­‐scale,	
  and	
  include,	
  
e.g.,	
  national	
  policies	
  on	
  condom	
  availability,	
  or	
  working	
  with	
  authority	
  figures	
  
such	
  as	
  the	
  police	
  and	
  government	
  officials.5	
  
	
  
Although	
  community	
  initiatives	
  occur	
  at	
  all	
  levels	
  of	
  service	
  delivery	
  for	
  key	
  
populations,	
  they	
  are	
  rarely	
  offered	
  on	
  a	
  large	
  enough	
  scale,	
  and	
  there	
  are	
  many	
  
examples	
  of	
  underserved	
  groups,	
  such	
  as	
  females	
  who	
  inject	
  drugs	
  and	
  
transgender	
  people.2,5	
  They	
  are	
  also	
  subject	
  to	
  social	
  factors,	
  e.g.,	
  legal	
  barriers	
  to	
  
key	
  populations	
  seeking	
  help,	
  and	
  stigma	
  and	
  discrimination.	
  There	
  is	
  a	
  
widespread	
  lack	
  of	
  capacity	
  and	
  what	
  is	
  offered	
  is	
  often	
  fragmented	
  poorly	
  
coordinated.5	
  Moreover,	
  there	
  needs	
  to	
  be	
  better	
  linkage	
  between	
  community-­‐
based	
  programmes	
  and	
  public	
  health	
  and	
  social	
  welfare	
  systems.4	
  
 
	
  
Programme	
  Activity	
  2:	
  Elimination	
  of	
  new	
  HIV	
  infections	
  in	
  children	
  
	
  
Community-­‐based	
  interventions	
  for	
  prevention	
  of	
  mother-­‐to-­‐child	
  transmission	
  
(PMTCT)	
  range	
  from	
  outreach	
  by	
  paid	
  or	
  unpaid	
  community	
  health	
  workers	
  and	
  
peer	
  support	
  groups	
  to	
  community-­‐based	
  testing	
  and	
  integration	
  of	
  PMTCT	
  with	
  
other	
  medical	
  services	
  such	
  as	
  antenatal	
  care	
  or	
  sexually	
  transmitted	
  infection	
  
clinics.2,5	
  Community-­‐driven	
  communication	
  about	
  PMTCT	
  can	
  help	
  overcome	
  
common	
  concerns	
  such	
  as	
  early	
  attendance	
  for	
  ante-­‐natal	
  care,	
  male	
  
involvement	
  and	
  follow-­‐up	
  of	
  infants	
  exposed	
  to	
  HIV.2,8	
  
	
  
Engaging	
  community	
  health	
  workers,	
  traditional	
  birth	
  attendants	
  and	
  women	
  
living	
  with	
  HIV,	
  is	
  seen	
  as	
  an	
  important	
  means	
  to	
  scale	
  up	
  PMTCT	
  services,	
  but	
  
there	
  a	
  numerous	
  social	
  and	
  structural	
  factors	
  that	
  leave	
  gaps	
  in	
  community	
  
based	
  services.	
  They	
  include	
  low	
  knowledge	
  in	
  the	
  population	
  of	
  mother-­‐to-­‐child	
  
transmission,	
  lack	
  of	
  support	
  from	
  family	
  members	
  and	
  stigmatizing	
  attitudes	
  
among	
  health	
  care	
  workers.	
  Services	
  are	
  often	
  inaccessible	
  too,	
  due	
  to	
  cost	
  or	
  
time	
  factors,	
  and	
  a	
  lack	
  of	
  health	
  care	
  workers.4	
  Although	
  PMTCT	
  is	
  an	
  
achievable	
  goal,	
  it	
  can	
  only	
  be	
  attained	
  by	
  sustained	
  engagement	
  with	
  women	
  
living	
  with	
  HIV	
  and	
  communities	
  from	
  informal	
  and	
  grassroots	
  levels	
  up	
  to	
  
global	
  coalitions.2,8	
  	
  
	
  
	
  
Programme	
  Activity	
  3:	
  Reduction	
  of	
  risk	
  of	
  HIV	
  exposure	
  through	
  changing	
  
behavior	
  and	
  social	
  norms	
  
	
  
Peer-­‐group	
  interventions,	
  condom	
  provision,	
  outreach	
  and	
  behavior	
  change	
  
programs	
  at	
  the	
  point	
  of	
  health	
  service	
  delivery	
  are	
  all	
  ways	
  in	
  which	
  the	
  
community	
  plays	
  a	
  role	
  in	
  behavior	
  change	
  efforts.	
  They	
  also	
  occur	
  at	
  the	
  
community	
  level,	
  e.g.,	
  via	
  street	
  theatre	
  and	
  other	
  public	
  events;	
  and	
  structurally	
  
through	
  HIV	
  policies	
  and	
  schools-­‐based	
  HIV	
  education.	
  Peer	
  education	
  is	
  a	
  
particularly	
  popular	
  community-­‐based	
  intervention.5	
  	
  
	
  
However,	
  prevention	
  of	
  HIV	
  transmission	
  through	
  behavior	
  change	
  is	
  complex	
  
and	
  subject	
  to	
  unique	
  social,	
  cultural	
  and	
  epidemiological	
  forces	
  in	
  different	
  
countries.	
  Moreover,	
  interventions	
  are	
  not	
  of	
  sufficient	
  scale	
  to	
  reach	
  the	
  point	
  of	
  
universal	
  access.	
  As	
  well	
  as	
  insufficient	
  funding	
  there	
  is	
  a	
  lack	
  of	
  consensus	
  on	
  
what	
  are	
  the	
  priority	
  issues	
  and	
  poor	
  coordination	
  between	
  different	
  service	
  
providers.5	
  
	
  
	
  
Programme	
  Activity	
  4:	
  Procurement,	
  distribution	
  and	
  marketing	
  of	
  male	
  
and	
  female	
  condoms	
  
	
  
Peer	
  group	
  and	
  social	
  networks	
  are	
  an	
  important	
  way	
  in	
  which	
  community	
  
mobilization	
  supports	
  the	
  promotion	
  and	
  distribution	
  of	
  condoms,	
  As	
  well	
  as	
  
interpersonal-­‐level	
  interventions,	
  there	
  are	
  also	
  community-­‐level	
  actions	
  to	
  
distribute	
  condoms	
  and	
  promote	
  their	
  acceptance	
  and	
  correct	
  use,2	
  and	
  in	
  some	
  
settings	
  this	
  has	
  also	
  been	
  done	
  at	
  a	
  structural	
  level	
  mandating	
  the	
  availability	
  of	
  
condoms	
  in	
  bathhouses	
  frequented	
  by	
  men	
  who	
  have	
  sex	
  with	
  men,	
  for	
  
example.5	
  
	
  
Despite	
  the	
  fact	
  that	
  there	
  is	
  strong	
  evidence	
  in	
  support	
  of	
  condom	
  use	
  for	
  HIV	
  
prevention,	
  there	
  is	
  a	
  lack	
  of	
  availability	
  of	
  low-­‐cost,	
  good-­‐quality	
  condoms	
  as	
  
well	
  as	
  a	
  lack	
  of	
  demand	
  and	
  other	
  barriers	
  such	
  as	
  religious,	
  legal	
  and	
  gender	
  
issues.5	
  
	
  
	
  
Programme	
  Activity	
  5:	
  Treatment,	
  care	
  and	
  support	
  for	
  people	
  living	
  with	
  
HIV	
  
	
  
The	
  involvement	
  of	
  people	
  living	
  with	
  HIV	
  (PLHIV)	
  in	
  delivering	
  care	
  and	
  as	
  peer	
  
educators	
  is	
  one	
  of	
  the	
  most	
  significant	
  means	
  of	
  community-­‐based	
  
interventions.2,4,5	
  Other	
  small-­‐scale	
  interventions	
  include	
  microfinance,	
  
nutritional	
  support	
  for	
  PLHIV	
  and	
  helping	
  families	
  affected	
  by	
  HIV	
  and	
  AIDS.	
  
Community-­‐health	
  workers	
  also	
  play	
  a	
  part	
  in	
  the	
  process	
  of	
  task-­‐shifting	
  to	
  
make	
  optimal	
  use	
  of	
  health	
  care	
  human	
  resources,	
  through	
  home-­‐	
  and	
  
community-­‐based	
  HIV	
  testing	
  and	
  counseling,	
  and	
  increasing	
  adherence	
  in	
  
antiretroviral	
  therapy.4	
  
	
  
However,	
  this	
  is	
  an	
  area	
  where	
  the	
  lack	
  of	
  human	
  resources,	
  capacity	
  and	
  
funding	
  creates	
  striking	
  gaps	
  in	
  service	
  provision,	
  and	
  efforts	
  are	
  undermined	
  by	
  
stigma,	
  discrimination	
  and	
  gender	
  inequalities.	
  Also,	
  services	
  are	
  particularly	
  
inadequate	
  for	
  certain	
  groups,	
  notably	
  key	
  populations	
  and	
  those	
  living	
  in	
  rural	
  
areas.5	
  The	
  needs	
  of	
  PLHIV	
  have	
  changed	
  over	
  time,	
  the	
  most	
  notable	
  shift	
  being	
  
the	
  impact	
  of	
  availability	
  of	
  HIV	
  treatment	
  which	
  has,	
  when	
  available,	
  	
  
transformed	
  HIV	
  from	
  a	
  terminal	
  illness	
  to	
  a	
  chronic	
  disease.6	
  
	
  
	
  
Programme	
  Activity	
  6.	
  Voluntary	
  medical	
  male	
  circumcision	
  in	
  countries	
  
with	
  high	
  HIV	
  prevalence	
  
	
  
Community	
  mobilization	
  is	
  an	
  important	
  means	
  to	
  promote	
  male	
  circumcision	
  
and	
  recruit,	
  screen	
  and	
  schedule	
  men	
  for	
  the	
  procedure.	
  Although	
  this	
  
programme	
  activity	
  is	
  targeted	
  at	
  populations	
  with	
  low	
  rates	
  of	
  male	
  
circumcision,	
  there	
  is	
  also	
  a	
  need	
  for	
  engagement	
  with	
  communities	
  practicing	
  
traditional	
  make	
  circumcision	
  to	
  ensure	
  all	
  men	
  have	
  access	
  to	
  safe	
  and	
  effective	
  
circumcision.	
  	
  
	
  
Despite	
  the	
  fact	
  that	
  engaging	
  volunteers	
  to	
  help	
  scale	
  up	
  male	
  circumcision,	
  
these	
  community-­‐based	
  interventions	
  are	
  also	
  undermined	
  by	
  the	
  same	
  gaps	
  as	
  
other	
  programmes:	
  lack	
  of	
  human	
  resources,	
  lack	
  of	
  infrastructure	
  support	
  and	
  
unreliable	
  funding.4	
  
	
  
	
  
	
  
The	
  costs	
  of	
  community	
  mobilization	
  
 
Because	
  the	
  UNAIDS	
  Investment	
  Framework	
  anticipates	
  community	
  
mobilization	
  will	
  be	
  one	
  of	
  the	
  means	
  to	
  ensure	
  efficiency	
  gains,	
  it	
  is	
  important	
  to	
  
consider	
  the	
  cost	
  implications	
  for	
  community	
  mobilization,	
  not	
  just	
  for	
  
programmes,	
  but	
  for	
  the	
  community.	
  	
  In	
  the	
  framework,	
  task-­‐shifting	
  
downwards	
  will	
  result	
  in	
  cost	
  savings	
  for	
  the	
  health	
  care	
  system.	
  However,	
  it	
  is	
  
important	
  that	
  funding	
  for	
  community	
  mobilization	
  is	
  increased,	
  in	
  line	
  with	
  the	
  
Investment	
  Framework	
  proposal,	
  so	
  that	
  costs	
  are	
  not	
  simply	
  shifted	
  from	
  
donors	
  to	
  the	
  communities	
  themselves.2	
  	
  
	
  

For	
  communities,	
  this	
  process	
  of	
  task-­‐shifting	
  can	
  bring	
  gains,	
  but	
  it	
  also	
  entails	
  
opportunity	
  costs.	
  These	
  can	
  be	
  calculated	
  in	
  monetary	
  terms,	
  but	
  they	
  also	
  
include	
  ethical	
  and	
  social	
  implications,	
  e.g.,	
  of	
  shifting	
  the	
  AIDS	
  response	
  from	
  
paid	
  professionals	
  to	
  volunteers	
  in	
  the	
  community.3,7	
  
	
  
The	
  costing	
  methodology	
  developed	
  by	
  UNAIDS	
  for	
  used	
  in	
  facilities-­‐based	
  
healthcare	
  was	
  adopted	
  in	
  a	
  costing	
  study	
  for	
  non-­‐facilities	
  based	
  social	
  care	
  
interventions.3	
  It	
  was	
  subsequently	
  field-­‐tested	
  in	
  studies	
  in	
  Cambodia,	
  Kenya	
  
and	
  Zambia.3,9,10	
  The	
  methodology	
  calculates	
  the	
  costs	
  to	
  an	
  NGO	
  of	
  including	
  
community	
  mobilization	
  in	
  a	
  particular	
  intervention,	
  as	
  well	
  as	
  the	
  opportunity	
  
costs	
  and	
  financial	
  benefits	
  to	
  the	
  community	
  concerned.	
  	
  
	
  
The	
  studies	
  conclude	
  that	
  community	
  mobilization	
  can	
  and	
  should	
  be	
  costed,	
  but	
  
that	
  most	
  in-­‐country	
  organizations	
  will	
  need	
  external	
  support	
  to	
  do	
  this.10	
  
Rather	
  than	
  seeing	
  the	
  cost	
  to	
  the	
  community	
  as	
  an	
  obstacle	
  to	
  community	
  
mobilization,	
  it	
  should	
  be	
  used	
  as	
  an	
  incentive	
  to	
  bring	
  in	
  new	
  funding	
  sources	
  
and	
  incorporate	
  a	
  broader	
  range	
  of	
  stakeholders,	
  such	
  as	
  employers	
  and	
  unions,	
  
to	
  support	
  national	
  AIDS	
  programmes.9	
  	
  
	
  
A	
  costing	
  study	
  in	
  Cambodia	
  identified	
  the	
  costs	
  of	
  community	
  mobilization	
  for	
  
an	
  intervention	
  with	
  key	
  populations.	
  It	
  calculated	
  that	
  the	
  cost	
  to	
  the	
  
community	
  of	
  participating	
  in	
  prevention	
  program	
  activities	
  for	
  men	
  who	
  have	
  
sex	
  with	
  men,	
  sex	
  workers	
  and	
  people	
  who	
  inject	
  drugs,	
  was	
  equivalent	
  to	
  over	
  
52	
  days’	
  income	
  per	
  year.9	
  Similarly	
  a	
  study	
  on	
  the	
  unit	
  cost	
  of	
  including	
  
community	
  mobilization	
  in	
  a	
  PMTCT	
  programme	
  in	
  Zambia	
  found	
  that	
  there	
  was	
  
a	
  net	
  benefit	
  to	
  participation	
  in	
  activities	
  to	
  strengthen	
  community	
  pathways	
  of	
  
referral,	
  but	
  a	
  significant	
  cost	
  to	
  participation	
  in	
  awareness-­‐raising	
  activities.10	
  	
  
	
  
The	
  studies	
  are	
  the	
  first	
  step	
  towards	
  testing	
  the	
  UNAIDS	
  Investment	
  
Framework’s	
  thesis	
  that	
  task-­‐shifting	
  to	
  the	
  community	
  can	
  increase	
  efficiency	
  in	
  
national	
  HIV	
  responses.9	
  
	
  
References	
  
	
  
1.	
  Schwartländer	
  B,	
  Stover	
  J,	
  Hallett	
  T,	
  et	
  al.	
  Towards	
  an	
  improved	
  investment	
  
approach	
  for	
  an	
  effective	
  response	
  to	
  HIV/AIDS.	
  The	
  Lancet	
  2011;377:2031-­‐
2041.	
  
2.	
  Drew	
  R.	
  Community	
  Mobilisation	
  and	
  HIV/AIDS.	
  What	
  does	
  it	
  mean	
  for	
  the	
  
International	
  HIV/AIDS	
  Alliance?	
  What	
  does	
  it	
  mean	
  for	
  the	
  investment	
  
framework?	
  Discussion	
  paper.	
  International	
  HIV/AIDS	
  Alliance	
  (2012).	
  
3.	
  Brady	
  R.	
  The	
  Cost	
  of	
  Community	
  Mobilisation.	
  Understanding	
  the	
  costs	
  to	
  the	
  
community	
  in	
  participating	
  in	
  HIV/AIDS	
  interventions	
  within	
  the	
  proposed	
  
UNAIDS	
  Investment	
  Framework	
  (2012).	
  
4.	
  Treatment	
  2.0:	
  The	
  Next	
  Phase	
  of	
  HIV	
  Treatment	
  and	
  Prevention	
  Scale-­‐Up.	
  A	
  
Community-­‐Based	
  Response.	
  
5.	
  Lillie	
  T.	
  Rapid	
  Literature	
  review.	
  Community	
  Mobilization	
  and	
  the	
  Six	
  
Programmatic	
  Areas	
  Outlined	
  in	
  the	
  “Towards	
  an	
  improved	
  investment	
  
approach	
  for	
  an	
  effective	
  response	
  to	
  HIV/AIDS	
  (2012).	
  
6.	
  Doupe	
  A.	
  Research	
  into	
  the	
  care	
  and	
  support	
  needs	
  of	
  key	
  populations	
  living	
  
with	
  HIV	
  (2011).	
  
7.	
  Budlender	
  D.	
  Compensation	
  for	
  Contributions.	
  Report	
  on	
  interviews	
  with	
  	
  
volunteer	
  care-­‐givers	
  in	
  six	
  countries.	
  Huairou	
  Commission	
  (2009).	
  
8.	
  Ackerman	
  Gulaid	
  L.	
  Promising	
  practices	
  in	
  community	
  engagement	
  for	
  the	
  
elimination	
  of	
  new	
  HIV	
  infections	
  in	
  children	
  by	
  2015	
  and	
  keeping	
  their	
  mothers	
  
alive	
  (2011).	
  
9	
  Brady	
  R.	
  Costing	
  Community	
  Mobilisation.	
  Identifying	
  the	
  unit	
  cost	
  of	
  
Community	
  Mobilisation	
  in	
  Key	
  Populations	
  programs	
  run	
  by	
  KHANA	
  in	
  
Cambodia.	
  	
  
10.	
  Smith	
  D.	
  Costing	
  Community	
  Mobilisation.	
  Identifying	
  the	
  unit	
  cost	
  of	
  
Community	
  Mobilisation.	
  PMTCT	
  in	
  the	
  DfID	
  funded	
  Maternal	
  Mortality	
  project	
  
in	
  Alliance	
  Zambia	
  (2011).	
  
	
  
	
  

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4 community-mobilization-and-the-if

  • 1. Community  mobilization  and  the  UNAIDS  Investment   Framework     Trends,  gaps  and  opportunities  in  mobilizing  the  community   response  to  HIV       A  new  framework  for  the  global  HIV  response     In  June  2011  a  policy  paper  published  in  The  Lancet  lays  out  a  new  framework   for  investment  for  the  global  HIV  response.  It  was  developed  by  an  international   panel  of  experts  and  is  intended  to  facilitate  more  focused  and  strategic  use  of   scarce  resources.1     The  investment  framework  takes  as  its  starting  point  a  human  rights  approach  to   the  HIV  response,  and  makes  a  distinction  between  basic  programme  activities   that  have  a  direct  effect  on  HIV  risk,  transmission,  morbidity  and  mortality;  the   critical  enablers  that  are  crucial  to  the  success  of  HIV  programmes;  and  synergies   with  development  sectors.     Critical  enablers  fall  into  two  categories:  social  enablers  that  create   environments  conducive  to  rational  HIV  responses,  and  programme  enablers   that  create  demand  for  programmes  and  improve  their  performance.  Examples   of  social  enablers  are  outreach  for  HIV  testing,  stigma  reduction,  human  rights   advocacy,  and  also  community  mobilization,  which  has  been  recognized  as  a   cornerstone  of  HIV  programmes.         The  crucial  role  of  community  mobilization     In  the  UNAIDS  Investment  Framework,  community  mobilization  is  defined  as   “…when  a  particular  group  of  people  becomes  aware  of  a  shared  concern  or   common  need,  and  together  decides  to  take  action  in  order  to  create  shared   benefits.”  Community  mobilization  is  a  key  element  of  the  investment  framework   because  it  leads  to  improved  uptake  of  HIV  programmes  and  promotes  local-­‐ level  advocacy,  transparency  and  accountability.1     Community-­‐based  organizations  are  uniquely  placed  to  address  scale-­‐up  of  HIV   treatment  and  prevention  and  are  already  providing  many  services.  Indeed,   community-­‐level  initiatives  are  widespread  in  every  area  of  the  global  HIV   response.     Recently  a  number  of  literature  reviews  have  examined  elements  of  community   mobilization  in  the  context  of  the  UNAIDS  Investment  framework.2-­‐10  The   common  themes  and  key  findings  of  those  reviews  are  summarized  here.     1.  Community  mobilization  is  crucial.  Community  mobilization  as  a  critical   enabler  can  be  sub-­‐divided  into  three  parts:  outreach  and  engagement,  support,  
  • 2. and  advocacy.2,3  For  it  to  be  successful  as  a  critical  enabler,  community   mobilization  requires  an  effective  and  strong  community  system  that  encourages   a  broad  spectrum  of  community  members  to  participate.2,3     2.  Communities  know  their  needs  best.  Community-­‐based  HIV  testing,   prevention,  treatment,  care  and  support  can  be  highly  effective  but  there  is  no   one-­‐size-­‐fits-­‐all  model  and  they  must  be  adequately  supported  and  resourced.2,4     3.  People  living  with  HIV  play  a  special  role.  PLHIV  need  to  be  at  the  forefront   of  community-­‐based  efforts,  both  as  in  civil  society  organizations’  traditional  role   of  advocacy,  and  increasingly  as  service  providers.2,4     4.  Community-­‐based  groups  are  for  advocacy  and  service  provision.  The   monitoring  and  advocacy  role  of  communities  affected  by  HIV  is  just  as   important  as  service  provision.  However,  there  is  also  an  inherent  tension   between  the  two-­‐  it  can  be  difficult  to  openly  criticize  organizations  and   institutions  that  are  also  a  source  of  funding  for  services.4,5       5.  Peer  groups  are  powerful.  Not  only  are  peer  groups  one  of  the  most  popular   means  of  community  mobilization,  they  are  also  one  of  the  most  effective.2,3  For   key  populations  at  risk  of  HIV,  only  community-­‐based  interventions  can   effectively  reach  their  target  audiences,  be  they  men  who  have  sex  with  men,  sex   workers  or  people  who  inject  drugs.4     6.  Task-­‐shifting  in  needed.  Community-­‐based  organizations  and  community   health  workers  can  play  a  key  role  in  task-­‐shifting  of,  for  example,  HIV  testing   and  counseling  to  improve  efficiency  in  the  health  care  system  and  remove   service  bottlenecks.4,5     7.  Voluntary  does  not  mean  free.  There  is  extensive  use  of  volunteers  and   unpaid  community  health  workers  for  HIV-­‐related  interventions.3  However,  even   volunteers  incur  costs,  both  for  management  and  to  the  individual.  Using  unpaid   community-­‐based  workers  is  fraught  with  challenges  (including  ethical   challenges)  and  even  using  volunteer  workers  still  requires  an  investment  in   training,  and  organizational  support.5,6  Women  predominate  in  the  voluntary   sector,  with  voluntary  duties  often  undertaken  when  aged  30  to  49,  the  life  stage   most  burdened  by  other  responsibilities.  Increasing  task-­‐shifting  to  volunteers   has  implications  for  gender  inequalities.7     8.  There  are  many  gaps  and  overlaps.  Community-­‐based  services  are  typically   poorly  coordinated  between  themselves  and  with  other  organizations.  Coalitions   of  community  groups  can  conduct  mapping  exercises  to  identify  areas  that  are   over-­‐served  and  those  that  are  neglected.4     9.  There  are  common  obstacles.  There  is  a  lack  of  resources  to  ensure  service   community-­‐based  services  are  delivered  on  sufficient  scale,  particularly  core   funding  that  is  not  restricted  to  specific  programmes.4  Community-­‐based   interventions  can  be  undermined  or  even  completely  prevented  by  legal  and  
  • 3. social  barriers  to  human  rights,  and  stigmatizing  behavior,  even  among  health   care  workers.8  Gender  inequalities  are  a  pervasive  obstacle.4-­‐6     10.  More  data  and  evidence  is  needed.  Although  there  is  much  anecdotal   evidence  on  the  effectiveness  of  community  engagement  in  the  HIV  response,   more  empirical  evidence  is  needed,  as  is  better  and  more  regularly  up-­‐dated  data   on  HIV  prevalence  and  the  impact  of  interventions.4       11.  Community  mobilization  can  turn  synergies  into  partnerships.  Making   use  of  synergies  with  other  development  sectors  is  a  key  component  of  the   Investment  Framework.1  Community-­‐based  organizations  play  a  crucial  role  in   exploiting  those  synergies,  in  particular  within  the  health  sector.2  Community   mobilization  can  be  crucial  to  building  partnerships  and  links  with  service   providers  in,  for  example,  sexual,  reproductive,  maternal,  newborn  and  child   health.       12.  The  benefits  of  community  mobilization  go  beyond  HIV.  The  crucial  role   of  community  mobilization  in  the  HIV  response  is  very  clearly  stated  in  the   Investment  Framework.  However,  it  also  has  benefits  beyond  HIV,  such  as   empowering  citizens  and  improving  economic  productivity  due  to  better  health.2         Community  mobilization  and  the  six  programme  activities  of  the   UNAIDS  Investment  Framework     Programme  Activity  1:  Focused  programmes  for  key  populations  at  higher   risk       Key  populations,  including  sex  workers  and  their  clients,  men  who  have  sex  with   men,  and  people  who  inject  drugs,  are  engaged  in  a  wide  range  of  community   mobilization  activities  at  all  levels,  from  interpersonal  and  group  levels  to   community  structural  and  environmental-­‐level  interventions.5  These  include   training,  peer  leadership,  outreach  behavior  change  activities.  At  a  community   level  interventions  are  typically  delivered  at  drop-­‐in  centres  and  include   community-­‐based  HIV  testing,  counseling  and  treatment.    Community-­‐level   activities  engaging  key  populations  are  not  necessarily  small-­‐scale,  and  include,   e.g.,  national  policies  on  condom  availability,  or  working  with  authority  figures   such  as  the  police  and  government  officials.5     Although  community  initiatives  occur  at  all  levels  of  service  delivery  for  key   populations,  they  are  rarely  offered  on  a  large  enough  scale,  and  there  are  many   examples  of  underserved  groups,  such  as  females  who  inject  drugs  and   transgender  people.2,5  They  are  also  subject  to  social  factors,  e.g.,  legal  barriers  to   key  populations  seeking  help,  and  stigma  and  discrimination.  There  is  a   widespread  lack  of  capacity  and  what  is  offered  is  often  fragmented  poorly   coordinated.5  Moreover,  there  needs  to  be  better  linkage  between  community-­‐ based  programmes  and  public  health  and  social  welfare  systems.4  
  • 4.     Programme  Activity  2:  Elimination  of  new  HIV  infections  in  children     Community-­‐based  interventions  for  prevention  of  mother-­‐to-­‐child  transmission   (PMTCT)  range  from  outreach  by  paid  or  unpaid  community  health  workers  and   peer  support  groups  to  community-­‐based  testing  and  integration  of  PMTCT  with   other  medical  services  such  as  antenatal  care  or  sexually  transmitted  infection   clinics.2,5  Community-­‐driven  communication  about  PMTCT  can  help  overcome   common  concerns  such  as  early  attendance  for  ante-­‐natal  care,  male   involvement  and  follow-­‐up  of  infants  exposed  to  HIV.2,8     Engaging  community  health  workers,  traditional  birth  attendants  and  women   living  with  HIV,  is  seen  as  an  important  means  to  scale  up  PMTCT  services,  but   there  a  numerous  social  and  structural  factors  that  leave  gaps  in  community   based  services.  They  include  low  knowledge  in  the  population  of  mother-­‐to-­‐child   transmission,  lack  of  support  from  family  members  and  stigmatizing  attitudes   among  health  care  workers.  Services  are  often  inaccessible  too,  due  to  cost  or   time  factors,  and  a  lack  of  health  care  workers.4  Although  PMTCT  is  an   achievable  goal,  it  can  only  be  attained  by  sustained  engagement  with  women   living  with  HIV  and  communities  from  informal  and  grassroots  levels  up  to   global  coalitions.2,8         Programme  Activity  3:  Reduction  of  risk  of  HIV  exposure  through  changing   behavior  and  social  norms     Peer-­‐group  interventions,  condom  provision,  outreach  and  behavior  change   programs  at  the  point  of  health  service  delivery  are  all  ways  in  which  the   community  plays  a  role  in  behavior  change  efforts.  They  also  occur  at  the   community  level,  e.g.,  via  street  theatre  and  other  public  events;  and  structurally   through  HIV  policies  and  schools-­‐based  HIV  education.  Peer  education  is  a   particularly  popular  community-­‐based  intervention.5       However,  prevention  of  HIV  transmission  through  behavior  change  is  complex   and  subject  to  unique  social,  cultural  and  epidemiological  forces  in  different   countries.  Moreover,  interventions  are  not  of  sufficient  scale  to  reach  the  point  of   universal  access.  As  well  as  insufficient  funding  there  is  a  lack  of  consensus  on   what  are  the  priority  issues  and  poor  coordination  between  different  service   providers.5       Programme  Activity  4:  Procurement,  distribution  and  marketing  of  male   and  female  condoms     Peer  group  and  social  networks  are  an  important  way  in  which  community   mobilization  supports  the  promotion  and  distribution  of  condoms,  As  well  as   interpersonal-­‐level  interventions,  there  are  also  community-­‐level  actions  to   distribute  condoms  and  promote  their  acceptance  and  correct  use,2  and  in  some  
  • 5. settings  this  has  also  been  done  at  a  structural  level  mandating  the  availability  of   condoms  in  bathhouses  frequented  by  men  who  have  sex  with  men,  for   example.5     Despite  the  fact  that  there  is  strong  evidence  in  support  of  condom  use  for  HIV   prevention,  there  is  a  lack  of  availability  of  low-­‐cost,  good-­‐quality  condoms  as   well  as  a  lack  of  demand  and  other  barriers  such  as  religious,  legal  and  gender   issues.5       Programme  Activity  5:  Treatment,  care  and  support  for  people  living  with   HIV     The  involvement  of  people  living  with  HIV  (PLHIV)  in  delivering  care  and  as  peer   educators  is  one  of  the  most  significant  means  of  community-­‐based   interventions.2,4,5  Other  small-­‐scale  interventions  include  microfinance,   nutritional  support  for  PLHIV  and  helping  families  affected  by  HIV  and  AIDS.   Community-­‐health  workers  also  play  a  part  in  the  process  of  task-­‐shifting  to   make  optimal  use  of  health  care  human  resources,  through  home-­‐  and   community-­‐based  HIV  testing  and  counseling,  and  increasing  adherence  in   antiretroviral  therapy.4     However,  this  is  an  area  where  the  lack  of  human  resources,  capacity  and   funding  creates  striking  gaps  in  service  provision,  and  efforts  are  undermined  by   stigma,  discrimination  and  gender  inequalities.  Also,  services  are  particularly   inadequate  for  certain  groups,  notably  key  populations  and  those  living  in  rural   areas.5  The  needs  of  PLHIV  have  changed  over  time,  the  most  notable  shift  being   the  impact  of  availability  of  HIV  treatment  which  has,  when  available,     transformed  HIV  from  a  terminal  illness  to  a  chronic  disease.6       Programme  Activity  6.  Voluntary  medical  male  circumcision  in  countries   with  high  HIV  prevalence     Community  mobilization  is  an  important  means  to  promote  male  circumcision   and  recruit,  screen  and  schedule  men  for  the  procedure.  Although  this   programme  activity  is  targeted  at  populations  with  low  rates  of  male   circumcision,  there  is  also  a  need  for  engagement  with  communities  practicing   traditional  make  circumcision  to  ensure  all  men  have  access  to  safe  and  effective   circumcision.       Despite  the  fact  that  engaging  volunteers  to  help  scale  up  male  circumcision,   these  community-­‐based  interventions  are  also  undermined  by  the  same  gaps  as   other  programmes:  lack  of  human  resources,  lack  of  infrastructure  support  and   unreliable  funding.4         The  costs  of  community  mobilization  
  • 6.   Because  the  UNAIDS  Investment  Framework  anticipates  community   mobilization  will  be  one  of  the  means  to  ensure  efficiency  gains,  it  is  important  to   consider  the  cost  implications  for  community  mobilization,  not  just  for   programmes,  but  for  the  community.    In  the  framework,  task-­‐shifting   downwards  will  result  in  cost  savings  for  the  health  care  system.  However,  it  is   important  that  funding  for  community  mobilization  is  increased,  in  line  with  the   Investment  Framework  proposal,  so  that  costs  are  not  simply  shifted  from   donors  to  the  communities  themselves.2       For  communities,  this  process  of  task-­‐shifting  can  bring  gains,  but  it  also  entails   opportunity  costs.  These  can  be  calculated  in  monetary  terms,  but  they  also   include  ethical  and  social  implications,  e.g.,  of  shifting  the  AIDS  response  from   paid  professionals  to  volunteers  in  the  community.3,7     The  costing  methodology  developed  by  UNAIDS  for  used  in  facilities-­‐based   healthcare  was  adopted  in  a  costing  study  for  non-­‐facilities  based  social  care   interventions.3  It  was  subsequently  field-­‐tested  in  studies  in  Cambodia,  Kenya   and  Zambia.3,9,10  The  methodology  calculates  the  costs  to  an  NGO  of  including   community  mobilization  in  a  particular  intervention,  as  well  as  the  opportunity   costs  and  financial  benefits  to  the  community  concerned.       The  studies  conclude  that  community  mobilization  can  and  should  be  costed,  but   that  most  in-­‐country  organizations  will  need  external  support  to  do  this.10   Rather  than  seeing  the  cost  to  the  community  as  an  obstacle  to  community   mobilization,  it  should  be  used  as  an  incentive  to  bring  in  new  funding  sources   and  incorporate  a  broader  range  of  stakeholders,  such  as  employers  and  unions,   to  support  national  AIDS  programmes.9       A  costing  study  in  Cambodia  identified  the  costs  of  community  mobilization  for   an  intervention  with  key  populations.  It  calculated  that  the  cost  to  the   community  of  participating  in  prevention  program  activities  for  men  who  have   sex  with  men,  sex  workers  and  people  who  inject  drugs,  was  equivalent  to  over   52  days’  income  per  year.9  Similarly  a  study  on  the  unit  cost  of  including   community  mobilization  in  a  PMTCT  programme  in  Zambia  found  that  there  was   a  net  benefit  to  participation  in  activities  to  strengthen  community  pathways  of   referral,  but  a  significant  cost  to  participation  in  awareness-­‐raising  activities.10       The  studies  are  the  first  step  towards  testing  the  UNAIDS  Investment   Framework’s  thesis  that  task-­‐shifting  to  the  community  can  increase  efficiency  in   national  HIV  responses.9     References     1.  Schwartländer  B,  Stover  J,  Hallett  T,  et  al.  Towards  an  improved  investment   approach  for  an  effective  response  to  HIV/AIDS.  The  Lancet  2011;377:2031-­‐ 2041.  
  • 7. 2.  Drew  R.  Community  Mobilisation  and  HIV/AIDS.  What  does  it  mean  for  the   International  HIV/AIDS  Alliance?  What  does  it  mean  for  the  investment   framework?  Discussion  paper.  International  HIV/AIDS  Alliance  (2012).   3.  Brady  R.  The  Cost  of  Community  Mobilisation.  Understanding  the  costs  to  the   community  in  participating  in  HIV/AIDS  interventions  within  the  proposed   UNAIDS  Investment  Framework  (2012).   4.  Treatment  2.0:  The  Next  Phase  of  HIV  Treatment  and  Prevention  Scale-­‐Up.  A   Community-­‐Based  Response.   5.  Lillie  T.  Rapid  Literature  review.  Community  Mobilization  and  the  Six   Programmatic  Areas  Outlined  in  the  “Towards  an  improved  investment   approach  for  an  effective  response  to  HIV/AIDS  (2012).   6.  Doupe  A.  Research  into  the  care  and  support  needs  of  key  populations  living   with  HIV  (2011).   7.  Budlender  D.  Compensation  for  Contributions.  Report  on  interviews  with     volunteer  care-­‐givers  in  six  countries.  Huairou  Commission  (2009).   8.  Ackerman  Gulaid  L.  Promising  practices  in  community  engagement  for  the   elimination  of  new  HIV  infections  in  children  by  2015  and  keeping  their  mothers   alive  (2011).   9  Brady  R.  Costing  Community  Mobilisation.  Identifying  the  unit  cost  of   Community  Mobilisation  in  Key  Populations  programs  run  by  KHANA  in   Cambodia.     10.  Smith  D.  Costing  Community  Mobilisation.  Identifying  the  unit  cost  of   Community  Mobilisation.  PMTCT  in  the  DfID  funded  Maternal  Mortality  project   in  Alliance  Zambia  (2011).