Strengthening COVID-19 vaccine confidence & demand during the US COVID-19 emergency response.

In October 2020, the CDC's Vaccinate with Confidence strategy specific to COVID-19 vaccines rollout was published. Adapted from an existing vaccine confidence framework for childhood immunization, the Vaccinate with Confidence strategy for COVID-19 aimed to improve vaccine confidence, demand, and uptake of COVID-19 vaccines in the US. The objectives for COVID-19 were to 1. build trust, 2. empower healthcare personnel, and 3. engage communities and individuals. This strategy was implemented through a dedicated unit, the Vaccine Confidence and Demand (VCD) team, which collected behavioral insights; developed and disseminated toolkits and best practices in collaboration with partners; and collaborated with health departments and community-based organizations to engage communities and individuals in behavioral interventions to strengthen vaccine demand and increase COVID-19 vaccine uptake. The VCD team collected and used social and behavioral data through establishing the Insights Unit, implementing rapid community assessments, and conducting national surveys. To strengthen capacity at state and local levels, the VCD utilized "Bootcamps," a rapid training of trainers on vaccine confidence and demand, "Confidence Consults", where local leaders could request tailored advice to address local vaccine confidence challenges from subject matter experts, and utilized surge staffing to embed "Vaccine Demand Strategists" in state and local public health agencies. In addition, collaborations with Prevention Research Centers, the Institute of Museum and Library Services, and the American Psychological Association furthered work in behavioral science, community engagement, and health equity. The VCD team operationalized CDC's COVID-19 Vaccine with Confidence strategy through behavioral insights, capacity building opportunities, and collaborations to improve COVID-19 vaccine confidence, demand, and uptake in the US. The inclusion of applied behavioral science approaches were a critical component of the COVID-19 vaccination program and provides lessons learned for how behavioral science can be integrated in future emergency responses.

Operationalizing the Centers for Disease Control and Prevention's Vaccinate With Confidence Framework During the COVID-19 Emergency Response in the United States.

In December 2020, 11 months after identifying the first laboratory-confirmed case of COVID-19 in the United States, the U.S. Food and Drug Administration authorized emergency use of two COVID-19 vaccines. To prepare the public for a large-scale vaccination campaign and build confidence in COVID-19 vaccines, the U.S. Centers for Disease Control and Prevention (CDC) funded more than 200 partners and developed a national Vaccinate with Confidence (VwC) COVID-19 framework to support Americans in their decision to get vaccinated. The evolving nature of the pandemic and highly variable confidence in vaccines across populations has resulted in many unique complexities and challenges to reaching universally high vaccination coverage. Here, we describe how 23 professional health associations and national partner organizations, focused solely on building vaccine confidence, operationalized CDC's VwC COVID-19 framework from February 2021 to March 2022. Capturing how partners deployed and adapted their activities to meet a shifting pandemic landscape, which began with high demand for vaccines that waned over time, is an important first step to understanding how this new strategy was utilized and could be implemented for future surges in COVID-19 cases and other routine immunization efforts. Going forward, evaluation of partner activities should be prioritized to capture learnings and assess VwC program effectiveness.

Poliovirus outbreak in New York State, August 2022: qualitative assessment of immediate public health responses and priorities for improving vaccine coverage.

In 2022, a case of paralysis was reported in an unvaccinated adult in Rockland County (RC), New York. Genetically linked detections of vaccine-derived poliovirus type 2 (VDPV2) were reported in multiple New York counties, England, Israel, and Canada. The aims of this qualitative study were to: i) review immediate public health responses in New York to assess the challenges in addressing gaps in vaccination coverage; ii) inform a longer-term strategy to improving vaccination coverage in under-vaccinated communities, and iii) collect data to support comparative evaluations of transnational poliovirus outbreaks. Twenty-three semi-structured interviews were conducted with public health professionals, healthcare professionals, and community partners. Results indicate that i) addressing suboptimal vaccination coverage in RC remains a significant challenge after recent disease outbreaks; ii) the poliovirus outbreak was not unexpected and effort should be invested to engage mothers, the key decision-makers on childhood vaccination; iii) healthcare providers (especially paediatricians) received technical support during the outbreak, and may require resources and guidance to effectively contribute to longer-term vaccine engagement strategies; vi) data systems strengthening is required to help track under-vaccinated children. Public health departments should prioritize long-term investments in appropriate communication strategies, countering misinformation, and promoting the importance of the routine immunization schedule.

Expanding PrEP Services for Men Who Have Sex With Men and Transgender Persons Through Health Department Programs: Key Processes and Outcomes From Project PrIDE, 2015-2019.

OBJECTIVE: Pre-exposure prophylaxis (PrEP) Implementation, Data to Care, and Evaluation (PrIDE) was a demonstration project implemented by 12 state and local health departments during 2015-2019 to expand PrEP services for men who have sex with men (MSM) and transgender persons at risk for HIV infection. We describe findings from the cross-jurisdictional evaluation of the project. METHODS: We analyzed work plans, annual progress reports, and aggregate quantitative program data submitted by funded health departments (n = 12) to identify key activities implemented and summarize key project outcomes. RESULTS: PrIDE jurisdictions implemented multiple health equity-focused activities to expand PrEP services to priority populations, including building program capacity, conducting knowledge and awareness campaigns, providing PrEP support services, and addressing barriers to PrEP use. Overall, PrIDE jurisdictions identified 44 813 persons with PrEP indications. Of these, 74.8% (n = 33 500) were referred and 33.1% (n = 14 821) were linked to PrEP providers, and 25.3% (n = 11 356) were prescribed PrEP. Most persons prescribed PrEP were MSM or transgender persons (87.9%) and persons from racial and ethnic minority groups (65.6%). However, among persons with PrEP indications, non-Hispanic Black/African American persons (14.9% of 18 782) were less likely than non-Hispanic White persons (31.0% of 11 633) to be prescribed PrEP (z = -33.57; P < .001). CONCLUSIONS: PrIDE jurisdictions successfully expanded PrEP services for MSM, transgender persons, and racial and ethnic minority groups by implementing health equity-focused activities that addressed barriers to PrEP services. However, PrEP prescription was generally low, with significant disparities by demographic characteristics. Additional targeted interventions are needed to expand PrEP services, achieve equity in PrEP use, and contribute to ending the HIV epidemic in the United States.

Expanding Data to Care Programs to Improve HIV Care Continuum Among Men Who Have Sex With Men and Transgender Persons: Key Processes and Outcomes From Project PrIDE, 2015-2019.

OBJECTIVES: During 2015-2019, five local and state health department jurisdictions implemented Data to Care (D2C) programs supported by Project PrIDE (Pre-exposure prophylaxis, Implementation, Data to Care, and Evaluation) to improve linkage or reengagement in HIV medical care among persons with HIV (PWH) who had gaps in care, particularly among men who have sex with men (MSM) and transgender persons. We describe findings from the cross-jurisdiction evaluation of the project. METHODS: We conducted a qualitative analysis of the final progress reports submitted by PrIDE jurisdictions to the Centers for Disease Control and Prevention to identify key D2C activities implemented and challenges encountered. We also conducted descriptive analysis on aggregate quantitative data to summarize key D2C program outcomes. RESULTS: PrIDE jurisdictions implemented multiple activities to build their D2C capacity, identify PWH who were not in care or virally suppressed, provide linkage/reengagement services, and monitor outcomes. Overall, 11 463 PWH were selected for follow-up, 45% of whom were MSM or transgender persons. Investigations were completed for 8935 (77.9%) PWH. Only 2323 (26.0%) PWH were confirmed not in care or virally suppressed; 1194 (51.4%) were subsequently linked/reengaged in care; among those, 679 (56.9%) were virally suppressed at last test. PrIDE jurisdictions identified data-related (eg, incomplete or delayed laboratory results), program capacity (eg, insufficient staff), and social and structural (eg, unstable housing) challenges that affected their D2C implementation. CONCLUSIONS: PrIDE jurisdictions successfully enhanced their D2C capacity, reached priority populations who were not in care or virally suppressed, and improved their engagement in care and health outcomes. Data-related and non-data-related challenges limited the efficiency of D2C programs. Findings can help inform other D2C programs and contribute to national HIV prevention goals.

Project PrIDE in Context: Evolution of Evaluation in the Centers for Disease Control and Prevention's Multi-Jurisdictional HIV Prevention Demonstration Projects.

Over the past decade, CDC has been implementing a high-impact prevention (HIP) approach to HIV, directing funds towards activities with the greatest likelihood of reducing new infections and disparities. Corresponding to this shift, the Division of HIV/AIDS Prevention (DHAP) began funding a series of multi-site demonstration projects to provide extra support and evaluative capacity to select health departments to initiate new HIP programming, with the intention of ascertaining and sharing lessons with other health departments. In this paper, we provide context for the PrEP, Implementation, Data2Care, Evaluation (PrIDE) evaluation by describing the evolution of evaluation goals and activities across three prior demonstration projects, highlighting four areas of change: 1) integrated evaluation and program implementation; 2) local program evaluation in addition to cross-site performance monitoring; 3) prescriptive allocation of resources to support local program evaluation; and 4) expansion beyond single site program evaluation to identify effective cross-site programmatic strategies. Together, these changes reflect our own learning about achieving the greatest contribution from multi-site projects and set the stage for unique aspects of program evaluation within PrIDE. We describe these features, concluding with lessons learned from this most recent approach to structuring and supporting evaluation within CDC DHAP's health department demonstration projects.

Effectiveness of HIV Stigma Interventions for Men who have Sex with Men (MSM) With and Without HIV in the United States: A Systematic Review and Meta-Analyses.

Stigma may contribute to HIV disparities for men who have sex with men (MSM). This systematic review quantified the effects of HIV stigma interventions for MSM on stigma and sex risk. We conducted a systematic search to identify US-based studies published between 2000 and June 2019 focused on HIV and MSM, and either measured stigma pre-post or included a stigma intervention component. Twenty-nine articles, representing 26 unique studies met inclusion criteria. Random effect models showed no intervention effect for reducing stigma and a non-significant increase in HIV testing. Significant decreases in condomless sex with males, condomless sex with females, and substance-influenced sex were found. Few intervention studies measured stigma pre-post. Findings suggest that including a stigma reduction component in interventions can improve HIV testing and reduce sex risk for MSM. Developing interventions to address stigma may be important in decreasing HIV infection among MSM and ending the HIV epidemic.

Patterns in COVID-19 Vaccination Coverage, by Social Vulnerability and Urbanicity - United States, December 14, 2020-May 1, 2021.

Disparities in vaccination coverage by social vulnerability, defined as social and structural factors associated with adverse health outcomes, were noted during the first 2.5 months of the U.S. COVID-19 vaccination campaign, which began during mid-December 2020 (1). As vaccine eligibility and availability continue to expand, assuring equitable coverage for disproportionately affected communities remains a priority. CDC examined COVID-19 vaccine administration and 2018 CDC social vulnerability index (SVI) data to ascertain whether inequities in COVID-19 vaccination coverage with respect to county-level SVI have persisted, overall and by urbanicity. Vaccination coverage was defined as the number of persons aged ≥18 years (adults) who had received ≥1 dose of any Food and Drug Administration (FDA)-authorized COVID-19 vaccine divided by the total adult population in a specified SVI category.† SVI was examined overall and by its four themes (socioeconomic status, household composition and disability, racial/ethnic minority status and language, and housing type and transportation). Counties were categorized into SVI quartiles, in which quartile 1 (Q1) represented the lowest level of vulnerability and quartile 4 (Q4), the highest. Trends in vaccination coverage were assessed by SVI quartile and urbanicity, which was categorized as large central metropolitan, large fringe metropolitan (areas surrounding large cities, e.g., suburban), medium and small metropolitan, and nonmetropolitan counties.§ During December 14, 2020-May 1, 2021, disparities in vaccination coverage by SVI increased, especially in large fringe metropolitan (e.g., suburban) and nonmetropolitan counties. By May 1, 2021, vaccination coverage was lower among adults living in counties with the highest overall SVI; differences were most pronounced in large fringe metropolitan (Q4 coverage = 45.0% versus Q1 coverage = 61.7%) and nonmetropolitan (Q4 = 40.6% versus Q1 = 52.9%) counties. Vaccination coverage disparities were largest for two SVI themes: socioeconomic status (Q4 = 44.3% versus Q1 = 61.0%) and household composition and disability (Q4 = 42.0% versus Q1 = 60.1%). Outreach efforts, including expanding public health messaging tailored to local populations and increasing vaccination access, could help increase vaccination coverage in high-SVI counties.

Project PrIDE in context: Evolution of evaluation in the centers for disease control and prevention's multi-jurisdictional HIV prevention demonstration projects.

Over the past decade, CDC has been implementing a high-impact prevention (HIP) approach to HIV, directing funds towards activities with the greatest likelihood of reducing new infections and disparities. Corresponding to this shift, the Division of HIV/AIDS Prevention (DHAP) began funding a series of multi-site demonstration projects to provide extra support and evaluative capacity to select health departments to initiate new HIP programming, with the intention of ascertaining and sharing lessons with other health departments. In this paper, we provide context for the PrEP, Implementation, Data2Care, Evaluation (PrIDE) evaluation by describing the evolution of evaluation goals and activities across three prior demonstration projects, highlighting four areas of change: 1) integrated evaluation and program implementation; 2) local program evaluation in addition to cross-site performance monitoring; 3) prescriptive allocation of resources to support local program evaluation; and 4) expansion beyond single site program evaluation to identify effective cross-site programmatic strategies. Together, these changes reflect our own learning about achieving the greatest contribution from multi-site projects and set the stage for unique aspects of program evaluation within PrIDE. We describe these features, concluding with lessons learned from this most recent approach to structuring and supporting evaluation within CDC DHAP's health department demonstration projects.

Experienced Homophobia and HIV Infection Risk Among U.S. Gay, Bisexual, and Other Men Who Have Sex with Men: A Meta-Analysis.

Purpose: Experienced homophobia-negative treatment and perceptions that gay, bisexual, and other men who have sex with men (MSM) encounter because of their sexual orientations-may promote HIV infection among MSM. We conducted a rapid review and meta-analysis to examine experienced homophobia in relation to HIV infection risk. Methods: We searched Embase, MEDLINE, PsycINFO, and Sociological Abstracts to acquire data from U.S. studies published during 1992-2017. Studies examined experienced homophobia in relation to sexual risk behavior, poor HIV care continuum engagement, and diagnosed HIV infection. Random-effects models yielded summary odds ratios (ORs) and 95% confidence intervals (CIs). Results: Experienced homophobia was associated with having any sexual risk behavior (OR = 1.33, 95% CI = 1.25-1.42, I2 = 89.2%), receptive condomless anal sex (CAS) (OR = 1.33, 95% CI = 1.14-1.56, I2 = 63.6%), HIV-discordant CAS (OR = 1.66, 95% CI = 1.29-2.13, I2 = 85.3%), an increased number of sex partners (OR = 1.16, 95% CI = 1.13-1.19, I2 = 0.0%), diagnosed HIV infection (OR = 1.34, 95% CI = 1.10-1.64, I2 = 86.3%), and poor HIV care continuum engagement among MSM living with HIV (OR = 1.45, 95% CI = 1.02-2.08, I2 = 47.0%). Effect sizes for any sexual risk behavior were larger in samples with ≥50% Black or Latino (vs. White) MSM and for family-based mistreatment and perceived sexual minority stigma (vs. other homophobia types). Conclusion: Experienced homophobia is associated with HIV infection risk among MSM. Its association with sexual risk behavior may be stronger among Black and Latino (vs. White) MSM and for family-based mistreatment and perceived sexual minority stigma (vs. other homophobia types). Research is needed to better understand causality in these relationships and the role of interventions to reduce homophobia.

Observed reactions among patients attending HIV treatment facilities to a brief video intervention on treatment initiation and adherence.

Entertainment-education can affect positive behavior change. Taking Care of Me is an effective, video-based intervention designed to improve patients' continuum of HIV care outcomes. The study's aim was to refine the pre-final video at points where patients stopped watching and missed embedded health messages. We evaluated the video using systematic unobtrusive observations triangulated with electronic medical record (EMR) data. We conducted observations in three HIV treatment facilities' waiting rooms in the southern US in 2016. Using a web-based data collection instrument, one observer spent 8 h at each facility observing patients' engagement with the video. We mapped the embedded messages in each scene and identified the messages that patients missed when they stopped watching. We compared missed messages to treatment initiation, medication adherence, and retention in care data abstracted from each clinic's EMR system. We were able to identify specific scenes where low levels of engagement corresponded to lower than expected retention in care outcomes and edit these scenes to improve engagement. Identifying and editing video scenes to increase viewership potentially could enhance intervention efficacy. Our methods could be used to assess and refine other video-based interventions being developed in resource limited settings.

Improving the HIV Prevention Landscape to Reduce Disparities for Black MSM in the South.

Black men who have sex with men (MSM) in the South have the highest rates of HIV diagnosis in the country adding to the persistent racial disparities in HIV experienced by this population. The current HIV prevention and care landscape is heavily driven by individual-level clinical and biomedical approaches that have shown progress in reducing HIV diagnoses, but yield less than adequate results in reducing the HIV racial disparities for Black MSM in the South. In efforts to enhance focus on reducing the racial HIV disparities and more completely address the needs of Black MSM in the South, we offer insight on comprehensive approaches that can complement our current HIV prevention and care portfolio. There are five domains we discuss which include: (1) leveraging and integrating resources; (2) building upon existing program models designed to reduce disparities; (3) workforce development and cultural sensitivity; (4) social determinants of health data utilization; and 5) policy considerations. We urge public health practitioners and healthcare providers to consider and incorporate the outlined approaches to improve HIV outcomes along the continuum of care and ultimately reduce disparities in HIV affecting the quality of life of Black MSM living in the South.

HIV Data to Care-Using Public Health Data to Improve HIV Care and Prevention.

BACKGROUND: "Data to Care" (D2C) is a public health strategy that uses surveillance and other data to improve continuity of HIV care for persons with HIV (PWH) by identifying those who are in need of medical care or other services and facilitating linkage to these services. The primary goal of D2C is to increase the number of PWH who are engaged in care and virally suppressed. METHODS: Data to Care can be implemented using several approaches. Surveillance-based D2C is usually initiated by health departments, using HIV surveillance and other data to identify those not in care. Health care providers may also initiate D2C by identifying patients who may have fallen out of care and working collaboratively with health departments to investigate, locate, and relink the patients to medical care or other needed services. RESULTS: Although D2C is a relatively new strategy, health department D2C programs have reported both promising results (eg, improved surveillance data quality and successful linkage to or re-engagement in care for PWH) and challenges (eg, incomplete or inaccurate data in surveillance systems, barriers to data sharing, and limitations of existing data systems). CONCLUSIONS: Data to Care is expected to enable health departments to move closer toward achieving national HIV prevention goals. However, additional information on appropriate implementation practices at each step of the D2C process is needed. This JAIDS Special Supplement explores how CDC funding to state health departments (eg, technical assistance and demonstration projects), and partnerships across federal agencies, are advancing our knowledge of D2C.

Effects of a brief video intervention on treatment initiation and adherence among patients attending human immunodeficiency virus treatment clinics.

BACKGROUND: Persons with human immunodeficiency virus (HIV) who get and keep a suppressed viral load are unlikely to transmit HIV. Simple, practical interventions to help achieve HIV viral suppression that are easy and inexpensive to administer in clinical settings are needed. We evaluated whether a brief video containing HIV-related health messages targeted to all patients in the waiting room improved treatment initiation, medication adherence, and retention in care. METHODS AND FINDINGS: In a quasi-experimental trial all patients (N = 2,023) attending two HIV clinics from June 2016 to March 2017 were exposed to a theory-based, 29-minute video depicting persons overcoming barriers to starting treatment, taking medication as prescribed, and keeping medical appointments. New prescriptions at index visit, HIV viral load test results, and dates of return visits were collected through review of medical records for all patients during the 10 months that the video was shown. Those data were compared with the same variables collected for all patients (N = 1,979) visiting the clinics during the prior 10 months (August 2015 to May 2016). Among patients exposed to the video, there was an overall 10.4 percentage point increase in patients prescribed treatment (60.3% to 70.7%, p< 0.01). Additionally, there was an overall 6.0 percentage point improvement in viral suppression (56.7% to 62.7%, p< 0.01), however mixed results between sites was observed. There was not a significant change in rates of return visits (77.5% to 78.8%). A study limitation is that, due to the lack of randomization, the findings may be subject to bias and secular trends. CONCLUSIONS: Showing a brief treatment-focused video in HIV clinic waiting rooms can be effective at improving treatment initiation and may help patients achieve viral suppression. This feasible, low resource-reliant video intervention may be appropriate for adoption by other clinics treating persons with HIV. TRIAL REGISTRATION: http://www.ClinicalTrials.gov (NCT03508310).

Per-partner condom effectiveness against HIV for men who have sex with men.

OBJECTIVE: Few studies have examined condom effectiveness for HIV prevention among MSM. We estimated condom effectiveness per partner in four cohorts of MSM during 1993-2003 (JumpStart, Vaccine Preparedness Study, VAX004 and Project Explore). METHODS: We used logistic regression to estimate the increase in odds of new HIV infection per HIV-positive partner for condom-protected receptive anal intercourse (PRAI; partners with whom condoms were always used) and condomless (unprotected) receptive anal intercourse (URAI; partners with whom condoms were sometimes or never used). To estimate condom effectiveness for preventing HIV transmission, we applied the concept of excess odds, the odds ratio minus 1. The condom failure rate was estimated as the excess odds per PRAI partner divided by the excess odds per URAI partner. Condom effectiveness was then 1 minus the failure rate. RESULTS: The excess odds of HIV infection per HIV-positive partner were 83% for URAI and 7% for PRAI. The resulting failure rate (9%) indicated per-partner condom effectiveness of 91% (95% confidence interval 69-101). CONCLUSION: The increase in odds of new HIV infection per HIV-positive partner for receptive anal intercourse was reduced by 91% for each partner with whom condoms were always used.

Improving Linkage, Retention, and Reengagement in HIV Care in 12 Metropolitan Areas.

The Centers for Disease Control and Prevention developed the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to support 12 health departments' improvement of their HIV prevention and care portfolios in response to new national guidelines. We systematically analyzed 3 years of progress reports to learn how grantees put into practice local intervention strategies intended to link people to, and keep them in, HIV care. All grantees initiated seven activities to support these strategies: (1) improve surveillance data systems, (2) revise staffing duties and infrastructures, (3) update policies and procedures, (4) establish or strengthen partnerships, (5) identify persons not in care, (6) train personnel, and (7) create ways to overcome obstacles to receiving care. Factors supporting ECHPP grantee successes were thorough planning, attention to detail, and strong collaboration among health department units, and between the health department and external stakeholders. Other jurisdictions may consider adopting similar strategies when planning and enhancing HIV linkage, retention, and reengagement efforts in their areas. ECHPP experiences, lessons learned, and best practices may be relevant when applying new public health policies that affect community and health care practices jurisdiction-wide.

Shifting Resources and Focus to Meet the Goals of the National HIV/AIDS Strategy: The Enhanced Comprehensive HIV Prevention Planning Project, 2010-2013.

In September 2010, CDC launched the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to shift HIV-related activities to meet goals of the 2010 National HIV/AIDS Strategy (NHAS). Twelve health departments in cities with high AIDS burden participated. These 12 grantees submitted plans detailing jurisdiction-level goals, strategies, and objectives for HIV prevention and care activities. We reviewed plans to identify themes in the planning process and initial implementation. Planning themes included data integration, broad engagement of partners, and resource allocation modeling. Implementation themes included organizational change, building partnerships, enhancing data use, developing protocols and policies, and providing training and technical assistance for new and expanded activities. Pilot programs also allowed grantees to assess the feasibility of large-scale implementation. These findings indicate that health departments in areas hardest hit by HIV are shifting their HIV prevention and care programs to increase local impact. Examples from ECHPP will be of interest to other health departments as they work toward meeting the NHAS goals.

Evaluation Framework for HIV Prevention and Care Activities in the Enhanced Comprehensive HIV Prevention Planning Project, 2010-2013.

OBJECTIVE: The Enhanced Comprehensive HIV Prevention Planning (ECHPP) project was a demonstration project implemented by 12 U.S. health departments (2010-2013) to enhance HIV program planning in cities with high AIDS prevalence, in support of National HIV/AIDS Strategy goals. Grantees were required to improve their planning and implementation of HIV prevention and care programs to increase their impact on local HIV epidemics. A multilevel evaluation using multiple data sources, spanning multiple years (2008-2015), will be conducted to assess the effect of ECHPP on client outcomes (e.g., HIV risk behaviors) and impact indicators (e.g., new HIV diagnoses). METHODS: We designed an evaluation approach that includes a broad assessment of program planning and implementation, a detailed examination of HIV prevention and care activities across funding sources, and an analysis of environmental and contextual factors that may affect services. A data triangulation approach was incorporated to integrate findings across all indicators and data sources to determine the extent to which ECHPP contributed to trends in indicators. RESULTS: To date, data have been collected for 2008-2009 (pre-ECHPP implementation) and 2010-2013 (ECHPP period). Initial analysis of process data indicate the ECHPP grantees increased their provision of HIV testing, condom distribution, and partner services programs and expanded their delivery of prevention programs for people diagnosed with HIV. CONCLUSION: The ECHPP evaluation (2008-2015) will assess whether ECHPP programmatic activities in 12 areas with high AIDS prevalence contributed to changes in client outcomes, and whether these changes were associated with changes in longer-term, community-level impact.