There are an estimated 15,000 military personnel dispersed throughout Mozambique with the greatest concentrations in Maputo, Nampula, and Sofala provinces. The Mozambican Armed Forces (FADM) are divided into Army, Navy, and Air Force. Most military facilities are located in remote areas. Enlisted recruits are trained in facilities located in districts with relatively good infrastructure and accessibility, which could increase their behavioral risk for HIV.

In line with the Government of Mozambique National Accelerated HIV Prevention Strategy to implement evidence-based and comprehensive prevention interventions targeted towards the general population and most-at-risk populations (MARPs), the USG supported the FADM in completing the second round of the Behavioral and Prevalence Study within their personnel and plans to support data collection to access Male Circumcision (MC) prevalence among young recruits. This kind of information is critical to ensuring interventions targeting the armed forces are evidence-based. Population Services International (PSI) will continue implementing general prevention activities and will start working to implement biomedical prevention of MC, all in collaboration with the USG agencies, Mozambican Military Health and other partners implementing similar interventions. The main goal of these interventions is to continue assisting the FADM's effort to reduce HIV incidence among soldiers and their families, and to increase its capacity to manage effective prevention programs. The objectives are: 1) To increase the capacity of FADM to perform HIV prevention awareness activities; 2) To increase awareness of the need for HIV prevention among military personnel and family, using innovative means for message delivery such as radio, video and TV added to the current strategies; 3) To improve access to and consistent use of condoms and reduction in sex partners; 4) To improve access to CT for military personnel and family members; 5) To increase referrals to appropriate care and support services for those infected with HIV; 6) To expand the availability of MC services through infrastructure development, training of doctors and technical assistance; 7) Reduce the incidence of malaria through distribution of mosquito nets.

The activities include IEC, BCC, peer education, dramatization, movies, murals, to influence abstinence, voluntary testing, fidelity, partner reduction, reduction of alcohol consumption, constant and consistent condom use, increase of MC prevalence among the troops in all military units. In the training camps, the program will include a component of gender based violence and forced sex. PSI will introduce a "green line" available for female recruits that are willing to discuss particular aspects related to gender based violence.

Prevention campaigns will also target the population surrounding military bases because the two groups are related. PSI will continue making available the camouflage and female condoms in all military units, including hospitals.

USG will fund PSI to install another radio at the Military Academy in Nampula to broadcast HIV awareness messages. As the project progresses, the military team operating the radio station in Maputo will be sent to Nampula to train their colleagues about the basic aspects of radio operation. USG will request to again have the US military radio team come to Mozambique for another set of trainings.

With the completion of this project, important prevention, care and treatment messages will reach all age groups and sexes including the troops located around the City of Nampula and the students of the Military Academy. One benefit of radio is the flexibility to discuss and inform people about a variety of topics. It is a tool that is crosscutting all program areas. In this particular case, we will encourage the connection between the military health and the provincial health directorate so that information related to malaria, TB, diarrhea, vaccinations, breast feeding, STI diagnosis and treatment, male circumcision, etc. can be broadcast for the benefit of the general population. This project is cost efficient not only because the broadcasts and radio station will be managed and operated by the military but also because it can generate some income from publicity and announcements requested by local enterprises and the general public. These funds will cover operational costs. The same M&E tools that are measuring the radio impact in Maputo will also be used in this station in Nampula. PSI will develop and introduce a training curriculum for awareness classes offered to the recruits and other soldiers in other military units. This partner will also scale up and improve mobile CT access to military forces and their families via training and supervision/support of military CT counselors; TA and CT campaigns to encourage testing among the military leadership. The PICT strategy will be introduced in all military health units. HIV status disclosure will be emphasized as well as discordant couples counseling. CT will be provided to young people (male and female) that are required to undergo medical check-ups in order to assess their ability/physical fitness for military basic training. Since part of the aforementioned check-ups also includes genital examination, USG will support the military health in order to take advantage of the opportunity that is given to gather information related to MC prevalence among these young people in order to support PSI's critical strategy of providing MC interventions at the military basic training camps and in other military highly concentrated areas. All proposed activities are linked with the Goal 1 of the Partnership Framework which is to reduce new infections in Mozambique.

PSI will ensure that the existing CT sites are well functioning, the quality of testing is assured, the counselors receive refresher courses and IEC materials (printed and media) are available in each site and in all military bases. M&E tools will be in place. Mobile testing and counseling campaigns will be reinforced and increased to target military bases without local CT services. The remote bases and the training camps will be considered and a van will be purchased and transformed into a mobile clinic. During these campaigns and specially during each CT session, the counselors will be trained to assess information about the clients' status in regards to MC and, educate the ones that test negative about the advantages of the intervention. The testing will follow the national algorithm and HIV positive clients will continue being referred for care and treatment as usual.

Adapting a protocol previously used in Lesotho, USG in conjunction with the FADM will do a study of MC prevalence among recruits' applicants. It will require MOH ethics approval of the protocol. The study will target young people and the data will cover the entire country.

PSI, in collaboration with USG and USG-supported partners, will support the expansion of male circumcision (MC) within the FADM. The aim is to increase the number of circumcised men and reduce the number of new HIV infections in the military.

PSI's initial priority will be to implement MC services at military entry points, namely basic training camps (Manhiça and Montepuez) where recruits receive training for 6 months. Currently, PSI conducts HIV prevention activities in these training camps. The plan for FY 2010 is to expand efforts for greater impact by offering comprehensive CT services and MC. MC will occur after graduation and the circumcised men will be required to stay at the training camps until healing is complete. The same approach will be used at the Special Forces (i.e., Red Berets and Fusiliers) training camps. PSI will tailor the approach at the Military Academy in Nampula, Sergeant's School and with the Peacekeeping Forces located in Boane, based on the unique needs and availability of personnel in these cadres.

Following the completion of a demonstration project and approval from MOD, providers will be trained according to national standards and will follow recommended clinical procedures. MC will be performed entirely by military medical staff to ensure sustainability and human capacity development. However, PSI will provide technical assistance and supportive supervision as needed.

PSI will also support infrastructure improvement at the existing facilities where MC services will be provided. Military facilities are typically degraded and will need rehabilitation to ensure that MC services are offered in an environment that will prevent and control infections. It is anticipated that a small area will be created to accommodate MC services and sterilization rooms will all be renovated. Exact locations and prioritization of MC service initiation will be coordinated with USG and MOH.

PSI will procure the needed commodities to effectively deliver services and will develop IEC materials for military personnel. MC services are not stand-alone and PSI will ensure that males are aware that abstinence, partner reduction, condom use, and reduction in alcohol consumption are also key for a life free of HIV.

Unprotected heterosexual sex is the primary route of HIV transmission among Mozambicans. A recent

study conducted with Mozambicans between the ages of 15 and 24 found that only 33% of males and

29% of females reported using a condom during their last episode of sexual intercourse, suggesting that

low rates of condom use may be a major factor in the spread of HIV. Multiple concurrent partners,

stigmatization, gender inequality, and misinformation about HIV also impact the spread of HIV infection

among the general population. Additional factors (e.g., mobility, sex workers, separation from family)

contribute to the even higher prevalence of HIV among members of the Mozambique Armed Defense

Forces (FADM). It is clear from these findings that developing effective risk reduction programs is critical

to limiting new infections in Mozambique. The military population's age group ranges from 18 - 45+ years

old. Based on this information and using the behavioral and prevalence study data, PSI will design

activities that address the major drivers of the epidemic within the Mozambican military. Some of those

are multiple concurrent partners, low condom use, heavy drinking, low CT (there is a need to move from

CT to the new concept of PITC). All aspects of risky behavior will be addressed and explored during peer

education sessions and, funds will be allocated to PSI to implement this comprehensive program. The

peer education program will have a particular piece targeting around 4000 recruits (men and women)

during their military basic training. As they complete the training, it is expected that these new soldiers

will be agents of behavior change within the barracks and in the communities surrounding the units

where they will be assigned to serve. PSI will work hard to promote HIV status disclosure within the

armed forces and will record a video documentary about the life of a soldier (male and/or female) that

lives with HIV. A military recorded video about CT will be produced (using the example from Botswana as

reference) and advertised on TV. During prevention campaigns soldiers LHIV will give testimonies to

fellow soldiers about their life.

These activities (the radio program and the HIV/AIDS training curriculum) will give the military other

options to disseminate and discuss a variety of information about all aspects related to HIV. Programs

aiming to influence reduction of risky behavior will be designed and broadcast. However, the installation

of the radio will require a component of infrastructure rehabilitation, equipment and training. Specific

programs will be designed to promote abstinence, partner reduction, consistent and constant condom

use because the majority of military students at the military academy are away from home and may

engage in risky casual sexual encounters. PSI will develop a training curriculum (adapted from other

countries) and it will be used during awareness classes offered to the recruits. The young recruits will be

trained in HIV basic aspects aiming to enrich the prevention program.The same curriculum will also be

used at the Military Academy in Nampula and at the sergeants' school in Boane. The HIV awareness

training curriculum will also be used by the radio operators to orient their programs and radio debates.

Part of the funds will be used to procure, buy and distribute long-lasting insecticidal mosquito nets

(LLINs) for the new recruits. When they complete the training they will leave the military training camps

with their own nets.