CDC awarded PSI the Prevention Program Targeting Youth and Most-at-Risk Populations (MARPs) in 2009, with support from COP09 funding. The overall goal of this activity is to reduce HIV and STI prevalence among youth and young most-at-risk populations (MARPs) aged 15-34 in the geographic areas surrounding youth-friendly centers in 8 of 30 Districts. Prevention programs for youth remain a high priority for both the GOR and the EP. Since the overall national prevalence is 3.1%, Rwanda's prevention programming must account for its largely HIV-negative population; reaching the youth population is the most long-term solution and an important opportunity to affect the progression of the epidemic. Averting new infections in this age group is not only cost effective, but is also the most sustainable way to turn the tide against HIV/AIDS in Rwanda.

Employing national and international best practices, PSI will promote abstinence and safer sexual behaviors, encourage uptake of HIV and STI services, improve access to HIV and STI prevention and treatment referrals through 4 fixed sites, and improve evidence-based and targeted HIV and STI "moonlight" outreach services at another 4 sites for MARPs, while strengthening monitoring and evaluation systems for the project. Implementation activities include targeted youth- and MARPS-friendly outreach and VCT/STI service delivery (with a focus on couples testing), promotion of correct and consistent condom use (including targeted condom distribution), intensive trainings in life skills and parent child communications, peer education by trained youth, and support for multi-level multi-media campaigns, including continued support for a FY08 and FY 2009 cross-generational sex (CGS) campaign, and early development and implementation of a Concurrent Partnership (CP) campaign. This activity will also continue support for the HIV/AIDS hotline, managed through subaward with the National

AIDS Commission. AB messages will focus on combating CGS and CP. OP messages will address the identified barriers to correct and consistent condom use among youth and young MARPS. CT messages will emphasize the importance of couples testing.

This activity contributes to the Partnership Framework objective of halving HIV incidence in the general population by 2012 by reducing risky sexual behaviors through targeted, evidence-based prevention interventions for MARPs, evidence-based interventions among in-school and out-of-school youth, HIV prevention at youth centers, targeted CT for youth and MARPS, and promotion of correct and consistent condom use among MARPS and the general population. It will contribute to efforts to coordinate and harmonize prevention activities in Rwanda, including technical support for the development of a strategic plan for behavior change communications among youth. Training and peer education efforts will contain messaging about the link between alcohol use, GBV and HIV exposure, including messages that address gender norms as a barrier to safer sexual behaviors.

Working with and through a range of local partners, PSI will strengthen local capacity to manage and implement activities over time, including strengthening public providers to provide youth-friendly follow-on services, strengthening the National Youth Council representatives and community-based partners to lead subgranted youth center management, and training and supporting local providers to implement youth-friendly VCT and STI diagnosis and treatment services. PSI will also continue developing the Rwandan Social Marketing institution, transitioning day-to-day management to well trained and supported senior staff who will receive day-to-day capacity building and mentoring from "twinned" senior technical advisor staff. Cost efficiencies will be realized with CDC support for finger prick testing, particularly for mobile CT, by strengthening commercial distribution networks for condom distribution, and by monitoring the selling price for condoms, to reduce the subsidy requirement according to the willingness and ability of target populations to pay.

Monitoring and Evaluation (M&E) activities will include support for follow-on behavioral surveillance surveys among youth and MARPs, routine client intake and satisfaction data analysis from CT service delivery, quality assurance tools such as training pre- and post-test analyses, mystery client monitoring of service delivery points, and routine supervision.

FY 2010 will continue to support comprehensive voluntary counseling and testing (CT), STI services and family planning (FP) counseling for youth and young MARPs at, and in communities around Dushishoze ("Let's take care" in the Rwandan language) youth-friendly centers, with quality of services supervised by PSI and district health authorities. FY 2010 will continue to fully support management and technical implementation at 4 fixed sites and extend MARPs-targeted mobile outreach services to an additional 4 sites, improving youth and MARPs access to high quality CT in 8 of 30 districts.

Evidence-based CT promotion and MARPs-targeted outreach services will ensure improved targeting and effectiveness of CT services. In 2007 and 2008, approximately 44,000 youth were tested at 4 centers; 2.8% of youth aged 15-24 (3.3% in girls; 2.4% in boys) tested HIV-positive. The centers successfully targeted vulnerable youth: boys tested at the youth centers were 6 times more likely to be HIV-positive than the national average, while girls were twice as likely.

In FY 2010, "moonlight" HCT and STI services (provided on weekend evenings) will be expanded to hotspots in Kigali city and around an increased number of youth centers to further improve MARPs targeting. PSI will also continue to work through youth cooperatives (where PEs are trained) and Rwandan Partner Organizations so that more vulnerable youth and traditionally hard-to-reach groups, such as motoboys and domestic workers, will be encouraged to seek VCT, STI and FP counseling and services.

FY 2010 CT efforts will continue to emphasize the importance of couples testing. Youth-friendly centers are proving to be an effective entry point for couples testing and counseling, which is a critical HIV prevention intervention in Rwanda, given that new HIV infections are occurring primarily among married, discordant couples. On average in 2007 and 2008, 23% of all clients at youth centers came as couples,

90% of whom were not yet married. Among these young couples seeking VCT at youth centers, ~6% of married couples, and ~4.5% of not yet married couples were serodiscordant, compared to 2.2% of cohabiting couples in the general population who were discordant (DHS 2005). In FY 2010, a couples' VCT pamphlet developed in FY 2008 and produced in FY 2009 will be distributed to young couples (e.g. at universities and through faith based organizations) to promote couples' HIV testing. Young couples will be reached through anti-AIDS clubs at most universities and colleges in Rwanda, which were established following the Inter-Universities Conference of the FY 2008 anti-cross generational sex campaign.

While accurate STI statistics are not available in Rwanda, being HIV-positive is clearly associated with prior history of STIs among the general population (DHS 2005) and among youth seeking VCT services at youth-friendly centers. The Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics (TRAC Plus) is developing revised national guidelines for management of STIs in FY 2009 and FY 2010 activities would collaborate with TRAC Plus and the MOH in the implementation of these guidelines. STI services (including screening, diagnosis, and treatment) and FP counseling will be provided as part of VCT services, thereby ensuring that youth who access the centers receive a comprehensive package of services. An STI/HIV integration model will be developed that screens high risk youth with STIs for HIV, and those with HIV for STIs (including male clients of CSWs and their sexual partners). We will also promote "repeat testing" for high-risk groups and develop innovative approaches to provide condoms and STI services to high risk youth and ensure linkages of these services to care and treatment.

Condoms will be offered liberally to all CT clients to ensure that people who test positive can protect themselves and their partners as they seek follow-on referral services. By promoting condoms for dual protection to all clients, regardless of HIV status, the activity will avoid stigmatizing people who test positive. HIV-positive clients will be referred to nearby health centers for care and treatment and prevention for positives programs (condom distribution and promotion, promotion of FP, partner disclosure, etc). Referrals will be verified by the VCT team, through regular visits to health centers to pick up counter-referral slips. HIV negative young men will be referred to the health system to access MC services, as soon as they are available through the health system, and all CT counseling will stress the ongoing importance of safer sexual behaviors, including correct and consistent condom use. Screening tools for history of sexual abuse and history of concurrent partnerships piloted in FY 2009 will be scaled up to reach individuals vulnerable to HIV.

The existing FY 2008 and FY 2009 brand for youth and MARPs friendly service (YMFS) providers (Dushishoze) will extend from the youth-friendly centers to public providers who will be trained and receive support for providing youth- and MARPs-friendly follow-on services. In FY 2010, PSI will pilot this approach with 10 public and private providers working in areas surrounding each of 4 fixed-site youth-

and MARPs-friendly centers. Once certified, providers will receive branded signage and uniforms, as well as educational materials and assistance in refurbishing their offices to make them more youth- and MARP-friendly. The youth centers will host weekly youth- and MARPs-friendly clinics, with providers serving the youth center in rotation. Providers will have an opportunity to build relationships with Dushishoze Center staff, and bring services to youth who may not be empowered to seek services on their own.

Supportive supervision and QA: Regular, joint supervision visits by will be carried out by district health authorities and technical PSI staff (VCT Specialist, VCT QA Manager, and/or M&E Manager) to provide support to VCT counselors and ensure high quality counseling and data collection. Client intake and satisfaction forms will be entered by PDA at site level and analyzed regularly to inform program activities. Dr. D providers will receive regular continuing education, and be monitored and supported through monthly visits to Dr. D clinics to reinforce and refresh skills and to ensure compliance with quality standards. Random mystery client visits to providers will confidentially assess provider quality.

Description of targets: • Service outlets providing VCT and STI services according to national and international standards: 6. This target includes 4 fixed sites and 2 mobile sites for moonlight VCT. The 2 mobile sites will serve the 4 fixed sites and 4 additional fixed sites funded under other funding sources, increasing access in 8 total districts. • Individuals trained in counseling and testing for HIV and STIs according to national and international standards: 120. This target assumes training of the local counselor team (~10) and 5 PSI VCT staff at each site, and 10 Dr. D providers in areas surrounding the 4 youth centers. • Individuals who received VCT and received their test results: 30,800. This target maintains FY 2009 targets at or around fixed sites (6,500 per youth center) plus 100 clients per month per additional youth center through moonlight VCT.

New activities and plans for transition: A team of ~10 local district-level VCT counselors will be established in each of 6 districts to meet counseling needs and promote sustainability of services. ~10 public providers from public and private clinics in each of 4 youth center districts will provide YMFS in their own clinics, and youth centers will host weekly provider clinics, with providers serving the youth center in rotation. This approach will maximize sustainability of YMFS services, giving providers an opportunity to build relationships with Dushishoze Center staff, and bringing services to youth who may not be empowered to seek them on their own. This activity will also support the development of the Rwandan Social Marketing institution. Finger prick VCT will significantly reduce the cost and complexity of outreach VCT services. Fixed CT

site management will increasingly be managed by sub-grant through Rwandan Partner Organizations, including the National Youth Council.

Capacity building activities: Members of the VCT team (counselors, lab techs and a counselor supervisor) will be trained in a variety of topics related to VCT using, where possible, GOR curricula, including, but not limited to, general counseling, couples' counseling, stress management, FP, STIs, VCT supervision techniques, PDA data entry and high-quality data collection techniques. Public youth-friendly Providers will be trained in delivery of YMFS, STI treatment and FP counseling and product use. As with other training activities, participative, adult learning techniques will be used, as well as ongoing support and supervision. In addition, PSI will provide technical input to TRAC Plus and CNLS to the BSS and data triangulation exercises, as required.

FY 2010 AB activities will continue to strengthen activities developed in FY 2009, including evidence- based training and interpersonal communication (IPC) interventions to improve life skills and knowledge about HIV and STI prevention among youth and young MARPs. Youth and young MARPs will be reached with AB messages by multiple, reinforcing and evidence-based messages delivered through IEC materials, the ABAJENE! radio show, listening clubs and a youth newspaper, as well as through the national CNLS Hotline, a free telephone service where trained staff provide HIV prevention information to callers, 90% of whom are under the age of 30 and not yet married.

FY 2010 PE trainings will continue to primarily target out-of-school youth. FY 2008 PSI program data indicated that, among youth who sought VCT services, those who never went to school or only attained primary school were more likely to be HIV+. In addition, the out-of-school youth selected as peer educators (PEs) from youth cooperatives were less likely to have comprehensive HIV knowledge (UNGASS indicator) than their age equivalents from the general population (DHS 2005). These results underline the importance of focusing on out-of-school youth, and show that the FY 2008 and FY 2009 approaches reached out-of-school youth PEs who lacked sufficient knowledge about HIV prevention before training.

FY 2010 plans will support AB messages by expanding comprehensive Youth and MARPs Friendly

Services (YMFS) in and around an increased number of youth- and MARPs-friendly "Dushishoze" ("think about it" in the local language) centers. Efforts will continue to preferentially increase access to youth center services for vulnerable young girls, as FY 2008 attendance registers indicated that girls comprise only 31% of youth center visitors. In addition to ensuring gender balance in youth center staff members, a girl-friendly youth center promotional pamphlet developed in FY 2009 will be distributed, and girl-friendly interventions such as aerobics, sewing and girls-only sports competitions, will be used as an entry point to empower girls and disseminate AB messages.

FY 2008 PSI program data reinforced the continued need for fidelity messaging for youth and young couples: among youth who sought VCT services at Dushishoze Centers, those who had concurrent partnerships (CP) were twice as likely to be HIV+. A couples' VCT pamphlet developed in FY 2008 and produced in FY 2009 will be distributed to young couples (e.g. at universities and through faith based organizations) to promote couples' HIV testing. Trained PEs will facilitate ABAJENE! clubs for young couples.

Supportive supervision and QA: Regular, joint supervision visits by will be carried out by PSI and youth center partners to out-of-school PEs at each anti-AIDS clubs in youth cooperatives, using standardized supervision tools. Bi-monthly meetings for PEs will be held at youth centers, to present activity reports, share successes and challenges, receive refresher training, and make work plans for the next 2 months. Message guidelines developed in FY 2009 by PSI's M&E Department will be used as tools to strengthen PE's capacity to carry out IPC sessions. In addition, film and comic book animation guides will guide PEs to conduct small group discussions.

Description of targets: 1. #of individuals reached through CNLS hotline with AB messages: 40,000. This target assumes AB messages will reach an average of 3,333 callers per month.

2. # of target population reached with individual and or small scale level HIV prevention interventions that are primarily focused on AB: 20,000.

3. # of individuals trained to promote HIV prevention programs through AB: 800. This target assumes that 8 groups of 25 out-of-school PEs at each fixed site, drawn from youth cooperatives or youth MARPs associations at district level, will be trained on peer education/life skills.

New activities and plans for transition: If MC services for the general population are available in FY 2010, new activities will raise awareness

among young men about MC services will be developed and scaled up. Work planning, budgeting, reporting and day-to-day management of implementation will be carried out in close collaboration with youth center partners to increase local ownership and management for sustainability. Discussions to "second" youth center partner staff (e.g. National Youth Council) to function as center coordinators and health educators was initiated in FY 2009. In FY 2010 this approach is expected to be formalized at all 4 fixed site youth centers with sub-grants provided to the local partners to manage day-to-day running activities. This activity will also contribute to the development of the Rwandan Social Marketing institution.

Capacity building activities: TOT and PE training activities are conducted jointly by PSI and youth center partners using standardized, evidence-based PE and PCC curricula as well as pre-post tests to evaluate the gains in knowledge (including comprehensive HIV knowledge) as a measure of the impact of trainings. Refresher trainings of PEs will take place at bi-monthly meetings.

In FY 2010, OP messages will focus on the identified factors influencing correct and consistent condom use, including condom stigma, relationship trust, and knowledge of how to use a condom correctly. Delivered by comprehensive youth- and young MARPs-friendly services in and around 8 "Dushishoze" ("Think about it" in the local language) centers, these messages will target most-at-risk out-of-school youth, youth living in urban areas and high HIV transmission zones, youth frequenting hotspots, OVC above 15, youth and MARPs who test positive at CT sites, and young sexually active couples. PSI and Rwandan Partner Organizations will implement "moonlight" road show "edutainment" interventions at hotspots to promote correct and consistent condom use, VCT and the CNLS Hotline in communities around youth- and MARPs-friendly centers on weekend evenings, one weekend per month per center. Hotspots will include restaurants, bars and cabarets where young MARPs frequent. This strategy will provide an integrated youth and young MARPs prevention program. All condom outreach activities will employ a condom demonstration kit produced in FY09, which provides a flip chart of demonstration instructions and condom activities, consumer leaflets, and demonstration materials.

Different studies have demonstrated how a comprehensive package of interventions to reduce risk behaviors for an individually focused, state-of-the-art project in key populations can substantially increase health-seeking behaviors and reduce HIV incidence in CSWs. Many commercial sex workers do not have the power or self efficacy to demand condom use from their clients. To do so may bring a variety of risks,

including losing the client (and, therefore, the income) and being physically or sexually assaulted. The potential for repeated HIV exposure during sex work makes HIV prevention among this population especially important for HIV programming. Although criminalization and stigma make it difficult, all CSW must have access to effective, comprehensive HIV prevention, including HIV/AIDS education, condom negotiation skills building, peer education/outreach, and sexual/reproductive health education and services. Structural interventions, such as "100% condom use" with clients, should be encouraged and implemented in ways that will not hinder access of programs to CSW.

A model of night-time services called "moonlight VCT" with appropriate mix of interventions will be developed for CSWs. The program will employ a mix of condom promotion, one-on-one risk reduction counseling, periodic screenings and treatment for sexually transmitted and HIV testing. A network of CSWs will be generated using peer recruitment in hotspot areas. Mobile/User-friendly discreet services will be opened in those areas that are identified as "hotspots" such as hotels, bars, nightclubs, and certain neighborhoods.

To support OP communications efforts, PSI will work with Rwandan Partner Organizations and existing private networks to increase condom access and availability for youth and young MARPs, particularly in areas around hot spots and at night. This includes retail outlet creation efforts, and condom distribution at youth centers and through mobile outreach services.

FY 2010 PE trainings will continue to primarily target out-of-school youth. FY 2008 PSI program data indicated that, among youth who sought VCT services, those who never went to school or only attained primary school were more likely to be HIV+. In addition, the out-of-school youth selected as peer educators (PEs) from youth cooperatives were less likely to have comprehensive HIV knowledge (UNGASS indicator) than their age equivalents from the general population (DHS 2005). These results underline the importance of focusing on out-of-school youth, and show that the FY 2008 approach reached out-of-school youth PEs who lacked sufficient knowledge about HIV prevention before training.

Supportive supervision and QA: Regular, joint supervision visits by will be carried out by PSI and youth center partners to out-of-school PEs at each anti-AIDS clubs in youth cooperatives, using standardized supervision tools. Bi-monthly meetings for PEs will be held at youth centers, to present activity reports, share successes and challenges, receive refresher training, and make work plans for the next 2 months.

Description of targets: 1. # of targeted condom service outlets created and supported: 400 (50 per 4 fully supported fixed site and per 4 sites receiving outreach services); 2. # of individuals reached through CNLS hotline with OP

messages: 40,000. This target assumes OP messages will reach an average of 3,333 callers per month; 3. # of target population reached with individual and or small scale level HIV prevention interventions that are primarily focused on OP: 20,000; and 4. # of individuals trained to promote HIV prevention programs through OP: 400 This target assumes that 4 groups of 25 out-of-school peer educators at each fixed site, drawn from youth cooperatives or youth MARPs associations at district level, will be trained to use the condom demonstration kit.

New activities and plans for transition: Work planning, budgeting, reporting and day-to-day management of implementation will be carried out in close collaboration with youth center partners to increase local ownership and management for sustainability. Discussions to "second" youth center partner staff (e.g. National Youth Council) to function as center coordinators and health educators was initiated in FY 2009. In FY 2010 this approach is expected to be formalized at all 4 fixed site youth centers with sub-grants provided to the local partners to manage day-to-day running activities. This activity will also contribute to the development of the Rwandan Social Marketing institution.

Capacity building activities: TOT and PE training activities are conducted jointly by PSI and youth center partners using standardized, evidence-based PE and PCC curricula as well as pre-post tests to evaluate the impact of trainings. Refresher trainings of PEs will take place at bi-monthly meetings.