In January 2008, PEPFAR Rwanda awarded a consortium of partners, with Population Services International (PSI) as the prime, a 5-year cooperative agreement to implement integrated behavior change and social marketing (BCSM) activities for HIV. The cooperative agreement also covers other significant health issues including malaria, family planning and maternal & child health. The main objectives of the 5 year agreement are to develop and manage a cost-effective marketing, sales and distribution network that improves access to branded products related to HIV/AIDS, malaria, reproductive health and child survival; to develop and implement health communication activities that enhance behavior and promote health seeking behaviors among Rwandans; to develop and enhance services and referrals, particularly mobile HIV counseling and testing, to most at risk populations (MARPs); to improve the management and technical capacity of Rwandan institution(s) to manage and implement similar programs in the future through a transfer of technical skills and capacity building, and to increase the availability of data and evidence available to inform programming in key health areas.

Social marketing and mass media communications activities under the BCSM project operate at national scale, while intensive community mobilization, mobile service outreach, and interpersonal communications operate in 15 of 22 PEPFAR-supported Districts. Key target populations and messages include youth 10-18 (for delayed sexual debut), high risk sexually active youth 15-29 (for secondary abstinence, partner reduction, correct and consistent condom use, and CT), married and cohabitating couples (for fidelity, correct and consistent condom use, and couples counseling and testing (CT), and MARPs (correct and consistent condom use, partner reduction and couples CT) including female sex workers, MSM, and people living with HIV/AIDS.

This activity contributes to Rwanda's Partnership Framework objective of halving HIV incidence in the general population by 2012 by reducing risky sexual behavior among the General Population, MARPs (including PLWHA), Discordant Couples, and Youth 15-24 through targeted evidence-based comprehensive prevention interventions including social marketing of condoms, behavior change communications (abstinence, fidelity and partner reduction, correct and consistent condom use, couples CT, and general life skills and parent-child communications for youth), and mobile outreach CT (including STI diagnosis and treatment referrals and FP/HIV integration).

Transition activities include technical and institutional capacity building for a range of Rwandan Partner Organizations to design, manage, and implement PEPFAR-funded activities over time. This includes providing institutional, technical and sub grant support for 11 local community based organizations to lead community mobilization and interpersonal communications, technical support for the sustained

development of the national Health Communications Center to lead multi-level, multi-media campaign development, technical capacity building for local CT providers to implement MARP-friendly approaches for outreach CT, integration of and training in social marketing research methodologies across research and technical partner institutions, and the development of a Rwandan Social Marketing Institution.

PLWHA-targeted interventions include a crosscutting water activity to increase knowledge and use of POU water treatment, hygiene, and safe water storage through health facilities providing VCT and ART, through faith-based RPO targeting PLWHA, and through associations of PLWHA through RRP+, the national network of PLWHA.

Cost efficiency will improve over the life of the project with condom pricing and cost recovery adjustments according to increased consumer ability and willingness to pay; continued development of a more efficient demand-based distribution system of strengthening existing commercial, institutional and community- based distribution networks; transition of direct implementation of community mobilization and interpersonal communications by PSI to more efficient community-based organizations; and coordinated mobile CT service delivery through local public providers using more cost effective CT approaches (such as finger prick).

PSI will conduct joint monitoring and evaluation activities with public, private and community partners, including routine GIS mapping of product distribution, routine analysis of CT client intake and satisfaction forms, rigorous pre- and post-test analysis of training activities, mystery client supervision of CT service delivery, and behavioral tracking surveys which will measure the impact of levels of exposure to communications activities on factors influencing key program indicators.

Research has shown that 90% of PLWHA are affected by diarrhea, which in turn results in significant morbidity and mortality. Hand washing, sanitation, water disinfection and safe storage have been proven to significantly reduce diarrhea rates. According to the 2005 Rwanda Demographic and Health Survey, only one-third of surveyed households had access to a protected source of drinking water. A significant cause of exposure to diarrheal disease-causing pathogens is inadequate access to safe water. Only 40% of the Rwandan rural population and 60% of the urban population have access to safe water. The objectives of the point of use (POU) activities are to ensure consistent use of POU water treatment products by PLWHA; to increase access to POU water treatment products by PLWHA; and to improve knowledge of POU and its effectiveness, hygiene, and safe water storage.

In FY 2009, 200 service outlets, serving 5,000 PLWHA were provided with HIV-related palliative care. Outlets included health centers and PLWHA--managed income generating cooperatives. Messages were delivered through peer education, IPC and door to door sessions conducted by CHWs and PLWHA association members. A total of 854 people were trained to provide HIV-related palliative care, including 462 public providers (22 district personnel and two providers each from 220 health facilities providing VCT/ART) and 392 PLWHA associations and community volunteers (12 RPO TOT, 80 PLWHA association members and 300 community volunteers).

POU programming through PSI includes distribution of two products, including Sûr'Eau, a locally produced POU liquid solution which recovers the cost of production with every bottle sold, and Pur, a targeted, internationally-produced flocculent disinfectant powder sachet which is particularly effective in treating turbid water and water retrieved from surface sources. Sûr'Eau was launched in FY07 with USAID funding for distribution through community health workers, the community health insurance program, public health facilities, Rwandan Partner Organizations (RPO), and commercial distribution networks. Pur will be launched with international funds in 2010 to target communities with particularly turbid surface water, leveraging existing commercial networks and RPOs, particularly those targeting PLWHA. This activity complements PSI's child survival activities around preventing diarrheal disease in children under five years

In FY 2010 PSI will intensify the POU program targeting PLWHA to increase knowledge of POU, hygiene

and safe water storage through health facilities providing VCT and ART, through faith-based RPO targeting PLWHA, and through associations of PLWHA through RRP+, the national network of PLWHA. Activities will include intensified training of trainers, peer education through trained RPO members, community-based distribution as an income generating activity for associations of PLWHA, community events, and mass media communications, which will help avoid stigmatizing the POU products for the general population. Water signage will be expanded for placement at water points in PEPFAR districts, so that safe water messages are targeted at points where communities gather. The activity will expand product availability at health facilities, ensuring access for VCT clients, regardless of HIV status. Additional starter stock will be provided to associations to expand distribution to PLWHA associations trained by partners supported by PSI. PSI will continue to integrate safe water, POU and hygiene messages into existing VCT, care and support materials in collaboration with GOR, USG clinical partners and community partners, to ensure consistent delivery of product and messages to people who present for testing.

PSI supports regular joint supervision visits between the PSI POU and M&E teams and local authorities who oversee technical quality of program implementation by RPOs. RPOs will also receive institutional support through regular financial and institutional mini-audits and ongoing mentoring by the BCSM capacity building partners of PSI, JHU-CCP and CHF. Training impact will be monitored by improved pre- and post-test QA materials and analysis.

In line with the Partnership Framework objectives, PSI will intensify activities with a particular emphasis on strengthening associations and RPOs targeting PLWHA in cholera-prone districts, and communities sourcing turbid surface water. Intensified sub-granting to local partner organizations, and all associated supportive supervision and capacity building activities, will strengthen the capacity of RPOs to solicit, lead and report on direct funding grants in the future. Community-based distribution of the locally produced product will provide a sustainable income generating opportunity for a locally produced cost recovery product which does not require a donor subsidy. RPOs and associations of PLWHA will be strengthened through training of trainers, institutional assessments and capacity building programs, ongoing mentoring and supportive supervision by the BCSM capacity building team of PSI, JHU-CCP and CHF. This, and all BCSM activities, will contribute to the development of a Rwandan Social Marketing Institution in a sustainable manner.

In collaboration with clinical partners, HCT services outside the clinics will improve the referral linkage for

care and treatment services. The clinics follow-up HIV-positive clients over a long period of time, and are well-place to focus on appropriate counseling for the prevention for positive program. Referrals are a particular challenge for transit camp inhabitants, some of whom come from other regions of the country.

Provision of HCT services will be complemented by interpersonal communication (IPC) to increase demand for HCT among MARPs, targeted condom social marketing activities and integrated BCC campaigns to address factors increasing risk for HIV transmission, such as concurrent partners, gender based violence (GBV), and alcohol abuse.

Supportive supervision and QA: Regular, joint supervision visits by will be carried out by district health authorities and technical PSI staff (VCT Specialist, HCT QA Manager, and/or M&E Manager) to provide support to VCT counselors and ensure high quality counseling and data collection.

New activities and plans for transition: New activities in CY 2010 will center around scaling up approaches to reach MSM. A roster of local VCT counselors meets the counseling needs, promoting sustainability of services. Sub-granting to a local partner to provide VCT services at Gikondo transit camp is being explored in FY 2009. This component will also contribute to the strengthening of a range of Rwandan Partner Organizations, including local providers who can implement outreach HCT, community based organizations which can mobilize communities and improve targeting, and the development of a Rwandan Social Marketing Institution. It will also facilitate the integration of social marketing research methodologies into the national research agenda and teaching curricula.

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. As with other training activities, participative, adult learning techniques will be used, as well as ongoing support and supervision.

Working through Rwandan Partner Organizations (RPOs) in 15 districts, FY 2010 AB activities will extend the AB messages developed for the WITEGEREZA and SINIGURISHA campaigns, since shifting social

norms and attitudes requires a long term approach. The WITEGEREZA or "Don't Wait" Social Support Campaign was designed in FY 2006 by the CNLS and Ministry of Health, with financial support from USAID, KfW, and DfID and technical support from PSI to address the lack of social support for children, which can put them at risk for HIV transmission. The campaign challenged the social norms that hinder parents in their efforts to help young boys and girls to manage their sexuality. Using a traditional Rwandan proverb, "Igiti kigororwa kikiri gito," or, "A tree is only straightened while it is young" the campaign was designed to remind parents that reaching young people early gives us the best chance of shaping positive sexual attitudes and behaviors later in life.

The SINIGURISHA anti-cross generational sex (CGS) campaign was designed in FY 2007 by CNLS and launched by the Ministry of Youth in FY 2008 to empower youth to recognize their right to refuse sugar daddies and sugar mommies, resist pressure from their peers to partake in CGS, and encourage self esteem and solidarity among youth. Evidence from a campaign evaluation planned for late FY 2009 will inform the direction and content of future communication interventions, with the long term goal of changing society's view of the practice and to promote a sense of responsibility among youth and adults to take public action against cross generational practices that put youth at risk.

In response to evidence that new HIV infections are occurring primarily among married couples in Rwanda, PSI will continue to work within the national BCC strategy to promote fidelity and discourage concurrent relationships. Since CGS is a form of concurrent partnership (CP), the campaign messages will lead nicely into a CP mass media campaign on this very issue which will also be supported from HVOP funds. In FY 2010, CP messages will be developed in collaboration with CNLS and approved by the National Committee for Behavior Change Communication (CNCCC). AB messaging is expected to focus on fidelity/partner reduction.

By strengthening the capacity of RPOs to deliver campaign messages through interpersonal communication (IPC) activities at the community level, RPOs are complementing mass media channels and extending campaign reach. A variety of IPC approaches are used to address and overcome barriers to healthy AB behaviors among target groups (out-of-school youth, couples, opinion leaders such as teachers, religious leaders, local authorities), including peer education and life skills training, peer outreach, community dialogues, family days, sports tournaments, as well as dance, theatre and cultural events.

Supportive supervision and QA include routine joint supervision of RPO field implementation, using standardized supervision tools; will inform program design and implementation. Pre-post tests will assess training quality and performance. Message guidelines developed in FY 2009 by PSI's M&E Department will be used as tools to strengthen peer educators' capacity to carry out IPC sessions.

Description of targets: (1) # of target population reached with individual and or small scale level HIV prevention interventions that are primarily focused on AB: 55,000 and (2) # of individuals trained to promote HIV prevention programs through AB: 150. This target assumes that 6 groups of 25 out-of- school peer educators, selected by RPOs at district level, will be trained on peer education/life skills.

New activities and plans for transition in FY 2010 include intensification of existing activities, with a focus on transition to a range of RPOs, including technical and institutional capacity building and sub-granting for indigenous community based organizations who will lead community mobilization and IPC, support for the ongoing development of the national Health Communications Center, and the development of the Rwandan Social Marketing Institution.

In terms of capacity building, BCSM will continue institutional strengthening for RPOs (including the Rwandan Social Marketing Institution) through ongoing institutional assessments and follow-on capacity building in the form of trainings, routine audits and follow-on checklists, mentoring exchanges, and ongoing feedback. International technical advisors funded by BCSM will be shifted out of line management roles and "twinned" with senior Rwandan staff to design, lead and implement program activities over time. This component will also support the ongoing strengthening of the national Health Communications Center, facilitate integration of social marketing research methodologies into the national research agenda and teaching curricula, and contribute to the development of a Rwandan Social Marketing institution.

PSI HVOP activities address factors influencing condom use, high-risk sexually active youth 15-29, urban men with discretionary income, MARPs, PLWHA and couples. Activities address condom stigma, lack of condom knowledge, and social norms, and barriers to condom communications. Other strategies include hot-spot activities to increase condom access at night through a test of targeted condom vending machines, behavior change communications targeting high-risk workers such as bar maids, domestic workers and commercial sex workers, and partnerships with Rwandan partner organizations (RPO) to distribute and use new condom demonstration kits to improve condom knowledge and self-efficacy. All condom communications integrate gender considerations to empower Rwandan women to access and negotiate condom use. PSI will also co-design and implement, with GOR, a multiple concurrent partnerships campaign, to promote condom use among couples.

PSI invests in developing a cost efficient demand-based condom distribution system by strengthening commercial distribution networks to reduce dependence upon PSI as a direct source of condoms. FY 2010 sales and distribution activities will strengthen existing commercial networks by engaging new wholesalers who can serve the national commercial distribution networks. PSI will support onsite and radio wholesaler promotions, promotional support to "prime" the distribution network, and "blitzing" retail outlet creation where retail outlet and quality of coverage fall below minimum standards according to routine distribution mapping audits. With a total marketing approach, social marketing will allow public and community distribution, to ensure Rwandans access at all levels of the socioeconomic spectrum through community-based distribution of condom demonstration kits, and training of trainers for RPOs to provide condom demonstrations. PSI will work to strengthen active distribution of public sector condoms, to ensure that all health facilities and community based distribution agents, particularly those offering treatment to PLWHAs, have condoms and are distributing them to clients seeking care. PSI also supports district-led advocacy events. Four districts will receive technical and financial support for advocacy events to engage the private sector to expand condom access and availability.

Using the GEM model, PSI will conduct in-depth gender norms qualitative analysis that will provide guidance for improving programming addressing gender and male norms. PSI will continue support for the development and interpretation of the planned rounds of the Rwandan Behavior Surveillance Study (BSS), focusing on mapping commercial sex workers and their clients and identifying the factors influencing risk behavior among BSS target populations. Supportive supervision and QA will be conducted through routine GIS distribution mapping to inform condom social marketing activities, directing retail outlet creation and product promotion to areas underserved by the existing commercial distribution networks. Pre- and post-tests will assess training quality and performance. Routine joint supervision of RPO field implementation with local authorities will inform program design and implementation.

The targets: • Condom service outlets created: 8,000 (including 3,000 new outlets and 5,000, which receive POS and IPC support in regional retail outlet creation efforts). • Target population reached with individual and or small-scale level HVOP HIV prevention interventions: 80,000 reached through bar promotions by temporary product promoters, through trained RPOs, and by PSI staff. • Individuals trained to promote HIV prevention programs through OP: 4,200. Including 200 retail representatives, and 4,000 representatives of RPO's.

New FY 2010 transition activities include intensifying activities, with a focus on transitioning to a range of RPOs, including technical and institutional capacity building and sub-granting for indigenous community

based organizations who will lead community mobilization and interpersonal communications, support for the ongoing development of the national Health Communications Center, and the development of the Rwandan social marketing institution (RSMI). PSI will continue efforts to strengthen existing commercial distribution networks to reduce dependence at all levels upon a donor-funded distributor as the direct supplier of condoms. Routine market and consumer analyses will assess pricing according to consumer willingness and ability to pay, and retailer willingness to stock, so price increases reduce the product subsidy required over time.

PSI will continue building institutional capacity of RPOs, including the RSMI, through institutional assessments and follow-on capacity building in the form of trainings, routine audits and follow-on checklists, mentoring exchanges, and ongoing feedback. International technical advisors funded by PSI will be shifted from line management roles and "twinned" with senior Rwandan staff to design, lead, and implement program activities. PSI will conduct joint monitoring and evaluation activities with private, public and community partners, including routine GIS mapping of product distribution, pre- and post-test analysis of training activities, and behavioral tracking surveys to measure impact levels of exposure to communication activities on factors influencing key program indicators.