BACKGROUND AND OBJECTIVES:

In 2009, CDC funded FHI to launch a project with TRAC Plus that aims to make the VCT encounter more effective for primary prevention. By: (i) increasing access to and uptake of VCT by highest risk HIV- negative non-testers, (ii) improving the identification of highest risk HIV-negative VCT clients, and (iii) providing these clients with intensified and personalized intervention counseling, the goal of this project is to reduce HIV transmission in Rwanda.

Over the past 7 years, testing and counseling (TC) services have been radically scaled up as part of the Rwanda's efforts to expand access to care and treatment. However, the VCT encounter has not fundamentally changed since its introduction. It remains principally intended to serve purposes of care and treatment (i.e., to detect and refer HIV-positive persons to treatment services) rather than to serve a more holistic purpose of prevention and referral to care. Structured around national guidelines, the current counseling session within VCT is formulaic rather individualized. While there is tremendous uptake of VCT in Rwanda, little is known about who the clients are, their motivations for testing, or their individual risk behaviors.

With the wide availability of VCT services now in Rwanda, there is an important but unexploited prevention opportunity. Inspired by theory-based counseling approaches with demonstrated efficacy in other contexts, FHI will assist TRAC Plus to develop and introduce intensive intervention counseling to HIV-negative clients with high risk behaviors who come to VCT.

With the aim of reaching more high-risk individuals who do not use VCT, FHI will also work with the CNLS, TRAC Plus and select health facilities to conduct VCT outreach.

LINKAGES TO THE PARTNERSHIP FRAMEWORK:

This project contributes to VCT and prevention objectives outlined in the Partnership Framework. Importantly, in making better use of now widely available VCT for purposes of primary prevention, the project promises to have a long-term positive impact in new infections averted. As the single most important strategy for reducing costs for programming and to the health system, preventing new HIV infections is an essential aspect of transition strategies aimed at reducing Rwanda's dependency on external aid to confront the HIV epidemic.

COVERAGE AND TARGET POPULATIONS:

The target population for this project is HIV-negative VCT clients with high risk behaviors. For non- testers, the project will extend services out to them through VCT outreach campaigns. Under COP10, the geographic scope will remain confined to select areas of Kigali with the intent of developing the guidelines and the tools for later expansion by TRAC Plus to other service sites throughout the country.

COST-EFFICIENCIES:

FY 2009 is the first year of project implementation. The major expenses for the activity will be consulting services from highly skilled and experienced psychiatrists who have pioneered successful approaches in

other contexts. Once the guidelines and tools are developed and integrated into TRAC Plus's training and support activities, the costs of implementing the project will be significantly reduced and eventually eliminated as the approach is adopted as part of standard practice.

M&E:

Per the proposal and plan submitted to CDC, progress in meeting the project's specific objectives and purpose will be assessed through quality assurance (QA), outcome indicators and project evaluation.

QA: Periodic reviews of client files will be conducted to test the sensitivity and specificity of the referral system by examining whether those identified by information in the file as at high risk actually received the appropriate referrals. Counseling supervisors will periodically observe VCT and intervention counseling sessions to evaluate counselor performance and provide supportive supervision. Using the data from the monitoring system, the rates of repeat testing in HIV-negative high risk clients, partner disclosure and sexual risk behaviors will be compared across various counselors to determine if there are issues to be mediated in the performance of specific counselors. In addition, periodic data quality audits will be conducted.

Outcome indicators: In consultation with TRAC Plus, FHI will finalize outcome indicators for this project. An illustrative list of these indicators follows:

• Increase VCT-seeking in persons at high risk 1. Number of VCT clients (high risk and others) who report having heard one of the outreach messages 2. Proportion of VCT clients testing HIV-positive • B. Empirically-identified high risk clients in VCT 1. Number and proportion of VCT clients (HIV-positive and negative) who are identified during VCT counseling as at high risk 2. Number and type of high risk clients referred to intensified intervention counseling who complete the referral • C. High risk clients receiving intensive intervention counseling 1. 5. Where interventions consist of several points of contact, proportion of high risk clients that complete each stage of the intervention 2. 6. Proportion and type of high risk clients having disclosed their status and to whom 3. 7. Percentage and type of high risk clients who self-disclosed or who disclosed with facilitation

Evaluation: As a proxy for failure to achieve change in risky-behaviors, TRAC Plus and FHI will review client records to identify clients who have come back to VCT after receiving intensified intervention

counseling services. Mid-term and end-of-project evaluations are proposed with subsets of randomly selected clients who prospectively agree to be contacted after a short (e.g. 2-month) period. During these follow-up interviews with clients, we will concentrate on 3 domains: • Knowledge and skills learned in counseling sessions, measured by administering adapted scales related to partner communication and problem solving, condom negotiation, and sexual communication. • Current self-reported risk behaviors. Since evaluation participants by definition will have been identified during counseling as at high risk, they will be re-assessed at follow-up to determine if they still satisfy the high risk criteria (as identified in the risk score algorithm). The interviews will also refer back to the risk reduction plans that were made in counseling sessions to examine obstacles and facilitators to achieving the plan. • Client satisfaction with counseling services received.

The key Testing and Counseling (TC) activities that will be supported during this period are described below.

IDENTIFYING MOST-AT-RISK VCT CLIENTS FOR INTENSIFIED PREVENTION COUNSELING:

Often "most-at-risk persons" are identified by membership in particular social group (e.g., armed forces,

sex workers, truckers) rather than by their personal behaviors. This means of identifying who needs intensified counseling is neither sensitive nor specific enough to correctly capture all most-at-risk persons (MARPs). Under this project, TRAC Plus and FHI will develop a risk score algorithm within VCT to empirically identify high risk VCT clients. The intent is thus to add an objective, and potentially more sensitive and specific, dimension to the correct identification of most-at-risk VCT clients, thus going beyond generalizations based on social characteristics which can also be stigmatizing. Once identified, high risk negative clients will receive personalized risk reduction counseling.

INTENSIFIED HIV COUNSELING FOR HIGH RISK HIV-NEGATIVE CLIENTS:

In the health facilities implementing this intervention, HIV-positive clients will be referred directly to care and treatment services, wherein they will receive the standard package of care and follow-up, including comprehensive positive prevention services (STI screening, risk reduction education, counseling on reproductive choices and contraception, support for disclosure, and couples VCT).

In FY 2010, FHI will implement interventions where high risk HIV-negative clients will be systematically screened for STI and referred for individualized intervention counseling. To avoid or minimize possible stigmatization of individuals referred for special, intervention counseling, these sessions will be offered within the already-existing generalized Social Work Services at participating health facilities. Modeled on a successful program targeting high-risk repeat HIV testers in North America, TRAC Plus and FHI will introduce a structured counseling session that facilitates client self-awareness of their sexual decision-making. The counseling session begins by prompting the client to describe in detail her/his most recent act of risky sexual intercourse and to recall their thoughts and feelings as experienced during the state of heightened sexual arousal, referred to as "on-line" thinking. The purpose of this provocation is to enable the client to clearly recognize, in an "off-line" counseling session, her/his altered risk perception during this aroused state. The client and counselor then critically examine the "self-justifications" for the risk-taking and emphasize how the client can incorporate new self-knowledge to adopt safer sex practices in future encounters.

For those individuals who are identified as at-risk because their partners are known or suspected to be HIV- and/or STI-infected, conventional, individually-focused risk reduction education needs to be supplemented with counseling that addresses relational dimensions of high risk behaviors and situations. To address these specific needs, TRAC Plus and FHI will introduce relationship-based counseling that, beyond condom acquisition and skills, emphasizes self-efficacy, negotiation and personal empowerment within (or outside) the risky relationship.

This counseling approach draws upon a number of studies wherein clients, mainly women, are provided

with negotiation and refusal skills (e.g., pre-foreplay decision-making, and where and when to ask for safer sex), learn about alternative risk reduction strategies (e.g., engaging in "outercourse"), and encouraged to reflect on their relationship and communication about sex within it. In order for individuals to negotiate effectively with their partners, they need to be comfortable talking about sex, yet also to feel agency and self-efficacy as relates to their own sexual pleasure and protection.

For both self-justification and relationship-based counseling sessions, the counselor will elicit risk reduction intention and help the client develop a personalized behavior change plan. Not only will the plans concretize the client's commitment to take action in the counseling setting, they will also provide a means for TRAC Plus and FHI to assess efficacy of the intervention.

At each level of intervention, TRAC Plus and FHI will work with health facilities to ensure that messages and services are youth-friendly. For instance, flexible opening hours, nonjudgmental communications style and content, assurances of privacy and confidentiality, and making sure that youth are considered when deciding where outreach campaigns will be conducted. At the same time, the project will refer youth clients to Youth Centers supported by Population Services International (PSI) for additional support.

Given that HCT is an important prevention strategy, it should be noted that this "HVCT" component is very much related to and intertwined with the HVAB and HVOP elements.

In the Targeted Interventions for Prevention (TIP) project sexual risk reduction education is part of FHI/TIP's promotion and implementation of comprehensive, science-based approaches to primary, secondary, and tertiary prevention of HIV. In FY 2010, the second year of the project, FHI/TIP will prioritize cross-referrals spanning community and clinical contexts to provide individuals with multiple behavioral and biomedical prevention services and, where indicated and feasible, these will include reducing socio-economic vulnerabilities that lead to high-risk situations.

In the clinic setting, primary prevention activities will entail behavior change education to reduce sexual risk, including delayed sexual onset for youth, partner reduction, partner testing and couples VCT, and improved STI diagnosis and management. With this funding, FHI/TIP will work with TRAC Plus in FY 2010 to establish an effective approach for identifying most-at-risk HIV-negative clients within VCT and provide intensified and personalized risk reduction counseling. As guidelines and tools from this initiative

become available, TRAC Plus and FHI/TIP will work with districts and health facilities to introduce the approach as part of routine, clinic-based primary prevention activities in FY 2010 and beyond.

These prevention activities will be comprehensive, linked, positive prevention programs that target HIV- positive persons and HIV-affected couples for secondary and tertiary prevention. Systematic and expanded positive prevention programs will include: • Behavior change education and support to HIV-positive persons to reduce risk of transmission to HIV- negative partners. • Condom promotion and delivery to HIV-positive individuals and -affected couples. • PMTCT, dual method promotion and family planning delivery for HIV-positive women and -affected couples. • HIV testing for partners of HIV-positive persons and couples VCT. • Counseling and support for HIV sero-discordant couples. • Routine STI screening and treatment for HIV-positive patients. • Referral to care, treatment and support services for HIV-positive persons.

FHI/TIPs HVAB activities are integrally related to HVCT and HVOP activities and form part of a comprehensive package. In terms of supportive supervision and QA, FHI/TIP will work hand in hand with TRAC Plus to implement supportive supervision, using standardized supervision tools, and will carry out program evaluation to inform program design and implementation. A client intake form and a risk score algorithm will be used to screen high-risk youth and assess primary or secondary abstinence. Pre-post tests will assess training quality and performance.

Description of targets: Targets will be developed with TRAC Plus.

In the Targeted Interventions for Prevention (TIP) project, FHI/TIP will promote and implement interventions targeting most-at-risk individuals as part of a comprehensive, science-based approach to primary, secondary, and tertiary prevention of HIV. In FY 2010, the second year of the project, FHI/TIP will prioritize cross-referrals spanning community and clinical contexts to provide individuals with multiple behavioral and biomedical prevention services and, where indicated and feasible, these will include reducing socio-economic vulnerabilities that lead to high-risk situations.

In the clinic setting, primary prevention activities will entail behavior change education to reduce sexual

risk, including delayed sexual onset for youth, consistent and correct condom use for youth and adults, partner HIV testing and couples VCT, and improved STI diagnosis and management. With this funding, FHI/TIP will also work with TRAC Plus in FY 2010 to establish an effective approach for identifying most- at-risk HIV-negative clients within VCT and provide intensified and personalized risk reduction counseling. As guidelines and tools from this initiative become available, TRAC Plus and FHI/TIP will work with other districts and health facilities to introduce the approach as part of routine, clinic-based primary prevention activities in FY 2010 and beyond.

These prevention activities will be comprehensive, linked, positive prevention programs targeting HIV- positive persons and HIV-affected couples for secondary and tertiary prevention. Systematic and expanded positive prevention programs will include: • Behavior change education and support to HIV-positive persons to reduce risk of transmission to HIV- negative partners. • Condom promotion and delivery to HIV-positive individuals and -affected couples. • PMTCT, dual method promotion and family planning delivery for HIV-positive women and -affected couples. • HIV testing for partners of HIV-positive persons and couples VCT. • Counseling and support for HIV sero-discordant couples. • Routine STI screening and treatment for HIV-positive patients. • Referral to care, treatment and support services for HIV-positive persons.

As such, the activities categorized as HVCT and HVAB are very integrally related to this HVOP component. In terms of supportive supervision and QA, FHI/TIP will work hand in hand with TRAC Plus to implement supportive supervision, using standardized supervision tools, and will carry out program evaluation to inform program design and implementation. A client intake form and a risk score algorithm will be used to screen high risk youth and assess primary or secondary abstinence. Pre- and post-tests will assess training quality and performance.

Description of targets: Targets will be developed with TRAC Plus.