The Rwanda EP five-year strategy highlights the military as a high-risk group. A Knowledge, Attitudes, Practices survey conducted in 2004 indicated that the majority of soldiers are single and under age 34. While some practice sexual abstinence and fidelity, their mobility, age, and income make them vulnerable to HIV. For married soldiers, the distance from their families can make it difficult to maintain stable relationships. Field assignments place military personnel far from the military and public health system, reducing their access to testing, treatment, care and support services. Since COP05, the US Department of Defense has supported the Ministry of Defense through technical partner PSI to implement high quality mobile VCT, promotion of safer sexual behaviors, and strengthening of anti-AIDS clubs. Over 27,000 military personnel have been tested, with all clients testing positive referred in for follow on treatment, care and support services. This Ministry of Defense-led "center of excellence" has significantly increased access to testing, treatment, care and support. A COP08 behavioral tracking survey will measure correct and consistent condom use, and the factors influencing safer sexual behaviors.

With COP08, the US Department of Defense awarded PSI a follow-on 3-year mechanism: HIV/AIDS prevention and services support to the Rwandan Defense Forces (RDF). This award intends to reduce HIV incidence and to mitigate the impact of the HIV/AIDS epidemic among Rwandan Defense Forces, their partners and surrounding communities by increasing safer sexual behaviors among soldiers and their partners (including abstinence, fidelity away from home, and correct and consistent condom use), increasing use of high quality VCT services by RDF, their partners, and high risk individuals in the local civilian population (including commercial sex workers), and improving referrals to care and support services. It also seeks to improve knowledge, attitudes, demand for, and referrals to male circumcision services, including parallel promotion of ongoing safer sexual behaviors such as correct and consistent condom use. PSI provides technical assistance to Directorate of Medical Services in Rwanda's Ministry of Defense to implement high quality mobile VCT (bringing VCT to the battalions in the field), to strengthen anti-AIDS clubs to promote safer sexual behaviors and MC, and to produce and disseminate communications materials, including videos, print materials, training aids, etc. Communications approaches include training of peer educators, interpersonal communications (IPC) through peer education and outreach, mobile video unit (MVU) and educational sessions, and community events.

COP10 will continue to support high quality VCT services with 2 mobile testing units targeting military personnel, their partners, and surrounding community members. CT promotion and services will educate about MC and the importance of ongoing correct and consistent condom use, referring uncircumcised soldiers in for MC services. Anti-AIDS club strengthening will continue in 15 districts, with trained peer educators (PEs) conducting ABC prevention activities which also address the links between HIV, alcohol

and gender-based-violence (GBV). Delivered through a range of channels, AB, OP, CT and MC messages will be informed by the findings of the behavioral survey being conducted by DMS and PSI in early COP09, focusing on the factors influencing sexual behavior and the attitudes towards MC. Spousal access to prevention information and CT services will improve in COP10 as a result of the spouse "mapping" proposed by DMS in COP09.

This activity fits with the partnership framework objective of halving the incidence of HIV in the general population by 2012 through the reduction of sexual transmission by promoting safer sexual behaviors and male circumcision. It also contributes to the PF framework objective of reducing HIV/AIDSS-related morbidity and mortality by referring HIV positive CT clients into follow-on treatment, care and support services. For transition, this activity will continue efforts to strengthen the Ministry of Defense Directorate of Medical Services to design, implement and monitor effective CT and AB, OP and MC communications activities. It will also strengthen anti-AIDS clubs to generate income to sustain activities, and strengthen program monitoring and evaluation for improved program effectiveness, including evidence-based message development based on the FY 2009 behavioral study, and qualitative focus group discussions, effective client intake data collection and analysis, routine supervision, and routine pre- and post-test training analyses.

In FY 2010 PSI will provide logistical and technical support to DMS to provide quality HCT services, training of the HCT team and support to ongoing, regular data analysis of client intake forms at DMS.

Two mobile VCT units will be available in FY 2010, one for RDF members and another for their spouses, partners or surrounding community members, as required. Family planning (FP) and MC information was integrated into pre- and post-test counseling in or before FY 2009. The approach to target spouses with HCT services will also be developed in FY 2010. First, DMS has proposed to carry out a mapping exercise to understand where spouses of RDF members are located in Rwanda. Then, dedicated mobile HCT services will be organized to reach spouses in a cost-effective and efficient manner. Spouses may also be referred to fixed military clinics for VCT, if possible. The approach may be modified in FY 2010 to promote couples' HCT, because testing of the RDF member and spouse together would be expected to improve disclosure rates and ensure that the couple is adequately supported through the process. In addition, family days will be convened to promote CHCT and other relevant topics. The DMS refers HIV- positive soldiers and their spouses to care and treatment services (provided by Drew Cares International), where they are supported by prevention with positives programs. In this regard, condoms are widely promoted through the military program for dual protection, and are generously available through military pharmacies. HIV-negative, uncircumcised soldiers will be referred to MC services, when and where available (see HVMC budget notes).

In FY 2009, the client intake form (that collects basic socio-demographic and behavioral information), was re-established, supplemented by training and joint supervision by PSI and DMS of the HCT team on the importance of high-quality data collection and data entry by PDA.

Members of the VCT team (DMS counselors, lab techs and a counselor supervisor) will be trained using, where possible, GOR curricula, in a variety of topics related to VCT, including, but not limited to, general counseling, couples' counseling, stress management, FP, 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.

17. Population Services International/Youth and MARPs Friendly Services

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.

In FY 2010, male circumcision (MC) communications activities will focus on formative research to inform IEC materials development, IEC materials development, public opinion leader (POL) and/or peer educator (PE) training and IPC approaches, as well as VCT counselor training to integrate MC content into pre- and post-test HIV counseling. MC communications will be informed by findings of the behavioral survey conducted by Directorate of Military Services (DMS) and PSI in early FY 2009, which focused in part on basic knowledge and attitudes related to MC. Focus group discussions will be held to explore potential barriers to MC and attitudes about prevention with condoms in light of male circumcision. MC communications will address four main areas: demand creation, education around the procedure, promotion of safe healing, promotion of sustained safer sexual behaviors after MC (partner reduction and/or consistent condom use). Together with DMS, IEC materials such as counselor aids/flipcharts, pre- and post-op pamphlets will be developed to create demand within the military and to educate men on the procedure. IPC approaches will use either POLs within the military who have undergone MC procedure, and are trained to educate and make referrals to others, or military anti-AIDS club PEs. HIV negative, uncircumcised RDF members will be referred from VCT services to MC services within the military health system.

Supportive supervision and QA: Regular, joint supervision visits by DMS and PSI will be carried out to provide guidance and encouragement to POLs and/or PEs in each anti-AIDS club. VCT QA Managers at PSI will carry out supportive supervision of DMS VCT supervisors and counselors to ensure that MC is integrated into VCT services.

Description of targets: • Number of target population reached with individual and or small scale HIV/AIDS prevention interventions primarily focused on MC: 15,000. The proportion of RDF members who are circumcised is currently unknown, but the vast majority of these men are HIV negative. As this is a new activity, the number of target population reached with MC messages (15,000) was estimated as approximately 15% of individuals or small groups reached by AB and OP messages. • Number of HIV negative individuals referred for MC services: 750. This target is based on 50 HIV negative, uncircumcised soldiers referred for MC from each anti-AIDS club. • Number of individuals trained as MC peer educators: 30. This target is based on two individuals trained per anti-AIDS club.

Plans for transition include joint development of materials, supervision and implementation of activities with DMS and other partners (e.g. JHPIEGO) to promote sustainability of interventions. In FY 2009, training approaches for VCT counselors were developed with DMS and JHPIEGO. In FY 2010, these materials will be used for refresher trainings which will reinforce counselor's capacity to integrate MC

messages into pre- and post-test counseling. In addition POL/PE training curricula for demand creation and education about the procedure will be adapted from those available from other PSI platforms (e.g. Swaziland, Zambia). As with other training activities, participative, adult learning techniques will be used, as well as ongoing support and supervision.

As in most locations, the military in Rwanda is a high-risk group for transmission of HIV/AIDS. A knowledge, attitudes, practices (KAP) survey conducted in 2004 indicated that the majority of soldiers are single and under age 34. While some practice sexual abstinence and fidelity, their mobility and age make them vulnerable to engage in high-risk activities and exposure to HIV/AIDS. For married soldiers, the distance from their families can make it difficult to maintain stable relationships.

In collaboration with the Directorate of Military Services (DMS), PSI/DOD AB activities will include strengthening anti-AIDS clubs through training, support and supervision of peer educators (PEs) in 16 anti-AIDS-clubs in 14 districts. Health communication approaches will include interpersonal communications (IPC) through peer education and outreach, mobile video unit (MVU) and educational (theater, poem and drama) sessions, production and distribution of IEC materials, and income generating activities.

PEs are trained in ABC prevention to address links between HIV, alcohol and gender-based-violence (GBV). PEs will carry-out IPC sessions with their colleagues, stressing AB or C to different target audiences within the Rwandan Defense Forces (RDF) (married or single), informed by the findings of the behavioral survey that was conducted by DMS and PSI in early 2009. PEs will encourage married members of the RDF to practice abstinence (A) while on duty, and be faithful (B) to their spouses. Quality of messages delivered through IPC activities will be ensured through the use of message guidelines, to help PEs flesh out myths/misconceptions, frequently asked questions, and how to respond to questions posed to them by their peers.

An interpersonal and mass media communication strategy will be employed in order to reach both primary and secondary (spouses and other partners) target audiences, with messages about abstinence, fidelity, couples' communication, family planning (FP) and parent-child communication (PCC), complemented by IEC materials (posters, a 40-minute MVU film, and comic book) developed in FY 2008 and produced in FY 2009. Spouses' access of AB information will improve in FY 2010 as a result of: 1) the "mapping" of spouses proposed by DMS in FY 2009; and 2) increased access to HIV prevention

services through a dedicated mobile VCT unit for spouses. Family days will be convened to promote FP, PCC and other topics.

In terms of supportive supervision and QA, there will be regular, joint supervision visits to be carried out by DMS and PSI to provide guidance and encouragement to PEs in each anti-AIDS club and supervision of approximately 6 IPC sessions/club and 6 clubs/month. 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 be developed to guide PEs to conduct small group discussions.

Description of targets:

1. Number of target population reached with individual and or small scale level HIV prevention interventions that are primarily focused on AB: 23,700. This target assumes that PSI and DMS staff directly reach 9,000 individuals through anti-AIDS club supervisions per year, and the military PEs from 15 anti-AIDS clubs reach 70,000 individuals, for a total of 79,000 individuals reached by all messages. Married or not sexually active individuals are estimated to be 30% of the total, or 23,700 individuals.

2. Number of individuals trained to promote HIV prevention programs through AB: 200. This target assumes a total of 20 trainers are trained through a TOT, and 12 PEs trained per anti-AIDS club.

New activities and plans for transition: Joint development of IEC materials, training curricula, supervision and implementation of activities with DMS will promote sustainability of interventions.

Capacity building activities: TOT and PE training activities are conducted jointly by DMS and PSI use standardized curriculum developed with DMS, as well as pre- and post-tests that measure gains in knowledge (including comprehensive HIV knowledge) before and after trainings. In FY 2008, efforts were initiated to harmonize training approaches across military program partners, including Drew University and JHPIEGO, leading to increased co-facilitation of trainings.

In collaboration with the Directorate of Military Services (DMS), OP activities in FY 2010 will include training, and support and supervision of military, civilian and commercial sex worker (CSW) peer educators (PEs) from anti-AIDS-clubs in 15 districts. Messages will focus on the factors influencing correct and consistent condom use (identified in the behavioral tracking survey implemented in early FY 2009) and positioning condoms for dual protection. Activities will focus on small group IPC supported by a condom demonstration kit developed in 2009. Health communications approaches will include interpersonal communications (IPC) through peer education and outreach, mobile video unit (MVU) and educational (theatre, poem and drama) sessions, and production and distribution of IEC materials. FY 2010 will scale up the pilot initiated in FY 2009 to train military anti-AIDS clubs in retail outlet creation or community-based distribution of Prudence condoms and Sûr'Eau point-of-use water purification solution to ensure availability of condoms in retail outlets and hotspots in communities surrounding military camps. Revenues will be used to strengthen anti-AIDS clubs.

Due to considerable advocacy efforts in FY 2008 to include CSW peer educators in PSI-supported military anti-AIDS clubs, CSWs will reach their peers with messages addressing the factors influencing correct and consistent condom use and reinforcing safer sexual behaviors of military members. CSWs will also increase access to VCT services and care and treatment.

OP messages will be informed by findings of the behavioral survey conducted by DMS and PSI in early FY 2009, which focused in part on condom use by partner type and identification of the factors influencing correct and consistent use. IEC materials that promote OP messages were developed in FY 2008 and produced in FY 2009, including a 40-minute film script that integrates messages on condom use, STIs, GBV and alcohol use. The film script was developed and pre-tested in collaboration with DMS and was approved by the National Committee for Behavior Change Communication (CNCCC). Comic book scripts created in FY 2009 to continue the storylines and further develop the characters and messages in the film will be continued through FY 2010.

Supportive supervision and quality assurance include regular, joint supervision visits to be carried out by DMS and PSI to provide guidance and encouragement to PEs in each anti-AIDS club, supervision of approximately six IPC sessions per club as well as six clubs per month.

Description of targets: • Number of targeted condom service outlets: 16. This target assumes that community-based distribution of condoms will be established at 16 military anti- AIDS clubs. • Number of target population reached with individual and or small scale level HIV/AIDS prevention interventions that are primarily focused on OP: 75,050.

Of the total of 79,000 individuals expected to be reached by all messages, 5% are estimated to not be sexually active. Therefore 95% of individuals (75,050) should be reached by OP messages. • Number of individuals trained to promote HIV prevention programs through OP: 200. This target assumes a total of 20 trainers are trained through a TOT, and 12 PEs trained per anti-AIDS club.

New activities and plans for transition: Joint development of IEC materials, training curricula, supervision and implementation of activities with DMS will promote sustainability of interventions. In addition, establishing community based distribution of health products by military anti-AIDS clubs is a more sustainable approach than direct budget provision.

Capacity building activities: Trainers will be trained to train others in use of the condom demonstration kit, an important tool produced in FY 2009 and standardized for national use. Military, civilian and CSW PEs in anti-AIDS clubs will be trained to use the condom demonstration kit in small group interventions.