Members of Rwandan Defense Forces (RDF) remain one of the highest-risk groups for HIV/AIDS infection in Rwanda because they are typically young, single and highly mobile. RDF has 3 military hospitals and 8 brigade clinics. In COP12, Charles Drew University (CDU) will ensure that HIV/AIDS support is integrated within existing RDF health service delivery systems with the aim of building capacity, human resource development, country ownership and sustainability. Consistent with the Partnership Framework, CDU, in partnership with the RDF, will continue in COP12 to provide TA in human resource development that includes pre-service and in-service training of RDF health personnel, as well as rehabilitation of RDF facilities. These efforts will improve the capacity of the RDF to provide quality HIV prevention, care and treatment services for military personnel, their families, and the surrounding communities. Services include HIV Counseling and Testing, PMTC, Pediatric Care and Treatment, HIV Palliative Care and Treatment, Laboratory services, TB/HIV Interventions, PwP, MC services through TA focusing mainly on in-service training of RDF health personnel, and M&E. The objectives are: 1) Improve HIV prevention services, ensuring in-country ownership and sustainability, and 2) Improve the quality, availability and sustainability of HIV treatment options for RDF personnel, family, and surrounding communities. CDU will provide technical support (training & supervision), human resource development (data managers placed at facility levels), as well as material support to the M&E activities at facility level in order to ensure data quality.

Three vehicles have been purchased previously; no new vehicle purchases are expected at this time.

In COP12, CDU will work to improve the capacity of RDF to provide quality HIV treatment & care for RDF personnel, their partners & families and community members living in surrounding areas at all 8 RDF health facilities throughout the country. The palliative care package will be integrated within existing health service delivery systems and offered to 4390 patients that includes clinical staging, CD4 count, OIs prevention through prophylaxis with CTX based on national protocols, psychosocial support and referrals of PLHIV to community based BCS services. A human Resource development focus will continue with the training of 110 RDF health care providers on HIV palliative care and 112 peer educators & lay counselors to provide psychosocial support at community levels through periodic inter-brigade/community interactive, experience-sharing discussions, meetings & workshops to increase treatment adherence and share success stories. To improve the health of RDF members deployed in remote, hard to reach areas, CDU will continue to support outreach services through MTCU along with monthly ARV drug distribution as a bridge to the achievement of full sustainability of HIV services for these deployed troops. MTCU services include: basic HIV lab tests, STIs/OIs screening &treatment, provision of CTX, ART, ART adherence support, psychosocial support, FP, nutrition counseling, PwP, spiritual care, bereavement care and hygiene education. CDU will continue to provide TA & material support to 14 Anti-AIDS clubs to sensitize & mobilize RDF personnel and community members on HIV/AIDS, prevention, care and support & adherence to treatment. At the brigade level, CDU will support: 1) formation of support groups of PLHIV and train members in the provision of home-based care services and referrals as appropriate (including PwP), 2) access to locally available nutritional support & Income Generating Activities. CDU will provide TA (supervision and M&E) to RDF to strengthen linkage between community-based & clinic-based HIV care services. CDU will intensify its support in retention of clients through quality services delivery.

In COP12, CDU will continue to support integration of HIV and TB services at all the 8 RDF facilities as per the national TB/HIV Protocol and supporting facilities to strengthen referral mechanisms within the same facility and between facilities which will enable patients diagnosed with TB and HIV adhere to TB treatment via DOTS, and have access to CTX prophylaxis and follow-up of CD4 and ART services if eligible as it has been done in COP11. In line with National Health Strategy, all 4390 HIV+ patients (100%) will be screened for TB and provided TB prevention services. All patients identified with TB will be counseled and tested, and all co-infected patients with will also receive TB treatment. A Human Resource Development approach will be used by the provision of training of 110 RDF health care providers in partnership with RBC/TB program. In addition, CDU will ensure through regular supervision to all RDF sites TB/HIV data is recorded & reported using the next generation TB/HIV indicators provided by PEPFAR. M&E will be provided using the national TB and HIV M&E framework and tools. To ensure ownership and sustained health impact, CDU will ensure that TB clinical care continues to be part of a continuum of a comprehensive HIV/AIDS care strategy by improving infrastructure at RDF hospitals and brigade clinics, as well as training RDF health providers to diagnose, treat monitor and report TB progression trends. In addition, CDU will ensure 100% of HIV+ TB patients eligible for ART will be immediately offered ART and TB treatment, and followed-up through existing RDF health delivery systems. To ensure successful TB prevention, CDU will provide patients with education regarding infection control strategies. At the brigade/community-level, Anti-AIDS clubs and support group activities will include TB awareness-raising activities. These activities support the Rwandan National Health Strategy for TB/HIV in preventing, diagnosing and treating patients with both TB and HIV patients.

In COP12, CDU will utilize a human resource development approach in continuing to train health care providers in all 8 supported RDF health sites that ensures the provision of an integrated package of care and support for 100% of HIV exposed and infected children. Care and support for HIV-exposed infants identified in PMTCT will include access to early infant diagnosis using DBS, provision of CTX prophylaxis, and tracking of mothers and infants lost-to-follow-up for re-engagement in care. CDU will also continue earlier enrollment of mothers in PMTCT, regular clinical assessments & staging, baseline CD4 count for all HIV-infected children, control CD4 count, viral load monitoring, management of other HIV-related illnesses (OIs, TB), INH & CTX prophylaxis and ART for eligible children and HIV-exposed infants. CDU will ensure the provision of integrated management of childhood illness, distribute long-lasting insecticide treated nets, safe water interventions, provide basic hygiene education and community outreach services including referral for complimentary food support and linkage to poverty alleviating programs at existing RDF health delivery sites. CDU will also provide training for 110 health care providers in psycho-social care for children and adolescents living with HIV/AIDS that assist adolescents in transitioning to adult care at all RDF sites. Nutritional support at CDU supported sites will include nutritional education, counseling to HIV positive mothers during pregnancy and after delivery regarding best feeding practices. CDU will ensure programmatic linkages to the Title II food support for all clinically eligible PLHIV (including children) in selected sites which provide complementary food support for HIV-exposed and affected infants. Existing RDF health delivery sites will establish HIV community outreach services by working with existing trained community health care workers to provide key HIV messages emphasizing care and referral for pediatric HIV cases. RDF liaisons collaborating with community health workers in surrounding communities constitutes an effective system to ensure continuity of care, retention into HIV care, and improved quality and sustainability of pediatric HIV services.

In COP12, CDU will provide TA to laboratories at all existing RDF health care sites located throughout the country that serve military personnel, their partners and family members and community members living in surrounding communities. All CDU supported laboratory sites will continue to collaborate and work within the National Referral Laboratory system and follow their policies. In addition, CDU will continue to work closely with other cooperating partners on key issues, particularly those pertaining to accreditation. All RDF laboratories will continue to provide the minimum package of HIV-related tests such as hematology and biochemistry, as well as provide other tests such as malaria testing and stool exams. Laboratories at the 2 military hospitals will also continue to provide CD4 count tests. The Rwanda Military Hospital laboratory will be supported to provide services at a referral hospital level. With quality laboratory infrastructure in place, the Rwanda Military Hospital laboratory will continue to receive TA from CDU with the goal of achieving full accreditation as a referral laboratory. The use of PEPFAR II indicators will be used for measuring quality in laboratory services. Following a human resource development approach, CDU will train 18 laboratory technicians on quality assurance protocols and Good Laboratory Practices. Laboratory support provided by CDU will continue to be integrated within existing health service delivery systems, staffed by medical personnel within the RDF health facilities, thereby ensuring cost effectiveness, continuity and sustainability of the program. This approach ensures increased ownership and facilitates a smooth transition of laboratory services to the RDF at the end of the funding period.

In COP12, CDU will continue to assist existing RDF health facilities to improve their IT infrastructure. In addition, CDU will provide support for quality data collection methodologies, analysis, reporting and use through ongoing training and supervision. The RDF will receive assistance with implementing continuous quality improvement process. Specific activities include improving existing data collection methodologies, processes and systems, as well as data analysis. These improve data collection processes will assist the RDF in evaluating the effectiveness of HIV treatment and care services provided in existing RDF health care delivery facilities. Specifically, CDU will 1) provide material and TA support to improve the existing military data systems, 2) update data reporting tools to monitor HIV care and treatment activities, 3) improve the capacity of existing RDF health care facilities through HMIS and OpenMRS in order to meet the national standard for monitoring & evaluation, as well as accuracy of patient records, 4) ensure that the national coding system for all patients receiving care in RDF health care facilities is implemented to, and 5) offer TA to improve hospital information management systems at the 2 existing military hospitals. Following a human resource development approach, CDU will conduct refresher training for 15 health service providers from all RDF sites on data collection, analysis, use and reporting according to the national HMIS guidelines. CDU will also work closely with the MOH/Monitoring and Evaluation Taskforce to ensure compliance with National HMIS plan. All CDU Strategic Information activities will be conducted within existing RDF health service delivery sites in a manner that will transfer knowledge to RDF staff, increase ownership and sustainability.

The overall goal of this activity is to decrease new HIV infections through male circumcision in the Rwanda Defense Forces (RDF). In COP12 CDU will offer circumcision as part of an expanded approach of HIV services embedded in existing RDF health facilities that also include HIV Testing and Counseling, treatment for STIs, promotion of safer-sex practices and condom distribution. VMMC will not replace other known methods of HIV prevention and will be considered as part of a comprehensive HIV prevention package. Sensitization meetings will be conducted regarding the role of circumcision in HIV prevention, including the fact that there is need to continue to practice abstinence, have fewer sex partners and use condoms. It is important that VMMC is provided to men who are HIV negative, emphasizing that it is important to know ones HIV status prior to receiving VMMC services. Emphasis will be made on abstinence from sexual activity for the recommended period after VMMC to allow complete healing of the wound. CDU will ensure that VMMC activities go hand in hand with HIV care and treatment and all VMMC clients will be counseled and tested for HIV. In COP12, 30 RDF health care providers trained on VMMC and appropriate infection control practices. CDU will also provide regular supportive supervision to all RDF VMMC sites across the country and follow-up to soldiers who have been circumcised in order to prevent infection and ensure compliance with VMMC management protocols. Together with PSI, IEC/BCC messages will be tailored to sensitize circumcised soldiers on basic hygiene, safe sex practices and the need for medical follow-up to monitor infection. In COP12, CDU will ensure that VMMC efforts are integrated in existing RDF health delivery facilities as an additional method for HIV Prevention. Together with JHIPEGO, CDU will take steps to ensure that providers are well trained in VMMC. CDU will also ensure that physical & clinical infrastructures are enhanced, and demand created for maximum utilization of VMMC services by RDF soldiers and surrounding community members. VMMC will be conducted on a voluntary basis with all socio-cultural considerations.

In COP12, CDU will continue to work with the RDF and other partners to ensure that VCT services are available in all 8 RDF health settings located throughout the country. CDU will employ counseling techniques that ensure confidentiality, minimize stigma and discrimination according to national guidelines and reach those individuals most likely to be infected. Couples Voluntary Counseling and Testing (CVCT) in ANC will be expanded and integrated with VCT services as a Prevention Intervention and PIT will be rolled out as a testing strategy. CDU plans to reach 9000 clients during COP12 with counseling that includes messages on alcohol reduction, prevention for positives, GBV, disclosure of status to partner, partner testing, and counseling for negatives and provision of condoms. A human resource development approach will include the provision of refresher training for 30 RDF health care providers. This approach will help ensure ownership and sustained health impact at the end of the funding period. Male circumcision will also be a pillar in the VCT program and all MC clients will be tested. An emphasis will be made on prevention counseling and follow-up for HIV positive clients, discordant couples and other high risk groups. HIV+ individuals will immediately be enrolled in HIV care and treatment to minimize the risk of lost to follow up. These activities will be coordinated to avoid duplication and maximize accessibility to the most at-risk populations. CDU will coordinate its activities with other partners, such as PSI, to avoid duplication, strengthen referral linkages and continue the promotion of TC among most at risk populations, including the military. CDU will provide TA, mostly in the area of in-service training and supportive supervision to ensure quality of VCT services that follow the standard testing algorithms and ensure the efficiency of the program and transition to RDF. CDU will also use new PEPFAR indicators to ensure the quality of all services delivered. In this regard, CDU plans to undertake operational research to assess the effectiveness of the referral system.

In COP12, CDU will continue to work with RDF and RBC to increase access to PMTCT services in 8 RDF health delivery sites located throughout the country through referral and follow-up of identified VCT and PIT clients to PMTCT services. The PMTCT interventions will be implemented as per the National Strategic Plan and fully integrated within existing RDF health service delivery systems. CDU and RDF will continue to use RDF HIV+ males as "entry points" to their families, maintaining a comprehensive demographic data base of each soldier and their family that is updated through MTCU implementation. This approach enables tracking and implementation at the brigade level via targeted training sessions for identified at-risk spouses of HIV+ soldiers, with HIV CT conducted simultaneously. CDU will promote full utilization of PMTCT and support the spouses of identified HIV+ soldiers to bring their children for HIV testing. CDU will strengthen the community outreach services through home visits to encourage HIV+ women to have their children tested. CDU will also work closely with potential health centers in targeted areas through training, linkages, referrals and sharing of clinical records to ensure follow-up and continuity of services of the identified HIV+ soldiers spouses. Couple CT will be an important tool for improving utilization of PMTCT services. CDU will ensure delivery of standardized PMTCT services to 2300 pregnant women attending ANC services and provide ART prophylaxis to 92 HIV exposed women at all RDF health settings. During COP12, an emphasis on Human Resource development will continue in order to maximize ownership and sustained health impact at the end of the funding period. Toward these ends, CDU will train 110 health service providers on PMTCT service delivery skills, ensure provision of necessary material & equipment, and provide supervision and M&E. CDU will also continue to provide nutritional support to 50 pregnant women in need of support in targeted RDF facilities while making linkages with other Title II USG partners to ensure access to adequate nutritional support and linkage to poverty alleviating programs for pregnant and lactating mothers & infants in other facilities.

In COP12, CDU will work to improve the capacity of 8 RDF health delivery sites to provide quality HIV treatment & care for military personnel, their partners & family members, as well as community members who live in surrounding areas. The package will be delivered within existing RDF health service delivery systems to 3650 individuals in a manner that ensures sustained health impact at the end of the funding period. The package includes clinical staging, CD4 count, viral load, OIs diagnosis, treatment and prevention through prophylaxis with CTX per national protocols, TB screening & treatment, and referrals of PLHIV to community-based care services. CDU will continue an emphasis on human resource development with the provision of refresher training on full package of HIV Care & Treatment to 110 RDF service providers. To improve the health of HIV-positive RDF personnel, CDU will support a Mobile Treatment and Care Unit (MTCU) for HIV-positive patients in hard-to-reach areas. The MTCU will provide comprehensive medical evaluations, basic HIV lab tests, STIs/OIs screening and treatment, provision of CTX, ART, ART adherence support, psychosocial support, FP, nutrition counseling, PwP, spiritual care, bereavement care, hygiene and malaria education. CDU will provide supportive supervision and M&E using new PEPFAR indicators to ensure quality data that will inform decision making. Peer educators and lay counselors will be trained to provide social support to patients through periodic inter-brigade/community interactive sessions. Peer-to-peer experience sharing discussions & workshops will be organized to increase treatment adherence & the sharing of HIV treatment success stories. CDU will also provide TA to RDF to strengthen linkages between community-based and clinic-based HIV care services. At the brigade and/or community level, CDU will support 1) the formation of support groups of PLHIV & train its members in the provision of home-based care services and 2) access to locally available nutritional support resources.

In COP12, CDU will scale up pediatric care and treatment by providing TA in the form of training, regular supervision and M&E at existing RDF health delivery sites in line with national policies and sustainability strategies. Data will be collected using the new PEPFAR & National indicators to ensure quality. CDU will provide an integrated package of care & support services for 100% of HIV-exposed infants and HIV-infected children. CDUs support to pediatric HIV treatment activities will ensure access to early infant diagnosis using DBS, provision of CTX prophylaxis and ART, tracking of mothers & infants lost-to-follow-up, regular clinical assessments, baseline CD4 count & percentages for all HIV-infected children, regular CD4 and viral load monitoring, management of other HIV-related illnesses (OIs and TB) and psychosocial support. Suspected TB cases will be investigated to establish a diagnosis and begin treatment as per national guidelines & INH prophylaxis provided to those exposed to active TB. Referral systems will be developed to ensure quality care. Following a human resource development approach, CDU will collaborate with RBC in the training of 110 health care providers in pediatric HIV/AIDS palliative and psycho-social care, with an emphasis on adolescent transition into adult care & treatment. All CDU supported RDF health deliver sites will establish HIV community outreach services by working with trained community health care workers to provide HIV education that emphasizes pediatric HIV care and treatment, and increased awareness and utilization of services. The collaboration of military liaison with community health workers in surrounding communities constitutes an effective system to ensure continuity of quality pediatric HIV care and treatment services, increased retention in care & treatment, as well as increased ownership and sustained health impact at the end of the funding period.