The overall goal of this activity is to decrease new HIV infections through male circumcision in the Rwanda

Defense Forces (RDF) by providing training and capacity building to perform the procedure safely.

Circumcision will be offered as a part of an expanded approach to reduce HIV infections in conjunction with

other prevention programs including AB messaging, TC, treatment for other sexually transmitted infections,

promotion of safer-sex practices and condom distribution.

The WHO and UNAIDS recommended that male circumcision (MC) be made available in countries highly

affected by HIV/AIDS to help reduce transmission of the virus through heterosexual sex. According to final

data from two NIH-funded studies conducted in Uganda and Kenya, routine male circumcision could reduce

a man's risk of HIV infection through heterosexual sex by 65%. According to the WHO, implementing

circumcision programs in sub-Saharan Africa could prevent about 5.7 million new HIV cases and three

million deaths during the next two decades if combined with other prevention activities, such as condom

use, responsible behavior, and knowing your and your partner's HIV status. WHO is encouraging access to

no-cost male circumcision to countries in Southern and East Africa where HIV rates are high and

circumcision rates are low. These countries are being asked to consider adopting male circumcision as "an

important and urgent" health priority, with the target group being boys and men ages 13 to 30.

In FY 2007, several questions were added to a mini-DHS and service provision assessment to assess the

acceptability of MC and readiness of clinical services and staff to safely perform the procedure in Rwanda.

In FY 2008, proposed activities will include correct communication and messaging to the population that the

benefits accrue over time and that MC does not provide complete protection. It is critical that the Rwandan

military know that even if circumcised, one can still contract and transmit HIV. Therefore, circumcised men

should continue to practice abstinence, have fewer sex partners and use condoms.

The communication approaches will occur at the national level through media campaigns that encourage

safe male circumcision as part of a complete approach to prevention, as well as local and inter-personal

communication strategies. Attention will be paid to the socio-cultural context, human rights and ethical

principles, health services strengthening, training, development of national policy on MC, gender

implications, service delivery and evaluation. Conducting MC in the Rwandan military is considered vital

since the members are predominately male, typically young, highly mobile and are considered a high risk

group. MC will be offered to HIV-negative soldiers on a voluntary basis.

Preliminary results from a study being conducted in Uganda and presented earlier this month to UNAIDS

and WHO officials found that HIV-positive men undergoing circumcision might be more likely to transmit the

virus to their female partners, if they have sex before the circumcision wounds have healed. Special

attention will therefore be placed on pre- and post- circumcision counseling to reduce the likelihood of

transmission during this crucial time period after the procedure.

DOD will work with the MOH to create a policy that recognizes circumcision as an effective HIV prevention

method alongside the ABC strategy and ensures that this service is provided to the public in a safe manner.

Likewise, the DOD will sensitize soldiers to practice abstinence, reduce sexual partners, or use a condom

during sex even after circumcision. It is important to prevent the perception that it is okay to engage in risky

sexual behavior after being circumcised.

Noted April 24, 2008: With periodic TA visits from DHAPP (Department of HIV/AIDS Prevention Program)

and in collaboration with clinical partners and the RDF (Rwanda Defense Forces), DoD will strengthen the

capacity of the RDF to link people with HIV diagnosis at military VCT sites to treatment, prevention and care

services as well as link people seen at hospital sites to community services. Specifically, TA will help

military health providers improve treatment of OIs, STI and TB among HIV+ military personnel and civilians

receiving care at three military hospitals and six brigade clinics in the country. In addition, TA will improve

treatment adherence, psychosocial support services and diagnosis and treatment of mental health problems

for the HIV + personnel and civilians receiving treatment and care at military health sites. The first

component of this activity involves providing four to five short-term TA visits from DHAPP headquarters

prevention specialists to support the RDF health providers with prevention, clinical management, diagnosis

and treatment of HIV/AIDS.

This activity contributes to the USG Five-Year Strategy and the GOR care and tretment plan for scaling-up

prevention and treatment services, building on existing services and ensuring quality and equitable access

to HIV treatment in an expanded number of sites/districts.

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The Senior Clinical Specialist will provide TA to DOD clinical partner Drew University to strengthen their

capacity to manage and improve clinical activities in PMTCT, TB/HIV, palliative care, TC, and HIV

treatment. Drew University is working to ensure that RDF, their family members, and communities

surrounding the military installations have equitable access to a high quality, sustainable continuum of care

through HIV/AIDS services. Drew University supports the provision of clinical services in three military

hospitals and five brigade clinics. In FY 2008, Drew University will provide clinical services to 3,000 PLHIV.

As Drew University scales up clinical services, DOD will hire a Senior HIV/AIDS Clinical Services Specialist

to focus on the treatment and clinical management of HIV/AIDS through evidence based approaches. This

position will provide consistent and credible representation of DOD to higher level MOH officials, donors, EP

partners, and coordination bodies for technical, policy and program management issues. In addition, the

Senior HIV/AIDS Clinical Services Specialist will provide TA to Drew University to strengthen their

performance and promotion of professional medical staff providing HIV/AIDS treatment and care. DOD

emphasizes staff retention, performance and promotion of professional expertise of medical staff for

providing HIV/AIDS treatment and care services. The 2004 USG-supported HIV/AIDS Human Resources

Assessment noted the severe shortage of physicians in Rwanda (270 physicians in the public workforce)

and the MOH appreciates the significant HR capacity needs necessary related to the need to improve

physician compensation and work environment. In addition to supporting Drew University clinical services,

this person will work closely with TRAC to train Drew University staff to develop patient education materials

for use in patient education for HIV/AIDS prevention, care, and treatment services.

Noted April 24, 2008: With EP funding, the DOD Coordinator position began in FY 2006 and continued in

FY 2007. Responsibilities for the DOD Coordinator are broad and include management, coordination, and

support of all DOD EP activities in Rwanda. In addition, this funding supports technical TA to DOD partners

with development, M&E of new and existing programs. Additionally, these funds support travel, training,

workshops and equipment.

With EP funding, the DOD Coordinator position began in FY 2006 and continued in FY 2007.

Responsibilities for the DOD Coordinator are broad and include management, coordination, and support of

all DOD EP activities in Rwanda. In addition, this funding supports technical TA to DOD partners with

development, M&E of new and existing programs. Additionally, these funds support travel, training,

workshops and equipment.

With the scale up of activities through Drew University and PSI, DOD will hire a new Senior HIV/AIDS

Clinical Services Specialist. This US direct hire position will provide TA on the treatment and clinical

management of HIV/AIDS, and provide TA to Drew University to improve its performance. In addition, this

person will represent DOD at high level meetings with the MOH, MOD, and donors and partners. Funding

for the new position will include transport facilitation, attendance at trainings and international HIV/AIDS

conferences and workshops, and purchase of office equipment.