Research on Male Circumcision demonstrates a 60% reduction in female-to-male HIV transmission, generating new hope for changing the course of the pandemic. Rwanda responded to the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommendations to pursue MC by establishing the goal to create and scale up MC services in the Rwandan military. MC coverage is less than 20% in the country and even if it is not a panacea, MC provides a greater protective benefit than any potential vaccine studied to date.

The overall goal of this activity is to decrease new HIV infections through male circumcision in the Rwanda Defense Forces (RDF) with emphasis that circumcision be offered as part of an expanded approach to reduce HIV infections in conjunction with other prevention programs, including HIV testing and counseling, treatment for other sexually transmitted infections, promotion of safer-sex practices and condom distribution. Male circumcision (MC) will not replace other known methods of HIV prevention and will be considered as part of a comprehensive HIV prevention package. Jhpiego's major goal is to develop "Troop Level" HIV/AIDS prevention capability within the RDF through the following objectives: a) To increase RDF capacity to deliver safe male circumcision services by training 120 clinicians including 16 master trainers by the end of the program year and b) To increase informed demand among the RDF for MC by training 155 health professionals who administer provider-initiated counseling and testing for HIV/AIDS including 16 master trainers by the end of the program year. These goals will be achieved by utilizing Jhpiego's signature, competency-based training pathway and Jhpiego's expertise, to provide the RDF with master trainers who will fill long-term clinical and counseling needs and by assisting the RDF to utilize a performance and quality improvement (PQI) methodology—Standards-Based Management and Recognition (SBM-R), to enable providers to progressively improve the provision of high-quality MC services and control for adverse events.

To scale up MC in the RDF, Jpiego will identify and address gaps at target sites, facilitate policy environment for confidential informed consent for male circumcision as an HIV/AIDS reduction strategy, expand HIV voluntary counseling and testing (VCT) curriculum to include MC and train counselors, train health care personnel to be able to conduct MC and counsel individuals, develop a cadre of national level trainers who are skilled in MC and implement Standards-Based Management and Recognition (SBM-R) in each facility. The goals and objectives are linked to the overall Partnership Framework goals of decreasing new HIV infections in high HIV prevalence regions with low male circumcision rates, and building the capacity of local bodies to implement and manage the various components of male circumcision programs.

The geographic coverage of MC activities within the RDF will be at eight (8) model sites delivering MC surgery services including counseling and testing at country level. As announced by the GOR, the initial target population of male circumcision activities will be the soldiers in the Rwandan Defense Force (RDF) and activities will be performed in accordance with RDF policies concerning recommended testing of active duty soldiers and mandatory testing of new recruits and denial of entry for those found to be positive. In addition to the biological benefits of MC, the program activities will contribute to strengthening of health systems by supporting the RDF in building standardized, competency-based systems to in-service education and providing a standardized approach to procurement of MC supplies.

In FY 2010, Jhpiego will build capacity of the RDF health providers to perform MC at the RDF sites,

improve system strengthening, provide standardized supervision and put in place measures to improve the MC strategy's cost efficiency over time. Such measures include coordinating service delivery with partners such as Drew University, who will be designing and providing standardized MC kits; and utilizing PSI's expertise in behavior change communication as a complement to Jhpiego's training expertise. Jhpiego will also be collaborating with the necessary officials, such as the RDF's Directorate of Medical Service (DMS) in order to reduce duplication of efforts.

Monitoring and Evaluation (M&E) To measure and report progress toward achieving project objectives, Jhpiego will implement a detailed and focused M&E plan and will rigorously monitor project activities, objectives and purpose. A Management Information System (MIS) will track inputs and outputs, such as: number and type of providers trained; equipment and consumables used; and number of clients seeking and receiving MC. Jhpiego's training database, known as TIMS , will be used to track the number of health personnel trained, including master level trainers. Staff will regularly monitor and measure project progress and performance according to a data collection schedule for a particular monitoring indicator. The philosophy of the project is, where resources permit, to measure the indicators as frequently as possible in order to avail information and feedback to the project implementation process in as timely a manner as possible. Data for the illustrative indicators will be collected through project and facility records. The needs assessment will include a facility survey and focus group discussions with hospital staff and military personnel, and will contribute to the project baseline with which to compare results.

The overall goal of this activity is to decrease new HIV infections through male circumcision among Rwanda Defense Forces (RDF) personnel. The program will be presented as part of an expanded approach to reduce HIV infections, and will be promoted in conjunction with other prevention programs, including HIV testing and counseling, treatment for other sexually transmitted infections, promotion of safer-sex practices and condom distribution. Male circumcision (MC) will not replace other known methods of HIV prevention and will be considered as part of a comprehensive HIV prevention package.

The following activities will be implemented during FY 2010 in order to reach MC goals. • Target sites strengthening: Based on assessment results, JHPIEGO will work with SCMS to ensure that supplies and equipment needed for MC are available at the site level. JHPIEGO will build the capacity of the RDF to project and budget for supplies they will need to operate independently. • Facilitate policy environment for confidential informed consent for male circumcision as an HIV/AIDS reduction strategy: In an endeavor to scale-up MC and sustainability, JHPIEGO will collaborate with the MC Task Force, other PEPFAR implementing partners, district level health authorities, the Rwandan Association of Surgeons, the Faculty of Medicine and the RDF for a multi-sectoral, multi-level approach to scaling up MC and promoting integration with other HIV prevention, care and treatment activities. • Expand HIV voluntary counseling and testing (VCT) to include discussion of MC and train counselors on MC: Building the capacity of counselors to communicate and disseminate information about MC is critical. Since MC only partially protects against HIV, it is important that MC is one aspect of a comprehensive package of HIV prevention services, and closely linked to effective counseling and testing for HIV. In accordance with WHO/UNAIDS guidance, JHPIEGO has incorporated an intense counseling effort into training program to educate clients as well as potential clients and their partners about the partial protective nature of MC and the need to use other prevention methods (such as abstinence, partner reduction and consistent condom use). To extend MC-related counseling and testing within the RDF and to build a referral system for HIV-negative males, JHPIEGO will support five-day MC counseling courses for existing VCT providers and lay counselors to increase their ability to answer questions about MC and refer HIV-negative men to MC services. • Train health care personnel to be able to conduct MC and counsel individuals: JHPIEGO has developed and employed a competency-based trainer pathway designed to enable countries fill human resources for health needs into the future. Hence, this project will use a competency-based approach to training that emphasizes the acquisition of clinical and counseling skills. Trainings will be conducted using both classroom learning for theory and clinical settings for learning on a clinical caseload. All trainings will be based on the WHO/UNAIDS/JHPIEGO MC Reference Manual and will be tailored to any national guidelines. This training package includes five main competencies: 1 - Group Education; 2 - Individual Counseling; 3 - Client Assessment and Informed Consent; 4 - MC Procedure; and 5 -

Postoperative Care. These modules will be tailored in length and emphasis depending on the specific audience. For example, providers of the procedure will receive reduced group education and counseling modules while counselors will receive abbreviated procedure modules with more emphasis on counseling and group education. JHPIEGO will also tailor training courses based on providers' surgical skills. On satisfactory completion of the training program, trainers will conduct follow-up visits to all providers in their place of work within 4-6 weeks. This is seen as an essential component to ensuring retention of information and mastery of skills. In addition to monitoring at least one procedure, the trainers will conduct a clinic audit to ensure that the clinic and the provider are meeting the minimum standards of quality for all aspects of service delivery. All providers completing the training program will agree to meet or exceed defined minimum standards of quality in their clinics and within their MC services. JHPIEGO will define these standards, taking into consideration: 1) a set of internationally agreed-upon performance standards for MC that the WHO is currently finalizing; and 2) relevant national guidelines. These standards will include a ceiling of 4% on moderate and severe adverse events (AEs). It will also include a minimum number of procedures that providers must perform monthly to maintain accreditation. Develop a cadre of national level trainers who are skilled in MC: JHPIEGO will continue to support Kanombe military hospital as a training center and will build the capacity of a core group of MC training team. MC training team will consist of one proficient MC provider and one proficient MC counselor who will participate in an MC training course. Following successful completion, a JHPIEGO Master Trainer will co-train with these new trainers in order to mentor them as they lead their first MC training courses for other providers. JHPIEGO will also provide technical support to TRACPlus to conduct training-of-trainers courses on MC in military health facilities. This cascade approach to training and mentoring of national level trainers who also participate in the program and quality improvement has proven successful for building long-term local capacity. • Implement Standards-Based Management and Recognition (SBM-R) in each facility: JHPIEGO recognizes that high-quality training alone is not sufficient for the introduction of new clinical services such as MC, especially given that it requires a surgical procedure and management of adverse effects. Therefore newly trained providers will require follow-up support. JHPIEGO has developed and implemented SBM-R, an internationally acclaimed system devised and first tested in Brazil, in 12 countries to address supporting quality implementation of training. JHPIEGO will use SMB-R to objectively measure, monitor performance standards so as to improve the quality of services of a range of HIV health care services, from HIV counseling and testing to antiretroviral therapy. Providers will be empowered to monitor the quality of their own health services, rather than waiting for outside supervision to make changes. JHPIEGO will establish an SBM-R system that will include the development of MC quality teams at the national level. The MC quality teams will include the national MC trainers, as well as other key stakeholders such as representatives of the national MC Task Force. These teams will develop, in collaboration with JHPIEGO, checklists, job aids and other tools to allow providers to measure performance based on minimum standards; these same tools will be used for external

assessment. Internal and external measurement against the standards (by the providers themselves and by the external MC quality teams) will occur on a regular basis to ensure ongoing identification of problems and continuous improvement. Sites that have achieved the seal of quality will receive several external assessments in their first year of operation. In subsequent years, external assessments will occur at least once per year, provided they continue to meet or exceed the minimum standards. Those sites that are struggling will work with the MC quality teams to develop a plan to address those gaps and will be visited at least quarterly until quality improves. Via JHPIEGO's USAID-funded Maternal Health Program (ACCESS) in Rwanda, SBM-R is already operating effectively, and the GOR has drafted national guidelines to support scale-up. • Managing Adverse Events (AEs): Maintaining a very low rate of AEs is critical to furthering ownership and scale-up of MC by the RDF. The training and quality assurance process will minimize the number and severity of AEs. JHPIEGO will also design a system for handling AEs that occur during or immediately following the procedure, and those that present after the client has been discharged. Providers will be trained to handle many of the complications that may take place during the procedure as well as the common minor complications that can occur in the first week after MC. A system of referrals will be established for each site to address cases they cannot treat. Providers will be trained to complete the AE forms provided in the WHO/UNAIDS/JHPIEGO MC manual. AE forms for minor complications will be collected at follow-up visits, while JHPIEGO will require that moderate or severe complications be reported immediately. JHPIEGO will conduct M&E and data collection and report this information regularly to the Ministry of Health. +C20