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INTERIM REPORT OF PROJECT IMPLEMENTATION

Title of the Project: Increase risk perception on HIV and STIs transmission among
Female sex workers and male clients of FSWs for accessing health services in
Kigali City.

1. Executive Summary
The initiative on Increasing risk perception on HIV and STI transmission among Female
sex workers and their male clients as well as accelerating PMTCT and male clients
access to health services in Kigali was supported by UNAIDS Country office in Rwanda.
The first phase of project implementation revealed a greater interest of administrative
leaders and stakeholders who attended the 2 initial meetings. Through the opening
remarks and during discussions administrative leaders demonstrated commitment to
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consider evidence informed in planning for HIV response especially response that
targets female sex workers and their potential male clients.

During the stakeholders consultative meeting 40 participants from civil society
organizations, national institutions and Female sex workers attended the meeting that
worked on evidence sharing and increasing risk perception on HIV and STIs transmission.
A specific meeting with Female sex workers also took place in Kigali and succeeded
bringing together 40 participants. Outputs of the meeting were informative on the
strategies to reach out male clients of female sex workers with information of HIV
transmission and HIV prevention related services.

Participants were informed that evidence from 2010 FSW BSS the HIV prevalence is
estimated at 51% nationally and 56% in Kigali city. The same source about 66% of FSWs
reported that the most frequent clients were married men, 21% of FSWs reported that
their most frequent clients were widowers, while 13% reported that their most frequent
clients were single to develop awareness and community dialogue approach as strategy
to succeed prevention of Voice of Community Organization succeeded in implementing
an innovative project supported by UNAIDS in 3 districts of Kigali city.

This evidence attracted the attention of all stakeholders who committed to plan for and
intensify prevention programs targeting specifically Female sex workers. The FSW would
serve as entry point if we are to reach male partners reiterated participants in both
meetings.
As follow up, a meeting with services providers is planned and we believe this is
essential as we plan for strengthening networking and referral system for access HIV
prevention services for key population in Kigali city and nationally.
The second installment will be utilized to work on this aspect of strengthening referral
system for STIs screening and management, HIV testing, condoms access and continuity
of services such as PMTCT in the sites of this projects implementation.

The final report will be submitted after implementation of the all projects related
activities hopefully by end of October 2014.

2. Project activities
Generally, the project implemented two activities including: male clients as well as
accelerating PMTCT and male clients access to health services in Kigali City and Training
of selected outreach peer educators male clients from 3 district of Kigali cities.

A Consultative meeting on sharing evidence and identifying key strategies for HIV
response targeting males clients of female sex workers in Kigali city was organized and
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participants were from Government Institutions, UN family and civil society
organizations among participants both 30 men and 10 women the workshop held at
Umubano Hotel on 5
th
June 2014.

The second activity included a training of 40 selected outreach peer educators (30
women and 10 men) from 3 district of Kigali cities held at St Francois d Assise on 7
th
July
2014 . The training was facilitated in a participatory approach, through presentations
from experts, questions were asked and focus group discussions were organized and
plenary discussions and recommendations were formulated in the following:

Initiate trans-boundary programs targeting Track Drivers and sexual trafficking
Sensitize domestic workers and bar servants/waiter on HIV prevention and other
STIs , VCT and Condom use in Kigali city
Eradicate stigma and discrimination against sex workers
Community dialogues on Men Risk perception of HIV and Men involvement


3. Activity 1 : consultative meeting on sharing evidence and identifying key strategies
for HIV response targeting males clients of female sex workers in Kigali city.
A Consultative workshop was organized on 5
th
June 2014 at UmubanoHotel Kigali.
Participants were from Government Institutions, UN family and civil society
organizations and Faith based organization both women and men partcicipated including
sex workers representatives as key informant persons.
3. 1 Opening Remarks
During the opening remarks VCO represented by his Chief Executive Officer Mr. Innocent
MUSORE. In his welcome remarks of various organization representatives who attended
the workshop, the Chief Executive Officer (CEO) of Voice of Community Organization, Mr.
Innocent MUSORE highlighted the importance of the event and requested everyones
contribution to make an event successful and to strategically target Female sex workers
and male clients of female sex workers with HIV services. Also appreciated the technical
support from RBC and financial support from UNAIDS on HIV response in Rwanda. He
emphasized on Rwandas continued progress towards universal access to HIV and AIDS
services, but still we have to do in the area of HIV prevention.
This was mentioned in reference to the BSS 2010 for sex workers which revealed that
HIV prevalence among female sex workers is at 51%. Therefore clients of female sex
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workers are at high risk of HIV infection yet the HIV prevalence among clients of female
sex workers is not known. The clients themselves are not known.
Mr. Innocent stressed the importance to mobilize leaders and experts in HIV response to
think about this issue and encouraged individuals, Civil Society organizations and private
institutions to act positively towards a sustainable response targeting male clients. I
hope we will be able to come out with some concrete and appropriate strategies
approaches and actions this workshop comes at the right time he reiterated.

The UNAIDS Country Director Dr. Dludlu Sibongile commended the Government of
Rwanda for its leadership in HIV response and the involvement of civil society
organizations in this journey towards ending AIDS epidemic. She appreciated the
initiative of VCO to organize such an important meeting to think about strategies to
target male clients of female sex workers. As you might be aware mixed AIDS epidemic
but also concentrated in certain groups. The BSS 2010 for sex workers revealed that HIV
prevalence among female sex workers is at 51%.She highlighted.

According to the same source about 66% of FSWs reported that the most frequent
clients were married men, 21% of FSWs reported that their most frequent clients were
widowers, while 13% reported that their most frequent clients were single. This
evidence, said Dr Sibongile, constitutes a CALL for actions and specific interventions
targeting male clients of female sex workers as well as their clients.

The representative from Rwanda Bio Medical Centre (RBC/IHDPC) Mr Aimable
MBITUYIMANA, HIV BCC/IEC specialist and RBC/ MoH the said that it the pleasure to
participate in such consultative meeting on strategies targeting male clients of female
sex workers.FSWs may contribute up to 46% of new infections in Rwanda, & their
clients up to 11%, this data shows how this group is at high risk of HIV infections. We
have to make sure there are no new infections in Rwanda he said. He thanked VCO in
collaboration with UNAIDS for this consultation workshop and call up on the active
participation to come out with strategies that will help in to reach national target in
reducing new HIV infection in Rwanda.



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4. KEY PRESENTATIONS
4.1 Overview of HIV epidemic among Key Population & strategies in Rwanda by
Aimable MBITUYIMANA from RBC
The presenter started his presentation by sharing global AIDS progress reporting data
on key populations in Rwanda, He said that , the prevalence among FSWs is 51%,66% of
the most frequent clients of FSW are married men.FSW may contribute up to 46% of
new infections in Rwanda, & their clients up to 11%.Truck drivers (TDs) are one of Most
at risk target groups identified by MoH for HIV and AIDS prevention in Rwanda.MSM are
at high risk for HIV for both physical (unprotected anal sex is a much riskier activity than
unprotected vaginal sex) and social (Stigmatization and discrimination make it less likely
that MSM will attend appropriate medical services for HIV and other STI screening and
treatment) reasons.
He highlighted some achievements where RBC estimated the population size of Female
Sex Workers (FSWs). Determinants of HIV behaviors among MSM in Kigali, Rwanda, and
the supply chain system for condoms in Rwanda. Mr Aimable highlighted some exiting
challenges includes; Quantity and quality of peer educators to reach key populations,
especially hard to reach groups like FSWs and MSM, Inadequate provision of friendly
services for key populations in health service delivery points and Auto stigma of key
populations limiting their capacity to access available services.
In his conclusion, he mentioned that HIV is still a public health challenge in Rwanda.
Specific and evidenced based interventions should be oriented and targeting Key
Population groups. Determining & ensuring roles of each & everyone (Government,
NGOs) is crucial towards best achievements for HIV response

4.2 Presentation on Findings of Gender assessment done by Mr. Dieudonne
RUTURWA from UNAIDS
Mr Ruturwa said that It was revealed that more than half (54%) of the Rwandan
population is under 19 and Young women between 18-24 years old are at considerably
higher risk for HIV infection than their male counterparts; due to conservative attitudes
toward sex and sexuality - not discussed at home, Gender inequality in relationships,
especially cross-generational relationships; girls cannot negotiate sex, have less access to
condoms. Also Sex workers and their clients: prevalence among sex workers is high
(51%); Clients of sex workers are expected to account for 19% of new transmissions.
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The Gender Assessment identified seven key recommendations for strengthening a
gendered HIV response and number of targeted recommendations aimed at addressing
specific gaps or barriers.
The key recommendations are summarized and should be used to guide planning,
programming, monitoring and evaluation of HIV programs and activities, as well as
interventions addressing gender equality and/or gender-based violence and HIV
epidemic

Promoting gender equality in HIV
programs
Advocating for an enabling
environment
Ensuring meaningful participation in
the response
Eliminating gender-based violence and
discrimination
Ensuring accountability for gender
equality
The presenter said that subordinate status of women and the stigma of being a sex
worker provide double vulnerability and inequality in relationships sex workers at
disadvantage to negotiate condom use. Among other key highlights include Sex workers
at risk for violence unable to report due to illegality of sex work, Clients of sex workers
link with larger sexual networks that can increase transmission risk, Clients frequently
are older men and men living in urban areas (Kigali City), Violence due to traditional
gender roles: e.g. husband beating wives, as well as stigma-related violence, Traditional
attitudes about sex discourage condom use; use of condoms signifies promiscuity or lack
of trust ; taboos around discussing sex/sexuality, Many men believe sex with a condom is
less pleasurable, Campaigns and condom distribution strategies have increased
availability, accessibility and affordability , but not necessarily uptake especially among
young men (80% report ability to obtain, but 66% report use at last sex)

In conclusion, he said that the GBV is a contributing factor to the epidemic where 54%
of women have ever experienced physical or sexual violence. We have to fight against
stigma & discrimination and any violence related to gender and therefore this will lead to
zero new HIV infections in Rwanda said Dieudonne.
4.3 SOPs for the condoms supply chain system in the Public Health sector for key
populations" presented by Andrew Ntwali from UNFPA
The presenter highlighted that sex the most practiced sport on earth, the main action
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leading to pregnancy, the main driver of the HIV transmission, it is not a fatality but a
reality, under the right circumstances, sex is a beautiful act of life and for most people, it
gives pleasure.
Services Challenges Action point
Condom
availability and
accessibility
Fight stigma around condom use and
ensure better access to condoms for
youth and key populations
Improve the community-
based network for
condom distribution,
prioritizing availability for
youth and key
populations

It was agreed that condom is the most effective prevention of HIV infection& RBC
highlighted that there is an overstock of condoms and among the highlighted strategies
of distribution includes; district& other private pharmacies and other health facilities,
government institutions (ministries), hotels, bars and schools, cooperatives or
associations, NGOs and youth groups. It was stressed that community health workers
should play a big role in the distribution at community level.To end AIDS, we need HIV
prevention options that are highly effective before, during and after exposure or
infection said Andrew.
5. Group discussions
Three group discussions were formed to
discuss on strategies for reaching out
male partners clients of female sex
workers. In each of the group there were
representatives of the Female sex workers
who served as key informants. Each group
prepared and presented in plenary key
points of the strategies to inform further
planning to reach out and communicate
prevention messages to male clients and appropriate techniques were formulated and
presented including use of interpersonal communication, dissemination of IEC materials,
set up of condom outlets and distribution of condoms in public high risk areas, involve
media (newspapers, billboards, radios, talk shows and map out special sites of male
clients to inform the delivery of messages to male clients of female sex workers. The
following recommendations were formulated during the group discussions:

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Conduct researches on male clients of sex workers
Focus groups with female sex workers and their clients
Trainings and campaigns emphasizing on risk perception male clients of FSWs
Trans-boundary programs targeting TDs
Closing remarks, the CEO of Voice of Community Organization appreciated participants
for their active participation and effort to fight against new HIV infections in Rwandan
populations and thanked RBC for collaboration and UNAIDS for the financial support to
Voice of Community Organization programs related to HIV prevention in Kigali city
The representative from RBC appreciated the initiatives of targeting males clients of
females sex workers and thanked UNAIDS for the support to the government of
Rwanda and he promised to collaborate to continue to collaborate with Voice of
Community Organizations and others civil society Organization to improve the wellbeing
of people and reduce new HIV infection and he declared to closed the workshop .

6. Activity 2: TRAINING OF OUTREACH PEER EDUCATORS IN 3 DISTRICTS OF KIGALI
CITY
A training of 40 selected outreach peer educators (30 women and 10 men) on increasing
knowledge of peer educators to reach male clients of female sex workers on AIDS
epidemic as well as accelerating PMTCT and male clients access to health services in
Kigali City held at Saint Francois dAssise on 7th July 2014.

During opening remarks the Chief Executive Officer of Voice of Community Organization,
Mr Innocent MUSORE, welcomed all participants by emphasizing on the importance of
the training and the role of peer educators in reaching female sex workers and their
clients for HIV response. He also appreciate the financial support from UNAIDS and the
collaboration with Rwanda Bio medical Centre and local authorities from Kigali city. He
called upon participants for active participation during the training for their attention, he
highlighted that this training initially was targeting male clients of females sex workers
but they said they are not ready to have an official training due to culture believes but
they proposed to get information in private way it is the reason that we are training
female sex workers to reach male clients.


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6 .1 KEY PRESENTATIONS
The first session was facilitated by Ayingoma Jean Pierre,HIV Advisor/RBC-MoH and was
on Site assessment and population size estimation of female sex workers in Rwanda,
2012. The following points were highlighted:
He defined Sex work as a mode of HIV transmission between the individual SW, other
high-risk groups and the general population.
The prevalence among female sex workers (FSW) is 51% in Rwanda.66% of the most
frequent clients of FSW are married men. Yet FSW may contribute up to 46% of new
infections in Rwanda, and their clients up to 11%.
Estimating the size of sex workers is important to effectively plan, implement,
monitor and evaluate HIV/AIDS prevention and care programs.
The objective of this size estimation was to provide reliable population size estimates
and an assessment of the sites of FSWs. It was carried out based on the information
provided by FSWs. The total number of FSWs identified in 156 sectors was 9822 and
2395 in Kigali city.
The size of male clients of sex workers could be 7 times higher than those of FSW.
And the main type
of sex work is
street based.
After the
presentation, he came
up focusing on
Alcohol and drug
abuse, sexual violence
and understanding
about condom. He
explained a lot on the
effect of drug and
alcohol abuse on decision making about use of condom before sex. The facilitator took
time to correct many of the misconceptions on condom use. The alcohol and drug abuse
session also helped us understand how these substances can help make one take
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irrational sexual actions. The session on alcohol and drug abuse and use of condom was
quite educative and revealing as peer educators discussed and shared experiences.
Some participants said that their male clients believe that if a man is circumcised he
cannot be infected by HIV which makes them to not use a condom. The facilitator said
that Male Circumcision reduces 60% of risk of contaminating HIV but it doesnt mean to
not use a condom. He encouraged peer educators to explain this fact to their clients and
practice safer sex always.

The availability of health services for female sex workers and clients on HIV testing,
treatment of STIs presented by a health provider from Kicukiro health center

Young female sex workers are mostly targeted as they are at high risk due to having
many partners and being young as well and STIs is also high among sex workers.
The presenter talked about some viruses and STIs as following (1)Human Papilloma
Virus ( HPV):very common and easily transmitted, penile, anal, oral.HPV warts are called
condyloma accuminatum .It may be internal if anal lesions and Increased risk of anal
carcinoma (like for cervical cancer in women).
He said that treating ISTs requires local control of warts, often recurs after treatment
and demands topical wart preparations and needs surger. (2)Herpes Simplex Virus
(HSV1:mainly oral symptoms and HSV2:mainly genital and anal symptoms):It causes
blisters and painful ulcers, recurrent symptoms for life,easy to spread ,incurable, no
vaccine and might increase HIV transmission. It is treated and prevented with acyclovir /
valacyclovir.(3)Gonorrhoea: easy to transmit, does not require transfer of sexual fluids
or blood and is exposed during anal or oral sex(anal pain and deep seated pain).

The facilitator defined also the confidentiality of medical information in the following
points:
The ethical principle or legal right that doctors, nurses and other health professionals
will hold secret all information relating to a patient, unless the patient gives consent
permitting disclosure.
Members of the health care team have the right to share health-related information
with one another for the purpose of providing clinical care. This only includes health
care professionals who have a need to know this information in order to provide or
supervise the care of a given patient.
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After the presentation, some participants reported having experienced STIs and other
diseases. Some had been tested and treated but others are not. They suggested
providing many health facilities for FSWs as they are afraid of going to health centers
that are unaware of dealing appropriately with key populations
7. Group discussions
Peer educators were gathered in three groups and discussed on problems they met at
health facilities; factors that make female sex workers and their clients to not use a
condom and which steps can be taken
to access on health care services.

Sex workers highlighted a challenge
that Availability of condoms among sex
workers has decreased so they required
to have condom in public box as
usually and use of alcohol among clients
and sex workers at the time of
purchasing sex is common.

Sex workers said that clients played
sex workers more money for sex without condom it was also recommended to carry out
quantitative research to map out the number of male clients of sex workers and their
risk perception. In addition, it was highlighted to train female sex workers as peer
educators to deliver messages to their clients.

By closing the training, the Chief Executive Officer call outreach peer educators to
identify and use knowledge acquired from the training in reducing New HIV infection
and to work with existing program in their respective settings in sharing what they
have learnt in this training in increasing HIV risk perception for behavior change.

8. Summary of recommendations of two activities
Advocacy for access to health services for key populations
Training of health workers to provide friendly, adequate, sensitive and confidential
services to females sex workers and their clients
Sensitization meetings with local leaders on awareness of key population as a
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priority in HIV prevention programs
Provide funds to start up income generating activities(IGAs) and technical support
on vocational education training (TVET)
Increase the number of days of training for peer educators
Train Health services on Health care for Key population
Equipping female sex workers and their male clients with the required knowledge
on HIV/AIDS
Increase the number of bill boards and screened messages addressing clients of
female sex workers
Dissemination of IEC materials(specific messages for male clients) in hotels , bars a
lodges and Hotspot in Kigali city
Set up of condom outlets and distribution of condoms in public high risk areas
Use of media (newspapers, billboards, radios, talk shows,)








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