This activity is related to activities in HTXS (7158, 7161), HVCT (8164), HVOP (8132), MTCT (7179, 7181, 7208, 7202, 7219, 7244, 8122, 8696, 8698), HVOP (8132), HBHC (7163, 7160), HTXS (7213), HTXD (8170, 7161, 7158), HVSI (7237), HKID (8150), HVTB (7162), HKID (8150).

In FY 2007 CRS will provide an expanded package of services for 11,263 pregnant women, including an estimated 473 HIV-positive women at 2 new CT/PMTCT sites, and 11 new CT/PMTCT/ART sites with an emphasis on quality services and continuum of care through operational partnerships, and sustainability of services through PBF. Eighty percent of these HIV-positive women (378) are expected to complete the course of ARV prophylaxis.

CRS will offer a standard package of PMTCT services that includes CT with informed consent, male partner and family-centered testing, IPTp in collaboration with PMI, ARV prophylaxis using combination ARV regimens and HAART for eligible women, IF counseling and support, referral for MCH services, and close follow-up of HIV-exposed infants for effective referral to appropriate services, and early infant diagnosis, where possible. In addition, CRS will ensure access to a comprehensive network of services for PMTCT clients and their families, link PMTCT services with other HIV and MCH interventions, and assure an effective continuum of care by increasing patient involvement and community participation in PMTCT services.

Health center staff will receive new and refresher on-the-job training in the expanded national PMTCT protocol, including use of site-level algorithms and checklists, as well as laboratory monitoring. In collaboration with DHTs, CRS will conduct performance improvement and QA of PMTCT services through regular supervision of sites, coaching, and strengthening capacity of sites in M&E. DHTs will build their QA and M&E skills, including in data collection, data use, and reporting.

Linking with MCH services, CRS will work with IntraHealth to incorporate safe motherhood and GBV screening into PMTCT activities. CRS will strengthen follow-up and tracking systems to ensure testing of family members, routine provision of CTX PT and infant diagnosis, ongoing infant feeding counseling and support in collaboration with UNICEF, Title II partners and World Food Program, CD4 monitoring and clinical staging, management of OIs, including TB and other HIV-related illnesses, psychosocial support services at clinic and community levels, identify and refer women who may be victims of gender-based violence to appropriate care in collaboration with Twubakane, and access to clinical and community prevention, care, and treatment services for family members.

CRS will assure linkage to treatment for eligible women and infant follow-up by using peer support groups, community mobilization, community volunteers, home visits, referral slips, community-based registers, patient cards and other monitoring tools to facilitate transfer of information between facilities and communities. To ensure these linkages, case managers will train and supervise community volunteers and organize monthly health center meetings with staff from all services to follow-up on referrals and other patient-related matters. In collaboration with CHAMP and case managers, providers will refer PMTCT clients and their families to HBC, OVC support, IGA, and facility- and community-based MCH services promoting key preventive interventions such as bednets, immunizations, hygiene/safe drinking water and nutritional support. These community-based services will assist in the monitoring and tracking of pregnant and postpartum HIV-positive women and their infants, as well as promote MCH and PMTCT health-seeking behaviors. In addition these case managers will ensure referrals of pediatric patients from PMTCT sites and nutrition centers to ARV services.

Through the PFSCM, CRS will provide ARV drugs, CD4 tests, RPR test kits, PCR, rapid HIV test kits, and hemoglobin testing materials to all supported sites. CRS will also collaborate with RPM+ to improve the capacity of providers in drug management, coordinated site-level storage, inventory, tracking and forecasting. In addition, CRS will collaborate with CHAMP, GFATM and PMI to refer 473 PLWHA and their families for malaria prevention services including bednet provision. CRS will provide weaning food for exposed infants in need at all EP-supported PMTCT sites. In addition CRS will leverage food aid from Title II and the World Food Program to meet the other nutritional needs of these food insecure households.

CRS will provide a package of support to two DHTs to strengthen their capacity to coordinate an effective network of PMTCT and other HIV/AIDS medical services. This network focuses on maximizing access to PMTCT and other HIV/AIDS services and improving quality of care at the most decentralized level. Support to DHTs will focus on strengthening the linkages, referral systems, transport, communications and financing systems necessary to support an effective PMTCT and other HIV/AIDS care network. CRS will provide a basic package of financial and technical support to DHTs, including staff positions, transportation, communication, training of providers using the trainers trained by TRAC, and other support to carry out their key responsibilities.

PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, CRS will shift some of its support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Full or partially reduced payment of PMTCT and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national quality supervision tool.

This activity relates to HBHC (7163) and HVAB (7157).

In FY 2006, CRS, in collaboration with Caritas-Rwanda, implemented the "Avoiding Risk, Affirming Life" project which focused on HIV prevention through abstinence, secondary abstinence and fidelity in marriage. CRS developed and distributed peer education and premarital counseling materials in all 22 participating parishes. Since the project began, 230 trained peer educators, teachers and priests have reached more than 32,000 youth and young adults with messages promoting abstinence and faithfulness in marriage. Other FY 2006 activities included a two-day workshop with 90 OVC participating in HIV prevention sessions and a one-day training on child rights and sexual exploitation for 19 church leaders. In June 2006, CRS and Caritas-Rwanda conducted a workshop for 15 newspaper and radio journalists and organized song competitions in the 22 parishes to raise awareness about HIV/AIDS, VCT and the fight against stigma and discrimination.

Since this inception of the EP, all USG clinical partners were expected to provide an integrated health message to all clients. In an effort to both harmonize and improve the quality of clinical services across USG partners, the EP will initiate standard AB prevention for positive interventions for beneficiaries starting in FY 2007.

In FY 2007 through these supplemental funds, CRS will provide prevention messages, focusing on abstinence and reduction of sexual partners to 16,535 beneficiaries in eight existing clinical sites, three additional sites, and their surrounding communities. During visits to clinics and pharmacies, the staff, including nurses and social workers who are hired as HIV case managers, will provide prevention education to patients using the curriculum and IEC materials for youth and pre-marital couples. The AB messages will be tailored to patients based on their age, marital status, HIV status, and identified risk behaviors. Using the "Avoiding Risk, Affirming Life" curriculum and materials, CRS will train 104 nurses, social workers ,community volunteers, youth and PLWHA peer educators to conduct health education for members of nearby associations of PLWHA, their families and communities.

As many risky behaviors can often be linked to other contextual factors such as unemployment, poverty, trauma, and psychosocial needs, CRS will work with CHAMP and other partners to strengthen referrals and mechanisms for patients to access IGA, vocational training, trauma counseling, legal support, mental health care and support for HIV-positive clients.

The integration of AB messages within the clinical package aims to provide a comprehensive services to every client and is part of the USG's strategy to strengthen prevention for positives and continue to reduce transmission of HIV.

This activity addresses the key legislative issue of gender and stigma and discrimination. This activity reflects the Rwandan national plan for HIV infection prevention and EP goal of averting 157,000 new infections by 2010.

This activity relates to activities in MTCT (8185), HVAB (8187), HBHC (7187, 7220, 7245, 8141, 8716), HVTB (7162), HKID (7156, 8148, 8150, 8152), HTXS (7158, 7161, 7213), HLAB (8189).

In FY 2006, CRS began providing basic palliative care to 6,535 PLWHA at eight sites. The package includes clinical staging and baseline CD4 count for all patients, follow-up CD4 every six months, management of OIs and other HIV-related illnesses, including OI diagnosis and treatment, and routine provision of CTX prophylaxis for eligible adults, children and exposed infants based on national guidelines, basic nutritional counseling and support, positive living and risk reduction counseling, pain and symptom management, and end-of-life care. In addition, CRS provides psychosocial counseling including counseling and referrals for HIV-positive female victims of domestic violence. To ensure a comprehensive package of care across a continuum, CRS through the partnership with CHAMP and other community services providers, refers patients enrolled in care to community-based palliative care services based on their individual need, including adherence counseling, spiritual support, stigma reducing activities, OVC support, IGA activities, and HBC services for end-of-life care.

In FY 2007, CRS will expand its package of palliative care services for the existing 6,535 patients and an additional 3,665 new patients at eight existing sites and six new sites, with an emphasis on quality of care, continuum of care through operational partnerships, and sustainability of services through PBF. Under this expanded package, CRS will provide a full range of adult and pediatric preventive care, clinical care, psychological support, spiritual and legal support services across a continuum of care, including provision of CTX prophylaxis for PLWHA and exposed infants in line with national guidelines, strengthened nutritional services through training and provision of nutritional care, including counseling, nutritional assessments using anthropometric indicators, and management of malnutrition through provision of micronutrient and multivitamin supplements, and links to Title II food support for clinically eligible PLWHA and children in line national nutrition guidelines. CRS will also support referrals for all PLWHA and their families for malaria prevention services, including for the provision of ITNs, in collaboration with CHAMP, GFATM and PMI; and referral of PLWHA and their families to CHAMP CBOs and other community-service providers for distribution of water purification kits and health education on hygiene. In addition, in collaboration with TRAC and CHAMP, CRS will ensure the provision of strengthened psychological and spiritual support services for PLWHA at clinic and community levels through expanded TRAC training in psychological support for all CRS-supported health facilities and community-based providers, including GBV counseling, positive living, and counseling on prevention for positives.

CRS will provide referrals for routine CD4, the prevention, diagnosis and treatment of OIs, and ongoing follow-up care for all PMTCT, VCT, TB and ART clients through strengthened linkages and referral systems between these services at clinic level. Through PFSCM, CRS will provide diagnostic kits, CD4 tests, and other exams for clinical monitoring, and will work with PFSCM for the appropriate storage, stock management, and reporting of all OI-related commodities.

In order to ensure continuum of HIV care, CRS, in collaboration with CHAMP, will recruit case managers at each of the supported sites. These case managers with training in HIV patient follow-up will ensure the proper referral of patients through the different services within the health system and the community. CRS-supported sites will assess individual PLWHA needs, organize monthly clinic-wide case management meetings to minimize follow-up losses of patients, and provide direct oversight of community volunteers. In addition, these case managers will train 160 community volunteers and provide them with necessary tools to provide services to patients in the community. The community volunteers will be motivated through community PBF based on the number of patients they assist and quality of services provided. CRS will work with CHAMP to develop effective referral systems between clinical care providers and psycho-social and livelihood support services, through the use of patient routing slips for referrals and counter referrals from community to facilities and vice versa. Depending on the needs of individuals and families, health facilities will refer PLWHA to community-based HBC services, adherence counseling, spiritual support through church-based programs, stigma reducing activities, CHAMP-funded OVC support, IGA activities, particularly for PLWHA female- and child-headed households, legal support services, and community-based pain management

and end-of-life care in line with national palliative care guidelines.

Increasing pediatric patient enrollment is a major priority for all USG clinical partners in FY 2007. Case managers will ensure referrals to care services for pediatric patients identified through PMTCT programs, PLWHA associations, malnutrition centers, and OVC programs. To do this, the case managers will have planning sessions with facilities and community-based service providers, and OVC services providers for more efficient use of patient referrals slips to ensure timely enrollment in care and treatment for children diagnosed with HIV/AIDS. Case managers will conduct regular case reviews with other partners included in the referral system to review the effectiveness of the system, identify challenges and design common strategies to overcome any barrier to pediatric patients routing between services. In addition, adult patients enrolled in care will be encouraged to have their children tested and positive ones taken to HIV care and treatment sites. To expand quality pediatric care, Rwanda's few available pediatricians will train other clinical providers, using the innovative Columbia UTAP model developed in FY 2006 and continuing in FY 2007. CRS will support health facilities to refer HIV-positive children to OVC programming for access to education, medical, social and legal services. CRS will also support sites to identify and support women who may be vulnerable when disclosing their status to their partner, and include in counseling the role of alcohol in contributing to high-risk behaviors.

PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, CRS will shift some of their support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Full or partially reduced payment of palliative care and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool.

In the context of decentralization, DHTs now play a critical role in the oversight and management of clinical and community service delivery. CRS will strengthen the capacity of two DHTs to coordinate an effective network of palliative care and other HIV/AIDS services. The basic package of financial and technical support includes staff for oversight and implementation, transportation, communication, training of providers, and other support to carry out key responsibilities.

This activity addresses the key legislative areas of gender, wrap around for food, microfinance and other activities, and stigma and discrimination through increased community participation in care and support of PLWHA.

Reprogramming 8/07: With these new funds AIDSRelief will recruit an international expert in TB.HIV to work with HIV and TB program for review and adaptation of guidelines, tools and job aids for integration TB.HIV at facility level. The expert will work with the two programs to conduct joint supervision at dsitrict level and support district health teams to conduct TB.HIV supervsiion at health center level. The expert will ensure that PEPFAR clinical partners provide appropriate support to health facilities in training, financial and human ressources to enable them to integrate TB and HIV activities. In addition AIDSRelief expert will coordinate with CDC laboratory advisor and USG HIV community services provider CHAMP project to integrate lab and clinical and community-based TB.HIV activities. In addition AIDSRelief will recuit local TB.HIV supervisors and provide them with transportation for national TB.HIV supervision. AIDSRelief will use part of these funds to provide training to TB services providers for lymphnode specimen preparation and routing to pathology laboratory as well as TA to laboratory to process those specimen. This activity will improve TB.HIV integration at facility, community and laboratory levels.

This activity relates to activities in HTXS (7158), HVCT (8164) and HBHC (7160).

In FY 2006 CRS started implementing national TB/HIV policy and guidelines at their eight supported sites. The program's achievements include an improvement in the percentage of TB patients screened for HIV from less than 50% to 70%. In addition, at CRS-supported sites, 60% of 6,535 patients enrolled in HIV care were screened for TB. All suspected TB cases among PLWHA are screened and referred for TB DOTS, cotrimoxazole prophylaxis, and ART, as appropriate.

In FY 2007 CRS will continue to support eight existing sites and add three new sites for the implementation of the TB/HIV component of the clinical package of HIV care. This activity has eight components.

This activity has eight components: the first component is to implement routine provider-initiated HIV testing to an estimated 300 TB patients at USG-supported sites. HIV testing will be conducted at sites providing TB services. The second component is to provide cotrimoxazole prophylaxis to all HIV-positive TB patients and ensure referral to HIV care and treatment services. The third component is the implementation of intensified TB case-finding among 10,200 PLWHA enrolled in care and treatment at USG-supported sites through routine TB screening using the national standardized questionnaire. The fourth component is to ensure timely TB diagnosis and treatment via DOTS to an estimated 400 PLWHA diagnosed with TB disease. The fifth component is the routine collection, recording, and reviewing of standard national TB/HIV program indicators at sites to inform and improve services. This data will also be routinely reported to the district and national levels through TRAC and PNILT. The sixth component of this activity is to support training of 50 doctors, nurses, social workers, and HIV and TB services providers on TB/HIV integration and standard operational protocols using the newly revised national training modules. The seventh component is to support sites to provide incentives for effective TB and HIV patients' case management and referrals between the two services by implementing clinical and community-based components of the national PBF system. The final component is support for 2 district hospitals to draft and implement a plan of TB infection control according to national guidelines developed in collaboration with WHO/OGAC project.

PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, partners will shift some of their support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Examples of quality indicators include correctly filling stock control cards in X-ray departments, the percentage of TB lab exams that are corroborated during quarterly controls, the number of X-rays of good quality with correct diagnosis and report in patient file, and the number of complete series of AFBs correctly done. Payment of indicators is linked to the quality of general health services through adjustments of payments based on the score obtained using the standardized national Quality Supervision tool and a performance incentive for the production of more than agreed upon quantities of each indicator.

This activity reflects the ideas presented in the Rwanda EP five-year strategy and the

Rwandan National Prevention Plan by advancing the integration of TB/HIV services through the operationalization of policies and increased coordination of prevention, care and treatment services

This activity is related to activities in MTCT (8185), HBHC (7177), HVCT (7261, 8167), and HTXS (7158, 7161).

In FY 2006, this USG implementing partner is supporting care and treatment services in eight sites. CRS does not have specific funding in 2006 for VCT.

In FY 2007, CRS will reach 10,000 individuals through a strategic mix of targeted PIT, family-centered CT, and client-initiated CT services that ensure confidentiality, minimize stigma and discrimination, and reach those individuals most likely to be infected. This activity will support CT services at eight existing and five new ART sites. At all CRS-supported health facilities, PIT services will target adult and pediatric inpatients presenting with TB and other HIV-related OIs and symptoms, malnourished children and HIV-exposed infants, and STI patients. PIT will be implemented with a revised counseling component whereby pre-test counseling is more focused with emphasis placed on post-test counseling. Moreover, case managers and community workers will be trained as counselors in order to provide continuous support beyond the consultation to encourage testing acceptance, family and/or partner tracing, and support for those who received their test results. A total of 100 doctors, nurses and social workers at CRS sites will be trained in PIT.

In collaboration with CHAMP, case managers will work with PLWHA associations, religious institutions, community DOTS programs, and OVC and HBC programs to identify those infected, in particular HIV-exposed infants, family members of PLWHA, and OVC. CT providers will continue to provide traditional CT (client-initiated) for those who wish to know their status, in particular for pre- and post-nuptial couples, ANC male partners, and youth. Counseling messages will emphasize prevention, including abstinence and fidelity, alcohol reduction, GBV sensitization, disclosure of test results, and follow-up care.

In order to counsel and test those individuals most likely to be HIV-positive, 20 new "contact counselors" will be recruited to conduct contact tracing of all patients who test positive for HIV at CRS sites. Contact counselors will be responsible for accompanying HIV-positive clients to their community, encouraging their spouse and family members to be tested, providing HIV testing, and identifying discordant couples who are in need of intensive prevention counseling. As Rwanda moves towards a disease registry-based system, individuals receiving services through these family and couple CT efforts will be entered into a database that utilizes the national identification number as the basis of a case report. Moreover, this system will permit the compilation of a sub-registry of HIV-discordant couples to allow expanded activities in prevention for seropositives. CDC will work with TRAC to establish policies and procedures for family and couples testing, and will play a focal role in the coordination of related M&E.

To strengthen the continuum of care for PLWHA and their families, partners will establish a formalized referral system to link community care and clinical services. The case manager, in collaboration with CHAMP, will ensure that HIV-positive patients are provided patient education, positive living counseling and referral for community-based services, such as IGA, through PLWHA associations, OVC, and HBC programs. At the health facility level, partners will ensure a system for supportive supervision of nursing and counseling staff, including training of select staff in supervision for CT, use of quality control checklists, and data quality control.

CRS will monitor site performance and provide patient referral tools developed by TRAC for timely enrollment of HIV-positive patients diagnosed in any service at the site. CRS will support sites to track PIT and contact tracing data for use at site level for program improvement and reporting. Through regular supervision at sites, patient satisfaction surveys, and HIV testing records review, CRS will ensure that basic ethical practices and confidentiality related to HIV counseling and testing are practiced at all sites.

PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, CRS will shift some of its support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Full or partially reduced payment of CT and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national

Quality Supervision tool.

PFSCM will procure HIV test kits and supplies for all sites. CRS will work with PFSCM and district pharmacies to ensure that all sites have adequate and secure storage facilities as well as inventory monitoring and tracking systems for the test kits.

This activity supports the EP five-year strategy for sustainability, national scale-up of counseling and testing, and provision of integrated treatment, care, and prevention services.

This activity relates to activities HTXS (7158, 7164, 7174, 7176, 7185, 7213, 7222, 7246, 7262, 8172), MTCT (8185), HVAB (8187), HBHC (7163), HVTB (7162), HVCT (8164), HTXD (8170) and HLAB (7224, 8189).

In FY 2006, CRS is providing a comprehensive package of ART services at eight sites serving 2,000 patients, including 200 children. The package includes treatment with ARV drugs, routine CD4 follow up, viral load testing for an estimated 400 eligible patients with decreased or stable CD4 after nine months of HAART, management of ARV drug side effects, and patient referrals to community-based care.

In FY 2007, CRS will expand quality clinical services to an additional three sites, continue support to the DHTs, increase sustainability through performance-based financing, and strengthen SI at all levels. This activity will reach 1,800 new patients, including 180 children, enrolled at a total of 11 sites.

With procurement support from PFSCM, CRS will provide ARV drugs, CD4 tests, and viral load tests to all supported sites. In order to ensure continuum of care, HIV case managers at sites will train and supervise community volunteers including CHWs, PLWHA association members, and other caretakers, in collaboration with CHAMP. Increasing pediatric patient enrollment is a major priority for all USG clinical partners in FY 2007. Case managers will ensure referrals of pediatric patients identified from PMTCT programs, PLWHA associations, and malnutrition centers. In addition, adult patients enrolled in care will be encouraged to have their children tested. To expand quality pediatric care, Rwanda's few available pediatricians will mentor other clinical providers, using the Columbia UTAP model developed in FY 2006.

In the context of decentralization, DHTs now play a critical role in the oversight and management of clinical and community service delivery. CRS will strengthen the capacity of two DHTs to coordinate an effective network of ARV and other HIV/AIDS services. The basic package of financial and technical support includes staff for oversight and implementation, transportation, communication, training of providers, and other support to carry out key responsibilities.

The Rwanda EP will continue a gradual shift in funding from input financing to performance-based financing. Through a strategic mix of input through the district support package and directly to health facilities, and output performance-based financing through the purchase of improved performance for specific HIV indicators, districts will receive the appropriate support to increase autonomy and sustainability.

In addition, CRS will strengthen district and facility level capacity for data collection, reporting and use with focus on ARV drugs management, HIV case management, and improved quality implementation and program evaluation. Sites will generate routine summary reports of patient-level data and will interpret that data to inform their programmatic operations. CRS will also organize periodic M&E workshops for all supported sites to discuss the collection and use of data at the site-level.

This activity supports the EP five-year strategy for national scale-up and sustainability and the Rwandan Government ART decentralization plan and addresses the key legislative issues of gender, stigma and discrimination.