Reprogramming 8/07: This activity has been abandoned.

This activity relates to activities in HBHC (8716, 8139).

The overall goal of this activity is to screen 3,000 HIV-positive women for cervical cancer and treat women found to have treatable lesions.

Cervical cancer, caused by the human papilloma virus (HPV), is the most common cancer among women throughout the developing world. HIV infection, especially in the later stages of immune dysfunction, has been shown to enhance the neoplastic effects of HPV, thereby increasing the incidence and progression of low- and high-grade cervical cytologic lesions. Prevention, detection and treatment of cervical cancer are therefore especially important for HIV-positive women.

In the US and Europe, screening for and treatment of cervical cancer is a basic standard of care for HIV-positive women. However, such care is generally absent for HIV-positive women in developing countries, principally for lack of capacity to collect and evaluate large numbers of pap smears. The incidence of cervical cancer in Rwanda is unknown; however, as in many other places in Sub-Saharan Africa, it is presumed to be many-fold higher than in the US or Europe, particularly among HIV-positive women.

Over the past 20 years, a growing body of literature has accrued regarding a new approach: Visual Inspection with Acetic acid (VIA or "see-and-treat") as an effective strategy for cervical cancer control in the developing world. Pap smears are eliminated from the diagnostic protocol and replaced with direct observation of the cervix (image-enhanced with dilute acetic acid) and immediate treatment of any visualized lesions. When suspicious lesions are found, simple, low-cost cryotherapy equipment is used to ablate the lesion while retaining full potential fertility. VIA is easier to use, can easily be taught to most medical personnel including nurses and midwives, and can be performed without complex and expensive equipment.

In FY 2007, Columbia will provide cervical screening by VIA and cryotherapy for 3,000 HIV-positive women over 35 years of age. They will be treated at CHK and at the National University Hospital of Butare. Women with lesions not amenable to treatment with cryotherapy will be provided with colposcopy, LEEP, and biopsy. Based on extrapolation from the prevalence of neoplastic changes previously found in VIA activities in Rwanda, 35-40% of the HIV-positive women are expected to have detectable lesions. In a subset of the HIV-positive women, we will also collect conventional pap smears, and pre-ablation biopsies will be performed on women with colposcopic findings, making it possible to assess the positive and negative predictive value of VIA in this population. Cytopathology and histopathology will be performed both locally and with a US partner so as to build local capacity through training of Rwandan diagnostic personnel (pathologists and cytotechnicians). Also included will be on-site training for Rwandan physicians, both generalists and gynecologists, to perform colposcopy and LEEP for the estimated 6% of women who require it.

This activity reflects the ideas presented in the Rwanda EP five-year strategy and the National Prevention Plan by contributing to the expansion of palliative care among those currently under treatment. Such preventative services that are offered by this activity will have significant implications on improved overall health of PLWHAs and will increase the capacity for facilities to offer effective palliative care.

While this effort to treat women with cervical cancer will result in new data about the frequency of treatable cervical lesions in HIV-positive women and the feasibility of including such care within PEPFAR, the activity is not primarily proposed as a public health evaluation. There is ample evidence in the medical literature to clinically justify regular screening for Rwandan women with HIV. Nevertheless, in recognition of the fact that generalizable knowledge will be gained in the course of providing care to women who need it, a Technical Evaluation backsheet will be submitted for this activity as well as a detailed protocol for IRB review in accordance with standard procedures.

This activity supports EP plan for basic care and support and will inform national HIV program on the burden of cervical cancer among HIV positive women and treatment

effectiveness.

Reprogramming 8/07: With these additionnal funds Columbia University will hire additionnal staff with focus on TB.HIV surveillance in prisons. These staff in collaboration with CDC office in Rwanda and with the technical assistance from CDC TB department will conduct surveillance activities in prison and coordinate on-going public health evaluations in TB.HIV in Rwanda

TB is a leading cause of morbidity and death among PLWA because of atypical clinical presentations of TB in that population. Those clinical presentations are hard to diagnose without a strong lab component of the TB care system. PEPFAR Rwanda supported the national TB and HIV program in this area with provision of X-ray machines and training since 2006 but less progress has been made in strengthening and expanding TB lab capacity. PEPFAR Rwanda is proposing to use these new funds to upgrade the TB lab in NRL and Butare and establish a network for TB culture from all TB diagnosis centers to those two reference labs.

The upgrading will include infrastructure improvement by renovation, introduction of new techniques like liquid culture, PCR, rapid test and additional techniques for TB diagnosis in children. Transportation will be provided to the 2 labs for TB lab networking. Additionnal staff will be recruited and trained in these new techniques. These new funds will contibute to support the training and supervision of all TB providers in Ziehl Nielsen staining technique, and a better coordination of TB activities between PNILT, NRL/CHUK and TRAC. In addition monitoring & evaluation as well as quality assurance systems will be strengthened. The CHK pathology lab will be upgraded to cope with the increasing demand of TB related pathology lab. Finally these funds will support the drafting of a national strategic plan for TB lab and networking strengthening as well as a plan for the integration of TB and HIV activities.

TB infection control is becoming a pressing issue as more people living with HIV/AIDS with higher susceptibility to TB are attending health care facilities and mingle everyday with patients with suspected TB. PEPFAR Rwanda has initiated a process to review and update national infection control guidelines and provide training to hospital staff. The implementation of these new guidelines will require some investments in infrastructure rehabilitation. With these new funds PEPFAR Rwanda will renovate two districts hospitals to comply with the new guidelines. This activity will reduce the rate of nosocomial TB infections, improve the work conditions for hospital staff and offer a better care environment for people living with HIV/AIDS .

This activity relates to activities in HVTB (7162, 7266, 7241, 8146), HTXS (7164, 7246), and HBHC (7177).

In FY 2006 Columbia University supported PNILT and TRAC to ensure integration of TB/HIV programs at the national level. Key accomplishments included: development, revision and implementation of national policies, tools and guidelines; strengthening M&E for national TB/HIV activities; design TB/HIV training modules based on international guidelines; coordination of training of service providers to implement and integrate TB/HIV activities and support to two TB/HIV model centers to pilot and scale-up TB/HIV activities. Dedicated TB/HIV staff at both centers implemented new TB/HIV activities, recording and reporting tools to ensure quality care for patients with TB and HIV. Achievements at the two model centers included: increasing HIV testing for TB patients from 50% in 2005 to 92% by the second quarter of 2006; Cotrimoxazole provision to all patients with TB and HIV. By the end of FY 2006, national indicators for screening PLWHA for TB will be piloted and implemented at both centers. Patient care and program results are reviewed regularly by TB and HIV service providers at both centers.

In FY 2007, Columbia University will support TB/HIV collaborative activities at the central level through continuing support for the existing long-term TB/HIV technical advisor at PNILT. This advisor will continue to support the national TB/HIV working group, support implementation and oversight of TB/HIV activities. Other activities will include revision of guidelines, curricula and tools, including national infection control guidelines, guidelines for the diagnosis of smear-negative and extrapulmonary TB, and pediatric TB guidelines (including a national TB screening algorithm for HIV-infected children) in coordination with WHO/OGAC project.

The technical advisor will also transfer skills and competencies to locally recruited TB/HIV advisors at PNILT, TRAC and the model centers to sustain TB/HIV integration in Rwanda. Columbia University, in collaboration with other USG partners will continue to lead implementation of new TB/HIV activities at the two model centers. Activities will include monitoring the burden of the TB immune reconstitution syndrome, expanding TB contact tracing and counseling and HIV testing of family members of patients with TB disease and HIV.

As TB/HIV activities have expanded in Rwanda, detailed program information and review has become increasingly important at all levels. Columbia University will support PNILT to implement a standard electronic TB register to be phased in at selected sites in 2007 and expanded nation-wide in 2008. This register has already been developed and is currently used in South Africa, Botswana, and Tanzania and will be adapted to additional focus countries in upcoming months. EP sites will have the ability to link TB data to TRACNet via a patient's TRACNet ID number.

TB/HIV technical advisors will be supported to participate in international TB/HIV conferences to share the Rwanda experience in rolling-out TB/HIV interventions and also learn from others countries' experiences. Short-term TA will be provided to the country team to ensure program quality and share lessons learned from other countries.

These activities support country 5-year strategic planning under its component of Integration of HIV into the overall health system and EP plan to increase ART patient enrollment.

[CONTINUING ACTIVITY FROM FY2006 - NO NEW FUNDING IN FY2007]

This activity relates to CT activity 2800.

In FY2005, Columbia University initiated innovative family and home-based testing activities to more effectively reach family members of PLWHAs with CT services. In FY2006, Columbia will scale up two of the models piloted in FY2005 with the goal of strengthening linkages between clinical services and home- or family-based care. These models are: 1) going to the homes of index patients to provide CT services to their family members, and 2) working with PLWHA associations to counsel and test family members of PLWHA. In the second model, CT services may be provided to relatives of PLWHAs either at the meeting place of the PLWHA association or at the ART center via whole-blood (finger-prick) rapid tests. Individuals targeted under this activity will not need to go to VCT sites for CT services. Counselors -- whether members of the PLWHA associations, case managers or site staff -- will maintain confidentially in accordance with the MOH guidelines. Columbia will carry out these activities in collaboration with the Rwandan Network of PLWHA and staff at Columbia-supported ART sites. The target for the number of individuals tested in FY2006 is 2000. This activity advances the Rwanda EP five-year strategy of integrating care with prevention and treatment services and expanding CT services beyond the health facility.

HIV/AIDS Pediatric care uptake has been slow in Rwanda because of the scarcity of pediatricians and the lack of skills from general practitioners. In COP07 PEPFAR Rwanda funded the extension of training and supervision of general practitioners by a team of pediatricians and senior MDs. With these new funds PEPFAR Rwanda will support additional training of trainers and providers in pediatric care and treatment, production and revision of pediatric HIV care and treatment manuals and tools, recruitment of needed pediatricians or medical doctors for district hospitals, and mentoring supervision of pediatric antiretroviral treatment at new USG-assisted sites. In addition to clinical management the training will emphasis on pediatric patient recruitment and follow-up. This activity will increase pediatric patient enrollment at national level.

This activity relates to HTXS (7158, 7161, 7164, 7176, 7190, 7246, 7256, 7262, 8172).

In FY 2006, Columbia UTAP supported TRAC and the MOH to revise norms and guidelines for HIV/AIDS care and treatment, including pediatric HIV/AIDS. In collaboration with IntraHealth, Columbia supported TRAC to design training curricula, clinical protocols, job aids and other tools to facilitate nurses' greater responsibilities in treating children with HIV/AIDS. In addition, Columbia established model pediatric HIV/AIDS care and treatment centers in two reference hospitals, CHK and CHUB. HIV positive children identified in VCT, PMTCT, nutrition centers, nearby PLWHA associations and outpatient clinics are referred to these centers. CHK and CHUB pediatricians conducted regular visits to other hospitals and health centers and trained 100 health care providers on pediatric HIV/AIDS management, and 18 district health teams on proper supervision. By the end of FY 2006, 800 children will be enrolled in care and 270 on ART at the two model centers.

In FY 2007, Columbia will support the MOH for the expansion of pediatric HIV care and treatment services and effective integration of HIV/AIDS services into the national health system.

Columbia will continue to support the model pediatric HIV/AIDS centers at CHK and CHUB to enroll 1,242 new patients into care, of which 360 will be on ART. Through expanded provider initiated testing and PCR testing for early infant diagnosis, additional children requiring care will be identified in PMTCT programs, nutrition rehabilitation centers and PLWHA associations. Psychosocial support, counseling, monitoring and evaluation systems will be strengthened to improve follow up. CHK and CHUB pediatricians will provide training, mentoring and supportive supervision to 200 health care providers at EP-supported ART sites. Columbia will identify barriers to improving pediatric care and treatment and devise strategies and activities to overcome them.

In order to effectively integrate HIV/AIDS services into the national health system, Columbia will provide TA to the MOH to implement district level HIV/AIDS training plans and train district medical officers on financial management and supervision.

These activities fully support the Rwanda EP five-year strategy for national scale up and sustainability, as well as the Rwandan Government ART decentralization plan.

This activity relates to activities in HLAB (7262, 7244, 8189).

In FY 2006, Columbia provided management and technical assistance to the NRL through long-term advisors, as well as through short-term consultant support. Key FY 2006 accomplishments in the management area include the development of a costed five-year strategic plan for NRL, and the submission of an application for a CDC cooperative agreement. In technical areas, through a subagreement and TA, Columbia assisted NRL to maintain its QA systems for HIV serology and CD4 testing, with over 60,000 serology specimens tested for quality, and all CD4 laboratories participating in the national QA system. Columbia began development of a data management system for NRL and the peripheral laboratory network through an expert consultancy and stakeholder discussions. Columbia also led the development of a protocol for laboratory evaluation of DPS specimen collection for viral load testing for hard-to-reach health facilities.

In FY 2007, Columbia will continue its capacity building activities at NRL by supporting technical activities as well as strengthening institutional infrastructure and management capacity critical to sustain the national network of laboratories for the Rwandan HIV care and treatment program. Direct TA will be provided through long-term advisors and periodic short-term assistance. Two long-term technical advisor positions will be continued in FY 2007. The first is an international-hire position providing support for quality HIV-related laboratory services, including evaluating new technologies, technician trainings, and guidance on technical and policy issues. The second is a continuing local-hire senior lab technician responsible for development and implementation of national standards, QA systems, and training. These technical advisors will continue to transfer skills, knowledge and capacity, ensuring sustained impact. Short-term advisors will also be utilized as needed for specific projects.

TB services at NRL require strengthening to meet the EP priority of providing quality direct AFB microscopy at the health facility level. Columbia will expand laboratory TA to the NRL TB laboratory to ensure high quality QA of smear microscopy, culture and drug sensitivity testing capability. These activities are essential to improve the diagnostic capability of the 174 TB diagnostic and treatment centers in Rwanda, in order to provide adequate access of basic QA smear microscopy services to all PLWHA that have active TB disease. This is also essential to support the management of patients with MDR TB and to avoid potential development and transmission of resistant disease among those PLWHA with active TB disease.

Columbia will continue to improve reference laboratory management through support for an international-hire management advisor. The laboratory management advisor will help develop management systems for finances, logistics, program data, transport and commodities and will mentor the new NRL Director of Finance position funded under the CDC cooperative agreement. The management advisor position continues to be critical in strengthening NRL's capacity to effectively manage multiple streams of funding, including substantial USG EP resources.

In collaboration with CDC, Columbia will continue the planning and implementation of a laboratory information system for NRL and district hospitals. Columbia will adapt existing software systems developed through CDC partnerships in other countries for use in Rwanda. The laboratory information system will streamline financial record keeping, as well as specimen tracking, inventory control, and programmatic indicator tracking. This activity was funded in FY 2006, but the anticipated implementation partnership could not be finalized and so the activity will be carried over into FY 2007.

These activities are consistent with Rwanda EP five-year strategic goals of strengthening NRL capacity to manage a national network of laboratories and the standardization of technical approaches and QA of HIV-related services throughout the national laboratory network.