PMTCT services uptake in Rwanda is high as indicated by ANC attendance and HIV counseling and testing. However mother and infant follow-up is weak due to high rates of home delivery and infants lost to follow-up. With these new funds MCAP will use its network of PLWA associations (in which most women and/or their husbands are registered) to increase hospital delivery for positive pregnant women thus ensuring completion of the new PMTCT regimen. In addition, MCAP will reinforce its outreach team and the MoH health animators with training, and transportation in order to track PMTCT defaulters and give them home visits if needed. MCAP will support PMTCT services providers in HIV care and treatment with emphasis on pediatric care. In addition, MCAP will ensure that all newborns to HIV positive mothers are put on Cotrimoxazole preventive therapy until confirmation of their HIV-negative status.

MCAP will sustain the PMTCT follow-up system through support to the sites for formal meetings and referrals to ensure that mothers and exposed children are followed up regularly in PMTCT ward but also from vaccination, TB and nutrition wards and to care and treatment ward.

This activity relates to activities in HTXS (7174, 7176), HVCT (7178, 7170, 8185), HBHC (7165,7177), HVOP (8133), MTCT (7181, 7208, 7202, 7219, 7244), HVOP (8133), HBHC (7165, 7177), HTXD (8170, 7214), HVSI (7237), HKID (8150), HHVA (8186), HVTB (7162, 7169), and HLAB (7172).

In FY 2006, Columbia is providing financial and technical assistance for PMTCT services in 14 health facilities in the Western province of the country and in Kigali. The PMTCT package includes CT, infant feeding counseling, CD4 count and clinical staging for HIV-positive woman, combination ARV regimens non-eligible women and HAART for eligible women, and delivery following safer practices, infant and mother follow-up, CTX for OI prevention and infant HIV testing.

In FY 2007, Columbia will provide an expanded package of services for 17,328 pregnant women, including an estimated 728 HIV-positive women at 10 existing CT/PMTCT/ART sites, 4 existing CT/PMTCT sites, and 6 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 (582) are expected to complete the course of ARV prophylaxis.

Columbia 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 FP and MCH services, and close follow-up of HIV-exposed infants for effective referral to appropriate services, and early infant diagnosis, where possible. In addition, Columbia 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, Columbia 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, Columbia will work with IntraHealth to incorporate safe motherhood, FP, and GBV screening into PMTCT activities. Columbia 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.

Columbia 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, Columbia will provide ARV drugs, CD4 tests, RPR test kits, PCR, rapid HIV test kits, and hemoglobin testing materials to all supported sites. Columbia will also collaborate with RPM+ to improve the capacity of providers in drug management, coordinated site-level storage, inventory, tracking and forecasting. In addition, Columbia will collaborate with CHAMP, GFATM and PMI to refer 728 PLWHA and their families for malaria prevention services including bednet provision. In collaboration with CRS, Columbia will provide weaning food for exposed infants in need. In addition Columbia will leverage food aid from Title II and the World Food Program to meet the other nutritional needs of these food insecure households.

Columbia will provide a package of support to six 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. Columbia 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, Columbia 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 HVAB (7157), HVOP (8133) and HBHC (7177, 7187).

In FY 2006, Columbia University began providing prevention for positives services as part of the clinical care package to 22,000 PLWHA enrolled at 35 clinical sites. Social workers and nurses conducted prevention education on a regular basis at those sites. In addition, they also trained peer educators, PLWHA and community volunteers to conduct extensive prevention outreach in the community and at PLWHA associations.

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 a standard prevention for positive package for beneficiaries starting in FY 2007.

In FY 2007, Columbia University will provide prevention messages, focusing on abstinence and reduction of sexual partners to 51,000 beneficiaries at 35 existing sites and seven new sites as well as their surrounding communities. During each clinical exam, consultation, and pharmacy visit, doctors, nurses and social workers who will function as case managers will provide prevention education to patients using the nationally approved curriculum and IEC materials for youth and pre-marital couples. Different messages will be used to match patients' profiles, circumstances and prevention needs.

Using CRS‘s "Avoiding Risk, Affirming Life" curriculum and materials, Columbia will train 268 nurses social workers, community volunteers, youth and PLWHA to conduct AB education in the community and with members of nearby PLWHA associations and their families.

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

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

This activity addresses the key legislative issues 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 HVAB (8186) and HBHC (7165, 7177).

In FY 2006, Columbia University began providing prevention for positives to 22,000 PLWHA enrolled in care at 35 sites. Social workers and nurses conducted education sessions, and peer educators at 10 district hospitals received training to promote CT among PLWHA association members and their families.

In FY 2007, Columbia University will continue the activity, expand the clinical services during post-test counseling for all clients, and add follow-up counseling with HIV-positive patients and their family members. Appropriate prevention messages will be integrated into the clinical setting and home based care, focusing on safer sex practices such as correct and consistent condom use, alcohol reduction and the link between HIV and GBV. These messages will reach 32,000 patients enrolled in HIV care at 35 existing and seven additional clinical sites. The messages will also reach 9,000 family members. A total of 250 nurses, social workers and community volunteers will be trained to conduct the education in the community and enrolled patients will be encouraged to bring their family members to HIV prevention sessions. Members of PLWHA associations and their families in the catchment area will also be encouraged to access those sessions.

During each interaction with the health facility - whether for pharmacy visit, clinical staging, CD4 count or health promotion meetings - social workers and case managers will provide HIV prevention messages and condoms with supportive CNLS-approved IEC materials. A condom demonstration session will be performed at consultations for all PLWHA, and at the CT session for their family members who are over age 14. Different messages will be used to match patients' profiles, circumstances, and prevention needs. Emphasis for this activity will be placed on reaching HIV-positive discordant couples and ART patients. Unmarried sexually active men and women who are HIV-negative but practice risky behaviors will also be counseled and supported to adopt risk reduction behaviors and the appropriate, consistent use of condoms.

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

This activity addresses the key legislative issues of gender, particularly violence reduction and male norms. This activity reflects the five-year EP strategy and the Rwandan national plan for HIV infection prevention and EP for 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, Columbia provided basic palliative care to 22,000 PLWHA at 35 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, Columbia 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, Columbia 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, Columbia will expand its package of palliative care services for the 22,000 existing patients in care and add 10,000 new patients at 35 existing and seven 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, Columbia 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. Columbia 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, Columbia 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 Columbia-supported health facilities and community-based providers, including GBV counseling, positive living, and counseling on prevention for positives.

Columbia 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, Columbia 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, Columbia, 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. Columbia-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 294 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. Columbia 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. Columbia will support health facilities to refer HIV-positive children to OVC programming for access to education, medical, social and legal services. Columbia 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, USAID 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. 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. Columbia 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.

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

In FY 2005, Columbia supported the GOR for national TB/HIV integration with TA to the MOH on TB/HIV policy and guidelines design. In FY 2006, Columbia started implementing these policies and guidelines at 35 clinical sites. The program's achievements include an improvement in the percentage of TB patients screened for HIV from less than 50% to 83%. In addition, at Columbia-supported sites, 60% of 22,000 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 FY2007, Columbia will continue to support 35 existing sites and add seven new clinical sites for the implementation of the TB/HIV component of the clinical package of HIV care. This activity has eight components: the first component is to implement routine provider-initiated HIV testing to an estimated 1,500 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 32,000 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 1,000 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 150 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 5 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 HVOP (8133), HBHC (7177), HTXS (7164, 7174) and HVCT (8167, 8730).

In FY 2006, Columbia is supporting care and treatment services in 35 sites and reaching approximately 7,000 clients with PIT. Per GOR norms, VCT will be offered in sites where patients can receive needed basic care such as PMTCT, CD4 staging, OI prophylaxis and treatment, and referral to community services and higher level clinical care. In order to improve the efficiency of CT services, partners are moving to rapid testing and advanced strategies for testing. In order to reach more clients, partners have increased male partner testing of PMTCT clients through community sensitization, facilitated couples testing through weekend CT services, improved pediatric case-finding through testing during immunization days and special family/child testing days during vacation days.

In FY 2007, Columbia will reach 30,240 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 35 existing and 7 new ART sites. At all Columbia-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 200 doctors, nurses and social workers at Columbia 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, 63 new "contact counselors" will be recruited to conduct contact tracing of all patients who test positive for HIV at Columbia 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.

Columbia 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. Columbia 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, Columbia 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, Columbia 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. Columbia 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 HTXS (7158, 7161, 7164, 7176, 7185, 7213, 7222, 7246, 7262, 8172), MTCT (7179), HVAB (8186), HVOP( 8133), HBHC (7177), HVTB (7180), HVCT (7178), HTXD (8170), and HLAB (7224, 8189).

In FY 2006, Columbia is providing a comprehensive package of ART services at 35 sites serving 10,620 patients, including 1,076 children. The package includes treatment with ARV drugs, routine CD4 follow up, viral load testing for an estimated 800 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, Columbia will expand quality clinical services to an additional seven sites, continue support to the DHTs, increase sustainability through performance-based financing, and strengthen SI at all levels. This activity will reach 3,600 new patients, including 360 children, enrolled at a total of 42 sites.

With procurement support from PFSCM, Columbia 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. Columbia will strengthen the capacity of eight 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, Columbia 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. Columbia 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.