This extension will continue the activities of a current implementer to prevent treatment interruption. During the extension, implementer will make transition to follow-on awardee expected to be determined in late May. [CONTINUING ACTIVITY FROM FY2006 -- NO NEW FUNDING IN FY2007] This activity relates to EGPAF HBHC (5111), ARV (2757), and PMTCT partners (IntraHealth 2774, PBF 2814, FHI (4764), and CHAMP (2805).

In partnership with the GOR and other donors, the EP will improve the quality, efficiency, and sustainability of PMTCT service delivery at existing and new sites through innovative approaches for quality assurance, performance improvement, and health financing. EGPAF will ensure access to a comprehensive network of services for PMTCT clients and their families and link PMTCT services with other HIV and MCH interventions. All EP-funded clinical partners will offer a standard package of PMTCT service delivery; the narratives are consistent for clinical partners, with some variations according to expertise.

EGPAF will support PMTCT services for 20,150 pregnant ANC women, including 1,610 HIV-positive women at 18 existing, 5 new and 6 PBF-graduating sites. EGPAF will ensure the provision of the full package of PMTCT services, including a revised strategy to include opt-out CT with informed consent; male partner testing; ARV prophylaxis using an expanded bi-therapy regimen; IF counseling and support; and referral for FP and MCH services. EGPAF will provide limited technical support to the 6 graduating sites to ensure PMTCT service delivery corresponds with PBF graduation criteria. Targets for the six graduated sites will be divided evenly between the PBF and EGPAF. HIV rapid test kits will be procured through RPM-plus, and ARVs and hemoglobin testing materials for PMTCT will be procured through Columbia MCAP.

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 for laboratory monitoring. In collaboration with DHTs, EGPAF will conduct performance improvement and QA of PMTCT services through regular supervision of sites, coaching, and strengthening capacity of sites in M&E of PMTCT. EGPAF will closely monitor adherence to the new regimen and document lessons learned in its implementation. Through targeted district support, Ngarama and Kabuga DHTs will build their QA and M&E skills, including in data collection, data use, and reporting. Linking with MCH services, EGPAF will work with IntraHealth to incorporate safe motherhood, FP, and GBV into PMTCT activities. EGPAF will strengthen the follow-up and tracking systems postpartum to ensure the following: routine provision of CTX PT and PCR testing for all exposed infants; ongoing infant feeding counseling and support in collaboration with UNICEF and PATH sub-partner; CD4 testing for HIV-positive mothers; management of OIs, including TB and other HIV-related illnesses; psychosocial support services at clinic and community levels; and access to prevention care and treatment services for family members. This could include use of referral slips, community-based registers, patient cards and other monitoring tools to facilitate transfer of information between facilities and communities. To reduce the risk of illness among malnourished mothers and infants, EGPAF will leverage food through WFP for pregnant and lactating women and weaned or non-breastfed infants. Recognizing the links between violence, alcohol and HIV transmission, facility-level lay counselors trained under CHAMP will also help to identify and refer women who may be victims of violence to appropriate care and support. In collaboration with CHAMP and CS coordinators, 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.

This extension will continue the activities of a current implementer to prevent treatment interruption. During the extension, implementer will make transition to follow-on awardee expected to be determined in late May. [CONTINUING ACTIVITY FROM FY2006 -- NO NEW FUNDING IN FY2006] See related activities: CHAMP BHC (2811) and PBF BHC (2815)

Consistent with the EP Rwanda's five-year strategy, COP06 financing will support the initiation of basic and palliative health care services for PLWHAs at all USG HCs. EGPAF will support a standard package of basic care and coordinate community support services outside the HC across a continuum of care in three districts, reaching 6300 HIV-positive patients, including 1700 pediatric patients and 1750 on ART. EGPAF will initiate palliative and basic care services at 15 existing HCs and five new HCs and will prepare six palliative and basic care sites for transfer to the PBF mechanism. Sites will need to demonstrate sufficient technical and institutional capacity before transfer to PBF. COP06 BHC targets and financing for these six sites will be divided between the PBF and EGPAF.

EGPAF will support a standard basic care package for PLWHAs that includes: initiation of an individual patient medical record; clinical staging and CD4 counts; ARV treatment for eligible patients; OI and palliative care (See RPM-Plus BHC 5116), and coordination with community support services. All eligible patients will be offered CTX prophylactic therapy. Consistent with MOH guidelines, EGPAF will support provider training for syndromic management of OIs, use of referral guidelines and management of common symptoms of HIV-related illnesses.

HCs will counsel all PLWHAs and their family members in ongoing "prevention for positives" counseling. Counseling will emphasize the role of alcohol in contributing to high-risk behaviors. HCs will work closely with CHAMP to coordinate community support of HIV/AIDS patients. EP partners will collaborate with other programs to leverage food aid, including therapeutic feeding, for PLWHA and for food insecure households. EGPAF-supported HCs will refer PLWHA and family members to clinical and psycho-social support services at health facilities and in the community. EGPAF will support a clinical care coordinator at each health to assure patients have community support of their clinical care.

EGPAF will pilot intensive pediatric care at HCs and collaborate with Columbia to develop national tools to improve outpatient pediatric care. EGPAF will reach HIV-exposed infants and children through follow-up of PMTCT mothers and identification of exposed infants at immunization. Infants born to HIV-positive mothers will receive CTX PT and early infant diagnosis through PCR. EGPAF will support HC nurses to monitor HIV-infected infants and to stage them for ART. Like other clinical partners, EGPAF will work with facilities, CHAMP and community support services to improve the system for identification of exposed and/or likely-infected infants and children.

EGPAF will provide support to the DHT in Ngarama and Kabuga districts (See EGPAF ARV 2855). EGPAF will also coordinate with ARC to assist in training providers in the Nyabiheke Refugee Camp and ensure a system of referral and support between Ngarama District Hospital and the camp. (See ARC 4865).

These clinical and community-based palliative care activities support the Rwanda EP five-year strategy to increase the national availability of palliative care through health facilities and HBC services. ****PLUS-UP**** $351,000 - GOR PMTCT guidelines encourage rapid cessation of breastfeeding for HIV-exposed infants at 6 months or as soon as feasible (AFASS). HIV-exposed infants who are weaned are at high risk of malnutrition and will require appropriate feeding methods during the weaning period. This is especially true if HIV exposed infants test negative at two months of age. All implementing PMTCT partners providing basic care services will work with WFP and Title II resources to leverage funding for food supplements during FY2006. This plus-up funding will support 1000 infants with infant formula for all USG partners providing PMTCT services.

This extension will continue the activities of a current implementer to prevent treatment interruption. During the extension, implementer will make transition to follow-on awardee expected to be determined in late May. [CONTINUING ACTIVITY FROM FY2006 -- NO NEW FUNDING IN FY2007] This activity is related to EGPAF-ARV services (#2757) EGPAF-CT (#2756), and TB-HIV-CHAMP (#5129).

Integration of TB and HIV services is a fundamental component of the Rwanda EP five-year strategy. EGPAF will reach 157 TB/HIV co-infected patients, including 65 pediatric patients, with TB treatment at 15 continuing, 5 new, and 6 graduating health centers. To support the Rwanda EP five-year strategy goal of sustainability, EGPAF will provide limited technical support to the PBF contractor for the six graduating sites to ensure high-quality and efficient TB/HIV service delivery in line with PBF graduation criteria.

As part of a standardized package of care for clinical care partners, HCs will integrate routine testing of all TB clients for HIV, systematic TB screening of HIV-positive clients, and provision of, or referral for, TB treatment, with a special emphasis on pediatric patients. Where TB services are not available, EGPAF will facilitate the collection and transport of sputum samples for testing at TB referral sites, and when necessary, the referral of clients for chest x-rays or other TB services not available on site. Should funds permit, EGPAF will procure a radiology machine at Ngarama District Hospital for TB x-ray capacity, and support the training of hospital staff in the use and interpretation of x-rays. EGPAF will also strengthen access to TB screening for family members, particularly HIV-exposed infants and children of HIV-positive co-infected patients. In collaboration with PNILT and Columbia, EGPAF will develop and pilot site-level level algorithms for diagnosing TB in HIV-positive children younger than 12 years. To increase provider capacity in management of TB-HIV, EGPAF will support on-the-job training and provide regular supervision and QA of TB-HIV activities. EGPAF will also integrate messages on the importance of TB/HIV co-infection into health center education activities.

To strengthen follow-up of TB/HIV patients, EGPAF will develop monitoring and tracking mechanisms within and between facilities to assure that patients access and complete treatment. This will include working with districts, sites and PNILT to strengthen routine date collection and reporting of TB/HIV co-infection, building on existing medical record systems from TB, ART, and PMTCT programs. EGPAF will also coordinate with CHAMP to ensure community-based follow-up of HIV and TB co-infected patients through HBC, including with the pilot community-based DOTS activity. In collaboration with CHAMP, the facility-based community services coordinator will train, support and supervise community volunteer HBC providers on TB/HIV follow-up and referrals.

PNILT, which is responsible for the National Tuberculosis Program in Rwanda and also serves as a key coordinating entity for implementation of Rwanda's Global Fund TB grant, is an active participant in this activity.

This extension will continue the activities of a current implementer to prevent treatment interruption. During the extension, implementer will make transition to follow-on awardee expected to be determined in late May. [CONTINUING ACTIVITY FROM FY2006 -- NO NEW FUNDING IN FY2007] This activity also relates to activities in EGPAF BHC (#5111), EGPAF ART (#2757), ARC CT (#4867) and CHAMP CT (#2806). In line with the EP goals, EGPAF will reach 26700 individuals through a strategic mix of high-quality PIT and client-initiated CT services that ensure confidentiality, combat stigma and discrimination, and reach those individuals most likely to need treatment. This activity will strengthen CT services at 5 new and 15 existing health facilities (including two hospitals), and prepare 6 sites for graduation to the PBF through limited technical support to the PBF contractor for the graduating sites. At all EGPAF-supported health facilites, PIT CT services will target adult and pediatric inpatients, patients presenting with TB and other HIV-related OIs and symptoms, malnourished children and HIV-exposed infants, and STI patients, with the goal of achieving 25% PIT of all those counseled and tested. Providers will routinely encourage testing of family members, particularly children, of ART and PMTCT patients. In collaboration with CHAMP and the CS coordinator, health providers will work with PLWHA associations, churches, community DOTS programs, and OVC and HBC programs to identify infected patients, in particular HIV-exposed infants, family members of PLWHA, and OVC.

CT providers will continue to provide traditional VCT (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, and disclosure of test results. EGPAF will support training or refresher training of new and existing staff in confidential PIT that includes modified counseling messages, and enhanced prevention to promote abstinence and fidelity, alcohol reduction, GBV, and disclosure. In line with the revised GOR CT protocol, health facilities will modify testing procedures from venous blood draw to whole blood/finger prick to maximize efficiency of rapid tests. To enhance efficiency of client-initiated testing at sites, nurse counselors will also be trained to perform rapid tests under the supervision of a laboratory technician. Lay counselors, PLWHA association members, and other non-health professionals will be utilized to support counseling and testing activities at the health facility level under supervision of nurses or other health center staff. At the health center level, EGPAF 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.

To strengthen the network model for PLWHA and their families, the partner will establish a formalized referral system to link community care and clinical services. PLWHA will be offered or referred for CTX PT, TB screening, CD4 and clinical staging, and other prevention, care and treatment services. The CHAMP clinical-community coordinator will ensure HIV-positive patients are referred for community-based services, such as IGA, PLWHA associations, OVC, and HBC programs

This extension will continue the activities of a current implementer to prevent treatment interruption. During the extension, implementer will make transition to follow-on awardee expected to be determined in late May. [CONTINUING ACTIVITY FROM FY 2006 -- NO NEW FUNDING IN FY 2007] See related activities: FHI-ARV (#4771)

EGPAF ARV Services has two different components: 1. Direct ARV treatment and 2. Support package to two DHTs in Ngarama and Kabuga districts to strengthen the ARV network model.

In collaboration with other ARV implementing partners and consistent with the MOH vision, EGPAF will continue to provide a standardized package of ARV services to 1000 patients (including 125 pediatric patients) at 6 sites, will expand ARV services to 750 (including 250 pediatric) new patients and will open at least 6 new ARV satellite sites as part of a coordinated network of HIV/AIDS services in 2 districts. EGPAF will also coordinate with ARC, assist in training providers in the Nyabiheke Refugee Camp and ensure a system of referral and support between Ngarama District Hospital and the camp (See Activity 4748). EGPAF will provide full ARV services at larger health centers and a limited package of ART services at satellite health centers using nurses as the primary ARV provider. EGPAF will ensure that all eligible women in PMTCT and eligible PLWHA are enrolled for ART at the health-center level by a nurse, supported by a physician from the local district hospital or according to DHT plans. Through DHT support, USG will support 20 of 29 DHTs nationally for additional personnel, training, clinical and program management, transportation and community-clinical linkages to oversee the expanding network of care.

To reach 750 additional patients, EGPAF will ensure that all eligible women in PMTCT and all eligible PLWHA will receive ART at the health center level by a nurse supported by a physician from district hospital or according to DHT plan. The district hospital physician will visit health centers on a regular basis to support ART initiation and review complicated ART and other cases at the health center. This model of expanded ARV treatment by nurses with physician back-up will be implemented more broadly by all ARV implementing partners in 2006. District hospital physicians will support nurses through regular visits, on-going phone access for urgent questions and clinical protocols to guide nurses' routine ARV practice. Patients needing urgent medical care beyond nurses' scope of expertise will be referred to the appropriate level of care. The long term goal is to maximize the capacity of the most decentralized level of service, thus increasing patients' access to ARV care.

EGPAF will provide a package of support to two health districts, including personnel and transportation. EGPAF will support development of referral, supervision, transportation and communication systems to send specimens, patients, providers, information, etc or otherwise support the network of cost-efficient, decentralized ARV services. Best practices and lessons learned in clinical management of HIV/AIDS patients and district management will be shared using the collaborative quality improvement approach (developed by QAP in COP FY04-FY05) supported by USS and DHTs. The district health teams will ensure coordination of care between district hospital and health centers including coaching and supervision of nurses at health centers, lab specimen transport from health centers and district hospital, referral between different levels of care.

EGPAF will continue to expand pediatric ART outpatient services, as part of a coordinated pediatric project including early infant diagnosis through PCR, CTX prophylaxis, and ARV treatment of eligible infants and children. ( See EGPAF BHC 5111 and MCAP 2787) EGPAF will integrate outpatient ART care with immunization, weight monitoring and treatment of acute childhood illnesses. EGPAF will provide women a respectful ARV services environment, appreciating unique gender specific issues that provide obstacles to access.

ARV patients will receive community support services for adherence and retention via the CHAMP ARV (See Activity 2809). ARV services include systematic HIV patient referral to community-based services providing psychosocial and spiritual support; ongoing prevention through interpersonal community groups for those testing HIV-positive to prevent further transmission; linkages with local community for adherence support and treatment retention; nutrition support including assessment and food. Referrals will also be made throughout the network of care to reproductive health and child health services,

particularly through PTMCT, basic care and CT activities. EGPAF will assure their services environment is sensitive to women's issues that may otherwise limit access to HIV/AIDS care. All USG-supported health facilities providing HIV/AIDS services will hire a community care coordinator to assure effective community support of clinical care, including ARV adherence and retention via CHAMP. Referrals will also be made throughout the network of care to reproductive health and child health services, particularly through PTMCT, basic care and CT activities.

These activities fully support the Rwanda PEPFAR country 5-year strategy by increasing institutional and human capacity for a district managed network model of HIV Clinical Treatment and Care services. In addition, this FY06 assistance will build district and site capacity to manage in 2007 graduated ARV sites through perfomrnace-based contracting.

***** PLUS-UP***** $100,000- Under the base COP06 budget, a limited amount of funding was allocated for a basic package of district support. With supplemental funding, EGPAF will provide additional personnel and TA support to one District Health Team (DHT) to further enhance supervision, transport and communications activities between health centers, district hospitals, district pharmacies and community based services for networked ART services. DHTs will have increased capacity to conduct supervision, quality assurance, and M&E within the network model.