Reprogramming 8/07: 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.

Reprogramming: 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. plus-up: **This activity has funds added through both plus-up funding and reprogramming.** In developing PMTCT programs in Rwanda over the past several years, great emphasis has been placed on quality service availability and scale-up of clients, tracking women after they leave the ANC services and pediatric diagnosis and follow-up. At the same time, concurrent funding from the US Government for broad-based promotion of family planning using USAID Child survival and health funding has seen significant scale up in acceptance of modern FP methods on a nation wide scale. Plus-up funding will be used to bridge the gap between these two successful programs and ensure that quality FP counseling and services already supported by the USG are made available as part of the routine PMTCT programming. Counseling will be made available to women and men as a part of integrated antenatal care services and will follow-up with availability of all modern methods including options for long term and permanent methods of contraception after birth. Significant commitment from the GOR on family planning as well as leveraging of resources from GFATM and UNFPA will ensure that these services are integrated nationwide as a part of a quality package of PMTCT/perinatal services. Note - no FP commodities will be purchased with these funds. This activity will be promoted nationwide.

This activity relates to MTCT (7179, 7181, 7219, 8185, 8697, 8698).

Rwanda has one of the highest maternal mortality ratios in Africa due to poor socio-economic factors and inadequate access and uptake of services. While PMTCT uptake is relatively high, most women only go for one ANC visit late in their pregnancy, deliver at home, and do not return for regular follow-up care. Women in MCH services should receive a full package of care that meets the entire health needs of the family to include targeted HIV/AIDS education and prevention messages, CT, nutrition counseling, infant feeding support, and promotion of early care-seeking behaviors. Similarly, women in PMTCT services should receive regular care such as family planning, IPTp for malaria, syphilis testing and treatment, iron supplementation, safe birth and neonatal care support. In order to improve service uptake, follow-up, and health outcomes, every provider-client contact needs to be maximized through an effective integration of services.

CAPACITY will work closely with USG implementing partners and GOR to integrate PMTCT and other MCH services such as family planning, safe motherhood, well-child visits, and malaria in pregnancy. This integration of services will facilitate improved identification, care and referral of women and HIV-exposed infants. To this end, this activity will support development of national policies, establishment of operational guidelines and adaptation of practical tools such as integrated registers, simple algorithms, and job aids. This activity will capitalize on synergies with other programs such as the PMI, Repositioning Family Planning, and Safe Motherhood, to leverage their financial and technical capabilities. Moreover, CAPACITY's involvement in health provider pre-service and in-service training allows for rapid updates of curricula as needed.

CAPACITY will provide support to PNLP through malaria in pregnancy, MCH and Integration Task Force teams, and TRAC through a long-term advisor position to ensure integration of PMTCT/MCH activities, the functioning of a national PMTCT/MCH integration group, the strengthening of M&E for national PMTCT/MCH activities and training of service providers in integrated PMTCT and MCH. The technical advisor will transfer skills and competencies to existing PMTCT and MCH Task Force staff within the MOH and TRAC to sustain PMTCT/MCH integration. A USAID clinical implementing partner will support two model centers to evaluate the efficiency and effectiveness of new PMTCT/MCH integration protocols and to provide feedback to the national PMTCT and MCH programs.

These activities support the GOR strategic goal of integrating HIV/AIDS services into the overall health system as well as the Rwanda EP goals of supporting sustainable activities

and increasing the quality of facility-based 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] See related activities: CHAMP BHC (2811), PBF-BHC (2815), RPM-Plus BHC (5116).

In COP06, Consistent with the EP Rwanda's five-year strategy, CAPACITY/IntraHealth will initiate palliative and basic health care services to reach 6,150 HIV-positive, including 1,350 ART patients and 1000 pediatric patients at ten continuing and six new health facilities and will prepare 15 advanced palliative/basic care sites for transfer to performance-based contracting via the PBF.

Capacity/IntraHealth will support a standard basic care package for all PLWHAs that includes: initiation of an individual patient medical record, clinical staging and CD4 counts, ARV treatment for eligible patients, OI and palliative care, CTX PT for eligible patients, community support referral and "prevention for positives" counseling. Treatment protocols for OIs and for infant treatment and diagnosis will comply with MOH guidelines. CApacity/IntraHealth will support training of providers and M&E to assure quality of care. Counseling will emphasize the role of alcohol in contributing to high-risk behaviors.

CAPACITY/IntraHealth-supported HCs will leverage food, including referrals for therapeutic feeding, for PLWHA and for food insecure households (particularly for pregnant and lactating women and their infants). CAPACITY/Intrahealth will train providers in management of OIs and other HIV-related illnesses, use of referral guidelines, clinical staging and psychosocial support for positives. Capacity/IntraHealth will reach HIV-exposed infants and children through follow-up of PMTCT mothers and identification of exposed infants at immunization, OVC programs, or other points of entry. Infants born to HIV-positive mothers will receive CTX prophylaxis and early infant diagnosis through PCR. Capacity/IntraHealth will support HC nurses to monitor HIV-infected infants and to stage them for ART. This EP partner will support coordination with CHAMP to improve the system for identification of exposed and/or likely-infected infants and children.

Capacity/IntraHealth will collaborate with DHTs to roll out training and supervision of providers in existing and new facilities in basic care of PLWHA, including HIV-exposed and infected children. Routine supervision and monitoring through use of checklists and supervisor coaching will ensure high quality services. Capacity/IntraHealth also will support health centers and DHTs to implement PAQs (community-provider partnership) at HCs.

Before graduating to performance-based contracting, sites will need to demonstrate sufficient technical and institutional capacity. Capacity/IntraHealth will work with the HC, DHT and PBF to develop transition plans to assure needed technical support. BHC targets and COP06 funding for these fifteen sites will be divided between the PBF and Capacity/IntraHealth for the transition year.

Capacity/IntraHealth will work with CHAMP (Activity #2811) to develop effective referral systems between clinical care providers and psycho-social and medical support services in non-clinical settings, including HBC, adherence counseling, spiritual support, stigma reducing activities, OVC support, IGA activities, and legal support services. Women will be specifically encouraged to engage in IGA to increase their capability to support their children and improve their own health and well-being. Capacity/IntraHealth will actively support effective integration of home based care services and clinical health services by hiring a clinical-community coordinator in each health center.

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 Capacity/IntraHealth ARV services (2777), CT (2775), and CHAMP HIV/TB (5129).

Integration of TB and HIV services is a fundamental component of the Rwanda EP five-year strategy. In coordination with all implementing partners, this activity will support the strengthening of TB/HIV services at 16 health centers with existing HIV services, including 10 continuing and 6 new sites. CAPACITY/IntraHealth will also prepare 15 sites offering TB/HIV services for graduation to PBF through limited technical support to ensure TB/HIV service delivery in line with PBF graduation criteria. Targets for these graduating sites are divided evenly between CAPACITY/IntraHealth and the MSH/PBF.

CAPACITY/IntraHealth will reach 150 TB/HIV co-infected patients through routine testing of all TB clients for HIV, systematic screening of HIV-positive clients for TB, and provision or referral for TB treatment. Where TB services are not available, CAPACITY/IntraHealth will facilitate the collection and transport of sputum samples for testing at TB referral sites, and, the referral of clients for chest x-rays or other TB services not available on site. Health providers will refer family members of HIV-positive co-infected patients for TB screening and treatment. In collaboration with PNILT, DHTs, and other partners, CAPACITY/IntraHealth will enhance provider capacity in management of TB/HIV through on-the-job training, use of job aids and site-level algorithms, regular supervision and QA of TB/HIV activities. CAPACITY/IntraHealth will also integrate messages on the importance of TB/HIV co-infection into health center education activities.

To strengthen follow-up and monitoring of TB/HIV patients, CAPACITY/IntraHealth will develop monitoring and tracking mechanisms within and across facilities to assure that patients access and complete treatment. This will include working with districts, sites and PNILT to strengthen routine data collection and reporting of TB/HIV co-infection, building on existing medical record systems from TB, ART, and PMTCT programs. CAPACITY/IntraHealth will also coordinate with the CSP to ensure community-based follow-up of HIV/TB co-infected patients through HBC, including with the pilot Community-Based DOTS activity in districts where the partner is working. In collaboration with CSP contractor, the facility-based community services coordinator will train, support and supervise community TB DOTS volunteers on TB/HIV follow-up and referrals.

PNILT (see activity #2731), which executes the National Tuberculosis Program in Rwanda and serves as a key coordinating entity for GFATM implementation of Rwanda's 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 CAPACITY/IntraHealth BHC (#5112), CAPACITY/IntraHealth ART (#2777) and CHAMP CT(#2806). In line with the EP goals, IntraHealth will reach 49,000 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 6 new and 10 existing health facilities. The new sites will be implemented in regions where Twubakane DHP is working to ensure synergies with family planning services. IntraHealth will also prepare 15 sites for graduation to the PBF through limited technical support to the PBF contractor for the graduating sites. All 15 sites will be allocated to the PBF contractor and CT targets will be divided between IntraHealth and the PBF.

At all IntraHealth-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% of all those CT. 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. IntraHealth will continue its successful VCT (client-initiated) services for pre- and post-nuptial couples and ANC male partners, and will build on its FP-PMTCT integration activities to offer routine counseling and testing for FP clients. Counseling messages will emphasize prevention, including abstinence and fidelity, alcohol reduction, GBV sensitization, and disclosure of test results. IntraHealth 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, IntraHealth 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, IntraHealth 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 activity has funds added through both plus-up funding and reprogramming.** 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.

This activity will support adaptation and implementation of a module for pre-service training of medical students in all aspects of HIV/AIDS care and treatment with special emphasis on ART and pediatric treatment. The current in-service curriculum will be reviewed, adapted and validated for pre-service training. This activity will significantly strengthen national long term capacity and ensure that all medical school graduates have had comprehensive training on all aspects of management of HIV/AIDS. "

This activity relates to HTXS (7161, 7174, 7176, 7190, 8172).

The effective functioning of the ART network depends on a qualified nursing workforce. The HIV/AIDS epidemic is overwhelming Rwandan nurses with an increasing patient load requiring more sophisticated care. To address this problem, the GOR eliminated the lowest-level nurses (A3, nursing assistant equivalent), upgraded the skills of mid-level nurses (A2, traditionally trained in secondary schools) to the level of registered nurses (A1), and accelerated Bachelor's of nursing education (A0).

An HIV/AIDS performance needs assessment carried out with MOH revealed the nursing schools had not incorporated HIV/AIDS curricula into their course work. In FY 2006, Capacity supported the MOH in revising its standards for nurses by developing a "Basic HIV/AIDS Care" course, and developed the new A1 nursing program being used in all five nursing schools, in collaboration with Columbia University and BTC.

In FY 2007, Capacity will continue to support nursing for HIV/AIDS care by targeting pre-service training, in-service training, and supporting the Nursing and Midwifery Task Force.

Capacity will continue to support the five nursing schools and will provide tuition for 50 A1 students selected by district leaders. The immediate goal for FY 2007 is to support the new A1 program by filling the gap in tutors, procuring training equipment, and covering some operational costs. Capacity will second regional expatriate HIV/AIDS nursing instructors, with Bachelors of Nursing or higher qualifications, for the A1 and A0 programs. These instructors will teach HIV/AIDS care and treatment to 300 A1 and 25 A0 students.

An additional 200 A2 and A1 nurses will receive in-service competency-based training focused on specific tasks nurses have to carry out to provide comprehensive HIV/AIDS care with remote physician supervision. Capacity will link in-service and pre-service training by having nursing students carry out their clinical practicum and study tours in surrounding health centers.

Capacity will support the Nursing and Midwifery Task Force to address human resource challenges such as recruitment and retention of qualified health professionals and developing standards that reflect evidence-based practices, particularly as they pertain to the expanded role for nurses in ART care.

These activities support the Rwanda EP 5-year strategy by increasing institutional and human capacity for a district managed network model of HIV clinical care and treatment services.

This activity is related to OHPS (7249) and to HTXS (7205)

This activity will provide human resource expertise to the MOH to strengthen the management of the national health workforce. CAPACITY emphasizes staff retention, performance and promotion of professional expertise of medical and nursing staff for providing HIV/AIDS care. CAPACITY also supports the implementation of the 2005-2009 HRH Strategic Plan, HRH national policies and procedures with TA and staff support as requested by the MOH.

In FY 2007, CAPACITY will support the MOH to develop clearly defined job descriptions for all employee categories and expand the personnel management system established in FY 2006 to help create effective supervision, feedback, and goal setting in accordance with existing civil service procedures. CAPACITY will support the utilization of a human resource information system, including a web-based database. The secure data base will track medical and nursing continuing education, particularly HIV/AIDS training, as well as basic employee information, such as performance evaluations and employment history. The web-based software will be connected to central and district offices and hospitals that have internet connectivity supported by the EP. This will allow central and district health planners to evaluate current and future human resource needs by cadre; compare the needs to currently available and projected human resources; and test various interventions to find the best way to close the gap between demand and supply of needed health care workers.

To further strengthen human resource planning and management, CAPACITY will support a team of three Rwandan Human Resources specialists (HR advisor, IT database administrator, personnel specialist) to provide workforce planning and personnel management TA and capacity building to the MOH. The seconded CAPACITY human resource advisor will be instrumental in the implementation of the 2005-2009 HRH Strategic Plan supported in FY 2006. The HRH Advisor will research employee retention, participate in donor HRH studies and conduct focus group research to document retention issues particularly within rural health centers where retention problems are the greatest. CAPACITY will also continue to provide TA in long-term work force strategic forecasting and planning to the Permanent Secretary of the MOH and its staff. These activities will be coordinated through the Health Cluster, which is an official coordinating body in Rwanda grouping key donors in the health sector, including the GTZ, BTC, DfID, and others. While other donors in the Health Cluster are contributing to a basket fund to address HR issues, the EP is providing targeted support through CAPACITY and PBF strategies to augment low salaries of health workers based on performance standards and outputs. In addition, the EP will complement investments made by USAID with CSH funds to strengthen systems and ensure capacity building of local institutions.

The direct outputs of this activity are to build the organizational capacity of the MOH and the human resource capacity of 30 individuals.

These activities reflect the ideas presented in the Rwanda EP five-year strategy and support the GOR's national strategy of human resources and organizational capacity building