This activity relates to OHPS (8181) and will be a follow-on activity to an existing FY 2006 activity.

Although exact estimates of the prevalence of GBV associated with women's participation in HIV services are not available, 2005 Rwanda DHS-III data reveals that nearly one-third (31%) of women in Rwanda have suffered from physical violence since the age of 15. In 47% of these cases, the perpetrator of these acts of violence was the husband or partner. Furthermore, 10% of women said that they had suffered from acts of violence while they were pregnant. The health and social consequences of GBV against women are severe but often not addressed by health providers, even though they have a unique opportunity to make an impact on this problem.

Currently, Twubakane is implementing a GBV/PMTCT Readiness Assessment in three districts in Rwanda. The assessment will take place in six USG-funded PMTCT sites in order to (1) assess current provider knowledge, attitudes/perceptions and practices of screening and counseling clients for GBV, (2) assess the facility readiness of PMTCT sites to provide GBV services, and (3) identify and assess existing GBV community and social services in the catchment area. The objective of this activity is to improve the quality of PMTCT services to prevent and mitigate GBV that may arise from women's disclosure of their HIV status. Twubakane created an Assessment Steering Committee including GOR and relevant stakeholders to guide the assessment process which will run through mid-2007.

With FY 2007 funding, the results of the current assessment will be used to develop and implement a multi-level and multi-sectoral GBV/PMTCT integrated strategy. The strategy will take a three-pronged approach: (1) to strengthen the policy/legal environment in Rwanda to address GBV; (2) to improve health service and delivery systems; and (3) to mobilize health providers and communities to respond to the needs of clients who live with GBV and HIV. In the area of policy and advocacy, Twubakane will hold a 3-day GBV and HIV/PMTCT service stakeholder retreat to disseminate the results of the assessment and discuss strategies and activities to improve services and reduce GBV. In collaboration with USG partners and other bilateral agencies such as the BTC, Twubakane will develop workplace policies and clinic protocols for the identification and management of GBV at PMTCT sites. This will include designing a GBV monitoring and record-keeping system. Twubakane will pilot these procedures and tools in the six PMTCT assessment sites. They will also adapt, translate and implement IntraHealth's one-day GBV workshop sensitization module for HIV and PMTCT service providers and supervisors in these sites. In addition, this activity will support south-to-south capacity building with a study tour to the Nairobi Women's Hospital's Gender Recovery Center and the Kwazulu Natal Forensic Nursing Program to evaluate potential models for the operationalization of the MOH's standards for the management of sexual violence. In addition, IntraHealth will build linkages between microfinance programs and GBV survivor services in collaboration with CHAMP. Finally, this activity will support RALGA and Profemme in their efforts to impact the efficacy of local governments in addressing GBV and engaging local leaders to become anti-GBV advocates.

The overall goal of this activity is to educate service providers on how to identify women experiencing GBV at selected PMTCT sites, assess whether these women are at increased risk for HIV transmission, and provide appropriate care and referrals to social services. By training service providers to identify women at increased risk for HIV transmission, this activity also seeks to build the capacity of physicians and nurses to recognize the links between GBV and HIV transmission and to understand the necessity of integrating medical and social services to effectively address this cross-cutting issue. This activity addresses the key legislative issue of gender, particularly reducing violence, and reflects the ideas presented in the Rwanda EP five-year strategy and the National Prevention Plan.

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Table 3.3.01:

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Table 3.3.08: Program Planning Overview Program Area: Orphans and Vulnerable Children Budget Code: HKID Program Area Code: 08 Total Planned Funding for Program Area: $ 9,587,814.00

Program Area Context:

With approximately 50 percent of individuals under the age of 15, Rwanda's population is young. Almost 30 percent of Rwandan children under the age of 18 are considered to be OVC according to the 2005 RDHS-III. This proportion is highest in the city of Kigali where 35% of children are defined as OVC. The 2006 Rwanda National Plan of Action for OVC estimates that there are 1,264,000 OVC in Rwanda. Of these OVC, 210,000 are estimated to be orphaned due to HIV/AIDS, and additional 27,000 are children living with HIV/AIDS. It is projected that the percentage of children orphaned as a result of HIV/AIDS will increase from seven percent to 52 percent by 2010. The EP focus on OVC infected with HIV/AIDS or from families affected by HIV/AIDS.

In Rwanda, the EP is the primary donor in OVC service provision. UNICEF, the other major international donor working with OVC, focuses only on central level TA and provides no direct services. There are limited private donations for OVC programs, but they are not dependable for steady program implementation. This creates a challenging environment for collaboration and referrals.

In FY 2006, USG assistance reached an estimated 27,000 OVC with a menu of services, including school fees, health insurance, food aid, psycho-social support and HIV prevention education. During the last year, CHAMP played the lead role in coordinating USG efforts to assist OVC and their families. CHAMP mapped USG community partners' activities in their 20 districts and began developing M&E tools to standardize how partners assess, monitor and report on the OVC they serve. In close collaboration with MIGEPROF, UNICEF, CNLS, MINISANTE, and other key stakeholders, CHAMP helped revise the National Plan of Action for OVC and participated in the development of a Round 6 OVC proposal for the GFATM.

In FY 2007, the EP aims to expand the coverage and quality of OVC services and build the capacity of national and local organizations serving OVC. The EP funding will support a full time position at MIGEPROF. USAID, CHAMP, and Track 1.0 partners will continue as active members of the OVC TWG which is currently preparing a GIS mapping of OVC and OVC implementers in Rwanda. CHAMP will assist the GOR with the development of district and sector level children's forums and orphan care committees to both ensure the participation of children and local leaders in OVC activities and to advance efficient coordination of services for OVC. ROADS, CHAMP, and the Track 1.0 partners will work closely with local women's groups, FBOs, and PLWHA associations to provide technical training in OVC care and support as well as institutional capacity building for these CBOs.

In FY 2007, local Rwanda partner organizations under CHAMP will greatly increase the number of OVC they support as the current international partners (World Relief and CARE) transfer their beneficiaries under the CHAMP umbrella to local partners. Using M&E tools developed in FY 2006, USG partners will assess and monitor all children receiving services in FY 2007. The GOR's menu of essential services for OVC closely mirrors the EP's core services: education, health, shelter, food, economic strengthening, psychosocial support, protection, and HIV prevention. Partners will either directly provide these services or refer them to other care and support programs. To expand OVC access to direct food aid and nutritional information, EP funding will provide support to three Title II partners. The EP OVC program will also wrap around PMI, microfinance, education, HIV prevention, and CT activities to ensure integration and linkages with other EP activities. All EP implementing partners will work to establish and strengthen referral networks and systems, particularly between ART, PMTCT, and CT to ensure that beneficiaries have access to the services available in their communities. In FY 2007, the GOR and USG clinical partners will also increase their efforts to identify and treat HIV positive OVC. Health facilities will begin testing malnourished children in their feeding centers who do not respond to supplementary feeding. As a result, USG anticipates increasing care and support to HIV positive children and their families in 2007.

The EP OVC partners will reach an estimated 45,000 OVC and train over 6,800 OVC caregivers by the end of September 2007. By the end of FY 2008, the EP expects to be serving over 60,000 OVC. CHAMP will

oversee the task of significantly increasing the number of beneficiaries by providing the needed technical and programmatic assistance to allow local partners and communities to take the lead in providing OVC services.

The EP OVC program addresses the key legislative issues of wrap around programming for food, education and microfinance. These activities support the EP five-year strategy to engage new partners, build sustainable local capacity, expand pediatric care, and link OVC care with other USG efforts.

Program Area Target: Number of OVC served by OVC programs 49,575 Number of providers/caregivers trained in caring for OVC 6,815

Table 3.3.08:

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Table 3.3.12: Program Planning Overview Program Area: Laboratory Infrastructure Budget Code: HLAB Program Area Code: 12 Total Planned Funding for Program Area: $ 5,677,880.00

Program Area Context:

The EP provides support and technical assistance to two key GOR institutions, the NRL and KHI to improve laboratory infrastructure and capacity at the national level for HIV testing, care and treatment. As in previous years, EP technical support for laboratory infrastructure in FY 2007 will continue to focus on key reference laboratory functions, including training, QA systems, and developing in-country expertise in performing new procedures for HIV-related care and treatment. Enhanced support for pre-service training at both KHI and NRL will assure sustained laboratory capacity in the years to come. All laboratory-related procurement will be consolidated into a single national system in FY 2007.

FY 2007 will continue an important shift in the utilization of USG resources and laboratory partner expertise to support laboratory infrastructure, with increasing emphasis on direct support to GOR. USG will increase direct support to NRL through the CDC cooperative agreement to manage certain key training and logistical functions, as well as support for HIV and TB-related QA activities. USG will continue funding ASCP to expand support for pre-service training of laboratory technicians at KHI through curriculum improvements and direct training support. These two partners are taking over activities that were initiated by CDC and Columbia UTAP in previous years. These shifts will allow Columbia and CDC to continue to focus more narrowly on laboratory service quality concerns, while broadening efforts against TB and malaria. This realignment of laboratory support resources is consistent with the strategic objectives of infrastructure strengthening and sustainability outlined in Rwanda's EP five-year strategic plan.

In FY 2007 CDC will continue to provide TA for training in OI diagnosis with emphasis on MDR and extrapulmonary TB and parasitic infections, new techniques to support program evaluation and surveillance, and molecular virology techniques for HIV drug resistance surveillance. Columbia UTAP will continue to support long-term technical positions at the NRL to assure quality HIV-related laboratory services through training and day-to-day mentorship of NRL staff. Columbia UTAP will also continue bolstering management and financial capacity at NRL by maintaining the long-term laboratory management advisor position and supporting improvements to the data management system for tracking specimens and reporting functions. All USG clinical implementing partners will have increasing responsibility for coordinating specimen transport and QA systems at the peripheral and district levels.

EP laboratory efforts face challenges as well. The BTC has long supported the TB section of the NRL; however this project is scheduled to end in FY 2007 with future funding uncertain. In response, USG plans expanded support for NRL TB QA/QC activities through the NRL cooperative agreement, Columbia UTAP and CDC. Another challenge for USG in the laboratory infrastructure area has been the long process of securing a fourth CDC direct hire employee to manage the EP laboratory portfolio. CDC hopes to have the position approved and filled before start of FY 2008 and will continue recruitment of an interim laboratory coordinator funded in FY 2006.

In FY 2007, PFSCM will be responsible for the procurement of all EP commodities through direct support to CAMERWA for the procurement, storage and distribution of all medicines, equipment and laboratory supplies. This consolidated approach to procurement will increase cost savings, and improve efficiencies in procurement and distribution of commodities. PFSCM will also take over the support of the CPDS and logistics management activities to ensure smooth functioning of the CPDS system, quality data for quantification, and strong communication between districts and CAMERWA.

Program Area Target: Number of tests performed at USG-supported laboratories during the 963,000 reporting period: 1) HIV testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring Number of laboratories with capacity to perform 1) HIV tests and 2) CD4 tests 55 and/or lymphocyte tests Number of individuals trained in the provision of laboratory-related activities 270

Table 3.3.12: