This activity relates to activities in HVCT (7242), HTXS (7246), HBHC (7245), MTCT (7179, 7181, 7202, 7208, 7219, 8122, 8184, 8185).

In FY 2006 TRAC is conducting TOT sessions for PMTCT service provision and supervision for 90 district-level supervisors and trainers from all 30 districts. These training sessions cover all aspects of the expanded national PMTCT protocol, including ARV prophylaxis, PCR testing for HIV-exposed infants, CTX for all HIV-exposed infants, routine CD4 testing and clinical staging for all HIV-positive pregnant women, counseling on infant feeding and nutrition for HIV-positive pregnant women and HIV exposed infants.

In FY 2007 TRAC will continue to conduct refresher training of trainers and supervisors in the expanded PMTCT protocol. To ensure quality of PMTCT services and consistent implementation of the new protocol, TRAC will conduct quarterly supervision of all districts.

With TA from CDC, TRAC will reinforce the M&E system for the PMTCT program, in particularly the M&E of the new PMTCT regimen, through the improvement of M&E tools, and documentation of best practices implemented by different partners.

In order to establish a system to trace HIV-positive mother/infant pairs, in collaboration with the national PMTCT TWG, TRAC will revise PMTCT norms and tools as needed (e.g. follow-up tools, client forms, monitoring tools for QA related to infant feeding counseling, etc) and disseminate them to all health facilities providing PMTCT services. The budget for this activity includes payment of two PMTCT technical advisors within TRAC's PMTCT/VCT unit.

This activity directly supports the Rwanda EP five-year strategy by scaling up PMTCT and strengthening the capacity of local institution.

This activity relates to activities in MTCT (8697), HBHC (7163, 8718, 7177, 7187, 7220, 8141, 8144, 8716), HTXS (7246).

In FY 2006, the EP supports TRAC for central activities to ensure quality of HIV palliative care. TRAC created a forum for information exchange between facility-based palliative care service providers to identify weaknesses and constraints as well as methods for program improvement (this includes quarterly workshops for health center staff, district supervisors, TRAC and DSS). TRAC defines the roles of different types of health facilities in OI service delivery in accordance with the network model (i.e. health center versus hospital) and monitors OI service delivery sites to determine the sustainability of activities.

In addition, in order to integrate all palliative care at both facility and community levels to ensure a continuum of care, the EP supported national policy and guidelines adaptation on palliative in FY 2006. TRAC is also revising and integrating into the national HIV training curriculum a module on psychosocial support as well as nutritional assessment, counseling and management of malnutrition. By the end of FY 2006, TRAC will have designed palliative care-related tools, including PLWHA case management tools, patient assessment and follow-up forms and referrals and counter-referral forms from facility to community and vice versa. In addition TRAC will have finalized the list of OI drugs, including use of opioids at clinic and community level for pain management.

In FY 2007, the EP will support TRAC to use the guidelines, curricula and tools developed in FY 2006 to conduct training of trainers' sessions on palliative care for 100 nurses, social workers, HIV case managers, and nutritionists. In addition, USG will support TRAC through a national nutrition advisor position to oversee all nutrition programming activities at central level and supervision of training and nutrition activities implementation at site and community levels. TRAC will supervise decentralized training on palliative care both for facility-based providers and community-based providers. TRAC will also design, in collaboration with PBF and the MOH Community Health Unit, key HIV program-related indicators to monitor for PBF at community level. Lastly, TRAC in collaboration with PFSCM, will provide timely and accurate data on OI drug and diagnostics consumption, and OI-related morbidity and mortality to the CPDS for drugs and reagent quantification.

These activities support the EP five-year strategic goals of promotion of a continuum of HIV care and Rwandan national plan for palliative care.

Reprogramming 8/07: This activity has been abandoned

In COP07 PEPFAR Rwanda provides funds to TRAC for integration TB/HIV activities. However TRAC and PNILT are still using diffetrent formats of monitoring and evaluation for integration activities. PEPFAR Rwanda will support TRAC for additional staff and transportation for periodic joint TRAC and PNILT supervsion of TB/HIV activities at district level and data analysis dissemination and use. This activity will contribute to improved integration TB and HIV in Rwanda.

Table 3.3.07:

This activity is related to activities in MTCT (2744), HBHC (7245), HVTB (7241), HTXD (2746), and HVSI (7238).

In FY 2006, TRAC is revising aspects of the national CT norms and guidelines which represent incremental changes that are reflective of the current policy environment. These new components include using lay counselors to conduct CT, routine CT for all malnourished children, and targeted PIT for hospitalized and TB inpatients. TRAC is also conducting TOT sessions on CT service provision, using the most recent norms and guidelines. TRAC conducts supervision visits of decentralized trainings three times a year and assures service quality through the training of district-level supervisors who conduct supervision activities at the site level.

In FY 2007, in collaboration with the EP Prevention TWG and other partners, TRAC will continue to revise national CT norms, guidelines, and tools (e.g. client forms, reporting forms, educational and supervision tools) and will disseminate them to all health facilities providing CT services. Ongoing revisions are necessary in order to address new approaches to CT and PIT as they become acceptable components of the national CT program. To this point, aspects of policy revision that have yet to be incorporated into the national guidelines include the finger-prick method of specimen collection, expanded and more flexible testing algorithms, abbreviated pre-test counseling in the context of PIT, and automatic family/partner tracing of all HIV-positive clients.

TRAC will also conduct three TOT sessions to train 90 people on CT service provision, including CT, PIT, and nutrition counseling. These training sessions will cover all aspects of the expanded national CT protocol. The participants in these trainings (trainers from each of Rwanda's 30 health districts) will subsequently train CT service providers in all CT sites. TRAC will conduct supervision of these decentralized trainings each trimester. In addition, TRAC will conduct two training sessions for district-level supervisors, who will make regular visits for CT sites to assure the quality of services.

As CT in Rwanda has expanded to include mobile testing and PIT, the GOR has recognized the need for a standardized referral system that will ensure adequate referral and follow-up of all HIV-positive clients. In FY 2007, TRAC will establish a harmonized referral system for CT services to be used in all counseling and testing approaches (fixed site, outreach, and mobile) throughout the country. Guidelines, forms, and tools for implementation of this system will be developed and disseminated.

The budget for this activity also includes long-term TA to the PMTCT/VCT unit at TRAC. The CT master trainer and CT program officer will lead the aforementioned CT policy revision process, coordinate and supervise TRAC's trainings, ensure collaboration with partners, and co-chair the CT/PMTCT technical working group.

This activity reflects the ideas presented in the Rwanda EP five-year strategy and the National Prevention Plan through scaling-up of CT services and capacity building of Rwandan institutions that design and lead the fight against HIV/AIDS at the central level.

Quality assurance, improvement and control are a vital part of HIV services - particularly as more people are put on ART. Moreover greater integration of overall services (for example Nutrition with ART services) is needed to ensure successful mainstreaming and assure a quality continuum of care. Rwanda EP supports clinical partners, TRAC and MoH decentralization office for QA/QI/QC of national HIV programs. However, because the priority of the national program has been the rapid scale up of HIV services, recent field supervision has turned up variability in service quality and interpretations of the basic package of services. Furthermore, reporting and field record keeping lacks consistency and national strategic vision. With these new funds PEPFAR Rwanda will work with MOH to reinforce ART program quality through substantial strengthening of the TRAC Quality assurance and facilitative supervision function. This activity has two basic components.

One component is to reinforce the M&E unit at TRAC for ART program monitoring, joint supervision and data analysis and use to improve program quality. The second component will be to use the expertise of an international institution to support TRAC in revising the definition of the ART basic standards of care that guaranty improved service quality at individual sites, to conduct training and supervision of district health teams in those standards and their applications at lower levels of the health system. The standards will focus in three areas namely the provision of services, the link with communities and administrative services. It is anticipated that this activity will be co-funded by both GFATM and EP.

This activity relates to HTXS (7161, 7176, 7190, 7205, 7262, 8172), MTCT (7244), HBHC (7245), HVCT (7242), and HVSI (7240).

In FY 2006, TRAC with TA from EP clinical implementing partners developed national clinical norms, guidelines and tools for ART, including registers, patient forms, and clinical IEC materials for patients. TRAC undertook regular supervision to ensure that HIV services at site level comply with these national norms. In addition, TRAC conducted four training-of-trainers sessions on care and treatment, including ARV and pediatric AIDS, with a practicum component emphasizing quality of care. TRAC also organized two training sessions for district-level supervisors and two training sessions for medical doctors at new ART sites. In collaboration with Columbia University and IntraHealth, TRAC developed a TOT plan for nurses working in HIV/AIDS care and treatment, which reached 300 HIV/AIDS service providers.

In FY 2007, USG will expand support to TRAC for routine monitoring of key ART impact indicators to ensure program quality. USG clinical services staff will continue providing TA to TRAC to revise guidelines, reach an additional 200 trainers and expand new activities in joint supervision to improve program quality.

In addition, USG will support TRAC to finalize the ART patient card checklist which will be integrated into the existing patient medical record to facilitate data recording and quality supervision. USG will also support TRAC to design an innovative joint supervision format based on experiences of other EP countries. Under this new supervision format, all ART implementing partners and other related programs such as TB will participate in joint supervisions with TRAC. TRAC and partners will conduct periodic visits to ART sites with a standard checklist to assess quality of HIV services integration, whether guidelines are followed, and ARV drug prescription patterns. The joint supervision teams will provide regular feedback to sites and share best practices in ART service delivery.

This activity supports the EP five-year strategy for national scale-up and sustainability and the Rwandan Government ART decentralization plan.

This activity relates to MTCT (7244), HBHC (7245), HVCT (7242), HTXS (7246), and HVSI (7237 9252).

In FY 2006, TRAC is undertaking multiple surveillance activities aimed at better understanding the state of the HIV epidemic in Rwanda. TRAC, in collaboration with CDC, is leading sentinel surveillance at 30 antenatal care facilities, training 60 site personnel, procuring tests and other materials, and supervising sites. The data collection for BSS among high risk groups including sex workers, truck drivers and youth, was carried out in FY 2005, and the data analysis and results publication is ongoing in FY 2006. In addition, TRAC is continuing its collaboration with CDC and the NRL on the survey of ARV drug resistance. Protocol development is completed and will be submitted to the National Ethics Committee and IRB for approval. TRAC staff continues to provide on-site IT training to all ART sites, including the use of TRACnet (Rwanda's phone-and web-based reporting system for HIV/AIDS) for reporting of ARV drug and program indicators.

In FY 2007, in collaboration with CDC, TRAC will continue ANC sentinel surveillance at 30 sites, training 90 personnel. TRAC will also begin preparations for the 2008 BSS among high-risk groups (questionnaire design, revision of tools, and training of interviewers). In addition, TRAC will continue its collaboration with CDC and the NRL in the area of HIV incidence surveillance, continuing the BED or other appropriate incidence assay using specimens from FY 2005 and FY 2006 sentinel surveillance. TRAC will also conduct a second threshold survey of ARV drug resistance including analysis and dissemination of results.

In the area of M&E, TRAC will continue to support data analysis and use on clinical care, treatment, and PMTCT services as needed to monitor quality of services. The TRAC M&E unit will continue to maintain the postings and organization of the digital library.

This activity reflects the ideas presented in the EP Five-Year HIV/AIDS Strategy in Rwanda and the GOR national multi-sectoral Strategic Plan for HIV/AIDS Control (2005-2009).

[CONTINUING ACTIVITY FROM FY 2006 -- NO NEW FUNDING IN FY 2007] ***PLUS-UP ADDITION: The Treatment and Research AIDS Center complex in Kigali takes in the TRAC ART clinic and VCT service, the National Reference Laboratory, the National Center for Blood Transfusion, and offices for central-level personnel working in the domain of clinical HIV/AIDS prevention, care and treatment. These funds will support the expansion and renovation of the complex to improve the quality of HIV services and ensure sufficient and appropriate working space for TRAC, NRL and CNTS staff. TRAC's mandate has recently been expanded to include coordination of MOH efforts in TB and malaria. The renovation will increase office space and meeting room capacity while freeing up space for the operations of the overcrowded TRAC clinic, which serves more than 2,500 ART patients. Improvements will leverage previous EP investment in office and ICT infrastructure, as well as technical capacity building at TRAC. This activity directly enhances EP partnerships with the NRL and CNTS, which are co-located with TRAC. This activity is consistent with the Rwanda EP five-year strategic goal of sustainable capacity building at national-level coordinating institutions.

Given that there is currently no isolation capacity in Rwanda for multi-drug resistant TB, these funds will also support the renovation of two isolation wards. One of these is located in Kigali Central Hospital and another in Butare at the University Hospital.***