This activity relates to MTCT (7208, 7179, 7244, 8697, 8698), HVAB (8700), HVOP (8711, 7251, 8134), HBHC (8718, 8144, 7177), HVTB (8670), HKID (8148, 8150, 8152), HVCT (8732), HTXD (8170), HTXS (7176, 8172, 8737), HLAB (8189). Funds for this activity will address the key legislative areas of gender, wrap around and stigma and discrimination.

Rwanda is host to almost 50,000 refugees in camps around the country. Refugee populations are considered to be at high risk of infectious disease, in particular HIV, as well as GBV and other forms of violence, and economic and psychological distress. While much is currently unknown about HIV prevalence rates in the camp populations in Rwanda, recent service statistics of newly implemented VCT and PMTCT programs in two camps record a prevalence rate around 5% among those tested, with at least 200 individuals currently known to be living with HIV. Since 2005, the EP has supported UNHCR implementing partners AHA and ARC to provide HIV prevention and care services in Kiziba, Gihembe and Nyabiheke refugee camps with linkages and referrals for treatment.

In FY 2007, USG will consolidate its support by funding UNHCR directly to expand the package of services for the prevention, care, and treatment of PLWHA. Funds will also be leveraged from the World Bank-funded GLIA and OPEC to complement EP-supported services. UNHCR will subcontract to AHA and ARC to continue providing a standard package of PMTCT services at 3 refugee camps - Kiziba, Gihembe and Nyabiheke - to reach 1,800 women with PMTCT and CT services and 40 HIV-positive women with the full short-course prophylaxis. AHA will also support a small camp of 2,000 refugees with PMTCT promotion and linkages to the nearby health center.

UNHCR partners 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, UNHCR partners 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, UNHCR partners 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.

UNHCR partners will work in close collaboration with the district hospital and USG clinical partners in their respective districts to strengthen the network system of services between the district hospital and the refugee health centers for referrals for services not available at the camps, including CD4 and PCR, diagnosis and treatment of complicated OIs and management of side effects, management of severe malnutrition, and for referrals for pediatric HIV infection as necessary. As Nyabiheke is the smallest and newest camp, the camps will refer HIV-positive pregnant women for referral for initial prescription of the PMTCT regimen.

UNHCR partners will strengthen the referral system between camp-based services, including ART, OVC, IGA and facility and community-based MCH services promoting and distributing key preventive interventions such as bednets, immunizations, hygiene/safe drinking water and nutritional support within the camps, through the use of 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 enhance community participation and ownership, UNHCR partners will take advantage of the networks of refugee community leaders, TBAs, refugee women's groups and PLWHA associations to promote services and messages that focus on stigma reduction, infant testing, GBV reduction, male partner testing, MCH and PMTCT health seeking behaviors, and to assist in the follow-up and tracking of PMTCT mothers and family members.

AHA, which supports a small camp of 2000 refugees in close proximity to Kigeme District Hospital, will also support PMTCT promotion and health seeking behaviors at the camp through creation of Anti-SIDA clubs, training of refugee leaders and refugee women's groups, and training of TBAs. AHA will work with Kigeme DH to ensure access to PMTCT services for pregnant women.

SCMS will procure all commodities for the revised PMTCT protocol, including ARVs, laboratory commodities, CTX and micronutrients. UNHCR refugee partners will work with SCMS and the district pharmacies to ensure adequate supply and appropriate storage facilities for these commodities at the camps.

UNHCR will provide technical support and monitoring of IP activities and data collection, and ensure appropriate reporting to USG/Rwanda through the hiring of a technical and program manager.

This activity relates to MTCT (8696), HVOP (8711), HBHC (8718), HVTB (8670), HKID (8148, 8150, 8152), HVCT (8732), and HTXS (8737).

Rwanda is host to nearly 50,000 refugees in four camps around the country. Refugee populations are considered at higher risk for diseases, particularly HIV, as well as other forms of violence, economic and psychological distress. While much is currently unknown about prevalence rates in the camp populations in Rwanda, recent service statistics of newly implemented VCT and PMTCT programs in two camps show a prevalence of 5% among CT clients. Since 2005, the EP has provided refugees with HIV/AIDS prevention and care services with linkages and referrals to local health facilities for treatment.

Because the EP will initiate a standard prevention for positive package for beneficiaries starting in FY 2007, UNHCR as a new clinical partner will include these interventions from the beginning of its implementation.

In FY 2007, UNHCR will expand AB activities to three camps, and initiate community-based AB activities in a fourth camp. At the clinic level, UNHCR will expand their services to include AB messages during post-test counseling of all clients and follow-up with HIV-positive patients and their family members. Different messages will be used to match patients' profiles, circumstances and prevention needs. The providers will adapt and integrate a screening tool to be used during initial and follow-up CT sessions. This tool will be used by providers to monitor HIV-positive patients, particularly for asymptomatic HIV-positive and patients on ART. Checklists and job aids will be used to facilitate the counseling messages. Partners will adapt program-level indicators into existing forms and tools for each of their sites.

UNHCR will also promote AB messages at the community level to in- and out-of-school refugee youth, men, and vulnerable women of reproductive age. UNHCR will train or, as necessary, provide refresher training to peer educators using AB materials adapted for the refugee context. UNHCR will support interpersonal prevention activities that aim to increase youth access to prevention services, such as anti-AIDS clubs, life-skills training, school-based HIV prevention education, and community discussions. Messages delivered will not only focus on abstinence and fidelity, but will also include topics on the relationship between alcohol use, violence, HIV, and stigma reduction. Young girls in the refugee community, particularly female OVC, are vulnerable to predatory sexual behaviors of older men, as well as child sexual abuse, domestic violence, and sexual harassment at school. Prevention efforts under this activity will focus on changing social acceptance of cross-generational and transactional sex. UNHCR will strengthen the GBV strategies and role-plays developed by FHI/REDSO. Key influential community members such as traditional and religious leaders and refugee camp leaders will also reinforce the messages of abstinence, delayed sexual debut, being faithful, reduction of GBV and responsible consumption of alcohol.

As many risky behaviors can often be linked to other contextual factors such as unemployment, poverty, trauma, and psychosocial needs, UNHCR will strengthen referrals and mechanisms in coordination with GLIA and other partners to provide refugee clients and their family members access to IGA, OVC programs, food support through wrap around Title II and WFP, vocational training, trauma counseling, legal support, and mental health care and support for at-risk clients.

CSWs are an important target group due to their risk exposure, difficulties to negotiate condom use, psychosocial needs, and the lack of alternative means for generating income. Cost-shared with C/OP funds, UNHCR will help establish support groups for CSWs to create opportunities for exchange and peer support, linkages to IGA and microfinance activities, vocational training, promotion of healthy RH behaviors, and psychosocial support and counseling.

This activity addresses the key legislative issues of gender, stigma and discrimination, and food and microfinance wrap around through HIV/AIDS BCC messages, and linking to other sectors for strengthening income-generation opportunities and access to food support for vulnerable refugee women, girls and their families. This activity reflects the priorities of the five year EP strategy and the GOR national prevention plan.

This activity is linked to MTCT (8696), HVAB (8700), HBHC (8718), HVTB (8670), HVCT (8732), and HTXS (8737).

Rwanda is host to nearly 50,000 refugees in four camps around the country. Refugee populations are considered at higher risk for diseases, particularly HIV, as well as other forms of violence, economic and psychological distress. While much is currently unknown about prevalence rates in the camp populations in Rwanda, recent service statistics of newly implemented VCT and PMTCT programs in two camps show a prevalence of 5% among CT clients. Since 2005, the EP has provided refugees with HIV/AIDS prevention and care services with linkages and referrals to local health facilities for treatment.

In FY 2007, the USG will centralize its support by funding UNHCR directly to expand the package of services for the prevention, care, and treatment of PLWHA. In addition, UNHCR will support a fourth refugee camp with C/OP promotion and BCC messages to reduce stigma and risk behaviors and encourage testing. Funds will also be leveraged from GLIA in the two large camps and OPEC to complement USG EP-supported services.

This activity will support the expansion of clinical services to include risk reduction and behavior change messages, including condom education and distribution to PLWHA and their family members. The 2004 UNHCR BSS and the FHI-supported RH assessment found high risk behaviors among refugee camp populations, including multiple partners, transactional sex, male cultural and societal norms that encourage high-risk behaviors and GBV, very low condom use, and alcohol abuse. UNHCR will target HIV-positive refugee patients, including discordant and married HIV-positive couples; unmarried HIV-positive refugee men and women; ART patients. Health providers and volunteers will also target C/OP messages to high-risk populations in clinics and camps-at-large. Target populations include CT clients who test negative, non-married and unemployed men, women- and out-of-school youth at-risk, STI clients, CSWs, and refugees with demonstrated high-risk behaviors such as alcohol abuse and a history of GBV. Health care providers and volunteers will use client contacts to deliver key prevention messages, which will be tailored to match to patients' profiles and circumstances.

UNHCR will adapt and integrate a screening tool for HIV-negative and positive clients to be used during CT and clinical sessions. Similar to the AB activities, health providers will also be trained or refresher trained to recognize signs of alcohol abuse and GBV and will integrate related messages and referrals into their counseling sessions.

In addition, UNHCR will support BCC messages in all four refugee camps. In Kiziba and Gihembe refugee camps, UNHCR will refer CSWs, vulnerable women, and youth-at risk to IGA and microfinance activities supported by GLIA funds. The EP funds will support C/OP activities in Nyabiheke and Kigeme refugee camps. BCC will target high-risk and vulnerable refugee populations and use anti-SIDA clubs, peer educators, community forums, and relevant IEC materials. Key messages will promote risk reduction behaviors, condom use, and address social norms, GBV, and alcohol abuse.

To monitor and track the reach of these messages and condom uptake, UNHCR will integrate program-level indicators, including DELIVER-supported condom distribution and tracking indicators into existing reporting forms and tools. USG will leverage UNFPA and GFATM public sector condoms for the camps.

This activity supports the key legislative issues of gender and stigma and discrimination. This activity reflects the Rwanda EP five-year strategy and the GOR National Plan for HIV Prevention (2005-2009) by strengthening integrated health communication (BCC and IEC) campaigns to prevent transmission of HIV to high-risk groups, promote condom use among at-risk and MARP populations, and increase demand for high quality CT services.

This activity relates to activities in MTCT (8696), HVAB (8700), HVOP (8711), HBHC (8716), HVTB (8670), HKID (8148, 8150, 8152), HVCT (8732), HTXS (7176, 8737, 8172), HLAB (8189).

Rwanda is host to almost 50,000 refugees in camps around the country. Refugee populations are considered to be at high risk of infectious disease, in particular HIV, as well as GBV and other forms of violence, and economic and psychological distress. While much is currently unknown about HIV prevalence rates in the camp populations in Rwanda, recent service statistics of newly implemented VCT and PMTCT programs in two camps record a prevalence rate around 5% among those tested, with at least 200 individuals currently known to be living with HIV. Since 2005, the EP has supported UNHCR implementing partners AHA and ARC to provide HIV prevention and care services in Kiziba, Gihembe and Nyabiheke refugee camps with linkages and referrals for treatment.

FY 2007 funding for this activity will support the provision and expansion of palliative care services to 480 PLWHA and the training of 120 health providers, laboratory technicians, and community volunteers in Kiziba, Gihembe, and Nyabiheke refugee camp health clinics and communities. The basic care package will include a full range of adult and pediatric preventive care services, clinical care, psychological, spiritual and social support services, including CTX prophylaxis for eligible adults and exposed infants in line with national guidelines, prevention counseling for positives, and strengthened nutritional services, including nutritional assessment according to anthropometric measures, nutrition counseling, and management of malnutrition through provision of micronutrients and multivitamin supplements and leveraging of food from GLIA and Title II partners for clinically-eligible malnourished PLWHA (particularly for pregnant and lactating women and exposed and infected infants).

UNHCR partners will ensure the provision of, or referrals for diagnosis and treatment of OIs and other HIV-related illnesses (including TB), routine clinical staging and systematic CD4 testing, medical records for all HIV-positive patients and infants, and referrals to community-based psychosocial and palliative care services. Infants born to HIV-positive mothers will be provided CTX, early infant diagnosis through PCR, and ongoing clinical monitoring and staging for ART.

In collaboration with USAID clinical partners and Columbia, UNHCR partners will work with the Byumba, Kibuye, and Ngarama DHTs to ensure that health clinic providers receive training or refresher training in basic management of PLWHA, including training in ART adherence support, and in the identification and management of pediatric HIV. UNHCR partners will monitor and evaluate basic care activities through ongoing supervision, QA, and data quality controls, and will continue to build the capacity of local refugee health care providers to monitor and evaluate HIV/AIDS basic care activities through ongoing strengthening of routine data collection and data analyses for basic care.

PFSCM will procure and distribute through CAMERWA all palliative care and OI drugs, laboratory supplies and diagnostic kits. UNHCR partners will work with PFSCM, RPM+ and the districts to ensure appropriate storage, management and tracking of commodities, including renovation of pharmacy units at the health centers for adequate ventilation and security.

UNHCR partners will continue to support the continuum of care through the establishment of referral and tracking systems for comprehensive basic care and support services for PLWHA. Partners will strengthen linkages between palliative care and PMTCT, CT, OVC, TB and ART services, and will continue to work with the respective district hospitals to ensure an ongoing system of referral and care between the camps and other HIV care and support services, such as transport of blood specimen for CD4 and PCR testing, management of complicated OIs, and periodic monitoring of ART patients. UNHCR partners will also link with community services and counselors in the camps, including community and spiritual leaders, refugee PLWHA association members, and social workers to ensure access to community-based clinical and psychosocial support for HIV-positive refugees and their families. This will include referrals for GBV and trauma counseling for HIV-positive women, prevention counseling for positive and discordant couples, HBC and OVC support, ART and TB adherence counseling, and spiritual support. UNHCR partners

will work with GLIA to ensure provision of, or referrals for other forms of palliative care activities in the camps including IGA, microfinance, and wrap around for food support, with particular attention to OVC and child-headed households affected by HIV/AIDS.

UNHCR will provide technical support and monitoring of IP activities and data collection, and ensure appropriate reporting through the hiring of an HIV/AIDS technical and program manager.

This activity addresses the key legislative areas of gender through reduction of GBV and support for women confronted with GBV as well as increasing women's access to income generating activities; wrap around through Title II food and GLIA-supported microfinance activities, and stigma and discrimination through increased community participation in the care and support of PLWHA.

This activity relates to activities in MTCT (8696), HVAB (8700), HVOP (8711), HBHC (8718), HVCT (8732), and HTXS (8737).

Rwanda is host to almost 50,000 refugees in camps around the country. Refugee populations are considered to be at high risk of infectious disease, in particular HIV, as well as GBV and other forms of violence, and economic and psychological distress. While much is currently unknown about HIV prevalence rates in the camp populations in Rwanda, recent service statistics of newly implemented VCT and PMTCT programs in two camps record a prevalence rate around 5% among those tested, with at least 200 individuals currently known to be living with HIV. Since 2005, the EP has supported UNHCR implementing partners AHA and ARC to provide HIV prevention and care services in Kiziba, Gihembe and Nyabiheke refugee camps with linkages and referrals for treatment. In FY 2007, the EP will consolidate its support by funding UNHCR directly to expand the package of services for prevention, care, and treatment services for PLWHA. Funds will also be leveraged from the World Bank-funded GLIA and OPEC to complement EP-supported services.

The overall goal of TB/HIV collaborative activities is to decrease the morbidity and mortality of TB among PLWHA at 3 refugee camps. In FY 2007, the EP will support UNHCR as a new partner to implement the TB/HIV component of the clinical package of HIV care in 3 refugee camps. Of an estimated 30 TB patients anticipated to be registered for TB treatment in the 3 refugee camps, 27 will receive HIV counseling and testing. These collaborative TB/HIV activities include eight key items: 1) implementing routine provider-initiated HIV testing of TB patients at TB service sites; 2) providing cotrimoxazole prophylaxis to all HIV-positive TB patients and ensuring effective referral to HIV care and treatment services; 3) implementing intensified TB case-finding among 20 PLWHA enrolled in care and treatment through routine TB; 4) ensuring timely TB diagnosis work-up and treatment via DOTS for those PLWHA with TB disease; 5) routinely collecting, recording, reporting, and reviewing standard national TB/HIV program indicators at sites to inform and improve services, these data will also be routinely reported at the district level and national level through TRAC and PNILT; 6) training 3 HIV service providers on TB/HIV integration and standard operational protocols using the newly revised national training modules; 7) providing incentives for effective case management and referrals between services by implementing the community-based component the national PBF system; 8) UNHCR will conduct sensitization campaigns in all EP supported camps to raise awareness about the link between TB/HIV using PNILT materials.

This activity reflects the ideas presented in the Rwanda EP five-year strategy under its component of integration of HIV into the overall health system and the National Prevention Plan to prevent, diagnose and treat patients with both TB and HIV patients.

This activity is related to activities in MTCT (8696), HVAB (8700), HVOP (8711), HBHC (8718), HVTB (8670), HKID (8148, 8150, 8152), HVCT (8732, 8167), and HTXS (8737).

Rwanda is host to almost 50,000 refugees in four camps around the country. Refugee populations are considered to be at high risk for HIV as well as GBV and other forms of violence, economic, and psychological distress. While little is currently known about HIV prevalence rates in the camp populations in Rwanda, recent service statistics of newly implemented VCT and PMTCT programs in two camps show a prevalence of 5% among CT clients with at least 200 refugees currently known to be living with HIV.

Since 2005, the EP has supported UNHCR implementing partners AHA and ARC to provide HIV prevention and care services in Kiziba, Gihembe and Nyabiheke refugee camps with linkages and referrals for treatment. In FY 2006, ARC received funds to support AB prevention activities in two camps. In FY 2007, USG will consolidate its support by funding UNHCR directly to expand the package of services for the prevention, care, and treatment of PLWHA. Funds will also be leveraged from the World Bank-funded GLIA and OPEC to complement EP-supported services.

Currently, HIV testing rates remain fairly low in the refugee camps, with less than 15% of the reproductive age population having been tested for HIV in the two larger camps. The third camp, Nyabiheke, has just started testing activities and there are not yet enough data to indicate the percent uptake for testing. FY 2007 funds will increase CT at these three refugee camps to reach a total of 4,000 refugees with CT services.

UNHCR partners will reach more refugees with CT by strengthening PIT for TB and STI patients, malnourished and non-thriving infants, and patients presenting with HIV-related illnesses. In line with a revised strategy for a family-centered approach to CT, UNHCR partners will train staff in approaches for reaching family members of HIV-positives including improved counseling techniques to increase disclosure and encourage partners and family members to get tested, and contact tracing through a care coordinator at the refugee facility. Ongoing community-based campaigns will utilize refugee groups, refugee community leaders, and PLWHA to communicate HIV/AIDS stigma reduction messages and promote CT.

Health providers in refugee camps will receive training or refresher training in PIT, as well as in counseling for youth, male partners, and other targeted populations in refugee camp settings. Counseling will emphasize partner reduction, stigma, and alcohol reduction to sensitize clients to issues related to GBV, as well as confront social norms that contribute to these issues. CT providers will be trained or given refresher trainings in GBV and trauma counseling for women, particularly for both HIV-positive and negative women and widows who may be victims of violence. To ensure quality CT service delivery, UNHCR partners will provide supportive supervision of CT staff through QA, monitoring provider performance, and data quality reviews and will continue to support and strengthen the capacity of refugee health care providers to monitor and evaluate CT services.

UNHCR partners will also strengthen routine referrals for comprehensive care and support services, including CTX screening and PT, TB screening, diagnosis and treatment, management of other OIs and related HIV-illnesses, CD4 count testing, PCR testing and CTX PT for exposed infants, ART referral and support, nutritional counseling and support, and other psychosocial support services, either on site or at nearby health facilities. In collaboration with district hospitals, UNHCR partners will develop referral plans for services not offered on site including diagnosis and management of complicated OIs, severe malnutrition, and laboratory tests. Partners will also continue to strengthen referrals for PLWHA and their family members for community-based services, including IGA, OVC, PLWHA associations, legal services, food wrap-around through Title II partners and WFP, community based programs for distribution of bed nets in collaboration with PMI and the GFATM, and hygiene and safe water initiatives.

PFSCM will procure HIV test kits and supplies for all camps. UNHCR partners will work with PFSCM and district pharmacies to ensure that all camps have adequate and secure storage facilities as well as inventory monitoring and tracking systems for the test kits. UNHCR will provide technical support and monitoring of partner activities and data collection, and ensure appropriate reporting through the hiring of a technical and program

manager.

This activity supports the EP five-year strategy by scaling up counseling and testing services and providing integrated treatment, care, and prevention services to high risk groups.

While limited funds were allocated for Refugee camp ARV services in FY 07, the majority of these monies were earmarked for Kiziba camp since the GOR had signaled their support for creating stand alone ARV services at this geographically isolated site. However, recently, TRAC has began to work with staff at Gihembe refugee camp to certify it as a ARV site. Consequently, the USG team would like to allocate $20,000 to the Gihembe camp for the costs associated with the accreditation process as an ARV site and to ensure that the Gihembe camp receives the full package of services that will be available at other USG sites. The package of services includes hiring dedicated staff to follow all PLWHAs from the time of diagnosis and ensure that they receive proper clinical and nutritional counseling and care.

This activity relates to MTCT (8696), HVAB (8700), HVOP (8711), HBHC (8718), HVTB (8670), HVCT (8732), HTXD (8170), and HTXS (7174, 7246, 7213).

Since 2005, USG/Rwanda has supported HIV/AIDS services in refugee camps. In FY 2007, USG will expand the package of services for the prevention, care, and treatment of PLWHA in refugee camps. EP support will be complemented by the World Bank-funded GLIA and OPEC.

Funding for this activity will support a standard package of ART services at 2 refugee camps for 120 existing patients and 60 new patients, including 10 eligible HIV-infected children. This package of services includes treatment with ARV according to national guidelines, follow-up clinical monitoring, CD4 count every six months, viral load to an estimated 5 eligible patients with decreased or stable CD4 after nine months of HAART, management of ARV drugs side effects, ongoing adherence counseling, nutritional counseling, and patient referral to community-based palliative care.

Partners will provide a full package of ART services at Kiziba camp and a more limited package of ART services at Gihembe. Nyabiheke camp will continue to work closely with Ngarama District Hospital to ensure access to ARVs. Partners will support training for the refugee camp health care workers for the provision of ART, adherence counseling, ongoing clinical monitoring, management of ART-related side effects, and referrals.

In collaboration with clinical partners, UNHCR partners will strengthen the network of services offered between the camps and the district hospital. In addition, UNHCR will ensure transportation of specimens for all laboratory tests not available at the camps, strengthened communication and referral systems, and periodic supervision by the DHT.

PFSCM will procure all ARV drugs and commodities and strengthen the supply chain management system. RPM+ will provide training in pharmaceutical and ARV drug management and rational use.

UNHCR partners will strengthen linkages between PMTCT, MCH, CT, and palliative care through improved and integrated MIS and organization of facility wide staff meetings. Where necessary, partners will adapt adherence and counseling tools for ART patients to the refugee setting. As part of the USG standard package of ART services, funds will be used to hire and train HIV case managers to strengthen linkages to community-based services and to improve follow-up of ART patients.

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.