This activity relates to activities in MTCT (7181, 7208, 8185, 7219, 7244, 8697, 7179, 8170), HVAB (8129), HVOP (8137), HBHC (8144), HVTB (8147), HVCT (8168), HXTD (8170), HTXS (8172), HLAB (7224, 8189). In FY 2006, USAID partners are providing financial and technical assistance for PMTCT services in 96 health facilities throughout Rwanda. The PMTCT package includes CT, infant feeding counseling, CD4 count and clinical staging for HIV-positive woman, combination ARV regimens non-eligible women and HAART for eligible women, and delivery following safer practices, infant and mother follow-up, CTX for OI prevention and infant HIV testing. In FY 2007 USAID awarded three new cooperative agreements - one of the three to IntraHealth - that will provide clinical services in existing sites and expand services according to the joint USG-GOR expansion plans within PEPFAR districts. IntraHealth will provide an expanded package at 15 existing VCT/PMTCT/ART sites, 13 existing VCT/PMTCT sites, and 7 new VCT/PMTCT sites with an emphasis on quality services and continuum of care through operational partnerships, and sustainability of services through PBF.

IntraHealth 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, IntraHealth 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, IntraHealth 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. Linking with MCH services, IntraHealth will work with IntraHealth/Twubakane to incorporate safe motherhood, FP, and GBV screening into PMTCT activities. Plus-up funding will be used to bridge the gap between the PMTCT and FP programs and ensure that quality FP counseling and services already supported by the USG are made available as part of the routine PMTCT and HIV 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 with commodities procured with CSH POP funds. IntraHealth will strengthen follow-up and tracking systems to ensure testing of family members, routine provision of CTX PT and infant diagnosis, ongoing infant feeding counseling and support in collaboration with UNICEF, Title II partners and World Food Program, CD4 monitoring and clinical staging, management of OIs, including TB and other HIV-related illnesses, psychosocial support services at clinic and community levels,identify and refer women who may be victims of gender-based violence to appropriate care in collaboration with Twubakane, and access to clinical and community prevention, care, and treatment services for family members. IntraHealth will assure linkage to treatment for eligible women and infant follow-up by using 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 ensure these linkages, case managers will train and supervise community volunteers and organize monthly health center meetings with staff from all services to follow-up on referrals and other patient-related matters. In collaboration with CHAMP and case managers, 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. In addition these case managers will ensure referrals of pediatric patients from PMTCT sites and nutrition centers to ARV services. Through the PFSCM, IntraHealth will provide ARV drugs, CD4 tests, RPR test kits, PCR, rapid HIV test kits, and hemoglobin testing materials to all supported sites. IntraHealth will also collaborate with RPM+ to improve the capacity of providers in drug management, coordinated site-level storage, inventory, tracking and forecasting. In addition, IntraHealth

will collaborate with CHAMP, GFATM and PMI to refer PLWHA and their families for malaria prevention services including bednet provision. In collaboration with CRS, IntraHealth will provide weaning food for exposed infants in need. In addition IntraHealth will leverage food aid from Title II and the World Food Program to meet the other nutritional needs of these food insecure households. PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, IntraHealth will shift some of their support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Full or partially reduced payment of PMTCT and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national quality supervision tool. IntraHealth will provide a package of support to 4 DHTs to strengthen their capacity to coordinate an effective network of PMTCT and other HIV/AIDS medical services. This network focuses on maximizing access to PMTCT and other HIV/AIDS services and improving quality of care at the most decentralized level. Support to DHTs will focus on strengthening the linkages, referral systems, transport, communications and financing systems necessary to support an effective PMTCT and other HIV/AIDS care network. IntraHealth will provide a basic package of financial and technical support to DHTs, including staff positions, transportation, communication, training of providers using the trainers trained by TRAC, and other support to carry out their key responsibilities.

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

This activity relates to MTCT (8698), HVAB (8130), HVOP (8138, 8137), HBHC (8144), HVTB (8147), HVCT (8168), and HTXS (8172). In FY 2006, all USAID clinical partners are providing a standard package of services including PMTCT, CT, OI, other palliative care, and ART. In order to improve prevention for positives programming, FHI is providing TA to TRAC to assess sexual and risk behaviors among PLWHA and their networks. FHI will use this information to revise clinical and community IEC materials to fill gaps in existing prevention for positives and adapt a training module for prevention messaging in clinical settings. The revised curriculum will be integrated into the national care and treatment training to be used by all clinical partners, including IntraHealth, in FY 2007. Since this inception of the EP, all USG clinical partners were expected to provide an integrated health message to all clients. In an effort to both harmonize and improve the quality of clinical services across USG partners, the EP will initiate a standard prevention for positive package for beneficiaries starting in FY 2007.

In FY 2007, USAID awarded three cooperative agreements - one of the three to IntraHealth - that will expand quality clinical services, including prevention messages. IntraHealth will expand its clinical services to include AB messages during post-test counseling and follow-up sessions with HIV-positive patients and their family members. Appropriate AB messages will be integrated into the clinical services and home based care. Health care providers, case managers and community volunteers will use client contacts to deliver key AB messages tailored to individual groups. Different messages will be used to match patients' profiles and circumstances and prevention needs. As many high-risk behaviors can often be linked to other contextual factors such as unemployment, poverty, trauma, and psychosocial needs, clinical partners will work with CHAMP and other partners to strengthen referrals and mechanisms for patients to access IGA, vocational training, trauma counseling, legal support, and psychological and mental health care and support for at-risk clients, particularly HIV-positive patients.

IntraHealth will adapt and integrate a screening tool for clients to be used during CT sessions, follow-up counseling, and patient monitoring, particularly of asymptomatic patients and patients on ART. Checklists and job aids will be used to facilitate and standardize the counseling messages providers deliver to patients. IntraHealth will also adapt program-level indicators into existing reporting forms and tools for monitoring. The clinical package aims to provide integrated services, including AB messaging, to every client and is part of the EP strategy to strengthen prevention for positives and continue to reduce transmission of HIV. This activity addresses the key legislative issue of stigma reduction. This activity reflects the Rwandan national plan for HIV infection prevention and EP goal of averting 157,000 new infections by 2008.

This activity relates to HVOP (7251, 8133, 8134), MTCT (8698), HVAB (8129), HBHC (8144), HVTB (8147), HVCT (8168), and HTXS (8172). In FY 2006, all USAID clinical partners are providing a standard package of services including PMTCT, CT, OI and other palliative care, and ART. In order to improve prevention for positives programming, FHI is providing TA to TRAC to assess sexual and risk behaviors among PLWHA and their networks. FHI will use this information to revise clinical and community IEC materials to fill gaps in existing prevention for positives and adapt a training module for prevention messaging in clinical settings. The revised materials will be piloted and integrated into the national care and treatment training curriculum to be used by all clinical partners, including IntraHealth, in FY 2007.

In FY 2007, USAID awarded three cooperative agreements - one of the three to IntraHealth - that will expand quality clinical services, including prevention messages. As an award recipient under the RFA, IntraHealth will expand services to include C/OP messages during post-test of all clients and follow-up counseling with HIV-positive patients and their family members. Appropriate prevention messages will be integrated into the clinical setting within health facilities and home based care. Health care providers, case managers and community volunteers will use client contacts to deliver key prevention messages that are tailored to individual groups. Different messages will be used to match patients' profiles, circumstances and prevention needs. Emphasis for this activity will be placed on reaching HIV-positive discordant couples and ART patients. Unmarried sexually active men and women who are HIV-negative but who practice high risk behaviors will also be counseled and supported to adopt risk reduction behaviors as well as appropriate and consistent use of condoms.

As many high-risk behaviors can often be linked to other contextual factors such as unemployment, poverty, trauma, and psychosocial needs, clinical partners will work with CHAMP and other partners to strengthen referrals and mechanisms for patients to access IGA, vocational training, trauma counseling, legal support, and mental health care and support for HIV-positive patients. The partners will adapt and integrate a screening tool for HIV-negative and positive clients to be used during CT sessions, follow-up counseling, and patient monitoring, particularly asymptomatic patients and patients on ART. Checklists and job aids will be used to facilitate and standardize the counseling messages providers deliver to patients. To monitor and track reach of these messages and condom uptake, IntraHealth will work with DELIVER to integrate C/OP reporting and condom distribution and tracking indicators into standardized reporting forms. Public sector condoms will be procured through GFATM and UNFPA. Additional condoms may be procured through CCP as necessary.

The clinical package aims to provide integrated services, including C/OP services, to every client and is part of the EP strategy to strengthen prevention for positives and continue to reduce transmission of HIV. This activity addresses the key legislative issues of gender, particularly violence reduction and male norms. This activity reflects the five-year EP strategy and the Rwandan national plan for HIV infection prevention and EP for averting 157,000 new infections by 2010.

This activity relates to activities in HBHC (7187, 7220, 7245, 8716, 9637, 7163, 7165, 8141, 8716), MTCT (8698), HVAB (8129), HVOP (8137), HVTB (8147), HVCT (8168), HTXS (8172, 7213), HLAB (8189). In FY 2006, USAID clinical partners provided basic palliative care to 22,779 PLWHA at 100 sites. The package includes clinical staging and baseline CD4 count for all patients, follow-up CD4 every six months, management of OIs and other HIV-related illnesses, including OI diagnosis and treatment, and routine provision of CTX prophylaxis for eligible adults, children and exposed infants based on national guidelines, basic nutritional counseling and support, positive living and risk reduction counseling, pain and symptom management, and end-of-life care. In addition, USAID partners provide psychosocial counseling including counseling and referrals for HIV-positive female victims of domestic violence.

To ensure a comprehensive package of care across a continuum, USAID partners, through the partnership with CHAMP and other community services providers, refer patients enrolled in care to community-based palliative care services based on their individual need, including adherence counseling, spiritual support, stigma reducing activities, OVC support, IGA activities, and HBC services for end-of-life care. In FY 2007, USAID awarded three coooperative agreement -one to IntraHealth - to provide an expanded package of services at 36 sites. IntraHealth will expand services with an emphasis on quality services and continuum of care through operational partnerships, and sustainability of services through PBF. Under this expanded package, IntraHealth will provide a full range of adult and pediatric preventive care, clinical care, psychological support, spiritual and legal support services across a continuum of care, including provision of CTX prophylaxis for PLWHA and exposed infants in line with national guidelines, strengthened nutritional services through training and provision of nutritional care, including counseling, nutritional assessments using anthropometric indicators, and management of malnutrition through provision of micronutrient and multivitamin supplements, and links to Title II food support for clinically eligible PLWHA and children in line national nutrition guidelines. IntraHealth will also support referrals for 11,890 PLWHA and their families for malaria prevention services, including for the provision of ITNs, in collaboration with CHAMP, GFATM and PMI; and referral of PLWHA and their families to CHAMP CBOs and other community-service providers for distribution of water purification kits and health education on hygiene. In addition, in collaboration with TRAC and CHAMP, IntraHealth will ensure the provision of strengthened psychological and spiritual support services for PLWHA at clinic and community levels through expanded TRAC training in psychological support for all IntraHealth-supported health facilities and community-based providers, including GBV counseling, positive living, and counseling on prevention for positives.

IntraHealth will provide referrals for routine CD4, the prevention, diagnosis and treatment of OIs, and ongoing follow-up care for all PMTCT, VCT, TB and ART clients through strengthened linkages and referral systems between these services at clinic level. Through PFSCM, IntraHealth will provide diagnostic kits, CD4 tests, and other exams for clinical monitoring, and will work with PFSCM for the appropriate storage, stock management, and reporting of all OI-related commodities. In order to ensure continuum of HIV care, IntraHealth, in collaboration with CHAMP, will recruit case managers at each of the supported sites. These case managers with training in HIV patient follow-up will ensure the proper referral of patients through the different services within the health system and the community. IntraHealth-supported sites will assess individual PLWHA needs, organize monthly clinic-wide case management meetings to minimize follow-up losses of patients, and provide direct oversight of community volunteers. In addition, these case managers will train 216 community volunteers and provide them with necessary tools to provide services to patients in the community.

The community volunteers will be motivated through community PBF based on the number of patients they assist and quality of services provided. IntraHealth will work with CHAMP to develop effective referral systems between clinical care providers and psycho-social and livelihood support services, through the use of patient routing slips for referrals and counter referrals from community to facilities and vice versa. Depending on the needs of individuals and families, health facilities will refer PLWHA to community-based HBC services, adherence counseling, spiritual support through church-based programs, stigma reducing activities, CHAMP-funded OVC support, IGA activities, particularly for PLWHA female- and child-headed households, legal support services, and community-based pain management and end-of-life care in line with national

palliative care guidelines. Increasing pediatric patient enrollment is a major priority for all USG clinical partners in FY 2007. Case managers will ensure referrals to care services for pediatric patients identified through PMTCT programs, PLWHA associations, malnutrition centers, and OVC programs.

To do this, the case managers will have planning sessions with facilities and community-based service providers, and OVC services providers for more efficient use of patient referrals slips to ensure timely enrollment in care and treatment for children diagnosed with HIV/AIDS. In addition, adult patients enrolled in care will be encouraged to have their children tested and positive ones taken to HIV care and treatment sites. To expand quality pediatric care, Rwanda's few available pediatricians will train other clinical providers, using the model developed in FY 2006 and continuing in FY 2007. IntraHealth will support health facilities to refer HIV-positive children to OVC programming for access to education, medical, social and legal services. IntraHealth will also support sites to identify and support women who may be vulnerable when disclosing their status to their partner, and include in counseling the role of alcohol in contributing to high-risk behaviors. In the context of decentralization, DHTs now play a critical role in the oversight and management of clinical and community service delivery.

IntraHealth will strengthen the capacity of four DHTs to coordinate an effective network of palliative care and other HIV/AIDS services. The basic package of financial and technical support includes staff for oversight and implementation, transportation, communication, training of providers, and other support to carry out key responsibilities. PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, IntraHealth will shift some of their support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Full or partially reduced payment of palliative care and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool.

This activity addresses the key legislative areas of gender, wrap around for food, microfinance and other activities, and stigma and discrimination through increased community participation in care and support of PLWHA.

This activity relates to activities in HVTB (7162, 7169, 7180, 7221, 8664, 7266), MTCT (8698), HVAB (8129), HVOP (8137), HBHC (8144), HVCT (8168), HTXS (8172). In FY 2006, USG partners started implementing National TB/HIV integration policy and guidelines at their supported sites. Partners refer all suspected TB cases among PLWHA for TB testing and expected new cases of active TB for TB DOTS, cotrimoxazole prophylaxis, and eligible patients for ART. In FY 2007, USAID awarded three cooperative agreements - one to IntraHealth - to support sites where the TB/HIV component will be integrated into the clinical package of HIV care. This activity has eight components: the first component is to implement routine provider-initiated HIV testing to TB patients at IntraHealth-supported sites. HIV testing will be conducted at sites providing TB services. The second component is to provide cotrimoxazole prophylaxis to all HIV-positive TB patients and ensure referral to HIV care and treatment services.

The third component is the implementation of intensified TB case-finding among PLWHA enrolled in care and treatment at USG-supported sites through routine TB screening using the national standardized questionnaire. The fourth component is to ensure timely TB diagnosis and treatment via DOTS to an estimated 384 PLWHA diagnosed with TB disease. The fifth component is the routine collection, recording, and reviewing of standard national TB/HIV program indicators at sites to inform and improve services. This data will also be routinely reported to the district and national levels through TRAC and PNILT. The sixth component of this activity is to support training of 120 doctors, nurses, social workers, and HIV and TB services providers on TB/HIV integration and standard operational protocols using the newly revised national training modules. The seventh component is to support sites to provide incentives for effective TB and HIV patients' case management and referrals between the two services by implementing clinical and community-based components of the national PBF system.

The final component is support for 4 district hospitals to draft and implement a plan of TB infection control according to national guidelines developed in collaboration with WHO/OGAC project. PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, IntraHealth will shift some of their support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Examples of quality indicators include correctly filling stock control cards in X-ray departments, the percentage of TB lab exams that are corroborated during quarterly controls, the number of X-rays of good quality with correct diagnosis and report in patient file, and the number of complete series of AFBs correctly done.

Payment of indicators is linked to the quality of general health services through adjustments of payments based on the score obtained using the standardized national Quality Supervision tool and a performance incentive for the production of more than agreed upon quantities of each indicator. These activities support Rwandan national plan for TB/HIV and EP to prevent, diagnose and treat patients with both TB and HIV patients.

This activity relates to activities in MTCT (8698), HVAB (8129), HVOP (8137), HBHC (8144), HVTB (8147), HVCT (8167, 7217, 7182), and HTXS (8172). In FY 2006, USAID partners are supporting VCT services in 100 sites to reach approximately 100,000 clients. In accordance with GOR norms, CT will be offered in sites where patients can receive needed basic care such as PMTCT, CD4 staging, OI prophylaxis and treatment, and referral to community services and higher level clinical care. In order to improve the efficiency of CT services, partners are moving to rapid testing and advanced strategies for testing. In order to reach more clients, partners have increased male partner testing of PMTCT clients through community sensitization, facilitated couples testing through weekend CT services, improved pediatric case-finding through testing during immunization days and special family/child testing days during vacation days.

In FY 2007, IntraHealth will reach 25,000 individuals through a strategic mix of targeted PIT, family-centered CT, and client-initiated CT services that ensure confidentiality, minimize stigma and discrimination, and reach those individuals most likely to be infected. This activity will support CT services at 36 sites. At all IntraHealth-supported health facilities, PIT services will target adult and pediatric inpatients presenting with TB and other HIV-related OIs and symptoms, malnourished children and HIV-exposed infants, and STI patients. PIT will be implemented with a revised counseling component whereby pre-test counseling is more focused with emphasis placed on post-test counseling. Moreover, case managers and community workers will be trained as counselors in order to provide continuous support beyond the consultation to encourage testing acceptance, family and/or partner tracing, and support for those who received their test results.

A total of 216 doctors, nurses and social workers at IntraHealth-supported sites will be trained in PIT. In order to implement PIT, all health care providers and case managers will receive CT training and all community workers will receive counseling training. In collaboration with CHAMP, case managers will work with PLWHA associations, religious institutions, community DOTS programs, and OVC and HBC programs to identify those infected, in particular HIV-exposed infants, family members of PLWHA, and OVC. CT providers will continue to provide client-initiated CT 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, disclosure of test results, and follow-up care. To strengthen the continuum of care for PLWHA and their families, IntraHealth will establish a formalized referral system to link community care and clinical services.

The case manager, in collaboration with CHAMP, will ensure that HIV-positive patients are provided patient education, positive living counseling and referral for community-based services, such as IGA, through PLWHA associations, OVC, and HBC programs. At the health facility 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. PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, IntraHealth will shift some of their support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Full or partially reduced payment of palliative care and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool.

PFSCM will procure HIV test kits and supplies for all sites. IntraHealth will work with PFSCM and district pharmacies to ensure that all sites have adequate and secure storage facilities as well as inventory monitoring and tracking systems for the test kits. This activity supports the EP five-year strategy for sustainability, national scale-up of counseling and testing, and provision of integrated treatment, care, and prevention services.

This activity relates to activities HTXS (7158, 7161, 7164, 7174, 7176, 7185, 7213, 7222, 7246, 7262), MTCT (7179), HVAB (8186), HVOP( 8133), HBHC (7177), HVTB (7180), HVCT (7178), HTXD (8170), and HLAB (7224, 8189). In FY 2006, USAID partners provided a comprehensive package of ART services to 11,900 patients at 57 sites, including 952 children. The package includes treatment with ARV drugs, routine CD4 follow up, viral load testing for an estimated 2,400 eligible patients with decreased or stable CD4 after nine months of HAART, management of ARV drug side effects, and patient referrals to community-based care. In FY 2007, USAID awarded three cooperative agreements - one of the three to IntraHealth - that will provide the same package at 57 existing sites and 18 new clinical sites.

IntraHealth will expand quality clinical services, continue support to the DHTs, increase sustainability through performance-based financing, and strengthen SI at all levels. This activity will reach 1296 new patients, including 130 children, enrolled at a total of 18 sites. With procurement support from PFSCM, IntraHealth will provide ARV drugs, CD4 tests, and viral load tests to all supported sites. In order to ensure continuum of care, HIV case managers at sites will train and supervise community volunteers including CHWs, PLWHA association members, and other caretakers, in collaboration with CHAMP. Increasing pediatric patient enrollment is a major priority for all USG clinical partners in FY 2007. Case managers will ensure referrals of pediatric patients identified from PMTCT programs, PLWHA associations, and malnutrition centers. In addition, adult patients enrolled in care will be encouraged to have their children tested.

To expand quality pediatric care, Rwanda's few available pediatricians will mentor other clinical providers, using the Columbia UTAP model developed in FY 2006. In the context of decentralization, DHTs now play a critical role in the oversight and management of clinical and community service delivery. IntraHealth will strengthen the capacity of 4 DHTs to coordinate an effective network of ARV and other HIV/AIDS services. The basic package of financial and technical support includes staff for oversight and implementation, transportation, communication, training of providers, and other support to carry out key responsibilities. The Rwanda EP will continue a gradual shift in funding from input financing to performance-based financing. Through a strategic mix of input through the district support package and directly to health facilities, and output performance-based financing through the purchase of improved performance for specific HIV indicators, districts will receive the appropriate support to increase autonomy and sustainability.

In addition, IntraHealth will strengthen district and facility level capacity for data collection, reporting and use with focus on ARV drugs management, HIV case management, and improved quality implementation and program evaluation. Sites will generate routine summary reports of patient-level data and will interpret that data to inform their programmatic operations. IntraHealth will also organize periodic M&E workshops for all supported sites to discuss the collection and use of data at the site-level. 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.