PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
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Table 3.3.07: Program Planning Overview Program Area: Palliative Care: TB/HIV Budget Code: HVTB Program Area Code: 07 Total Planned Funding for Program Area: $ 4,963,448.00
Program Area Context:
In 2004, WHO estimated the TB incidence in Rwanda to be 371/100,000 including 160/100,000 new smear-positive TB cases. This represents a 270% increase over the past 14 years - much of which has been fueled by the HIV epidemic. The DOTS strategy for TB control has been implemented in Rwanda since 1990 through the national TB program and Rwanda has 100% DOTS coverage in health facilities. The GOR has made TB/HIV a priority with support from EP, WHO and GFATM. In 2005 and 2006, a national policy on TB/HIV collaborative activities, implementation guidelines and standardized TB/HIV reporting were established. Key donors to PNILT include the USG, GFATM (Round 4), Damien Foundation, and WHO.
The most recent UNAIDS report on the HIV epidemic estimates that 3.1% of adult Rwandans are now living with HIV/AIDS. HIV infection is the single greatest risk factor for developing active TB disease with an annual risk of 5-10%. With EP support, PNILT implemented national TB/HIV reporting and surveillance. In 2005 and the first 2 quarters of 2006, 46-48% of TB patients were reported to also be HIV-positive. GOR estimates that there are 2000-3000 HIV-positive TB patients per year who are eligible for ART. USG efforts are consistent with the GOR and the WHO TB/HIV Framework which highlights the need for integrated programming, decreasing the burden of TB among PLWHA and increasing the availability of HIV care for TB patients. Reaching EP targets requires further expansion of the four core activities emphasized for TB/HIV programming: routine HIV testing of all TB patients; provision of care and treatment to all HIV-positive TB patients; screening all HIV-positive patients for active TB disease; linking all HIV-positive TB suspects to TB diagnosis and DOTS therapy.
EP assistance to TB/HIV control has included technical and financial support, assistance with national implementation guidelines, and training health care workers. In 2005 and 2006, the EP supported national coordination through a long-term TB/HIV technical advisor and program coordinators at PNILT and TRAC. With this assistance a national TB/HIV integration working group was established and continues to meet quarterly. The PNILT technical manual has been revised to include a chapter on TB/HIV, the TB register was revised to include HIV information and national reporting has been standardized and implemented at TB services sites. A baseline evaluation conducted in 2005 showed that approximately 48% of a sample of 438 TB patients registered for treatment at 23 geographically representative sites had a known HIV status, and that HIV-positive patients had a 6-fold increase in mortality compared to those that were HIV-negative. Ninety-six percent of TB patients reported acceptance of HIV-testing, if offered. The evaluation also showed that little information has been collected regarding HIV-positive TB patients' access to HIV care and treatment. These results have been used to modify national guidelines to promote TB/HIV activities. Early implementation of the national TB/HIV policy and guidelines has led to a reported national increase in HIV-testing of TB patients from 46% in 2004 to 77% by the second quarter of 2006. Moreover, in the second quarter of 2006, 43% of HIV-positive TB patients had documented access to cotrimoxazole prophylaxis and 30% were on ART.
In 2006, implementation of the national guidelines to screen all PLWHA for TB began at USG-supported sites. From January to June 2006, of 8,738 PLWHA enrolled in HIV care at 34 USG-supported health facilities, 2,830 (32%) were screened for TB. Of those screened, 174 (6%) were diagnosed with active TB and were started on TB treatment. A standardized paper-based ARV HIV register is being finalized and includes data on routine TB screening of PLWHA.
Despite significant progress, GOR, EP and WHO have identified numerous challenges that exist in integrating, coordinating and expanding services. These challenges include the need for sustained political commitment to support TB/HIV collaborative activities between programs at all levels, implementation of PIT, access to cotrimoxazole prophylaxis at all TB services sites, ensuring effective referral systems between programs for treatment, accurate recording and reporting of cases, effective supervision and review of program results. In FY 2007, the EP will continue to address these challenges by supporting
national-level coordination and program supervision through two national TB/HIV technical advisors and program coordinators at PNILT and TRAC. The EP will also expand a best practice model of integrating TB/HIV activities piloted in FY 2006 to 136 other USG-supported sites. A key element of the success of these efforts will be improving the diagnosis of TB among PLWHA by expanding intensified TB case finding at all HIV care and treatment sites, including implementing routine strategies for screening HIV-positive children for TB. In FY 2007, all PLWHA in care at USG-supported sites will be screened for TB and the 2,200 expected TB patients will be provided with cotrimoxazole and ART as appropriate. Conversely, all TB patients to be registered at USG supported sites will be offered HIV testing and those patients who test positive will be provided with a full package of HIV services including cotrimoxazole, palliative care and ART if needed.
The EP will also improve national TB diagnostic capacity by augmenting the pathology laboratory at CHK and the University of Rwanda National Pathology Laboratory. Activities will include recruitment and training laboratory staff and doctors on lymph node specimen preparation and diagnosis. Given the threat of MDR TB and new strains of XDR TB, the EP will also place an emphasis on implementing infection control guidelines at 27 hospitals in 22 districts to reduce and prevent TB transmission among PLWHA. The EP will continue to promote the integration of TB/HIV care into core programs, and continue efforts to improve the standard of care provided by EP partners, particularly those in HIV care and treatment, PMTCT, family-centered VCT and community programs. In addition, the EP will expand TB/HIV collaborative activities and services to 11 of Rwanda's 19 prisons.
The program will continue to support TB/HIV surveillance which yields valuable data for monitoring and program management. A web-based standard electronic TB register will be adapted for use in Rwanda based on the South African electronic TB register model. Program data will be used to benchmark quality at the district level and coordinated supportive supervisions will be used to reach quality and program targets.
The EP plan will continue collaboration with GFATM and will leverage USG resources going directly to WHO to scale-up TB/HIV activities. In addition, the EP will promote sustainability through performance-based financing and improve TB/HIV program quality through improved program data recording and use at USG and non-USG sites.
Program Area Target: Number of service outlets providing treatment for tuberculosis (TB) to 137 HIV-infected individuals (diagnosed or presumed) in a palliative care setting Number of HIV-infected clients attending HIV care/treatment services that are 3,500 receiving treatment for TB disease Number of HIV-infected clients given TB preventive therapy 0 Number of individuals trained to provide treatment for TB to HIV-infected 500 individuals (diagnosed or presumed)
Table 3.3.07:
