This is a continuing activity from FY 2007. No narrative required.

In FY 2008, CDC will support one expatriate staff and one local staff member of the EP prevention team.

Working in a country with a national HIV prevalence rate of 3.1%, it is vital for the EP to design and

implement prevention strategies that can affect behavior change and reduce the number of new infections

in order to stem the progression of the epidemic. The prevention team will be responsible for evaluating

prevention activities, monitoring the epidemic through analysis of available data, collaborating with the

National Prevention TWG on development of best practices, and providing strategic guidance to the country

program.

The Prevention Specialist will also manage the CDC-funded prevention and TC activities by providing

general oversight, TA, and support for monitoring and reporting of supported activities. This will include

management of and TA to the Healthy Schools Initiative, CDC's largest prevention program, and the new

PHE of couples testing.

This activity will also include the provision of TA from CDC headquarters to evaluate in-country programs

and develop guidelines for best practices for use among all EP-supported prevention partners. This TA will

support evaluation of behavior change prevention programs with youth, data use and analysis for

development of an effective prevention strategy, and incorporation of international best practices in

prevention.

This activity is comprised of two components: 1) an estimation of the size of high risk populations in

Rwanda and their characteristics, and 2) technical support for Prevention for Positives (PFP).

Commercial sex workers (CSWs) are often one of the groups with the highest HIV prevalence due to their

high-risk sexual behavior and their limited access (due to stigma, discrimination, and marginalization) to

services for HIV prevention, treatment, and care. A high prevalence of HIV in CSWs is a concern both for

members of these subpopulations and for the general population, as sexual mixing can facilitate

transmission of HIV from high-prevalence to low-prevalence groups.

Among EP focus and other bilateral countries, there is considerable variability in the proportion of HIV

attributable to CSWs. Country-level responses to HIV prevention among these groups is also variable, and

in some instances inadequate. In Kenya, South Africa, and Tanzania, where HIV is spread mainly through

generalized, heterosexual transmission, there is increasing evidence of HIV transmission among CSWs,

with potential for rapid spread among them. In Tanzania, Mozambique, and several other countries, in

addition to CSWs, HIV is occurring among individuals involved in "transactional sex" (the exchange of sex

for money and/or other goods with concurrent sexual partners) who are both vulnerable to HIV and likely to

be a bridge group to the general population.

In FY 2008, FHI will work closely with the OGAC prevention technical working group to define, implement,

and evaluate programming for prevention of HIV in Persons Engaged in High-Risk Behaviors (PEHRB).

Specifically, multiple technical assistance visits will result in collaboration with FHI to define and implement

a package of services for CSWs, including community-based outreach, TC, condom programming, STI

screening and treatment, and referral to PMTCT and HIV treatment and care for those who are HIV-

infected. In addition, the TWG and FHI will work together to determine policy, training, procurement and

data needs to facilitate comprehensive HIV prevention programs for national coverage in Rwanda, and

prepare tools which can assist all partners in implementing and expanding such programs.

Technical support from the TWG will also help to conduct population size estimations of two to three high

risk groups including CSWs and MSMs. Strategic information obtained by these estimations is necessary in

order to determine prevalence and will contribute to the overall understanding of these groups in Rwanda

and their need for HIV services.

The second component of this activity is to provide technical assistance to assure that activities provided for

in FYs 2007 and 2008 requiring clinical and community partners to carry out Prevention for Positives are in

fact carried out and conducted using the best methods available. The activity will provide for TA from US-

based scientists to clinical and community partner organizations and their facilities. Funding for this activity

includes travel for technical support.

Prevention for Positives is an essential part of a total prevention and care package to reduce the

transmission of HIV disease.

Reinforcing existing programs by assuring training of physicians and community counselors who will be

providing prevention counseling for HIV positives will help reinforce partner reduction and safer sex

practices in this high risk group. In addition, assuring strategic placement of trained counselors and training

physicians who are assigned and/or working at ART sites will help ensure that clients most in need will

benefit from the counseling. Community counselors will promote couples counseling and provide

prevention for positive messages to all their clients, but particularly PLHIV, to reduce their high risk

behaviors through abstinence, being faithful to one partner or promoting "secondary abstinence" and

counseling and discussing condom use for those discordant couples. Trained community counselors will

benefit from training HIV positive individuals on aspects of health, including prevention to all their HIV

positive clients.

In this activity, trainers will use a provider counseling manual currently being finalized at CDC and a

DOD/OGAC manual based on the U.S. military program in practice since 1985. The program is based on

one-hour modules for counselors to train/discuss with HIV positive patients issues including abstinence,

safer sex, nutrition, drugs and alcohol, partner notification, disclosure, and medical aspects of HIV.

The overarching goals of the proposed activities are: (1) to build capacity in the central MoH to coordinate

TB/HIV activities in collaboration with WHO-OGAC and UTAP TB/HIV central support, and (2) to conduct

evaluations that inform the national programs. In FY 2006 CDC supported MoH in TB/HIV collaborative

activities through guidelines and tools development at the central level and conducted targeted evaluations

to inform national program quality and scaling up. CDC continues to support the MoH in developing TB/HIV

guidelines, curriculum, and tool design in collaboration with WHO. CDC supports TDYs from CDC Atlanta

for training in TB laboratory, TB lab assessment and technical support for targeted evaluations in TB/HIV.

CDC also funds regional technical assistance to support PNILT to implement the electronic TB register in

Rwanda, and to link it to the TRACNet database.

In FY 2007, CDC funded the TDY of a CDC/international expert in infection control for the training organized

by WHO OGAC project as this expertise is not available among WHO staff. In order to meet the PEPFAR

priority of providing quality smear microscopy services and effective TB diagnostic services for PLHIV, CDC

supported short-term TB laboratory TA to work with NRL and Columbia University to enhance the

performance of the smear microscopy EQA system and the quality of culture and drug sensitivity testing

services. Surveillance for extremely drug-resistant TB (XDR) will be conducted at CHK among TB patients

that are failing TB treatment. In FY 2007, CDC provided short-term support to train one additional lab

technician in performing cultures and drug sensitivity testing at the supranational reference lab in Antwerp.

In FY 2008, CDC will continue to bring experts to train additional hospital staff in infection control and to

review the planned national infection control policy and individual infection control plans. Two TDYs will be

supported, one for the expanded training and another for infection control plan review and lessons sharing.

CDC will continue to support TDYs for the targeted evaluations initiated in FY 2007, the evaluation of TB

screening and diagnosis among HIV infected children, the evaluation of the diagnosis process for extra

pulmonary and smear negative TB, and an evaluation to validate the national tool used to screen PLHIV for

TB. A total of six TDYs will be supported for these evaluations. CDC will continue to support the laboratory

system in Rwanda for new TB diagnosis, scale-up TB culture capacity, and decentralize quality assurance

for microscopy and TB culture, and add capacity for DST for MDR and X-DR TB. A total of four TDYs will be

supported for these laboratory related activities. Lastly CDC will provide technical assistance to PNILT and

EP implementing partners working in 10 state prisons in Rwanda for routine TB surveillance based on

experiences gained in the first two prisons where Columbia University is providing HIV services in FY 2007.

CDC will also provide funds and TA to WHO to continue TB/HIV collaborative activities in Rwanda. The

activity is the continuation of the WHO/EP TB /HIV collaboration project started in FY 2006 with central

funding from OGAC to WHO. As part of ongoing EP and WHO collaboration, the EP has set aside

$2,000,000 for FY 2006-2007 WHO-EP country-level TB/HIV activities in Kenya, Rwanda and Ethiopia. The

funding level for Rwanda was $350,000. The goal of this grant was for WHO to work with EP and host

country health authorities to reinforce central level support for effective provision of HIV counseling and

testing for all clients attending TB clinics, the strengthening of networks between TB and HIV/AIDS program

areas. Specifically, the project is to ensure cross-referral of clients between the TB and HIV/AIDS programs

so that people with TB are placed and continued on anti-retroviral treatment (ART) and People Living with

HIV/AIDS are screened and, if eligible, treated for TB, and to develop collaborations with TB programs to

enhance provision of ART and in particular to ensure adherence through innovative programs (e.g., use of

existing DOT providers/services, provision of ART through existing DOT centers, using DOT providers to

provide ARVs, etc…). The annual action plans and reports are planned jointly with EP. The main activities

for the project in Rwanda are: 1) review of national guidelines, norms, and tools for TB/HIV integration, 2)

training of service providers, to support data recording reporting, and use for improved TB/HIV collaborative

activities, 3) training of providers on diagnosis of smear negative and extra pulmonary TB disease, and 4)

reduction of nosocomial TB infections through training and implementation of their plan in selected facilities.

In June 2007, a national project officer was recruited by WHO and based at PNILT. The national guidelines

and norms were reviewed. In collaboration with CDC an expert was brought in country to train 36 doctors

from all district hospitals on TB infection control concepts and guidelines. In addition 84 doctors were

trained on reading and interpretation of chest X-rays. This initial collaboration with WHO (mission office,

AFRO, WHO Geneva) also led to supporting PNILT to apply and successfully receive a global fund grant for

broader TB and MDR TB control activities.

It was agreed during the partners meeting that WHO was instrumental to facilitate and coordinate TB/HIV

activities in Rwanda and reach this level of achievement. All partners proposed the EP-WHO work plan

timeline and budget to be extended for one more year (until September 2008) and a new project for the

period from mid-2008 to mid-2009 should be prepared and included in the Rwanda COP as the OGAC

central funding ends.

This is a continuing activity from FY 2007. No narrative required.

This is a continuing activity from FY 2007.

CDC provides direct support for laboratory infrastructure activities through CDC technical staff in-country as

well as through short-term TA from CDC headquarters. In FY 2007, CDC's Division of Parasitic Diseases

(the DPDx group), developed a set of training materials and conducted procurement of supplies needed for

a week-long training of trainers in parasitology diagnostics. CDC also provided TA for the development of

the laboratory component of an ongoing national ART program evaluation. CDC is currently recruiting a full

time laboratory advisor to be placed at the CDC office and hopes to have that position filled before October

2007.

In FY 2008, CDC will continue direct support for laboratory infrastructure activities through the long-term lab

position described above. The CDC laboratory advisor will provide day-to-day oversight of EP-funded lab

partner activities, including the NRL cooperative agreement and other clinical partners. The lab position will

also provide ongoing assistance with development and implementation of national laboratory policy. The lab

advisor will also work with laboratory coalition partners to develop a plan forTA during FY 2008 and work

with them to complete the projects which are being funded.

Since the current capacity of district hospital laboratories to diagnose OIs remains limited, CDC will continue

to support laboratory capacity for diagnosis through the DPDx program for diagnosis of parasitic diseases.

This support will include procurement of diagnostic supplies and ongoing training at NRL for technician

trainers, as well as TA for improving NRL's supervision capacity and systems, particularly in malaria

diagnosis. CDC will continue to provide TA to lab professionals in evaluating new techniques for specimen

collection for viral load testing, and for applying these new techniques for public health program evaluation.

CDC will work closely with Columbia University to adapt laboratory information system software for use in

Rwanda's NRL and select district hospitals.

CDC technical support to NRL is consistent with Rwanda EP five-year strategic goals of strengthening NRL

capacity to manage a national network of laboratories, and standardization of technical approaches and QA

of HIV-related services through a network model. DPDx's ongoing procurement, training and QA activities

will provide an excellent platform upon which to further strengthen laboratory capacity and systems under

PMI. In FY 2008, the program will extend DPDx activities to all district hospitals.

In FY 2008, CDC will continue support for long term TA provided by a CDC Epidemiologist and an inter-

agency HMIS Coordinator while also continuing short term TA in surveillance, HMIS, and M&E.

The epidemiologist on the EP SI Team will serve as the surveillance focal point to providing TA to TRAC

and the NRL for their surveillance activities. FY 2008 surveillance activities will include: ANC sentinel

surveillance, behavioral surveillance, HIV drug resistance monitoring and HIV incidence testing for

surveillance. In addition, the EP will provide support for integration of HIV surveillance in PMTCT. This

support will strengthen the national capacity to collect, interpret, and use surveillance data, and complement

TRAC's proposed surveillance activities in FY 2008.

During 2008, CDC will also continue to support an EP HMIS Coordinator to coordinate HMIS activities with

the GOR, EP agencies, EP partners, and multilateral organizations such as the WHO and UNAIDS. The

Coordinator will assist the GOR in strategic planning for information systems in the health sector and will

help strengthen GOR capacity in information systems development, implementation, management and data

use to collect critical data. The EP HMIS Coordinator will also provide technical support to EP partners to

implement the HIV Registry (in collaboration with Voxiva and TRAC), and to scale up the rollout of the

electronic TB register that is being adapted from South Africa.

CDC will also provide short term TA to support HMIS activities, including supporting the rollout of the case

registry, behavioral surveillance, and EP strategic information activities. These funds will also continue to

support one local hire data manager who is seconded to TRAC.

In addition, during FY 2008, Rwanda will serve as a pilot country for M&E capacity building trainings. GOR

and EP staff will attend the following trainings: M&E 101 for program managers, economic evaluation,

qualitative evaluation, and data utilization. The training activities will contribute to building sustainable M&E

capacity in Rwanda, with a focus on data quality and data utilization for program improvement.

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) by directly supporting the

development of sustainable strategic information systems for the national HIV/AIDS program.

With these funds CDC/Rwanda will recruit a senior level position to facilitate and advocate policy changes

needed to better implement EP in Rwanda. In addition, 25% of this person's time will be devoted to planning

and follow-up of activities aimed at building capacity of systems and structures that contribute to planning,

implementation, and monitoring of HIV/AIDS program in Rwanda. CDC/Rwanda staffing structure reflects

program needs in line with "staffing for results."

During the past year, the EP team has lacked expertise in systems strengthening and policy. The new

position will initiate policy dialogue with MOH, CNLS, and other ministries involved in EP implementation.

For example, advocacy has been initiated to adapt the HIV testing policy to include whole blood draw by

finger prick, HIV testing for minor children without adult guardian, and PITC. In many cases, policy

advocacy has failed due to the lack of a dedicated staff member who can focus on engaging decision

makers in ongoing discussions and support these advocacy efforts with data from Rwanda and elsewhere.

This new staff member will review existing policies, identify program areas where policy changes are

needed, collect data with the help of technical staff, rally interested parties, and initiate and follow-up the

processes that guarantee the successful policy change in these areas. This person will report regularly to

the EP team on the state of the policy changes, communicate new and updated policies to EP

implementing partners, and also follow up on their implementation.

The second objective of this long term technical assistance is to plan and follow-up all EP system

strengthening activities including infrastructure, training, and staffing at health facilities. The EP in Rwanda

has invested significantly in interventions that support Rwandan institutions, as well as systems that benefit

HIV programs, including attendant issues such as education, governance, and economic security. There is

a need to assess this support and continue interventions that have proven to effectively build the capacity of

the overall health system. This staff member will oversee strategic planning of system strengthening

activities during COP development, follow-up their implementation and help document the impact of the

support on the broader health system. This activity contributes to the implementation of EP activities and

the sustainability of health systems in Rwanda.

This activity will establish a program for training at least one district health services manager in each of the

23 districts in which the EP works over time. In the first year, the program would aim to teams of two to four

individuals in approximately six to eight districts. This will be accomplished in partnership with the MOH

through the Sustainable Management Development Program (SMDP). SMDP's objective is entirely

consistent with the EP goal of strengthening human capacity in a sustainable way. Established in 1992, the

program has worked successfully in more than 63 countries to develop highly trained health professionals

with appropriate and tailored leadership and management expertise. Further, it has worked closely with the

EP to tailor programs to meet the needs of countries receiving EP funds.

The basic model for SMDP that will be followed in Rwanda is: 1) to undertake an in- country assessment

with relevant EP and host country officials of how a program can be designed to meet the identified needs;

2) to design a program that both trains officials and allows them to apply that training toward EP objectives;

3) to identify key in-country officials who will come to the United States for the annual six week Management

International Health (MIPH) course held each year in Atlanta. The MIPH course designed for future trainers

is intended for public health professionals from developing countries who have support to conduct

management capacity building in their own countries; 4) to undertake highly tailored, applied management

training projects in which trainers apply their training to their own work and together with technical

assistance from the Division of Epidemiology and Surveillance Capacity Development (DESCD) to train

other foreign nationals in applying management and leadership skills to their ongoing responsibilities. This

typically consists of two to three weeks in the classroom followed by supervised applied learning projects,

which are typically undertaken over six to nine months.

Six factors together justify a compelling need for properly trained health system managers with leadership

skills, as Rwanda implements the EP. First, the dramatic scale-up of the program has created an acute

need for managers who can accountably oversee large sums of money spread over multiple program areas.

Second, inputs from GF and other donors require sophisticated managers who can wisely integrate and

account for multiple sources of funding. Third, the GOR's decision to decentralize dramatically health

service implementation and to empower district level managers has highlighted the need for every district to

have a cadre of properly trained health managers. Fourth, district managers have responsibility for assuring

performance in some of the most managerially challenging aspects of this complex program including:

assuring linkages between community and clinical partners; assuring equity of service delivery and quality;

and integrating national and EP information systems and targets. Fifth, the national decision to deploy

complex financing schemes at the district level such as Performance Based Financing mutuelles also

funded in the EP for selected populations, require sophisticated managers with an understanding of health

finance. Finally, despite these demands, as Rwanda rebuilds its educational system it is suffering from a

dire shortage of properly trained health managers, particularly at the district level.

The goal of this program is to train managers at the district level to successfully manage the responsibilities

associated with the EP funded sites in their catchment areas. The funds provided in COP 2008 will fund

approximately six individuals for the MIPH course.

Rwanda is in dire need of properly trained epidemiologists and laboratorians as it seeks to modernize its

public health system. There is a chronic shortage of Rwandans in these fields that are so critical to the EP

and the broader health sector. This activity will begin establishment of a formal Field Epidemiology and

Laboratory Training Program (FELTP) in Rwanda to develop highly trained epidemiologists and laboratory

management personnel for the Rwandan health ministry. The goal of this program is to provide

competency-based in-service training with a primary focus on EP related activities. The program

participants will be integrated within the departments of the MOH and will perform epidemiologic studies,

surveillance development, analysis, evaluation activities, laboratory management improvement projects,

and other public health service activities such as program management activities and outbreak

investigations. This project will enhance the public health system within which HIV/AIDS surveillance,

activities and programs are occurring in Rwanda.

This training program will be coordinated with CDC's DESCD and a university system. However, it will rely

on a field orientation that provides practical experience as well as service to the MOH and implementation

of the EP. The formal program occurs over a two-year period and culminates in the granting of a master's

degree. It will be designed to produce leaders who can craft and develop programs and systems that

incorporate the strategic information focus of the EP and a broader vision of the complete public health

system.

The curriculum for the program, pending approval by the university body granting the degree, will train

participants in a series of 5-6 courses over the two year period. This will incorporate didactic training

evaluated through a traditional examination process and field-based activities including specific

investigations, evaluations, and research as a part of a thesis project. Specific coursework will include

Advanced Analytic Epidemiology, Public Health Program Management, Laboratory Management (for lab

trainees only), communications in a program that provides a unique field-based component, and use of

strategic information for decision making in public health programs.

In FY 2008, an initial in-country assessment will be undertaken. This will result in the development of a

workplan, curriculum, a short course on applied epidemiology, and a supervisor's short course. The

program will rely to the extent possible on the African Field Epidemiology Network for both technical

expertise and cost-savings.

The FELTP program has a history and record of supporting the EP goal to build sustainable capacity in

critical areas. FELTP programs currently exist in more than 40 countries, including many EP countries.

More than 92 percent of graduates remain in service to the host government and 70 percent of programs

have been sustained for more than 10 years. The majority of programs originally created with CDC support

continue without assistance from CDC. Adapted from CDC's Epidemiology Intelligence Service, the

program mixes classroom and applied work to produce world class public health leaders.

Based on the EP ‘Staffing for Results' exercises conducted in collaboration with OGAC for FY 2008, CDC is

proposing to increase staff within technical areas by adding six new positions. Specifically, the office is

proposing to recruit a HIV/AIDS Treatment Specialist (2846), a TB/HIV Specialist (2846), a Systems

Strengthening & Policy Officer (16764), a Senior Program Manager, Prevention Services Expert (2844), and

a Monitoring and Evaluation Specialist (2848), to better support the implementation of EP activities. The

CDC will also fill the existing Chief of Party and Epidemiologist positions. In addition to personnel costs,

which includes ASPH fellows and COMFORCE contractors, this activity includes equipment and services to

support general office operating expenses. In line with CDC's consolidation of IT services, the program will

purchase services from the new ITSO Infrastructure Services Support package in order to improve

operational effectiveness and efficiency.