Noted April 24, 2008: With these additional funds CRS in collaboration with TRAC will purchase vehicles

and fuel and recruit drivers to carry supervisors recruited by TRAC to initiate and scale-up quality

performance measurement of PMTCT program in Rwanda.

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

This is a continuing activity from FY 2007.

CRS began providing basic palliative care to 5,300 PLHIV at 14 sites in FY 2007. Palliative care services in

FY 2008 will continue including clinical staging and baseline CD4 count for all patients; follow-up CD4 every

six months; management of OI, STIs, and other HIV-related illnesses; 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, CRS will continue to provide psychosocial counseling including counseling and referrals

for HIV-positive female victims of domestic violence. To ensure comprehensive services across a

continuum, CRS through the partnership with CHAMP and other community services providers, refers

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. Through SCMS, CRS will provide diagnostic kits, CD4 tests, and

other exams for clinical monitoring, and will work with SCMS for the appropriate storage, stock

management, and reporting of all OI and STI-related commodities.

In FY 2008, CRS will expand its services to provide palliative care for 5,300 existing patients and an

additional 3,672 new patients at 14 existing sites and five new sites including two ART sites and three

TC/PMTCT sites. Expanded services will emphasize quality of care, continuum of care through operational

partnerships, and sustainability of services through PBF. Strengthened nutritional services through training

and provision of nutritional care will include counseling; nutritional assessments using anthropometric

indicators; management of malnutrition through provision of micronutrient and multivitamin supplements;

and links to Title II food support for clinically eligible PLHIV and children in line with national nutrition

guidelines. CRS will also support referrals for all PLHIV and their families for malaria prevention services,

including for the provision of LLITNs, in collaboration with CHAMP, GFATM, and PMI; and referral of PLHIV

and their families to CHAMP CBOs and other community-service providers for distribution of water

purification kits and hygiene health education. Strengthened psychological and spiritual support services for

PLHIV at clinic and community levels will be done through expanded TRAC training in psychological

support for all CRS-supported health facilities and community-based providers, including GBV counseling,

positive living, and counseling on PFPs.

In addition, the MOH will implement a new community health policy in FY 2008. The policy calls for the

election of male and female leaders for every 100 households to lead community health activities, organize

other community volunteers into associations and supervise their activities. With the assumption of 20

community health leaders per each health facility, CRS will support 19 facilities to train, equip, and

supervise 380 community health leads. They will also organize periodic meetings to ensure quality and

coverage of community-based HIV services and linkages between communities and facilities. In addition to

these health community leads, CRS will also train 130 health care workers.The facility-based case

managers, health community leads, health care workers, and community-based volunteers constitute an

effective system that ensures continuum, coverage and quality of palliative care.

In order to ensure a continuum of HIV care, CRS, 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

referrals to care services for pediatric patients identified through PMTCT programs, PLHIV 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 referral slips to ensure timely enrollment in care and treatment for children diagnosed with HIV/AIDS.

Case managers will conduct regular case reviews with other partners included in the referral system to

review the effectiveness of the system, identify challenges and design common strategies to overcome any

barrier to pediatric patients routing between services. In addition, adult patients enrolled in care will be

encouraged to have their children tested and infected persons taken to HIV care and treatment sites.

CRS-supported sites will assess individual PLHIV needs, organize monthly clinic-wide case management

meetings to minimize follow-up loss of patients, and provide direct oversight of community volunteers. The

community volunteers will be organized in associations motivated through community PBF based on the

number of patients they assist and quality of services provided. CRS will work with CHAMP to develop

effective referral systems between clinical care providers and psychosocial 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 PLHIV to

community-based HBC services, adherence counseling, spiritual support through church-based programs,

stigma reducing activities, CHAMP-funded OVC support, IGA activities (particularly for PLHIV 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.

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, CRS 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. DHTs now play a critical role in the oversight and

management of clinical and community service delivery. CRS will strengthen the capacity of two 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.

Increasing pediatric patient enrollment is a major priority for all EP clinical partners in FY 2008. To expand

quality pediatric care, Rwanda's few available pediatricians will train other clinical providers, using the

innovative model developed in FY 2006 and continuing in FY 2007 and FY 2008. CRS will support health

facilities to refer HIV-positive children to OVC programming for access to education, medical, social and

legal services. CRS 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.

This activity addresses the key legislative areas of gender, wrap around for food, microfinance and other

Activity Narrative: activities, and stigma and discrimination through increased community participation in care and support of

PLHIV.

In FY 2007, CRS began to implement the national TB/HIV policy and guidelines at their 14 supported sites.

The program's achievements include an improvement in the percentage of TB patients tested for HIV and

improving the HIV-infected TB patient's access to HIV care and treatment (increased proportion of patients

accessing cotrimoxazole and ART). In FY 2008, the goal is to ensure at least 95 % of all TB patients are

HIV tested, 100% of co-infected patients receive cotrimoxazole and 100% of those eligible receive ART at

14 AIDSRelief supported ART sites. At five AIDSRelief-supported PMTCT and HIV care and treatment

sites, 70-80% of 5,300 patients enrolled in HIV care are routinely screened for TB. However, lower than

expected numbers of PLHIV in care and treatment are diagnosed and treated for TB. The priority in FY

2008 will be to expand implementation of regular TB screening for all PLHIV, and for those with suspect TB,

ensuring adequate diagnosis and complete treatment with DOTS.

In FY2007, CRS supported sites with materials and training in routine recording and reporting for the

national TB/HIV programmatic indicators. Initial uptake and quality of services has been variable at different

sites. In FY 2008, CRS will support individual sites to both collect quality data, and to report and review

these data in order to understand and improve their program and support integration of TB and HIV services

at the patient and facility level, per national guidelines. Additionally, in FY 2007 two staff from each district

underwent initial respiratory infection control training and have begun drafting infection control plans.

HIV services are not yet available at all facilities in Rwanda. In order to ensure effective integration of TB

and HIV, CRS is supporting integrated planning and TB/HIV training to both HIV service providers and TB

service providers. CRS also plans to increase support to integrate diagnostic services, including

coordinating specimen transport for both programs, and patient transport for appropriate diagnostic services

(such as chest radiography and diagnostics required for extrapulmonary TB) to referral centers and

appropriate follow-up.

In FY 2008 This EP implementing partner will continue to support 14 existing sites and add five new sites

for the implementation of the TB/HIV component of the clinical package of HIV care.

Besides site level TB/HIV support activities, in FY 2007 CRS also supported in a senior TB/HIV staff

position to participate in TB/HIV programming implementation and monitoring at national level in

collaboration with PNILT and TRAC and other EP partners. In addition, this EP implementing partner

provided TA, training and materials to Butare University and Kigali national hospital pathology labs for the

diagnosis of smear negative and extrapulmonary TB. Physicians were trained in lymph node aspiration,

while lab technicians were trained in specimen processing. In FY 2008, CRS will continue supporting this

staff position, and support two laboratories trainings, and provide additional training to five other regional

laboratories in pathology specimen processing. The materials and supplies for these three laboratories are

purchased under SCMS. This activity reflects the ideas presented in the Rwanda EP five-year strategy and

the Rwandan National Prevention Plan by advancing the integration of TB/HIV services through the

operationalization of policies and increased coordination of prevention, counseling and testing and care and

treatment services. Lessons learned from integrating TB and HIV will serve in integrating HIV into the

primary healthcare system.

This activity is continuning from FY 2007. No new narrative is required.

Noted April 24, 2008: With these new funds CRs through its consortium member Institute of Human

Virology ( IHV) will support district hospitals in Rwanda for quality performance measurement at those

facilities and also at decentralised health centers. A set of indicators is being developped by Ministry of

Health and the national PBF program to measure the quality of HIV services. As part of the quality

improvement activity IHV will provide technical assistance to TRAC and hospital staff to improve their

services delievery filling the gaps identified by the quality indicators on patitent retention, data recording at

site, ontime CD4 count, TB screening in HIV patients, etc...This activity will improve the quality of HIV

service in Rwanda.

This is a continuing activity in FY 2008. However there is a new component in which CRS/AIDS Relief,

through the Institute of Human Virology (IHV), will build clinical capacity in Rwanda to ensure quality of HIV

services -including a significant emphasis on timely CD4 count, viral load and shifting to second line

regimen, prevention services, PITC--and continuity of care. In order to assure appropriate emphasis on

testing and prevention services, expertise will be used from CDC, WHO, or other organizations as

appropriate. Mentoring for a broader range of providers than those who treat HIV positive individuals,

including those who come into contact with untested HIV patients in outpatient or inpatient settings, will be

an essential component of this program.

Unprecedented HIV treatment scale-up is occurring in resource challenged health facilities in Rwanda,

where there is limited technical support and minimal local experience in providing continuity of care. Local

providers need additional support to provide quality care, increase clinical judgment and clinical decision

making, and to assure that testing and prevention services are given the same importance by clinicians as

treatment. However, this will not be accomplished through the prevailing didactic training model alone.

Significant challenges include: (1) it is difficult to apply classroom style didactic training to clinical practice;

(2) the sheer number of patients that require treatment and prevention services makes classroom training

difficult; (3) there are few local providers with ART or prevention expertise; and (4) the limited use of

evidence-based data in the different targeted populations to guide the clinical decision making process.

This makes the need for a new model of resident in-service training even more acute.

EP will support, through AIDSRelief, a national-level intensive mentoring and quality improvement program

in partnership with TRAC PLUS and the MOH. The primary goal is to build HIV care, treatment and

prevention expertise within the Ministry's clinical staff and local mentoring teams comprised of physicians

and ancillary health care providers and those with prevention expertise. The clinical mentoring teams will

support HIV prevention, care, and treatment programs at all levels of the national health care system

through an interdisciplinary team approach.

The focus will be on: encouraging and training health care clinical staff in implementing provider-initiated

HIV testing and counseling (PITC); prevention for positives (PFP); patient medical management with

emphasis on HIV care, treatment, and prevention; management of complex patient issues; in-patient

medical management with emphasis on accurate diagnosis and appropriate treatment of opportunistic

infections; community adherence and treatment support; laboratory and radiographic infectious disease

diagnostics; outpatient health care management and HIV care management; and addressing clinical

challenges in different aspects of health care delivery. Moreover, the mentoring teams will not only provide

front line providers with greater clinical and prevention skills, but they will also identify best practices and

develop initiatives to improve the overall quality of care and prevention through better clinic management

decisions, mainstreaming and integration of HIV testing and prevention services into clinical care, clinical

flow, and overall clinical program benchmarking—including explicitly measuring performance in PITC and

prevention for positives.

A key component of this activity will be on encouraging and training health care clinical staff in provider-

initiated testing and counseling and prevention for positives activities. This activity will include continuing to

work with the GOR to establish policies and protocols for provider-initiated testing and counseling and

developing training tools for health workers. It will also address reducing institutional or other barriers to

testing and making PITC a standard of good care. Provider-initiated HIV testing and counseling is endorsed

by WHO and UNAIDS and presents an opportunity to ensure that HIV is more systematically diagnosed in

health care facilities in order to facilitate patient access to needed HIV prevention, treatment, care and

support services. PITC must become the standard of care which is taught and practiced by clinicians.

AIDSRelief activities in this area will be in alignment with the WHO Guidance on provider-initiated HIV

testing and counseling in health facilities, and will take into account the current environment and capacity of

the GOR and the health care facilities. An initial needs assessment that assesses removal of barriers to

routine PITC and PFP will provide a baseline evaluation and help develop and introduce a harmonized and

supportive system within each health facility. This activity will also link directly with the Rwandan EP

programs priority of making Prevention for Positives the standard of care in all treatment settings.

These activities will also emphasize building advanced HIV treatment knowledge particularly in the areas of

side effects, resistance, durable treatment response and the latest HIV information and data,

implementation of continuity of care systems and long term follow-up, and quality improvement. At the

community provider level, the emphasis will be on enhancing basic clinical skills and site level capacity for

developing treatment and adherence programs. HIV/ARV treatment education competence will be

enhanced through training of trainers, teaching community focused curricula and development of training

materials. Training will also focus on improving competence for community adherence staff, community

counselors, nurses, and volunteers. In the field, preceptors will assist community workers with identifying

side effects to treatment and developing specific follow-up plans for new patients starting ARVs. In the clinic

preceptors will provide training for the counseling and education of patients who are preparing for ARV and

problem solving techniques for addressing specific adherence problems. At the district hospital, the

preceptors will also provide general clinical care guidance to district medical officers who are often young

and inexperienced.

This activity will support nationwide coordination of treatment, care, and prevention quality improvement

activities, integration of existing systems and national standards into the mentoring, coordination of key

stakeholders and implementing partners, data analysis and dissemination, performance monitoring of the

project, and supervision of the mentoring teams. The training will be followed with on-site mentoring and

technical assistance, semi-annual refresher trainings and introduction of new tools and technologies. The

mentoring team and the site providers will perform together continuous chart reviews, disease specific chart

Activity Narrative: reviews, mortality rounds and case studies (including studies focused on prevention services). By reviewing

specific clinical problems, the mentors will improve clinical practice and provision of care and prevention

services.

The initial plan is to form four mentoring teams stationed at four regional district hospitals, but the final

number of mentoring teams necessary will be determined in coordination with TRAC PLUS. These teams

will be hired and trained on models of comprehensive care, treatment, prevention and evaluation. They will

build on their skills and improve techniques to form an effective mentoring and quality improvement program

team at the decentralized level. Each team will be comprised of at least one physician, one nurse educator,

one adherence and community prevention specialist, and one laboratory technician. Each team will be

responsible for at least 5-8 sites in an initial phase until these sites have reached capacity and implemented

improvement activities. The portfolio of the mentoring teams will increase gradually as new sites are

phased in for capacity development and participation. One highly experienced antiretroviral treatment expert

(Preceptor) will be paired with 2-5 less experienced providers (Mentors) per region. The mentors and the

preceptor will work as a team within a selected district hospital, seeing patients together two to three days a

week. Seeing patients in follow-up together is critical for clinical decision making, to see progression of the

disease, confirm diagnosis, witness the outcomes of a shared decision making process, and monitor that

appropriate prevention services are provided to the patient. This interaction will lead to highly experienced

local experts/mentors who are taught the process of HIV continuity of care, efficient outpatient clinic

management, quality improvement techniques, as well as clinical decision making.

The goal is to build local clinical capacity to manage complexities associated with HIV/AIDS and to make

sound programmatic and clinical judgments to improve the quality and depth of health care services,

including prevention services provided to the local communities.