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

Sex workers 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 sex workers 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 sex workers. 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 sex workers, with potential for rapid spread among them. In Tanzania, Mozambique, and several

other countries, in addition to sex workers, 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 TA visits will result in collaboration with FHI to define and implement a package of

services for sex workers, including community-based outreach, TC, condom programming, STI screening

and treatment, 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 that can

assist all partners in implementing and expanding such programs.

Currently, FHI is providing STI services for sex workers at two clinical sites in Kigali. This funding will be

used to support STI services for sex workers in two additional sites, one in Kigali and one in Gitarama,

where HIV/AIDS care and treatment services are also available. These locations are EP-supported sites

and are selected based on the sex worker and truck driver populations in the area. FHI will collaborate with

the TWG on evaluation of these services for the purpose of developing best practices and evidence-based

prevention programming in high-risk groups. Funding will also be used for at least one regional visit to

another EP country in order to learn about and/or share best practices in this area.

This is a continuing activity from FY 2007.

FHI began providing basic palliative care to 17,807 PLHIV at 59 sites. 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 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, FHI will continue to provide psychosocial

counseling including counseling and referrals for HIV-infected female victims of domestic violence. To

ensure comprehensive services across a continuum, FHI, 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, FHI 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-related commodities.

In FY 2008, FHI will expand its services to provide palliative care to 17,807 existing patients in care and add

6,373 new patients at 59 existing sites, including 32 ART sites and 49 TC/PMTCT sites. Expanded services

will emphasize on 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, and 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 national nutrition guidelines. FHI 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 health education

on hygiene. In addition family planning education, counseling and methods will be provided to PLHIV and

their spouses. This service will be located within the counseling unit of the site to reduce need for referrals.

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 FHI-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. FHI will support 59 facilities to

train, equip, and supervise 20 community health leads per health facility reaching a total of 1,370 lead

health workers trained. These community health workers will organize periodic meetings to ensure quality

and coverage of community-based HIV services and linkages between community and facilities. The facility-

based case managers, community health leads and community based services providers constitute an

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

In order to ensure continuum of HIV care, FHI 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 referrals slips to ensure timely enrollment in care and treatment for children diagnosed with

HIV/AIDS. FHI -supported sites will assess individual PLHIV needs, organize monthly clinic-wide case

management meetings to minimize follow-up losses 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. FHI 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 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.

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. FHI will support health

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

legal services. FHI 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. 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 ones taken to HIV care and treatment

sites.

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, FHI 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.

In the context of decentralization, DHTs now play a critical role in the oversight and management of clinical

and community service delivery. FHI 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.

Activity Narrative: 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

PLHIV.

In FY 2007, FHI began implementing the national TB/HIV policy and guidelines at their 59 supported sites.

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

less than 70% to 95% and improving 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 eligible patients receive cotrimoxazole and 100% of those who are

eligible receive ART. In addition, at 59 FHI-supported PMTCT and HIV care and treatment sites, 100 % of

16,642 patients enrolled in HIV care are routinely screened for TB. However, lower than expected numbers

of PLWHA in care and treatment are diagnosed and treated for TB. The priority in FY 2008 will be to

expand implementation of regular TB screening and for all PLHIV, and for those with suspect TB, ensuring

adequate diagnosis and complete treatment with DOTS.

In FY 2007, FHI 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, FHI 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 of the six

supported districts underwent initial respiratory infection control training and have begun drafting infection

control plans which is being implemented in one hospital.

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

and HIV, FHI is supporting integrated planning and TB/HIV training to both HIV services providers and TB

services providers. This EP partner 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 FHI will continue to support 59 existing sites for the implementation of the TB/HIV component of

the clinical package of HIV care.

In addition to TB/HIV activities at their supported sites, FHI will recruit three TB/HIV focal points in FY 2008.

These focal points will be provided with extensive TB/HIV training and transportation. These staff located at

FHI office will join those located at AIDSRelief, Columbia University, PNILT and TRAC and decentralization

unit at Minisante to compose the national core team of supervisors for TB/HIV integration. The team will

ensure the functioning of the national TB/HIV working group, conduct monthly regular supervision to district

and feedback sites on the improvement and achievements for TB/HIV activities. 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.

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

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