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

This is a continuing activity from FY 2007.

EGPAF began providing basic palliative care to 6,469 PLHIV at 33 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, EGPAF 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, EGPAF, 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, EGPAF 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, EGPAF will expand its services to provide palliative care for 6,469 existing patients and add an

additional 3,661 new patients at 33 existing sites and four new sites, including 26 ART sites and 37

palliative care 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

with the national nutrition guidelines. EGPAF 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. In addition, EGPAF will collaborate

with TWUBAKANE ensure provision of Family planning services; 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

EGPAF-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. EGPAF will support 37 facilities

to train, equip, and supervise 20 community health leads per health facility, along with other health care

workers, reaching a total of 808 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, EGPAF 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. EGPAF-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. EGPAF 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. EGPAF will support health

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

legal services. EGPAF 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, EGPAF 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. EGPAF will strengthen the capacity of five DHTs to coordinate an effective

network of palliative care and other HIV/AIDS services. The basic package of financial and technical

Activity Narrative: support includes staff for oversight and implementation, transportation, communication, training of

providers, and other support to carry out key responsibilities.

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 EGPAF began implementing the national TB/HIV policy and guidelines at their 24 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 those who are co-infected receive cotrimoxazole and

100% of all eligible patients receive ART. In addition at EGPAF-supported PMTCT and HIV care and

treatment sites, 100% of 10,130 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 EGPAF 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, this EP partner 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, EGPAF 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 EGPAF will continue to support 26 existing sites and add 11 new sites for the implementation of

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

These 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.