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

This is a continuing activity from FY 2007.

IntraHealth began providing basic palliative care to 8,586 PLHIV at 32 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, IntraHealth 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, IntraHealth, 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, IntraHealth

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, IntraHealth will expand its services to provide palliative care for 8,586 existing patients and add

an additional 2,056 new patients at 32 existing sites and five new sites, including 20 ART sites and 32

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. IntraHealth 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 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 IntraHealth-supported health facilities and community-based providers,

including GBV counseling, positive living, and counseling on Prevention for Positives.

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. IntraHealth will support 37

facilities to train, equip, and supervise 20 community health leads per health facility, in addition to other

health care workers, reaching a total of 996 lead health workers trained. These CHWs 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, IntraHealth 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. IntraHealth-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.

IntraHealth 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 USG 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. IntraHealth will support

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

and legal services. IntraHealth 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, IntraHealth 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. IntraHealth 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

Activity Narrative: 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 Intrahealth, Inc. began implementing the national TB/HIV policy and guidelines at their 26

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 those who are eligible receive ART.

However, lower than expected numbers of PLWHIV care and treatment are diagnosed and treated for TB.

The priority in FY2008 will be to expand implementation of regular TB screening and for all PLHIV, and for

those with suspect TB, ensure adequate diagnosis and complete treatment with DOTS.

In FY2007 Intrahealth, Inc. supported sites with staff 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, Intrahealth, Inc. is supporting integrated planning and TB/HIV training to both HIV services

providers and TB services providers. Intrahealth 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 Intrahealth Inc. 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 continuing from FY 2007. No new narrative is required.

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