The overall goal of this activity is to build capacity at central level for TB/HIV guidelines, tools, best practices

sharing, improving TB diagnosis, supervision and monitoring evaluation of TB.HIV integration activities.

In FY 2007, Columbia University is supporting TB/HIV collaborative activities at central level through

continuation of a long-term advisor and four national supervisors at the national TB program to oversee

collaborative activities. This includes support to the national TB/HIV working group for: guidelines,

curriculum and tool revision. It also includes support for supervision by the national programs for quality TB

and HIV services to co-infected patients---particularly to strengthen the implementation of routine HIV

counseling and testing, prevention education, and referral for HIV care (if needed) for all TB patients at the

TB/DOT clinics. Additionally, it includes implementation of standardized, symptom based TB screening and

intensified TB case finding in HIV-infected patients at the ART clinics. In addition Columbia is supporting

PNILT for the implementation of an electronic TB register at selected sites. Support to two model centers

established in FY 2005 will continue (With Plus-up funds in FY 2007, Columbia (through its agreement with

PNILT and national reference laboratory) is strengthening TB capacity throughout the Rwanda laboratory

network. Lower-tier laboratories will use basic Ziel-Nielsen staining of specimens, and three reference

laboratories located in NRL, Kigali University Teaching Hospital (KUTH), and Butare University Teaching

Hospital will perform more complex assays such as TB culture, molecular diagnostics (PCR), TB resistance

testing, MAC and other atypical mycobacterium diagnostics. In addition, the three reference laboratories will

oversee the training and supervision of TB-related activities in the lower tier labs, improving quality of the

microscopy-based diagnostic tests. A strong referral system will be developed to transport specimens from

the lower tier labs to the reference laboratories for TB culture and other specialized tests. The Plus-Up

funds is also contributing to better coordination of TB activities, including monitoring and evaluation

systems, between PNILT and NRL, CHUK and TRAC.

Quality assurance systems was strengthened by guiding NRL in the development of an external quality

assurance (EQA) program for TB-related diagnostics. The CHK pathology lab will be upgraded to

accommodate the increasing volume of TB-related anatomical pathology and clinical pathology specimens.

Finally these funds supported the drafting of a national strategic plan for TB lab diagnostics and lab

networking strengthening, in coordination with the overall national plan for integrated TB and HIV activities.

In addition to the TB laboratory activities, ICAP will strengthen TB/HIV integration in three prisons currently

providing ART services in Rwanda (ICAP-supported sites) and assure that systems are in place for effective

data collection and tracing of HIV patients released to the community, including those co-infected with HIV

and TB. ICAP will hire staff to work with the prisons on these aspects of TB/HIV integration ICAP will assist

with the coordination of these activities with KUTH, BUTH, NRL and PNILT. ICAP will procure all equipment

and contract with a local company to renovate laboratories at KUTH, BUTH and NRL.

In the first 6 months of FY 2008, Columbia University through the TRAC 1.0 mechanism will continue to

strengthen national TB and HIV integration until the new award is made for UTAP follow-on. Columbia will

continue supporting PNILT and NRL with existing and additional staff positions and trainings. These

positions together with those located at FHI, AIDSRelief, TRAC and CDC will constitute the national

supervision team that supports the national working group, designs and adapts guidelines and training

curriculum and tools, and provides routine reporting and data analysis and use by central level and health

facilities. This team will conduct monthly data review and feedback to all districts in Rwanda and those

districts will in turn inform their respective health facilities. In addition Columbia will support additional staff

positions and training at NRL, for TB culture molecular diagnostics (PCR), TB resistance testing, MAC and

other atypical mycobacterium diagnostics as the demand is expected to grow in FY 2008 with scale-up

active TB case findings among PLWA , smear negative suspect TB clients and their families. Columbia will

continue to support the network of TB lab with transportation of specimens from low tier lab to the main

three lab NRL, CHK and Butare University lab. In FY 2008 Columbia will support the decentralization of TB

quality assurance to decrease the workload on NRL. These activities will reinforce timely diagnosis of extra

pulmonary and smear negative TB thus decreasing the high mortality currently associated with delayed

diagnosis of these types of TB disease.

With UTAP ending in March 2008, it is expected that Columbia University through TRAC 1.0 mechanism will

continue the activities until a new award is made. UTAP follow-on will continue the same activities planned

above for Columbia University TRAC. 1.0 during the second half of FY 2008 to ensure continuity of

program

In FY 2007, the UTAP mechanism (Columbia as prime partner) supported the MOH for the expansion of

pediatric HIV care and treatment services and effective integration of HIV/AIDS services into the national

health system. The UTAP mechanism that supported Columbia is ending in March 2008, and CDC is

issuing another funding announcement opportunity to replace the UTAP mechanism.

In FY 2007, Columbia is supporting the model pediatric HIV/AIDS centers at CHK and CHUB. Through

expanded PITC and PCR testing for early infant diagnosis, additional children requiring care are identified in

PMTCT programs, nutrition rehabilitation centers and PLHIV associations. Psychosocial support,

counseling, M&E systems are strengthened to improve follow up. CHK and CHUB pediatricians are

providing training, mentoring and supportive supervision to health care providers at EP-supported ART

sites.

In FY 2008, the new mechanism will support various MOH units including the MCH task force and TRAC.

In addition, it will promote integration for pediatric care including uptake, guidelines review, training

supervision and integration of PMTCT, IMCI, MCH and ART services. These funds will complement

previous UTAP activities for six months in FY 2008. The first six months are covered with funds in the

MCAP Supplemental.

HIV/AIDS pediatric care uptake has been slow in Rwanda because of the scarcity of pediatricians and the

lack of skills among general practitioners. In FY 2007 the EP funded training and supervision of general

practitioners by a team of pediatricians and senior MDs. With these new funds, the EP will support

additional training of trainers and providers in pediatric care and treatment, production and revision of

pediatric HIV care and treatment manuals and tools, recruitment of needed pediatricians or medical doctors

for district hospitals, and mentoring supervision of pediatric ARTat new EP-assisted sites. In addition to

clinical management, the training will emphasize pediatric patient recruitment and follow-up. This activity will

increase pediatric patient enrollment at the national level.

These activities fully support the Rwanda EP five-year strategy for national scale up and sustainability, as

well as the Rwandan Government ART decentralization plan.

New cooperative agreement (TBD)

In FY 2008, the partner will provide technical assistance and capacity building activities at NRL by

supporting technical activities as well as strengthening the institutional infrastructure and management

capacity critical to sustain the national network of laboratories for the Rwandan HIV care and treatment

program. Direct TA will be provided through long-term advisors and periodic short-term consultants as

needed. Two long-term technical advisor positions will be provided in FY 2008. The first will provide support

for HIV-related quality laboratory services, including evaluations of new technologies, technician trainings,

and guidance on technical and policy issues. The second advisor, a local-hire senior lab technician, will be

responsible for development and implementation of national standards, QA systems, and training. These

two technical advisors will transfer skills, knowledge and capacity to ensure a sustained impact.

The partner will improve NRL's laboratory management through support of an international-hire

management advisor. The laboratory management advisor will help develop management systems for

finances, logistics, program data, transport and commodities and will mentor the new NRL Director and

Finance position funded under the CDC cooperative agreement.

The partner will upport the decentralization of NRL supervision and QA within the national laboratory

network. This decentralization will include continued strengthening of the five regional district laboratories.

PCR for Early Infant Diagnosis and viral load determination will be supported at NRL and CHUB via

equipment maintenance and staff training.

TB services at NRL require strengthening to meet the EP priority of providing reliable AFB microscopy at

the health facility level. The partner will support laboratory TA to the NRL and CHUB TB laboratories to

ensure high quality smear microscopy, liquid culture and drug sensitivity testing capability. These TB

diagnostic and treatment capabilities are essential in order to provide PLHIV adequate access to

comprehensive quality TB-related services. These capabilities are also essential for the support of patients

with MDR TB. Extrapulmonary TB diagnostics will be available through continued support to CHUB and

CHUK anatomopathology laboratories.

ACM (Atelier central de maintenance) and NRL maintenance units for laboratory equipment will be

strengthened with training and staffing to guarantee the quality of results within the national laboratory

network. Also, small laboratory renovation/rehabilitation will be performed to assure building sustainability

inside the national laboratory network.

The partner will strengthen and integrate QA/QC/QI into all HIV-related laboratory areas: serology,

chemistry, hematology, CD4, TB, and malaria. New QA/QC approaches will be explored in those HIV

specific areas. National specimen transportation systems will be strengthened. Specific laboratory target

evaluations on new technical alternatives and new technologies will be supported to improve the

accessibility and reliability of care and treatment programs. For example, new alternative technologies will

focus on specific HIV areas such as CD4 (dipsticks, micro-chips etc) or TB infant diagnostics. Protocols

and/or indicators should be designed to evaluate laboratory performance impacts on care and treatment

programs.

The partner will support laboratory staff skills development through local (KHI), regional and international

training programs, with an emphasis on integration of all HIV-related laboratory activities and total quality

management as part of the laboratory accreditation process.

In collaboration with CDC, the partner will maintain and improve the laboratory information system for NRL

and support the LIS extension at district hospitals. The laboratory information system will manage financial

record keeping, as well as specimen tracking, inventory control, and programmatic indicators.

All of these activities are consistent with Rwanda's EP five-year strategic goals of strengthening NRL's

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

of HIV-related services throughout the national laboratory network.