PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
The overall goal of this activity is to decrease new HIV infections through behavior change communication.
The focus is on abstinence and fidelity targeting military personnel.
PSI/Rwanda and the Directorate of Military Services (DMS) work together to promote HIV prevention
among members of the Rwanda Defense Forces (RDF). While some soldiers practice sexual abstinence
and fidelity, living away from their families, mobility and age make them vulnerable to HIV.
PSI/Rwanda is implementing community-based activities among soldiers, their sexual partners, and
surrounding communities to increase safer sexual behaviors. Key prevention strategies are 1) capacity
building of AIDS support clubs 2) peer education and IPC sessions (including cine-mobiles), and 3)
promotion of counseling and testing services
Using the results of a behavioral survey conducted in late 2007, the DMS and PSI will update
communication materials to reflect best practices in the following areas; AB; couples counseling and
testing; integration of FP into HIV/AIDS prevention (including PMTCT); men as partners; GBV and
prevention of alcohol abuse.
In FY 2009, these activities will continue with the program reaching at least 20,000 members of RDF with
prevention messages. The military AIDS support clubs will work to sensitize surrounding communities about
risky sexual behavior. The DMS will strongly encourage soldiers to get tested with their partners. MC
activities (described in CIRC narratives) will be closely integrated into this activity.
This activity is related to HVOP and CIRC activities.
New/Continuing Activity: Continuing Activity
Continuing Activity: 12873
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
12873 4004.08 Department of Population 6322 132.08 PSI-DOD $80,000
Defense Services
International
7230 4004.07 Department of Population 4344 132.07 PSI-DOD $60,000
4004 4004.06 Department of Population 2574 132.06 PSI-DOD $35,000
Emphasis Areas
Gender
* Addressing male norms and behaviors
Military Populations
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Estimated amount of funding that is planned for Education $150,000
Water
Table 3.3.02:
The overall goal of this activity is to decrease new HIV infections in the military through BCC with a focus on
correct andconsistent use of condoms.
PSI and the Directorate of Military Services (DMS) work together to promote HIV prevention among
members of the Rwanda Defense Forces (RDF). While some soldiers practice sexual abstinence and
fidelity, living away from their families, mobility and age increase their HIV risk.
PSI is implementing community-based activities among soldiers, their sexual partners, and surrounding
communities to increase safer sexual behaviors. Key prevention strategies are 1) capacity building of AIDS
support clubs 2) peer education and IPC sessions (including cine-mobiles), and 3) promotion of counseling
and testing services
communication materials to reflect best practices in the following areas: AB, couples counseling and
testing, integration of FP into HIV/AIDS prevention (including PMTCT), condoms for dual protection, men as
partners, Gender Based Violence and prevention of alcohol abuse.
In FY 2009, PSI will continue these activities, emphasizing correct and consistent condom use; ensuring
condom access and availability including minimizing the stigma surrounding condoms; promoting condom
negotiation skills with partners, and further emphasis on the role alcohol plays in risky behavior. Additional
IEC materials promoting condom use will be developed. PSI will train 200 volunteers to reach 30,000
individuals with prevention messages. The military AIDS support clubs will work to sensitize surrounding
communities about risky sexual behavior.
The DMS will strongly encourage soldiers to have HIV tests together with their partners. Male Circumcison
activities (described in CIRC narratives) will be closely integrated into this activity. The DMS will also
distribute approximately 2,000,000 condoms in FY 2009.
This activity is related to HVAB and CIRC activities.
Continuing Activity: 12874
12874 2803.08 Department of Population 6322 132.08 PSI-DOD $144,000
7229 2803.07 Department of Population 4344 132.07 PSI-DOD $60,000
2803 2803.06 Department of Population 2574 132.06 PSI-DOD $35,000
Estimated amount of funding that is planned for Human Capacity Development $144,000
Table 3.3.03:
ACTIVITY IS NEW IN FY 2009.
The overall goal of this activity is to decrease new HIV infections in the Rwanda Defense Forces (RDF)
through male circumcision (MC) with emphasis that MC be offered as a part of an expanded approach to
reduce HIV infections in conjunction with other prevention programs, including HIV testing and counseling
(TC), treatment for other sexually transmitted infections, promotion of safer-sex practices and condom
distribution. Male circumcision will not replace other known methods of HIV prevention and will be
considered as part of a comprehensive HIV prevention package.
In FY 2009, Population Services International (PSI) will conduct MC communication and messaging
activities targeting the general population. The activities will utilize interpersonal communication strategies
as well as local- and national-level media campaigns that encourage safe MC as part of a complete
approach to prevention, that the benefits accrue over time, and that MC does not provide complete
protection.
Additionally, PSI will conduct a study tour to the Society for Family Health Zambia (a PSI Affiliate that began
piloting MC services in September 2007, and launched mobile MC in March 2008) to assess their fixed and
mobile MC/TC programs for piloting in Rwanda. This partner will also develop and integrate MC counseling
messaging into all military BCC and VCT activities. These messages will focus on: MC myths and
misconceptions; emphasizing that MC will not fully prevent HIV transmission; reinforcing condom and
partner reduction messaging; the need to know HIV status before receiving MC; and the need to abstain
from sexual activity to allow for complete wound healing.
In FY 2008, PEPFAR worked closely with the Rwanda Ministry of Health (MOH) and other donors in a
national task force to develop policy that recognizes the MC as an effective HIV prevention method
alongside the ABC strategy. The MOH has also requested donor support for the expansion of MC services
beginning with the Rwanda military (one of Rwanda's most at-risk populations). Conducting MC in the
Rwanda military is considered vital since the military is predominately male, typically young, highly mobile
and is considered a high risk group.
These activities address the key legislative issues on gender, particularly with respect to male norms and
stigma reduction. The activity supports the Rwanda PEPFAR five-year strategy by collaborating with the
GOR to implement prevention activities for the military. Focusing prevention efforts on the military is a key
strategy of both PEPFAR and Government of Rwanda.
New/Continuing Activity: New Activity
Continuing Activity:
* Increasing gender equity in HIV/AIDS programs
Program Budget Code: 08 - HBHC Care: Adult Care and Support
Total Planned Funding for Program Budget Code: $10,823,667
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
The Government of Rwanda (GOR), in collaboration with international donors, implementing partners, and local organizations,
continues the rapid scale up of HIV prevention, care, and treatment services. According to EPP/Spectrum data from 2008, the
median estimate of the number of HIV-infected individuals in Rwanda is 149,000. Of these, 71,799 are estimated to be in need of
ART. (Source: 2008 Epidemic Update; MOH and CNLS).
Statistics:
Cumulative national cohort through March 2008:
•As of September 2008, 63,878 patients had initiated ART, of which 6,095 (9.5%) were children (Sources: TRACnet; CIDC/MOH)
oOf these, 58,082 (91%) patients were currently on ART (Note: likely overestimation).
oApproximately 1% of adult patients were on second line regimens (Source: CIDC, HIV/AIDS/STI (HAS) Unit)
•As of March 2008, 51,387 patients were currently on ARV treatment, including 5,058 children, at 176 health facilities across
Rwanda (Sources: TRACnet; CIDC/MOH)
oOf these, 30,370 (59%) were on ART at sites supported by PEPFAR partners.
oOf health facilities, 114 (65%) were directly supported by PEPFAR.
•National ART coverage: in 2007 was estimated at 70%; will likely reach or exceed the national target of 80% by the end of 2008.
•ART Outcomes - of adult patients who initiated ART during 2004 and 2005, roughly 86% and 92% were alive on ART after 6 and
12 months, respectively. By 6 months, 3.6% were dead, 3.1% were LTFU, 0.2% had stopped treatment, and 1.3% had
transferred out; by 12 months, 4.6% were dead, 4.9% were LTFU, 0.27% had stopped treatment, and 4.3% (were transferred out.
(Source: TRACPlus Report on the Evaluation of Clinical and Immunologic Outcomes from the National Antiretroviral Treatment
Program in Rwanda, 2004 - 2005; MOH) - More recent data are not currently available.
•The National Treatment Plan aims to extend ART treatment services to >67,000 patients, including >6,400 pediatric patients by
December of 2008 - surpassing the PEPFAR target of 50,000 on ART by the end of FY 2009.
•CTX prophylaxis - there are no reliable data regarding the coverage of cotrimoxazole prophylaxis among eligible HIV-infected
patients, either nationally or within PEPFAR-supported clinical settings.
Key Policy Changes during FY2007-2008:
In FY 2007, TRACPlus - Center for Infectious Disease Control/MOH (CIDC) disseminated new clinical guidelines for HIV care and
treatment. Significant changes include a recommendation for routine viral load testing at 12 months however this
recommendation has not been fully implemented by clinical partners for a variety of reasons, including lack of training, inadequate
laboratory capacity, and cost. In addition, in FY 2008, the CIDC HAS Unit intends to change from preferred zidovudine- and
stavudine-containing first-line ART regimens to preferred tenofivir (TDF)-containing first-line ART regimens. PEPFAR partners
expect that this change will begin implementation in late FY 2008, and that it will have implications for FY 2009, particularly given
the immediate cost increases associated with transition to TDF.
In FY 2007, the GoR made significant strides towards establishing an effective policy basis for HIV pre-ART care in Rwanda,
including revised cotrimoxazole prophylaxis (CTX) guidelines, new opportunistic diagnostic and treatment guidelines, and new
guidelines for diagnosis and treatment of sexually transmitted infections. These guidelines have been elaborated in draft form and
will be finalized in FY 2008. In addition, Mildmay International and the African Palliative Care Association have provided support
to the MOH for development of a national policy on opioid drugs, which will lay the foundation for implementation and scale-up of
effective pain management strategies. A new national policy on task shifting to support nurse ART prescription is also expected in
FY 2008. In FY 2008, performance based financing, a key aspect of the PEPFAR Rwanda strategy for ensuring program
sustainability and quality which has been rolled out to all health centers, will be scaled up to include all District and referral
hospitals, as well as community-based services.
Treatment:
In FY 2008, PEPFAR will continue supporting all levels of the decentralized ART network, starting from central level institutions
and extending to the community as the most peripheral point of service. PEPFAR will scale-up ART support by putting 11,922
newly eligible patients including 1,106 children on ART at 157 PEPFAR-supported sites. As the number of patients rapidly grows,
PEPFAR will continue to work with GOR and other donors to evaluate and ensure the quality of HIV-related services. This
includes programs designed to provide site and program-level feedback regarding quality of clinical services and support at
central levels to update guidelines, training materials, and job aids. PEPFAR will also provide training to assist clinicians to identify
patients in need of 2nd-line regimens by evaluating clinical, adherence-related and immunological criteria, as well as the use of
targeted viral load testing (until laboratory capacity has been expanded to enable compliance with the current guidelines).
At the central level, PEPFAR will continue working with CIDC, the National Reference Laboratory (NRL), and other key Units in
MOH through direct cooperative agreements and a number of its partners. PEPFAR will continue to support MOH to revise
national guidelines, tools, curricula, and conduct training of trainers. In FY 2009, with PEPFAR funding, MOH will coordinate joint
supervisory visits to clinical sites in coordination with the district health teams (DHTs) to provide promote data quality and use.
At the district level, PEPFAR partners will continue providing financial and technical support to their respective DHTs to strengthen
linkages, referrals, transportation of patients and specimens, communications, forecasting, drugs and commodities distribution,
and financial systems. In addition, PEPFAR partners will strengthen district level supervisory, management, mentoring and
reporting capabilities. Each USG partner has been assigned districts where they are charged with providing support to all of their
health care facilities and personnel. In districts where other donors are supporting some HIV-related clinical services (e.g. VCT by
GFATM), PEPFAR partners are still responsible to work with donors to establish functional linkages that support continuity of care
across sites and services. Each partner also is charged with providing direct mentoring and capacity building support to their
district health team, thus building capacity to decentralize supervisory and quality assurance activities.
At site level, PEPFAR partners will provide a standardized package of ARV services through support and development of a
coordinated network of HIV/AIDS services linking ART with PMTCT, TB, FP, MCH and other services. Following a tiered
approach to service delivery, USG partners will provide comprehensive ART services at larger facilities and a basic ART services
at satellite health centers. Nurses will serve as the primary HIV service provider at these more distal sites of the health care
system and have physician back-up at district level facilities. PEPFAR will continue supporting task shifting by strengthening
nurse training through pre-service and in-service training, use of simplified protocols, and assigning district hospital physicians to
support nurses in managing ART cases through regular mentoring visits and remote support via telephone for urgent questions.
At the community level, PEPFAR partners will ensure continuity of care and adherence support through case managers,
community health workers (CHWs), and peer support groups. Through community mobilization activities, home visits, and
monitoring and evaluation tools, community health workers will facilitate communication and linkage between facilities and
communities in order to improve patient retention. CHWs will provide adherence counseling, patient education, and referrals for
drug side effect management. In FY 2009, PEPFAR will continue to expand efforts to provide nutritional support to qualifying
adults and pregnant and lactating women. In FY 2009, PEPFAR will support basic program evaluation activities, such as an
evaluation of patient outcomes in the national HIV care and treatment program.
Basic Care and Support:
Consistent with the guidance from the PEPFAR Basic Care and Support TWG, the Rwanda country team defines Basic Care and
Support as the delivery of at least 1 clinical and 1 non-clinical intervention to an HIV-infected individual. PEPFAR and its
implementing partners have supported and will continue to support access to a comprehensive range of basic care and support
(BCS; formerly "palliative care"; also referred to as "care") services, including clinical and non-clinical (prevention, psychological,
spiritual, and social care services) interventions at both the facility and community level. To date, the majority of prevention, care,
and treatment services for PLHIV have been provided in the health facility setting, with implicit linkages to community care.
Clinical services include the provision of CTX for eligible adults
(revised national guidelines now call for universal prophylaxis for all HIV-infected individuals, regardless of clinical and
immunologic status), CD4 testing and clinical staging, diagnosis and treatment of common opportunistic infections (OIs),
adherence counseling, clinical monitoring, nutritional assessment and support, prevention counseling, including "prevention for
positives", and referrals to community-based care and support services. While social care services have been primarily provided
through community-based activities, some clinical partners also provide patients with health "mutuelles" (a basic type of health
insurance), transportation support, income generation through PLHIV associations, and linkages to food support. Coordination of
community-based BCS activities continues to be a challenge. PEPFAR Rwanda and partners are working with the national
Palliative Care TWG, and relevant GOR entities, such as the Community Health Task Force in MOH, to ensure that HIV/AIDS
community services are integrated into overall community health planning.
Prevention, psychological, social, and spiritual services in the community are provided through 12 Rwandan faith- and community-
based organizations, and hundreds of PLHIV associations in 20 districts (out of 30). All care providers (facility- and community-
based) have incorporated prevention messages and appropriate prevention counseling into their care activities, especially for HIV-
positive individuals and their families. In FY 2007, PEPFAR supported an assessment of facility-community linkage models
developed by clinical partners (report currently pending). In addition, the "Rwanda Community Health Needs Assessment" was
completed in September 2008. Findings from these assessments will inform BCS programming in FY 2008 and 2009.
Specifically, PEPFAR will continue to promote a linkages model, which utilizes facility-based staff, and community- and home-
based volunteers. The model aims to improve the communication and coordination between clinical and community levels to
ensure a continuum of care for HIV-positive individuals and their families. Robust supervision, monitoring and evaluation of these
linkages will be essential.
To date, PEPFAR-Rwanda has counted persons as receiving care through the reporting of clinical partners only, not community-
based partners. Each clinical partner is responsible for a unique set of districts and, overall, PEPFAR supports clinical services in
23 of 30 districts in Rwanda. In addition to of service provision, PEPFAR is augmenting the capacity of Rwandan community-
based organizations to ensure the sustainability of care services, including technical and organizational capacity for the 12
Rwandan partner organizations currently under CHAMP. This community services project will be ending with FY 2008 funding,
and PEPFAR is planning to design and award a new community services activity for FY 2009.
PEPFAR procures all BCS-related commodities through the Supply Chain Management System (SCMS), including drugs for the
prevention and treatment of OIs, and laboratory and diagnostic kits for improved and expanded OI diagnosis, and in coordination
with the GOR's central procurement agency, CAMERWA. The exceptions are: the provision of bed-nets for PLHIV, which is being
done through JSI/DELIVER; and the provision of Sur Eau, which is being procured and distributed by PSI through the POUZN
project.
For a variety of reasons, a standard "package" of BCS services has not been identified, either by GOR stakeholders or
implementing partners. Nonetheless, PEPFAR Rwanda will continue to promote coverage of key clinical interventions (CTX, bed-
nets, safe water products, etc.) that have been demonstrated to reduce morbidity and mortality of PLHIVs. In FY 2009, PEPFAR
will also continue to emphasize the use of a family-centered approach for care; improvement of pain management; improved
prevention counseling for HIV-positives through the provision of targeted risk reduction and behavior change messages (in both
clinical and community settings); support for caregivers; and, improved linkages (community to clinic, within clinical services and
wrap-arounds). On-going wrap-around activities in FY 2009 include: the provision of bed-nets (through PMI), provision of safe
water product and hygiene education (through POUZN); a new award to leverage food aid for PLHIV (Title II and WFP); support
for economic growth and livelihoods (IGA assessment with EGAT; Land O'Lakes dairy IGA project); and links to services for
gender based violence. Improvement of psychosocial support, including mental health screening and treatment within HIV
services, is an increasing priority for the GOR, and one that PEPFAR plans to support in FY 2009. Finally, PEPFAR Rwanda will
support basic program evaluation activities, including assessment of patient outcomes in pre-ART settings and the impact of
community-based clinical services.
Table 3.3.08:
This is a continuing activity from FY 2008. No narrative required.
Continuing Activity: 12875
12875 4006.08 Department of Population 6322 132.08 PSI-DOD $495,000
7231 4006.07 Department of Population 4344 132.07 PSI-DOD $450,000
4006 4006.06 Department of Population 2574 132.06 PSI-DOD $255,000
* Reducing violence and coercion
Table 3.3.14:
