THIS IS A CONTINUING ACTIVITY FROM FY 2008, ALREADY APPROVED

New/Continuing Activity: Continuing Activity

Continuing Activity: 17074

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17074 17074.08 U.S. Agency for To Be Determined 7636 7636.08 TBD Solar

International

Development

Program Budget Code: 10 - PDCS Care: Pediatric Care and Support

Total Planned Funding for Program Budget Code: $2,401,435

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

ACTIVITY UNCHANGED FROM FY 2009

Rwanda is a small central African nation about the size of the state of Maryland. With approximately 9 million inhabitants, it is one

of the most densely populated countries in the continent, with most people living in rural areas. As in other countries the HIV

epidemic has affected persons from all age groups including children who acquire the disease largely through vertical

transmission. The estimated prevalence of HIV among women of reproductive age in Rwanda is 3.6 % based on data from the

2005 Demographic and Health Survey (RDHS 2005) and data from recent PMTCT program records suggests that the prevalence

is 4.1% for women coming for PMTCT services. Approximately, 396,255 women are expected to give birth in 2008 in Rwanda

and of these 12,635 will need antiretroviral prophylaxis. From August 2007 to August 2008, 275,746 were tested for HIV and,

during the same period, an estimated 6,081 infants were born to HIV-infected mothers and will be in need of follow-up services. It

is estimated that 17,212 HIV-infected children under 15 years of age currently live in Rwanda (Source: TRACPlus - Center for

Infectious Disease Control/MOH (CIDC), CNLS. HIV-AIDS in Rwanda. 2008 Epidemic Update).

Since the initiation of the national ARV treatment program in Rwanda in 2003, a total of 200,000 persons are living with HIV of

which 89,335 people were provided with HIV-related basic care; 63,878 had initiated ART of which 59,900 are currently on ART.

of the patients currently on ART 5,289 are children under 15 years of age. An estimated 8,933 HIV-infected children under 15

years of age are currently enrolled care and 5,144 are receiving ART as of September 30, 2008. PEPFAR, the Global Fund, the

World Bank and the Clinton Foundation are some of the major donors working with the Government of Rwanda (GoR) to develop

and implement programs for HIV-affected and infected infants, children and adolescents. Presently, PEPFAR supports care and

treatment services at 188 sites in Rwanda and PMTCT services at 146 sites distributed throughout 22 of the 30 districts in the

country. ART prophylaxis for children is available at all PMTCT sites while pediatric ART treatment is available at all 134 ART

sites. All ART sites supported by PEPFAR provide care and treatment services for children.

Almost all partners funded by PEPFAR provide care and treatment services to children in Rwanda, including: CIDC, Columbia

University through its UTAP, MCAP and Track 1.0 funding mechanisms, Family Health International, the Elizabeth Glaser

Pediatric AIDS Foundation, IntraHealth, AIDSRelief, and Drew University; while the DSS in the Ministry of Health provides

capacity building for the decentralized levels, supportive supervision, coordination and integration of HIV services into other health

services. Approximately, 58.1 % of all children receiving ART are enrolled in programs supported by PEPFAR. Approximately 10

% of all patients enrolled in care and treatment programs funded by PEPFAR are children less than 15 years of age.

PEPFAR, in collaboration with the GoR, has provided funding to Columbia University for the development of two pediatric HIV

care and treatment centers of excellence (COE) located in the Kigali Hospital Centre, (Center Hospitaliare Universitaire de Kigali,

or CHUK) and the Butare University Hospital Center (Centre Hospitalaire Universitaire de Butare, or CHUB). CHUK and CHUB

are the two largest referral centers in the country and are also teaching hospitals although the main medical school campus in the

country is located at CHUB. Renovations for the CHUK pediatric HIV center of excellence were completed earlier in 2008 and is

now fully operational; 5 physicians, 5 trained pediatric HIV nurses, one data manger and one administrator staff this out-patient

clinic that provides services to 319 HIV-infected children of which 129 are currently receiving ART. Approximately, 163 HIV-

exposed infants are also followed at this site. Approximately, 205 children are in care at CHUB and 105 on ART. Personnel from

the COEs provide PITC services for children admitted to various pediatric wards at both CHK and CHUB and work to link these

children and their families to care and treatment services at the COE or at ART facilities closer to their homes. In FY 2008, both

COEs will be fully operational and will be instrumental in not only providing clinical services for complicated pediatric HIV cases,

providing long-distance patient management advice and mentoring but also as major training resource for the national pediatric

HIV program.

While progress has been made to scale-up of services for children, the pediatric HIV program in Rwanda still is lagging behind in

achieving the 10% target established for PEPFAR programs. Some of the challenges faced include: lack of sufficient numbers of

trained health care professionals with experience in pediatric HIV care and treatment service provision; lack of fully implemented

PITC for the pediatric population; limited active pediatric HIV case finding among families of persons enrolled in care and

treatment or identified through VCT; limited availability to early infant diagnosis (EID) services; lack of finger-stick rapid HIV

antibody testing in children; poorly implemented maternal and infant follow-up services and linkages between PMTCT, Maternal

Child Health and ART programs and sites; limited emphasis on pediatric HIV in community mobilization activities, and limited

linkages between facilities and communities to support follow-up and retention into care for children. Other areas in need of

support include: expanding capacity at CIDC for data collection, management and analysis that includes both care and treatment

indicators for children, harmonized data collection, reporting tools between USG partners and nationally; limited focus on pediatric

HIV program needs and activities at the MoH and a poorly staffed care and treatment unit within CIDC with limited focus on

pediatric HIV care and treatment. Finally, pediatric HIV outcome data in Rwanda is lacking as is information on quality of HIV

services provided to children, including information about retention, adherence, treatment failure rates, adequacy of clinical and

laboratory monitoring and appropriate use of second-line treatment in children.

The USG supports activities at all levels of the health care system for pediatric HIV care and treatment. At central level,

cooperative agreements and other funding mechanisms with relevant MoH units, such as CIDC, the National Reference

Laboratory (NRL), UDPC, the Maternal and Child Health units in the Ministry are designed to build capacity for system

strengthening, capacity building and improved quality of health care service delivery for women and their children. At TRAC, the

USG provides support for the development, revision and up-dating of HIV related guidelines and training materials. It is

anticipated that by the end of 2008, recently up-dated treatment guidelines based on WHO recommendations will be disseminated

nationally. Training materials with updated pediatric HIV treatment modules will be developed and begin implementation during

the remainder of FY 2008. In collaboration with the USG team, implementing partners and other donors will work to develop a

training plan to increase the number of health care providers with training in pediatric HIV care and treatment. These training

materials will be completed in the next 6 months and the training plan will be designed to provide in-service training for physicians,

nurses, counselors, pharmacists and lab technicians. Pre-service training for nurses, medical students and other health care

providers with modules including pediatric HIV care and treatment are planned for FY 2009 and will be conducted by Tulane

University in Collaboration with the IntraHealth Capacity Follow-on mechanism.

Support to CIDC, UPDC and district health teams provided directly to the MoH or through PEFPAR implementing partners will

support the expansion of quality pediatric services to more decentralized sites of the health care system. The work that BASICS is

conducting with the MCH unit in the MOH to update IMCI training materials has supported the expansion of basic HIV services for

children at 296 health centers in 25 districts, in collaboration with EGPAF. This work will continue in FY 2009 to reach all health

care centers with MCH services in all 30 health districts in Rwanda.

PEPFAR support to the NRL has been critical to develop and increase the capacity of the health care system to provide early

infant diagnosis (EID) services for HIV-exposed infants. The NRL laboratory currently receives DBS samples from 126 sites in the

country, and processes approximately 1,722 samples every month. In FY 2009, the USG will continue to provide funding to

support EID capacity building by strengthening the NRL, strengthening the logistics system and ensuring the supply of reagents

and sample collection materials. In FY 2008, PEPFAR provided support to NRL and the Butare University Hospital Center

(CHUB) to establish a second lab to process DBS samples for EID; in FY 2009, this lab will be supported to reach full capacity to

process DBS samples in Rwanda. In FY 2008,PEPFAR supported efforts to update and improve EID data collection, conduct a

program evaluation and this activity will be completed in FY 2009. The results will serve to support further program expansion.

For FY 2009, the USG will work with the NRL, CIDC, the UPDC and its implementing partners to expand EID access to all

PMTCT sites in Rwanda. The NRL also will receive support from the USG to further expand CD4 count and percentage capacity

throughout the country. At present, 23 districts have capacity to process CD4 samples, 15 new CD4 machines will be purchased

in FY 2009 and placed at strategic sites in Rwanda to increase access to CD4 counts for pregnant women and children. Soft-ware

and reagents to up-grade existing FACScount machines to provide CD4 % were purchased in FY 2008 and will be fully integrated

into existing and new machines for FY 2009. The USG will work with the GoR and other donors to ensure that EID capacity , CD4

reagents and other commodities for national coverage are secured for FY 2009 after UNITAID support for the Clinton Foundation

is ended (See laboratory section).

For FY 2009, the strategic approach for USG-funded activities to support the national plan and PEPFAR goals to expand and

improve service provision for HIV-exposed, affected and infected infants, children and adolescents is to support implementation of

HIV care and treatment services for children at all existing and planned USG-supported ART sites in Rwanda (157 sites in 23

districts). All PEPFAR-supported implementing partners will be asked to aggressively put into place provider initiated testing (PIT)

at all pediatric in- and out-patient settings at their sites. In addition, USG partners will be asked to implement systematic testing of

family members of patients currently enrolled in care and treatment clinics where they support ART. PEPFAR partners will

continue to support district health teams, and Global Fund supported sites to implement provider initiated testing for children at all

district facilities.

Centrally, the USG will work with the MoH to update, develop and disseminate HIV testing and counseling materials and job aids

to support the broad implementation of PIT for children in Rwanda. For the remainder of FY 2008, the USG team and its

implementing partners will work with the GoR to finalize necessary validation studies, normative guidance documents, guidelines

and algorithms to make available finger-stick rapid HIV antibody for the pediatric population. Working at district, site and central

levels, PEPFAR will work with partners and the GoR to increase availability of early infant diagnosis to all PMTCT sites by end of

FY 2009. This will require efforts to support the NRL to expand its capacity for sample processing; data base modifications and

logistic network reinforcement to ensure rapid test result turn around times. By FY 2009, a second laboratory should be fully

functional to support EID in Rwanda, doubling the national capacity to process DBS samples.

Table 3.3.10: