Under the Rwanda Defense Force (RDF), there are a total of three military hospitals and five brigade clinics throughout the country. Drew University began working in two military hospitals and three brigade clinics in FY 2005. The support includes TA and training on ARV and palliative care, M&E, and lab infrastructure.

In addition, Drew University will provide 2300 pregnant women with HIV counseling and testing for PMTCT who will then receive their results and be provided with an expanded package of PMTCT services including: CT with informed consent; male partner and family centered testing; Intermittent preventive Treatment in pregnancy (IPTP) in collaboration with PMI; ARV prophylaxis using an expanded bi-therapy regimen and ARV treatment for eligible women; infant feeding counseling and support; referral for FP and MCH services; and close follow-up of exposed infants for effective transfer to appropriate services. In collaboration with CRS who is procuring local fortified food, Drew University will provide weaning food for exposed infants in need. Through the Directorate of Military Services (DMS) and a combination of input TA and output performance-based financing, Drew University will ensure access to a comprehensive network of services for PMTCT clients and their families, link PMTCT services with other HIV and MCH interventions, and assure an effective continuum of care by increasing patient involvement and community participation in PMTCT services.

Drew University will train RDF providers with new and refresher on-the-job training in the expanded national PMTCT protocol, including use of site-level algorithms and checklists, as well as for laboratory

monitoring. In collaboration with DMS, Drew University will conduct performance improvement and QA of PMTCT services through regular supervision of sites, coaching, and strengthening capacity of sites in M&E of PMTCT. Drew University will support DMS build their QA and M&E skills, including in data collection, data use, and reporting.

Additionally, it is increasingly becoming hard for HIV-positive soldiers to disclose their status to their spouses in the absence of a professional counselor. To respond to this, both the RDF and Drew University plan to use RDF HIV-positive males as the entry points to their families. Drew University will build a strong family tracking approach based on the information systems where cross-cutting data of each HIV-positive soldier has been collected and categorized during the mobile treatment and care unit, implemented at the brigade level. To do this, Drew University will organize training sessions for identified at-risk spouses of HIV-positive soldiers, and simultaneously conduct HIV counseling and testing.

In this "pool" of at-risk soldiers' spouses, Drew University will promote PMTCT-seeking behavior and support identified HIV-positive soldiers' spouses to bring their children for HIV testing. Drew University will strengthen the community outreach services such as home based care especially in hard-to-reach areas, to encourage HIV-positive women to have their children tested. Drew University will maximize the potential of health centers (with PMTCT services) in targeted areas, through training, linkages, referrals and physical hand-over of dossiers, to take-over follow-up of the identified HIV-positive soldiers' spouses in a sustainable manner. During FY 2010, couple HIV counseling will be an important tool of improving PMTCT services uptake, as part of a comprehensive approach to HIV treatment and care in RDF settings. Drew University will ensure that PMTCT services at RDF health settings conform to national and international standards through training of 85 health service providers in 8 RDF health facilities on PMTCT service delivery skills, and provision of materials and equipments. Drew University will make linkages with other USG food partners, such as WFP and CRS/IBYIRINGIRO, in order to ensure access to adequate nutrition support for pregnant and lactating mothers as well as infants.

In collaboration with other USG partners, Global Fund, and PMI, case managers and providers will refer PMTCT clients and their families to HBC, OVC support, IGA, and facility- and community-based MCH services promoting key preventive interventions such as bednets, immunizations, hygiene/safe drinking water and nutritional support. These community-based services will assist in the monitoring and tracking of pregnant and postpartum HIV-positive women and their infants, as well as promote MCH and PMTCT health seeking behaviors which will intensify case finding and improve adherence to the new regimen. In addition these case managers provide quality HIV treatment to infected children and ensure referrals of pediatric patients from PMTCT sites to ARV service and to nutrition centers.

Through CAMERWA/SCMS, Drew University will ensure ARV drugs, CD4 tests, RPR test kits, PCR, rapid

HIV test kits, and hemoglobin testing materials are available in all supported sites.

In FY 2009, with PEPFAR assistance, Drew University supported BCS at three military hospitals and five brigade clinics, providing palliative care to 2,006 PLWHA. Basic care services supported by Drew included clinical staging and baseline CD4 count for all patients; follow-up CD4 tests; management of OIs 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. Drew also provided psychosocial counseling and referrals for HIV-positive female victims of domestic violence in the community served.

In addition, Drew trained peer educators to provide social support to HIV+ individuals, and periodic discussion group workshops were organized to increase treatment adherence and share success stories. In collaboration with the CHAMP project, the Global Fund and PMI, Drew referred the 2,006 PLWHA and their families to malaria prevention services, including the provision of bed nets. Drew assisted the RDF to strengthen referrals to community-based support groups for improved treatment adherence and increased access to non-clinical HIV care services. Through the Partnership for Supply Chain Management, Drew provided OI-related drugs, CD4 testing, and OI diagnostics for the clinical management of PLWHA. Drew worked with SCMS to ensure appropriate stock management, inventory

control, and storage for all USG-procured commodities at Drew-supported sites.

In FY 2009 Drew developed and distributed an HIV care package to all HIV+ individuals receiving care at its supported sites and contributed to the Mutuelles health insurance plan for all individuals receiving HIV care at Rwandan Defense Force (RDF) sites. Through PEPFAR support, Drew ensured the provision of improved quality of HIV treatment and care services, and trained 85 RDF providers at the facility level in diagnosis and treatment of STI/OIs/mental health disorders. To improve the health of HIV+ patients, Drew implemented a mobile treatment and care unit (MTCU) affiliated with the health facility, which conducted outreach HIV staging, clinical evaluation and treatment initiation and conducted follow-up with hard-to-reach HIV+ patients. The MTCU ensured the provision of a continuum of care and treatment services, which included but is not limited to: basic HIV laboratory tests; STIs/OIs screening and treatment; provision of CTX prophylaxis; ART; ART adherence support; psychosocial support; family planning; nutrition counseling; prevention for positives; HIV status disclosure; spiritual care; bereavement care; and hygiene and malaria education. BCS activities were implemented in conjunction with other services such as VCT, FP, ART, TB/HIV, OIs, and/or STIs at RDF facilities.

In FY 2010, these activities will continue at three military hospitals and five brigade clinics. Drew will continue to provide technical assistance to RDF to strengthen linkages between community-based and clinic based HIV care services. At brigade and/or community levels, Drew will support: the formation of civilian and military allied associations of PLWHA and train members in provision of home-based care services; access to locally available and/or self-initiated nutritional support; HIV prevention with positives, which includes training of caregivers on adequate management, distribution and use of care package; and clinical HIV detection and referral. Drew will intensify its support in regular follow-up and referral of clients in order to retain clients through quality services delivery. In FY 2010, Drew will also conduct an operational research to determine the causes of increasing loss to follow-up of pre-ART and ART patients at supported sites. Drew will also continue to support SGBV initiatives being piloted in collaboration with the Population Council, the National Police, MOH-MCH unit and other USG partners. SGBV activities will be extended to other supported sites once initial assessments have been completed.

Drew University will continue to support capacity building in the military for program management, clinical care of patients and in M&E systems and data use for decision making and progressive transition activities to the host institution for sustainability of HIV services. To ensure comprehensive services across a continuum of care, Drew, through a partnership with peer educators and other community services providers, will refer patients enrolled in care to community-based BCS services based on their individual need. These services include adherence counseling, spiritual support, stigma-reducing activities, OVC support, IGA activities, and HBC services for end-of-life care. In collaboration with the supply chain partner, Drew will continue to provide diagnostic kits, CD4 tests, and other exams for clinical

monitoring, and will work with the supply chain partner to ensure appropriate storage, stock management, and reporting of all OI-related commodities.

Drew University works to improve the capacity of the Rwandan Defense Force (RDF) to provide quality HIV treatment and care for military personnel, their partners and families, and community members who live in the areas surrounding military facilities. In FY 2009, with PEPFAR assistance, Drew University supported services at three military hospitals and five brigade clinics, providing treatment to 2,006 PLWHA.

Through its mobile team and eight services sites, Drew ensured the provision of a continuum of care and treatment services, which includes: basic HIV laboratory tests; clinical staging and CD4 counts for all patients; a control CD4 count every six months; STIs/OIs screening and treatment; provision of CTX prophylaxis; ART; ART adherence support; psychosocial support; referrals for victims of SGBV; family planning; nutrition counseling; prevention for positives; HIV status disclosure; spiritual care; bereavement care; and hygiene and malaria education.

In addition to treatment services, in FY 2009 Drew trained peer educators to provide social support to HIV+ individuals, and periodic discussion group workshops were organized to increase treatment adherence and share success stories. In collaboration with the CHAMP project, the Global Fund and PMI, Drew referred the 2,006 PLWHA and their families to malaria prevention services, including the provision of bed nets. Drew assisted the RDF to strengthen referrals to community-based support groups for improved treatment adherence and increased access to non-clinical HIV care services. Through the Partnership for Supply Chain Management, Drew provided OI-related drugs, CD4 testing, and OI diagnostics for the clinical management of PLWHA. Drew worked with SCMS to ensure appropriate stock management, inventory control, and storage for all USG-procured commodities at Drew-supported sites.

In FY 2010, Drew will continue to provide technical and material support to three military hospitals and five brigade clinics located in the districts of Kicukiro , Nyamagabe, Gatsibo, Muhanga, Musanze, Huye, Ngoma and Rusizi to ensure the provision of quality anti ART to 2,006 HIV-positive individuals, including 300 newly diagnosed cases. Drew will provide technical assistance to the RDF to strengthen linkages between community-based and clinic-based HIV care services. At brigade and/or community levels, Drew will support the formation of civil-military allied associations of PLWHA and will train members in provision of home-based care services. Drew will also support access to locally available and/or self-

initiated nutritional support for those patients facing food instability.

In FY 2010 Drew will emphasize HIV prevention with positive through the training of lay counselors on the appropriate management, distribution and use of care package and the training of clinical providers to assess patients with regard to risk behaviors, medical adherence, STIs, family planning, and condom use. Providers will also be mentored on the most effective customized prevention messages for HIV positive patients. In FY 2010 Drew will further train 85 RDF medical personnel in HIV case detection and referral to HIV care and treatment.

In FY 2010, Charles Drew University will continue to work with the RDF and TRAC Plus to improve

infrastructure for and increase access to HCT services in 8 RDF health settings located in the districts of

Kicukiro, Muhanga, Musanze, Nyamagabe, Gatsibo, Ngoma, Rusizi and Huye. Drew will employ

counseling techniques that ensure confidentiality, minimize stigma and discrimination, and reach those

individuals most likely to be infected. Couples HIV Counseling and Testing (CHCT) will be expanded and

integrated in HCT services as a prevention Intervention and PIT will be rolled out as a testing strategy.

Drew University plans to reach 5,000 clients during the FY 2010 and counseling will include messages on

alcohol reduction, prevention for positives, GBV, disclosure of status to partner, partner testing, and

counseling for negatives - including ABC messaging and provision of condoms. A renewed emphasis will

be made on prevention counseling and follow-up for positive clients, discordant couples and activities to

reach high risk groups with HCT. These activities will be coordinated to avoid duplication and maximize

coverage to most at-risk populations. Drew will coordinate its activities with other partners such as CHF,

PSI, and FHI/ROADS to avoid duplication, strengthen referral linkages and continue to support the

promotion of HCT among most at risk populations including the military. Drew University will provide

technical support in the area of M&E to ensure quality of HCT services following the standard testing

algorithms. In this regard, Drew University plans to undertake operational research to assess the

effectiveness of the referral system.

Approximately 2,295 HIV-positive adults are enrolled in care at the health facilities of the Rwanda Defense Forces (RDF). Of these, 2,006 are receiving ART. In FY 2010 Drew University will provide support to significantly increase services for the pediatric population reached through military health care

facilities. In FY 2009, Drew University provided an integrated package of care and support services for HIV-exposed infants and HIV-positive children at all 8 Drew University sites.

In FY 2010, the activities established in FY 2009 at the three military hospitals and five brigade clinics will continue. Drew CARES will provide care and support for 85 HIV-exposed as well as infected children. Care and support for HIV-exposed infants identified in PMTCT will include access to early infant diagnosis using dried blood spots, provision of Co-trimoxazoleprophylaxis until their HIV status is known, infant feeding support, and tracking of mothers and infants lost-to-follow-up for re-engagement in care. To provide early initiation of ART for all HIV-positive infants, Drew University will assist in the implementation of early infant diagnosis and follow-up through training for PMTCT staff as well as lab technicians, and through the development of an efficient and reliable sample transportation system. Drew University's care and support model for HIV-positive children includes provision of regular clinical assessments (monthly for HIV-exposed infants and every six months for older, stable children); staging and baseline CD4 counts or percentages for all HIV-positive children; follow-up CD4 every six months or more frequently as needed; management of HIV-related illnesses, including OI diagnosis and treatment; and routine provision of Co-trimoxazoleprophylaxis for eligible children and for all HIV-exposed infants. Drew University will support the implementation of the new pediatric care and treatment guidelines through training and supervision. All pediatric patients will be screened for TB at least once every six months. Children suspected of having TB will be investigated to establish a diagnosis, and treatment will be initiated as per national guidelines. Children without active TB disease but who were exposed to an active case will be provided with INH prophylaxis.

In addition, sites will provide nutritional counseling, pain and symptom management, end-of-life care, and integrated management of childhood illness (IMCI) at its MCH clinics. Sites will also distribute long-lasting insecticide-treated nets (LLIN), implement safe water interventions, and provide basic hygiene education and community outreach services including referral for complimentary food support. In collaboration with TRAC Plus, Drew University will provide refresher training for health care providers in psychosocial care for children living with HIV/AIDS and launch psychosocial care services at all its ART sites. In order to improve treatment adherence, Drew University will assist health facilities in mentoring child and adolescent support groups that have been established at the sites as a component of psychosocial support for HIV-positive children and adolescents.

Activities aiming at strengthening nutritional services at Drew University-supported sites will include training of health care providers and counseling to HIV-positive mothers during pregnancy and after delivery to enable them to make informed choices about infant feeding. The nutritional support package for children is comprised of nutritional assessments using anthropometric indicators, the provision of food support to HIV-exposed infants, and management of malnutrition with micronutrient and multivitamin

supplements. Drew University will ensure programmatic linkages to the Title II food support for clinically eligible PLWHA and children (implemented by PEPFAR and World Food Programme in selected districts), and to the USAID/Ibyiringiro project which provides complementary food support for HIV- exposed infants at USG supported sites in Rwanda. Drew University will also reinforce vegetable gardening at health facilities that have received PMTCT food support though the World Food Programme.

Drew University supported sites will establish HIV community outreach services by working with trained community health workers. Key HIV messages emphasizing pediatric HIV, care and nutrition will be discussed during monthly meetings at the health facilities. By providing HIV messages on a regular basis, sites aim to ensure a continuous flow of information to and from the community in order to increase awareness and increase service utilization. The facility-based military focal points and community health workers in the military neighborhood constitute an effective system to ensure continuity of care, promote retention in care, and to improve coverage and quality of pediatric HIV services. Drew University will also support the development of systems for referral of HIV-positive children to access malaria prevention services, including the provision of LLIN and home-based management of malaria.

Through work with the Supply Chain Management System (SCMS) and CAMERWA (Central Purchasing of Essential Drugs, Medical Consumables and Equipment in Rwanda), the national pharmaceutical warehouse, the district-level pharmacy, the National Reference Laboratory (NRL) and the regional laboratory network, Drew University will ensure training of health service providers on the management of HIV-related opportunistic infections, drug and reagent stock management and distribution, adherence counseling, good pharmacy record-keeping and data use.

Approximately 2,295 HIV-positive adults are enrolled in care at the facilities of the Rwanda Defense Forces (RDF). Of these, 2,006 are receiving ART. While the number of children currently enrolled in care and treatment at these facilities is small, in FY 2010 Drew University will provide support to significantly increase services for the pediatric population reached through military health care facilities.

In FY 2010, Drew University will continue with its support to all 8 RDF facilities in Rwanda. In line with national policies and sustainability strategies, the Kaduha Military Hospital--the second military facility located in Nyamagabe--will begin improving clinical HIV service provision using a performance-based financing (PBF) model.

In FY 2010, Drew University will continue to support the provision of quality ARV services to251 children currently on treatment and to30 new pediatric patients at 5 ART sites. Drew University will also support the initiation of early infant diagnosis and the implementation of the new CD4-based treatment protocol. Moreover, ART sites will continue to monitor patients for treatment failure and to offer appropriate second-line treatment.

In collaboration with the district hospital team, regular follow-up visits will be made to these sites. Infants and children on ART will be assessed monthly at each visit for issues related to adverse events, toxicity and adherence to ART. Drew University will also assist heath providers in mentoring children and adolescent support groups that are established at the sites as a component of psychosocial support for HIV-positive children and adolescents. These clubs will be used to provide ongoing support for children in care and on treatment, and to assist with addressing issues around treatment adherence.

Clinicians from the district team will review complicated ART and non-ART cases. Nurses at RDF sites will continue to be trained and mentored in provider-initiated testing, the follow-up of patients, and in the detection and referral of complicated cases to district hospitals. With international technical assistance, Drew University will continue to support Quality Improvement of patient management with a review of indicators, medical dossiers and viral load measurements. Drew University will ensure the participation of health center and country program staff in District Health Team meetings for better collaboration. It will work with the National Reference Laboratory to expand the diagnostic resources for HIV at the sites. Drew University will also endeavor to improve reporting linkages with CAMERWA (Central Purchasing of Essential Drugs, Medical Consumables and Equipment in Rwanda) and continue mentoring health center staff with a view to increasing their ability to receive, manage, and forecast the needs for ARVs.

Drew University will continue to assist the Rwanda Defense Forces (RDF) to improve IT infrastructure at RDF hospitals and brigade clinics for monitoring the health status of HIV-positive soldiers and civilians receiving care within the military health system. Drew University will also assist the RDF in monitoring the effectiveness of referral of newly diagnosed HIV cases from brigade and mobile clinics to RDF hospitals for evaluation and treatment. Moreover, the capacity of RDF will be built in the utilization of HIV-related data in a continuous quality improvement process. Planned activities include the improvement of the existing data system to match with new developments in health information systems within the military setting; an evaluation of Drew University's HIV treatment and care services in RDF;

and an assessment of the extent to which information systems have facilitated HIV service delivery. Specifically, Drew University will:

• Provide material and technical assistance to improve the data system that enables the military to conduct routine HIV testing of all military personnel. • Design and implement data reporting tools to monitor HIV treatment and care outreach activities such as home-based care and other community-clinical linkages. • Develop a secondary target tracking system for all patients receiving HIV treatment and care in RDF sites, including military spouses, partners and family members, and enroll them in HIV care services that are medically indicated such as prevention for positives, VCT, PMTCT, and nutrition services. • Strengthen the health management information system of the military, and improve data quality. • Develop a data access network among RDF sites enabling HIV treatment and care providers to update data through the main server using access codes. • Ensure that the national coding system for all patients receiving care in RDF health facilities is implemented to enable universal access to patient data at major RDF service delivery outlets. • Initiate the use of personal digital assistants (PDAs) and improve the electronic medical record system for HIV-positive patients. • Train RDF health providers and policymakers in data analysis and in the use of the generated information to improve the quality of HIV treatment and care services. • Conduct a mid-term evaluation of HIV treatment and care service delivery in RDF.

Drew University will work closely with the MOH/Monitoring and Evaluation Taskforce to ensure alignment with the national HMIS strategy.

The overall goal of this activity is to decrease new HIV infections through male circumcision among Rwanda Defense Forces (RDF) personnel. The program will be presented as part of an expanded approach to reduce HIV-infections, and will be promoted in conjunction with other prevention programs, including HIV testing and counseling, treatment for other sexually transmitted infections, promotion of safer-sex practices and condom distribution. Male circumcision (MC) will not replace other known methods of HIV prevention and will be considered as part of a comprehensive HIV prevention package.

The World Health Organization (WHO) and UNAIDS recommended that MC be made available in countries highly affected by HIV/AIDS to help reduce transmission of the virus through heterosexual sex.

According to data from two NIH-funded studies conducted in Uganda and Kenya, routine MC could reduce a man's risk of HIV-infection through heterosexual sex by up to 65%. According to the WHO, implementing circumcision programs in sub-Saharan Africa could prevent about 5.7 million new HIV cases and three million deaths during the next two decades, if combined with other -factors such as condom usage, responsible behavior and knowing the HIV status of one's partner. The WHO is encouraging countries to provide access to no-cost MC to countries in Southern and East Africa, where HIV rates are high and circumcision rates are low, to consider adopting MC as an important and urgent health priority, with the target group being boys and men ages 13 to 30 years. However, Drew recognizes that it is critical for men to know that, although they are circumcised, they can still contract HIV and transmit it to their partners. Therefore, circumcised men should continue to practice abstinence, have fewer sex partners and use condoms. It is important that MC is provided to men who are HIV negative, emphasizing that it is important to know one's HIV status prior to receiving MC.

Drew will provide regular supportive supervision and follow-up to soldiers who have been circumcised in order to prevent infection and ensure compliance with MC management protocols. Together with PSI, IEC/BCC messages will be tailored to sensitize circumcised soldiers on basic hygiene, delayed safe sex and the need for medical follow-up for infection control both at RDF health facilities and the mobile clinic.

In FY 2010, Drew will ensure that male circumcision efforts are further rolled out in RDF as an additional method for HIV prevention for 6,000 men. In collaboration with JHIPEGO, Drew will take care to ensure that providers are well trained, physical and clinical infrastructures meet hygiene and safety standards, and communities and patients are sensitized on the risks and benefits of MC. RDF is an ideal institutional setting to begin the roll out of MC as an HIV prevention intervention, as the RDF has taken a lead in controlling HIV among Rwandan troops, who are primarily young, sexually active males. In addition, with the help of Drew through PEPFAR support, the RDF has expanded HIV care and treatment to three military hospitals and five brigade clinics. Drew will build capacity for MC in the RDF through the development of treatment protocols, training of providers, sensitization of soldiers and their partners for circumcision and the enhancement of physical infrastructure of clinical sites so that proper circumcision may be conducted.

MC will be conducted on a voluntary basis on HIV-negative soldiers, as studies have demonstrated that since HIV-positive men who have undergone circumcision may be more likely to transmit the virus to their female partners if they have sex before the circumcision wounds have healed. Attention will be paid to socio-cultural context, human rights and ethical principles, health services strengthening, training, gender implications, service delivery and evaluation. Conducting MC in the Rwanda military is considered vital since the military is predominately male, young, and highly mobile, characteristics which put this group at a higher risk of infection.

These activities address the key legislative issues of gender (particularly male norms) and stigma reduction. Furthermore, these programs reinforce the PEPFAR strategy of strong collaborating with the GOR, as well as the Partnership Framework and National Strategic Plan for HIV/AIDS, both of which prioritize prevention efforts among military personnel.

Under the Rwanda Defense Force (RDF), there are a total of three military hospitals and five brigade clinics throughout the country. Drew University began working in two military hospitals and three brigade clinics in FY 2005. The support includes TA and training on ARV and palliative care, M&E, and lab infrastructure.

In addition, Drew University will provide1,841 pregnant women with HIV counseling and testing for PMTCT who will then receive their results and be provided with an expanded package of PMTCT services including: CT with informed consent; male partner and family centered testing; distribution of long-lasting insecticide treated net (LLIN) in collaboration with PMI; ARV prophylaxis using an expanded bi-therapy regimen and ARV treatment for eligible women; infant feeding counseling and support; referral for FP and MCH services; and close follow-up of exposed infants for effective transfer to appropriate services. In collaboration with CRS who is procuring local fortified food, Drew University will provide weaning food for exposed infants in need. Through the Directorate of Military Services (DMS) and a combination of input TA and output performance-based financing, Drew University will ensure access to a comprehensive network of services for PMTCT clients and their families, link PMTCT services with other HIV and MCH interventions, and assure an effective continuum of care by increasing patient involvement and community participation in PMTCT services.

Drew University will train RDF providers with new and refresher on-the-job training in the expanded national PMTCT protocol, including use of site-level algorithms and checklists, as well as for laboratory monitoring. In collaboration with DMS, Drew University will conduct performance improvement and QA of PMTCT services through regular supervision of sites, coaching, and strengthening capacity of sites in M&E of PMTCT. Drew University will support DMS build their QA and M&E skills, including in data collection, data use, and reporting.

Additionally, it is increasingly becoming hard for HIV-positive soldiers to disclose their status to their spouses in the absence of a professional counselor. To respond to this, both the RDF and Drew

University plan to use RDF HIV-positive males as the entry points to their families. Drew University will build a strong family tracking approach based on the information systems where cross-cutting data of each HIV-positive soldier has been collected and categorized during the mobile treatment and care unit, implemented at the brigade level. To do this, Drew University will organize training sessions for identified at-risk spouses of HIV-positive soldiers, and simultaneously conduct HIV counseling and testing.

In this "pool" of at-risk soldiers' spouses, Drew University will promote PMTCT-seeking behavior and support identified HIV-positive soldiers' spouses to bring their children for HIV testing. Drew University will strengthen the community outreach services such as home based care especially in hard-to-reach areas, to encourage HIV-positive women to have their children tested. Drew University will maximize the potential of health centers (with PMTCT services) in targeted areas, through training, linkages, referrals and physical hand-over of dossiers, to take-over follow-up of the identified HIV-positive soldiers' spouses in a sustainable manner. During FY 2010, couple HIV counseling will be an important tool of improving PMTCT services uptake, as part of a comprehensive approach to HIV treatment and care in RDF settings. Drew University will ensure that PMTCT services at RDF health settings conform to national and international standards through training of 85 health service providers in 8 RDF health facilities on PMTCT service delivery skills, and provision of materials and equipments. Drew University will make linkages with other USG food partners, such as WFP and CRS/IBYIRINGIRO, in order to ensure access to adequate nutrition support for pregnant and lactating mothers as well as infants.

In collaboration with other USG partners, Global Fund, and PMI, case managers and providers will refer PMTCT clients and their families to HBC, OVC support, IGA, and facility- and community-based MCH services promoting key preventive interventions such as bednets, immunizations, hygiene/safe drinking water and nutritional support. These community-based services will assist in the monitoring and tracking of pregnant and postpartum HIV-positive women and their infants, as well as promote MCH and PMTCT health seeking behaviors which will intensify case finding and improve adherence to the new regimen. In addition these case managers provide quality HIV treatment to infected children and ensure referrals of pediatric patients from PMTCT sites to ARV service and to nutrition centers.

Through CAMERWA/SCMS, Drew University will ensure ARV drugs, CD4 tests, RPR test kits, PCR, rapid HIV test kits, and hemoglobin testing materials are available in all supported sites.

In FY 2009, Drew University supported 85 HIV and TB services providers at facilities for continuous

TB/HIV integration using the TRAC/PNILT TB/HIV training module, counseled all 2000 TB patients registered at three military hospitals and five brigade clinics for HIV test and provided testing services to 90% of those who accepted to take the test. Drew University supported facilities to strengthen referral mechanisms within the same facility and between facilities which enabled patients diagnosed with TB and HIV adhere to TB treatment via DOTS, and had access to Co-trimoxazoleprophylaxis and follow-up of CD4 and ART services if eligible. In addition, Drew University through regular supervision to supported sites ensured that TB/HIV data were recorded and reported following national guidelines and staff conducted quarterly M&E meeting with PLWA associations, community health workers with the aim analyzing data and use them for program quality improvement.

In FY 2010, these activities will continue at three military hospitals and five brigade sites. Drew University will provide 2,006 HIV-positive clients with TB preventive therapy and eligible patients for ART. Drew University will ensure that TB clinical care continues to be part of a continuum of a comprehensive HIV/AIDS care strategy by improving the infrastructure at RDF hospitals and brigade clinics and train RDF health providers to diagnose, treat and through an established information system, monitor and report TB progression trends.

Drew University will ensure that the provision of preventive Co-trimoxazoleprophylaxis continues to be integrated into a HIV care package, so as to encourage TB prevention and reduce clinical treatment. With EP support, Drew University will ensure that 100% of HIV+ individuals enrolled into care in RDF sites receive TB testing and treatment (if positive) and in the same manner, 100% of TB patients will be tested for HIV through PIT. 100% of HIV+ TB patients eligible for ART will be automatically enrolled and followed-up through in-facility referrals and linkages. TB preventive Co-trimoxazoleprophylaxis will also be provided to HIV+ enrolled on care whether on and/or pending starting ART. To ensure successful TB prevention, Drew will support TB awareness-raising activities, mainstreamed at brigade/community-level through existing associations of HIV+ individuals. Drew will strengthen data collection and reporting system using the next generation TB/HIV indicators provided by PEPFAR.

These activities support Rwandan national plan for TB/HIV and EP to prevent, diagnose and treat patients with both TB and HIV patients.