The Ibyiringiro project will continue to improve the livelihoods, security, and resiliency of households impacted by HIV and AIDS through 3 Strategic Objectives:

SO1: Improve the services available to People Living with HIV (PLWHA) and Orphans and Vulnerable Children (OVC). Ibyiringiro will continue its work with clinical sites and Community Health workers (CHW) to ensure adequate care and support to PLWHA. 776 currently served CHW will receive refresher training on nutrition and palliative care. CHW kits will be replenished based on needs. The Ibyiringiro project will continue its family/household-centered approach by training family members about improved nutrition practices, care for HIV positive children, household food production and opportunities to increase household income. Ibyiringiro will continue to work with HIV-positive individuals to educate household groups. PLWHA, especially children, pregnant women and lactating mothers nutritional status will be monitored and receive nutrition counseling. In order to ensure follow-up of the nutrition and health status of HIV positive children who graduated from the food assistance done at PMTCT sites, IBYIRINGIRO will link these OVC and their families to existing Ibyiringiro supported groups/cooperatives, especially the nutrition program, agriculture and saving and lending groups. The livelihoods and resiliency of PLWHA and OVC households will be strengthened through continuous assistance in setting up backyard nutritious gardens. In this regard, Ibyiringiro will continue to use peer educators or farmer field school approach, where PLWHA will be trained on bio-intensive agriculture techniques at the village level.

PLWHA associations will be facilitated to receive support from HIV negative people through establishment of Savings and Internal Lending Groups (SILC). Existing SILC groups will continue to receive support to improve their capacity to manage their saving and to push groups to give out more loans to members. The project will also increase the capacity of SILC groups to reach the next stage managing self-identified IGAs. During the cycle, SILC groups will receive basic business skills training in order to help them manage IGAs.

The strategy will also identify PLWHA households interested in small animal husbandry. Selected healthy animals will be given to PWHA with a basic training on how to raise animals. These animals will help them to improve their gardens with organic manure, improve their nutrition with animal products and gain some profits in selling animals.

SO2: Cooperatives of PLWHA provide high quality services to their members. Most associations that have been supported by Ibyiringiro at this stage have already started their registration process. These associations will be supported until they complete the national registration.

New PLWHA associations will be selected and assisted with the transformation process into cooperatives. At the same time, Ibyiringiro will strengthen their capacity to establish sustainable managerial, financial and organizational systems. A comprehensive package of training and follow-up will be implemented to achieve the above goals. Ibyiringiro will continue to provide the four sessions of training which are: advocacy, leadership and good governance, cooperative structure and management, and finally business planning skills development.

SO3: Improved nutritional status of infants and mothers enrolled in PMTCT programs. Ibyiringiro will continue to contribute to the national efforts to improve the nutrition education and providing high quality weaning food to HIV-positive mothers following TRAC Plus standards. For the weaning period from the 6th to 18 months, mothers will have improved access to fortified weaning foods at PMTCT sites throughout the life of the project.

Ibyiringiro will continue to provide nutrition and food assistance to at least 2,000 mothers frequenting ANC and PMTCT sites. Mothers will continue to receive counseling on AFASS, EBF and safe weaning when appropriate. Ibyiringiro will continue to work through different national technical working groups to continuously review and improve approaches as well as the management committee.

The Ibyiringiro project will continue to coordinate with key organizations such as TRAC Plus, CNLS/CDLS, RCA, MINAGRI, RRP+, MOH Nutrition and Community Health Desks through national technical working groups to ensure project interventions are in line with the GOR priorities and standards.

This is a continuing activity.

In FY 2009 CRS/Ibyiringiro supported 41,386 clients across 24 districts to receive basic care and support services (BCS). In FY 2010, CRS/Ibyiringiro will continue to work with clinical and community partners using community health workers (CHWs) to ensure adequate palliative care support to PLWHA. The 776 CHWs currently working with CRS/Ibyiringiro will receive refresher training on palliative care, particularly on how to assess nutritional status using mid upper arm circumference (MUAC) and body mass index (BMI) measurements and how to provide nutritional counseling. CHW kits will be replenished based on the needs identified. CHWs and clinics will continue to strengthen the continuum of care for PLWHA between the clinic and the community. To this end PLWHA will be linked to facilities by CHWs. All moderate to severe cases of malnutrition will be immediately reported to the health center and severe cases will be followed by the district hospital. CHWs and other community support groups will refer HIV exposed children, pregnant and lactating women living with HIV/AIDS who need nutrition and food support to PMTCT services and food distribution sites.

CRS/Ibyiringiro will continuously update its mapping of health facilities and HIV prevalence to facilitate linkage with other community and clinic HIV services. The project will continue its family-centered approach by working with different community-based associations to improve the health and nutritional status of over 15,300 PLWHA and their families through the "positive deviant" nutrition approach. All nutrition education programs will be integrated with hygiene and sanitation sessions. A major component of the positive behavioral practices will be supporting PLWHA to have increased access to diverse foods through small gardens. To this end CRS/Ibyiringiro will use peer educators or the "farmer field school" approach, where PLWHA will be trained in bio-intensive agriculture techniques at the village and household levels using a demonstration plot. Households will receive some basic supplies, including

seeds for vegetables and fortified crops, which will help transform their kitchen gardens into important sources of nutrition.

To address issues of stigma and discrimination, Savings and Internal Lending Communities (SILC) will try to attract PLWHA, as membership alongside HIV negative individuals in SILCs reduces discrimination against PLWHA and gives them an opportunity to better their lives and communities. Target communities will be sensitized about the importance of establishing Savings and Internal Lending Groups and supported in efforts to organize themselves into savings groups. This program will increase the capacity of the SILC to reach the next stage of development-- the management of self-created income generating activities (IGAs). As part of the program SILC groups will receive training on basic business skills in order to help them manage IGAs. This training will also attract and help identify PLWHA households interested in small animal husbandry. Of the PLWHA households interested in animal husbandry beneficiaries will be selected based on the recommendations of local leaders and PLWHA cooperatives, keeping in mind the need for beneficiaries to own a minimum amount of land for grazing and upkeep. Healthy animals will be given to PLWHA, along with basic training on how to raise and care for them. These animals will improve the nutritional intake of PLWHA, increase their income though the sale of animals and animal products, and fertilize their gardens with organic manure.

CRS/Ibyiringiro will also support national efforts to develop the management capacities of PLWHA cooperatives. In FY 2010 the project aims to increase the capacity of 50 PLWHA associations (comprising 4500 members) sufficiently for them to acquire legal status as cooperatives. Selected PLWHA associations will be assisted with the transformation process into cooperatives and supported until they obtain national registration as cooperatives. Training and assistance for registration will be prioritized for associations based on assessments and the current ability of the association to become registered and begin IGAs. Once they receive registration, the cooperatives will be trained in good governance, financial management and accountability, allowing them to establish sustainable managerial, financial and organizational systems. CRS/Ibyiringiro will provide the four training sessions offered on it training menu: advocacy; leadership and good governance; cooperative structure and management; and business planning skills. The training will use existing training tools developed by CRS/Ibyiringiro in collaboration with RCA.

In supporting improved services available to People Living with HIV (PLWHA) and orphans and vulnerable children (OVC), the Ibyiringiro project will continue to improve the livelihood security and

resiliency of households impacted by HIV and AIDS through 3 strategic objectives (SO):

SO1: The services available to PLWHA and OVC are improved. Ibyiringiro will continue its work with clinical sites and community health workers (CHW) to ensure adequate care and support to PLWHA. Existing 776 CHW will receive refresher training on nutrition and on basic care and support. CHW kits will be replenished based on the needs.

The Ibyiringiro project will continue its family/household centered approach by strengthening the capacity of family members to adopt improved nutrition practices, to care for HIV-positive children, to enhance household food production and the generation of household income. Ibyiringiro will continue to work with community health workers to educate groups of households. The nutritional status of PLWHA, and especially of children and pregnant and lactating women will be monitored, and they will receive nutrition counseling. In order to ensure follow-up of the nutrition and health status of HIV-positive children who graduated from the food assistance done at PMTCT sites, Ibyiringiro will link these OVC and their families to Ibyiringiro-supported groups/cooperatives, especially the nutrition program, agriculture, and saving and lending groups. The livelihoods and resiliency of PLWHA and OVC households will be strengthened through assistance in setting up backyard nutritious gardens. In this regard, Ibyiringiro will continue to use peer educators or a farmer field school approach to train PLWHA in biointensive agriculture techniques at the village level.

PLWHA associations will be facilitated to receive support from HIV-negative people through the establishment of Savings and Internal Lending Communities (SILC). Existing SILC groups will continue to receive support to improve their capacity to manage their savings and to encourage them to give out more loans to members. The project will also increase the capacity of SILC to reach the next stage of managing self-identified income-generating activities (IGAs). During the cycle, SILC groups will receive training in basic business skills in order to help them manage IGAs.

The strategy will also identify PLWHA households interested in small animal husbandry. Animals will be given to selected PLWHA together with basic training on how to raise animals. The animals will help them to improve their gardens with organic manure, enrich their diet with animal products, and generate additional income by selling animals.

SO2: Cooperatives of PLWHA provide high quality services to their members. Most of the associations that have been supported by Ibyiringiro at this stage have already started their registration process. These associations will be supported until they get the national registration. New selected PLWHA associations will be assisted with the transformation process into cooperatives. At the same time, Ibyiringiro will strengthen their capacity to establish sustainable managerial, financial and

organizational systems. A comprehensive package of training and follow-up will be implemented to achieve the above goals. Ibyiringiro will continue to provide the four sessions of training which are: advocacy, leadership and good governance, cooperative structure and management, and finally business planning skills development.

SO3: Improved nutritional status of infants and mothers enrolled in PMTCT programs. Ibyiringiro will continue to contribute to the national efforts to improve the nutrition education and to provide high quality weaning food to HIV-positive mothers pursuant to TRAC Plus standards. For the weaning period from the 6th to 18 months, mothers will have improved access to fortified weaning foods at PMTCT sites throughout the life of the project.

Ibyiringiro will continue to provide nutrition and food assistance to at least 2,000 mothers frequenting ANC and PMTCT sites. Mothers will continue to receive counseling on acceptable, feasible, affordable, sustainable exclusive breastfeeding and safe weaning when appropriate.

Ibyiringiro will continue to work through different national technical working groups to continuously review and improve approaches. In addition, it will rely on databases for a better follow-up of progress and achievements.

Using the food by prescription model, food will be provided in conjunction with HIV treatment and care services in order to strengthen the effectiveness and uptake of these services and to improve clinical outcomes.

The Ibyiringiro project will continue to coordinate with key organizations such as TRAC Plus, CNLS/CDLS, RCA, MINAGRI, RRP+, the nutrition and community desks at the MOH, and through different national technical working group to ensure project interventions are in line with the GOR priorities and standards. Ibyiringiro will continue also to coordinate with existing PEPFAR clinical implementers, such as CHAMP, and other national HIV program implementers such as WFP, Global Fund, and PMI to capitalize on the high potential for complementarities and synergy.

This is continuing activity from FY 2009.

In FY 2010, Ibyiringiro will continue to contribute to the national efforts to improve nutrition education and

provide high quality weaning food and supplemental food respectively to HIV-exposed infants and pregnant and lactating mothers.

Ibyiringiro will improve access to fortified weaning foods for HIV-affected young children and their mothers. Ibyiringiro will procure 300,000 Kg of corn soy blend (CSB) and distribute to 184 PEPFAR- supported hospitals and health centers in collaboration with EGPAF, IHI, ICAP and FHI. Mothers will be assisted to adopt safer and more effective infant and young child feeding practices through group education and individual counseling. Clinical staff will receive continuous support to provide quality nutrition-related services to HIV-affected infants and mothers. Additionally, 200 health care providers will be followed up through workshops to improve their skills on infant and young child feeding (IYCF) education, nutritional counseling and messaging as well as client monitoring and CSB stock management.

Ibyringiro will support the revision, adaptation and printing of IEC materials on IYCF (a take home brochure for mothers summarizing key HIV-exposed IYCF topics, a flipchart and an interactive film on expression and flash heating of mother's milk for health care workers to use during counseling sessions.

PMTCT sites will continue cooking demonstrations on how to prepare the CSB as a complementary food and other foods. Health center staff will continue to provide counseling sessions to 4,504 mothers in areas of breast health, proper lactation, acceptable, feasible, affordable, safe and sustainable (AFASS) weaning and IYCF.

Results of the rapid assessment on nutritional knowledge, practices and attitudes of pregnant and lactating HIV-positive women, done by PATH/EGPAF, will inform the planned extension of Ibyiringiro project activities in supporting nutritional counseling to HIV-positive mothers.

Ibyiringiro will continue to provide nutrition and food assistance to at least 2,000 HIV-positive pregnant and lactating mothers frequenting ANC and PMTCT where the supplemental feeding to exposed children is already on-going. The women will be selected based on national nutritional guidelines and include any HIV-positive women who are either pregnant or breastfeeding, not receiving any other food aid, or from a food insecure family (especially woman who eats once per day and recognized indigent by the local authorities).

Providing supplemental rations to mothers will increase attendance at ANC and PMTCT sites during pregnancy and post-natal period. Mothers will continue to receive counseling on AFASS, EBF and safe weaning when appropriate. Each mother will receive an individual ration of 6Kg of CSB per month from pregnancy to 6 months after delivery.

While CRS will continue to ensure the procurement of CSB and its distribution to the 184 sites, EGPAF will continue to ensure the technical lead among the different partners, including training of FOSA staff, provision of job aids and BCC tools.

All PEPFAR clinical implementing partners will participate actively in the nutrition steering committee led by TRAC Plus to ensure a continuous improvement of the interventions through joint supervision and continuous feed-back and monthly exchange.