AIDSRelief is a comprehensive anti-retroviral therapy program in ten countries over sub-Saharan African and the Caribbean. In Rwanda, AIDSRelief is providing treatment to more than 3,721 people, including 524 children. Based on its successes and lessons learned from the past year of project implementation, the AIDSRelief program in Rwanda will continue to expand access to treatment services to reach 4,972 patients by the end of February 2011.

The goal of this Consortium is to ensure that people living with HIV/AIDS have access to quality HIV care and treatment and that they are supported for successful adherence that assures viral suppression. AIDSRelief intends to expand, on a sustainable basis, the provision of ART to the greatest number of needy patients in these ten countries, consistent with good medical science, national priorities and programs, and cost-effective deployment of program resources. In this regard, AIDSRelief is committed to working in close collaboration with the Government of Rwanda and the in-country US government team to help strengthen the infrastructure of the MOH in general, through increasing liaison with the District Health Team, and specifically, the capacity of the health staff of its points of service to provide quality antiretroviral therapy.

AIDSRelief has established a multi-disciplinary technical assistance team for Rwanda, the Country Technical Coordinating Team (CTCT), which is responsible for overseeing the implementation of the program. The CTCT includes people with expertise in HIV/AIDS clinical care for adults and children, palliative care, patient adherence, laboratory diagnostics, prevention of mother-to-child transmission, drug procurement and pharmaceutical services, financial and grant compliance, and the management of strategic information. Together with corresponding sections of the Government of Rwanda, the Ministry of Health/TRAC and the in-country US Government team, the CTCT and AIDSRelief will make an impact on this disease, for the benefit of all persons now living with HIV/AIDS in Rwanda.

AIDSRelief is contributing to the achievement of Partnership Framework goals through its activities notably the expansion of the geographical coverage in Nyamasheke District, the improvement of the quality of the comprehensive HIV Treatment, care and support provided; and the strengthening of national staff expertise on HIV Prevention, Treatment, Care and Support at National, District and Health facility levels:

• AIDSRelief has expanded its HIV services from 3 to 20 LPTFs in Nyamasheke and Burera districts within the past four years. • As of October 31, 2009, the program has enrolled 9,722 patients in care, of which 3,721 are on treatment. Overall, there has been over a 34% increase in both care and treatment enrollment between FY08 and FY 2009. • AIDSRelief has strengthened staff capacity for the use of the new PMTCT protocol, focused on evidence-based maternal and pediatric HIV care; trained and mentor site staff on early HIV diagnosis (DBS, clinical) and provided transition feeding assistance to exposed Infant. • At all AIDSRelief supported sites, PLWHA systematically receive opportunistic infection prophylaxis, treatment and other co-infection treatment according to national guidelines. • An effective system was put in place by AIDSRelief with facility-based case managers, health community leads, health care workers, and community-based volunteers to ensure continuum, coverage and quality of basic care and psychosocial support to PLWHA which contributes to reduction of stigma and discrimination of PLWHA and OVC in the community. • In collaboration with CAMERWA and SCMS, AIDSRelief provided TA to health facilities to ensure the availability and rational use of quality drugs and commodities.

AIDSRelief is supporting 20 Health Facilities including 19 (17 health centers, 2 district hospitals) in Nyamasheke District, Western Province deserving 353,207 and one health center in Bungwe Sector in Burera District Northern Province deserving 24,810 inhabitants.

AIDSRelief is contributing to health system strengthening at all levels. Staff at Health facilities received intensive clinical training and mentoring, training on data management and use of IQChart software for patient management and monitoring, technical support on finance, compliance and administration. At community level, AIDSRelief emphasized community outreach and home care through PLVIH associations, community health leads and volunteers. As part of AIDSRelief Rwanda's commitment to build the national capacity in HIV care and treatment services, AIDSRelief has been working closely with government counterparts, TRAC Plus-CIDC and the National Reference Laboratory (NRL), training and mentoring over 150 health professionals. Training contents ranged from basic HIV care and treatment to

strengthening the capacity for diagnosis of extra pulmonary TB among PLVIH.

To ensure monitoring and evaluation of the planned activities, AIDSRelief will strengthen monitoring and data management systems for collecting, managing and analyzing clinical data at LPTFs. AIDSRelief will work with TRAC Plus by providing technical assistance to the sites to integrate, modify and improve their existing medical records system to meet the reporting requirements of TRAC Plus/MOH, donor and other stakeholders.

With TRAC Plus/MOH, AIDSRelief will continue to identify areas of system strengthening to enable organizations to enhance and sustain HIV service delivery. Specific efforts will focus on promoting integration of supervision and mentoring activities with district hospitals' support teams and TRAC/MOH mentoring teams, on-going assessment of local partner's strengths and weaknesses, and mentorship in the area of strategic information.

In FY 2010, AIDSRelief will continue to provide technical support to PEPFAR partners using IQChart (International Quality Clinical HIV/AIDS Registry Tool). AIDSRelief will mentor Monitoring and Evaluation officers on the released vision of IQChart containing PMTCT, OIs and STIs indicators; support the National Strategic Information Technical Working Group in process of rolling out the new HIV data management system; and Partner with MOH on the EMR and HMIS working group.

AIDSRelief will continue to build the data quality culture of LPTF staff to ensure quality (clean, complete and valid) of chronic care data through Data Quality Audit mentoring activities at District and LPTFs level. AIDSRelief will continue to support CTCT and district health teams in defining clinical indicators that will help LPTF address gaps in program services. AIDSRelief will also continue to provide local partners with data analysis tools and methods, and build capacity at LPTF in routine program data collection and analysis (using systems including but not limited to IQChart).

AIDSRelief Strategic information staff will continue to build LPTFs capacity to ensure compilation and timely submission of reports required by stakeholders & donors including TRAC Plus, CDC, OGAC and other LPTF & CTCT specific reports. In accordance with transition philosophy, the SI team will provide relevant Technical Assistance to ensure LPTFs receive information in a timely manner and are able to generate their own reports. AIDSRelief will continue technical capacity transfer to local partners that will focus on reinforcing data management capacity and monitoring, building data demand and information use (DDIU) so that local partners can generate their own reports, thereby enhancing data ownership (Sustainability). The SI team and District health Directorate team will develop a plan and outline activities that promote the use of SI to enhance Local Partner service delivery.

AIDSRelief will continue the mentorship on IQChart in LPTFs to strengthen their capacity to accurately collect, enter, store and retrieve program data for use in planning, monitoring, reporting, and improving quality, and demonstrated ability to fulfill GOR/MOH and donor reporting requirements. AIDSRelief will continue the ongoing Information Technology support (Computer Software and Hardware troubleshooting, including anti-virus update) in all LPTFs.

This is a continuing activity from FY 2009.

In FY 2009, CRS/AIDSRelief (AR) provided basic care and support services (BCS) to 8,332 adult HIV positive individuals at 20 sites, in 2of the 30 districts of Rwanda. In FY 2010 AR will continue to provide BCS to8972 adults at those sites, which include 18 health centers and 2 district hospitals.

In FY 2010 AR will continue to improve the timeliness of BCS services for better patient follow-up and outcomes. BCS provided by AR include: clinical staging and baseline CD4 count for all patients; follow-up CD4 every six months, or every 3 months for patients with CD4 cell counts <500, in accordance with national clinical guidelines; routine provision of co-trimoxazole (CTX) prophylaxis for all adults living with HIV, as per national guidelines revised in 2009; basic nutritional counseling and support; positive living and risk reduction counseling; pain and symptom management; and end-of-life care. In addition, AR will

continue to provide psychosocial counseling for HIV-positive female victims of domestic violence and as part of a "prevention with positives" strategy. To ensure comprehensive services across a continuum, AR will continue to refer patients enrolled in facility-based care services to community-based BCS services, including: adherence counseling; provision of long-lasting insecticide treated bed-nets (LLINs) for PLWHA and their families in collaboration with GFATM and PMI; provision of spiritual support, stigma reducing activities, OVC support, IGA activities, and home-based care (HBC) services for end-of-life care. AR will also facilitate access to point of use purification commodities to PLWHA at supported sites. Nutritional services will be strengthened by training providers on nutritional counseling, as well as by conducting nutritional assessments using anthropometric measurements. AR will assist in the management of malnutrition through the provision of micronutrient and multivitamin supplements and the creation of linkages to the CRS Ibyiringiro project for clinically eligible PLWHA and children, in line with national nutrition guidelines. will be done through expanded To expand psychological and spiritual support services for PLWHA at both the clinic and community levels, AR-supported health facility and community-based providers will receive training from TRAC Plus on GBV counseling, positive living messaging, and prevention with positives. AR will continue to integrate natural family planning messages and methods, as well as IMCI, into HIV services.

In collaboration with the supply chain partner, AR will provide diagnostic kits, CD4 tests, viral load tests and other tools for clinical monitoring, as per national guidelines. AR will work with the supply chain partner to ensure the appropriate storage, stock management, and reporting of all OI- and STI-related commodities. AR will continue to provide TA to TRAC Plus by participating in TWGs which review care and treatment guidelines/tools developed by that institution, or in any way requested by TRAC Plus.

In FY 2010, the transition of TRACK 1.0 activities will lead to a redistribution of sites supported by AR. AR will continue to provide BCS for 2,896 existing patients and 927 new patients at fourteen AR- supported sites, while BCS services for 2,729 existing patients and 513 new patients at six sites will be provided by the Government of Rwanda. However AR will continue to support quality improvement efforts at the six transitioned sites.

In FY 2010, AR will expand its prevention with positives strategy to enable PLWHA to adhere better to treatment, avoid sexual risk behavior and engage in positive living. Expanded services will emphasize quality of care via the Continuous Quality Improvement program. AR will also focus on securing the continuum of care through linkages with community-based organizations, and ensuring the sustainability of services through performance based financing.

AR will continue to assist health facilities in developing community health care and home care services, alternative testing, and mobile medication dispensing. AR, in conjunction with local health centers, will

conduct contact tracing of all patients who test positive for HIV at AR-supported sites. AR will support health facilities in their use of community volunteers and support group members to follow up HIV positive clients in their communities and to encourage spouses and family members to be tested. Depending on the availability of funds, these volunteers will provide HIV testing in their communities and identify discordant couples who need intensive prevention counseling. Community workers/volunteers will receive refresher training on the recognition of signs and symptoms of key OIs, the provision of basic palliative care, the implementation of basic care packages, the management of medication toxicities, and the proper utilization of referral systems. Community volunteers will continue to be supported through professional associations and the provision of PBF based on the number of patients they assist and quality of services provided.

PBF is a major component PEPFAR Rwanda's strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the national PBF project and in line with the transition of activities to national institutions, AR will support PBF by participating in health facility performance evaluations and serving PBF technical advisory teams.

In order to ensure a continuum of care, AR data clerks will liaise with other testing services to identify and reconnect with treatment those patients previously lost to follow up. AR will develop effective referral systems between clinical care providers and psychosocial and livelihood support services through the use of patient routing slips for referrals between community services and health facilities.. In addition AR will strengthen the capacity of two district health teams to coordinate an effective network of palliative care and other HIV/AIDS services.

(Track 1.0) This is a continuing activity from FY 2009.

In FY 2009 AR supported 16 ART sites and, as of February 2009, had provided ART services to 3,390 adult patients. In FY 2010 AR will continue to provide ARV services for 1,909 existing patients and 692 new patients at 11 of the currently supported sites; the other five sites will be transitioned to management of the MOH. However, AR will continue to delivering services at the five transitioned ART sites, providing quality treatment for 1,481 existing patients and 434 new patients.

AR will continue to support Local Partner Treatment Facilities (LPTFs) in enrolling patients who test positive for HIV into treatment. Patients who test positive will immediately be provided a CD4 count and

initiated into appropriated treatments, and subsequently actively supported throughout their ART treatment, and also CD4 tests for all HIV-positive people tested at non-ART sites will be done and Bactrim provision before they become eligible to ART and then transferred to ART sites In collaboration with district hospital teams, regular follow-up visits will be conducted to these LPTFs. Clinicians from the district team will review ART and non-ART complicated cases and nurses from the team will mentor the site's nurses on provider-initiated testing follow-up of patients, and the detection and referral of complicated cases to district hospitals. Supported by international technical assistance, AR will continue to promote quality improvement through reviews of indicators, medical dossiers and viral load measurements. The results of these reviews will be used to develop and strengthen clinical capacity for more efficient and high-quality patient management. AR will ensure the participation of district health team in meetings with health center staff and AR personnel in order to improve collaboration between stakeholders. AR will work with the National Reference Laboratory to expand diagnostic resources for HIV at supported sites. AR will also work to improve reporting linkages with CAMERWA and to mentor health center staff on strategies to effectively receive, manage, and forecast the need for ARVs and drugs for OI and palliative care.

PBF is a major component PEPFAR Rwanda's strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the national PBF project and in line with the transition of activities to national institutions, AR will support PBF by participating in health facility performance evaluations and serving PBF technical advisory teams.

AR will strengthen the capacity of two DHTs to coordinate an effective network of palliative care and other HIV/AIDS services. The basic package of financial and technical support will include staff for oversight, implementation, transportation, communication, training of providers, and other key responsibilities.

In FY 2009, AR participated in a pilot program to strengthen the delivery of services to victims of sexual and gender-based violence (SGBV) at three supported sites. The goal of the program was to ensure a comprehensive response to cases of SGBV, with a focus on clinical management and the role of the health facility as both a place of referral (to/from the police) and as a referrer to follow-up services, such as more extensive psychosocial and trauma counseling, legal assistance, temporary shelter, and reintegration into the community. In FY 2009 AR provided training on the comprehensive management of SGBV clients to clinical staff, counselors, and CHWs at the three pilot sites as well as its other supported sites. AR also participated in the development of national SGBV guidelines and strategies.

In FY 2010 AR will continue to support the pilot program at the three initial sites and will expand it to seventeen other AR-supported sites. AR will assist in the implementation of the program by providing

refresher training and mentoring to clinical staff, providing clinical equipment, drugs and PEP kits, and IEC and reporting tools. In collaboration with the district hospital staff, AR will support and conduct ongoing quality assurance and supportive supervision for health providers. The community role will be strengthened through refresher trainings for local support teams and CHWs in order to improve access for victims to quality services. Support groups for SGBV survivors will be created to facilitate their reintegration into the community. Linkages between clinical services (PMTCT, VCT, ART, etc) and sexual violence services will be strengthened through the reinforcement of the existing referral and communication systems. AR will also participate actively in the strengthening of the national response to SGBV.

This is a continuing activity from FY 2009.

In FY 2010, Catholic Relief Services under the consortium AIDSRelief (AR) will reach 43,098 individuals at 14 supported sites with a strategic mix of targeted PIT, family-centered HCT, and client-initiated HCT services that ensure confidentiality, minimize stigma and discrimination, and reach those individuals most likely to be infected. Support will be provided to six transitioned sites to give quality HCT services to 13,605 individuals. PIT services will target adult and pediatric in-patients presenting with TB and other HIV-related OIs and symptoms, malnourished children, HIV-exposed infants, and STI patients. PIT will be implemented with a revised counseling component whereby pre-test counseling is more focused with emphasis placed on post-test counseling. Moreover, community workers will be trained as counselors in order to provide continuous support beyond the consultation to encourage testing acceptance, family and/or partner tracing, and support for those who received their test results.

AR will work with religious institutions, community DOTS programs, and OVC and HBC programs to identify those infected, in particular HIV-exposed infants, family members of PLWHA, and OVC. HCT providers will continue to provide traditional HCT (client-initiated) for those who wish to know their status, in particular for pre- and post-nuptial couples, ANC male partners, and youth. Counseling messages will emphasize prevention, including abstinence and fidelity, alcohol reduction, GBV sensitization, disclosure of test results, and follow-up.

In order to counsel and test those individuals most likely to be HIV-positive, CBTS will conduct contact tracing of all patients who test positive for HIV at AR sites. Contact counselors will be responsible for accompanying HIV-positive clients to their community, encouraging their spouses and family members to

be tested, providing HIV testing, and identify discordant couples who are in need of intensive prevention counseling. To strengthen the continuum of care for PLWHA and their families, partners will establish a formalized referral system to link community care and clinical services. AR in collaboration with CHF, will ensure that HIV-positive patients are provided patient education, positive living counseling and referral for community-based services, such as IGA, through PLWHA associations, OVC, and HBC programs. At the health facility level, partners will ensure a system for supportive supervision of nursing and counseling staff, including training of select staff in supervision for HCT, use of quality control checklists, and data quality control.

AR will monitor site performance and provide patient referral tools for the timely enrollment of HIV- positive patients diagnosed in any service at the site. AR will support sites to track PIT and contact tracing data for use at site level for program improvement and reporting. Through regular supervision at sites, patient satisfaction surveys, and HIV testing records reviews, AR will ensure that basic ethical practices and confidentiality related to HIV counseling and testing are practiced at all sites.

PBF is a major component of the Rwanda strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the national HIV PBF program, CRS will shift its support for output financing based on site performance to technical participation on health facility performance evaluations and on PBF technical extended team meetings. Payment of indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool. District Health Teams (DHTs) are now playing a critical role in the oversight and management of clinical and community service delivery. AR will strengthen the capacity of two DHTs to coordinate an effective network of HIV/AIDS services. The basic package of financial and technical support includes staff for oversight and implementation, transportation, communication, training of providers, and other support to carry out key responsibilities.

This is a continuing activity from FY 2009.

As of October 2009, CRS/AIDS Relief (AR) is providing basic care and support to 719 HIV-positive children at 20 sites. By the end of FY 2010 the number of beneficiaries is expected to increase to 978 children at 20 sites, including 18 health centers and 2 district hospitals. The package of services is provided in collaboration with local community service providers and includes co-trimoxazole prophylaxis, nutrition counseling and food support, insecticide-treated bed nets (ITN), and safe water interventions. In

addition, AR supports the provision of follow-up services for HIV-exposed infants who are maintained on co-trimoxazole prophylaxis until their HIV status can be confirmed.

FY 2010 starts the first year of transition of TRAC 1.0 partners' activities. AIDS Relief will transition to the Ministry of Health (MOH) 11 HIV care and treatment sites which will be selected based on their demonstrated capacity to continue implementing high quality care for children with minimum support.

AR will continue to provide basic care and support for 356 existing children and 213 new children at 14 AR-supported sites. AR will also continue to support the 11 transitioned sites for quality care and support for 337 existing children and 63 new children. AR supports the implementation of new guidelines/tools developed by TRAC Plus.

To address the need to expand the diagnosis of HIV in the pediatric population, AR will increase testing for targeted pediatric populations within the catchment areas of its existing sites. Using each adult HIV patient enrolled in care and treatment at AR-supported sites as an index case, AR will offer HIV testing for their partners and children and enroll the infected family member/s into care and treatment services. To provide early initiation of ART for all HIV-positive infants, AR will assist in the implementation of early infant diagnosis and follow-up through training for PMTCT staff and lab technicians, as well as through developing efficient and reliable sample transportation systems. AR-supported sites will link with OVC service providers operating in the same districts to offer HIV testing services for children according to national guidelines, and to ensure enrollment of HIV-positive children into care and treatment services. In addition, AR-supported sites will link with malnutrition and TB centers within their facilities or at specialized sites located in the vicinity to provide HIV testing to all pediatric inpatients and outpatients, and to enroll the infected children into care and treatment services. AR will also work to establish and strengthen linkages with PLWHA associations in the local network, and the administrative district authorities and health teams to support activities aiming at increasing community awareness of issues related to pediatric HIV and to increase pediatric HIV testing and enrollment into care.

Local partners have repeatedly expressed the need for appropriate pediatric psychosocial resources including tools, job aids, and curricula. AR will support the implementation of new guidelines /tools and the pediatric and adolescent patient file. AR will also continue working with the pediatric support groups for improved psychosocial management of HIV-positive and -affected children and adolescents.

At AR-supported sites, HIV-positive children will be staged clinically and immunologically (using CD4 counts or percentages), and eligible infants and children will be enrolled in ART as per the new national Pediatric Guidelines. AR will work with the MOH and other clinical implementing partners to train health care providers on the updated pediatric HIV treatment guidelines which include changes for early

treatment of HIV-positive infants and in CD4 thresholds for treatment initiation of children between 36 and 59 months of age. Systematic chart reviews will continue in FY 2010 to identify children who are eligible for treatment according to the new protocol.

All pediatric patients will have regular anthropometric evaluations to identify early signs of malnutrition and to ensure prompt initiation of nutrition rehabilitation interventions. Newly identified patients will be screened at enrollment and at regular intervals for signs and symptoms of common opportunistic infections or other infectious complications of HIV in children, including: candidiasis, pneumonia, malaria, meningitis, and Pneumocystis jiroveci pneumonia (PCP).

AIDS Relief will work to implement a system to assess the vulnerability of HIV-exposed, infected and affected children. It will conduct home visits for families with HIV-positive children in order to identify and manage accordingly those that need special attention. In order to ensure a continuum of HIV care, AR data clerks will continue to liaise with community-based treatment specialists (CBTS) and OVC service providers to ensure referral to care services of pediatric patients identified through PMTCT programs, PLWHA associations, malnutrition centers, and OVC programs.

AR will ensure that site-level providers are trained or receive refresher training in pediatric HIV patient management according to the new national guidelines. Providers will receive in-service training and coaching on a regular basis. In collaboration with TRAC Plus, AR will continue to dedicate personnel to the national team that will provide continued mentoring to clinical staff at AR supported sites.

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, AR 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.

In FY 2009, AR worked closely with TRAC Plus to implement a mentoring program to train health care providers in the management of HIV and HIV/TB in adults and children. This program will continue in FY 2010 to support the building of capacity at site and district level to provide quality clinical services for children. With improved data on pediatric HIV care, AR, in collaboration with TRAC Plus and the national performance-based financing unit within the MOH will support health facilities to build and sustain a system of performance measurement and improvement. This system will use basic pediatric HIV care and support and treatment data to regularly review program performance and to design/implement appropriate interventions with a view to improving the quality of services. AR staff in charge of each

district will ensure that meetings to review data take place on a regular basis and that the improvement plan is implemented at individual sites. Yearly district-level meetings are planned where each facility will share their performance data and improvement strategies. AR will ensure that pediatric HIV care is integrated with adult HIV care and that the family approach is reinforced.

Performance-based financing (PBF) is a major component of the Partnership Framework for ensuring long-term sustainability and for maximizing performance and quality of services. In coordination with the national HIV PBF project and according to the new support approach to improving key national HIV performance and quality indicators, Catholic Relief Services will shift its support for output financing to technical participation to health facility performance evaluations and extended PBF technical team meetings. Full or partially reduced payment of palliative care and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool. District health teams (DHTs) are now playing a critical role in the oversight and management of clinical and community service delivery. AR will strengthen the capacity of two DHTs to coordinate an effective network of basic care and support and other HIV/AIDS services. The basic package of financial and technical support includes staff for oversight and implementation, transportation, communication, training of providers, and other support to carry out key responsibilities.

This is a continuing activity from FY 2009.

As of October 2009, AR supported 16 ART sites and provided ART services to 524 children. It expects to reach 556 children actively on ART by the end of February 2009.

In FY 2010, AR will continue to provide ARV services to 220 existing children and 112 new children at 11 AR-supported sites. AR will also continue to provide support for quality treatment of 332 existing children and 70 new children at 6 ART sites that will be transitioned to the Ministry of Health (MOH). AR will continue to support local partner treatment facilities (LPTFs) to enroll patients in treatment by initiating early infant diagnosis, treatment and new CD4-based protocol. AR-supported sites will continue to check for opportunistic infections (OIs) and other HIV-related illnesses, to identify treatment failure among patients on first-line regimen, and to offer appropriate treatment. AR will allocate a full-time TA at TRAC Plus to support pediatric HIV treatment programs in order to improve the quality of services.

In collaboration with the district hospital team, regular follow-up visits will be made to ART sites.

Additionally, infants and children on ART will also be assessed monthly at each visit for issues related to adverse events, toxicity and adherence to ART. AR will assist heath facilities in mentoring children and adolescent support groups that have been 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 these sites will continue to be trained and mentored for provider-initiated testing, to follow-up patients, and to detect and refer complicated cases to district hospitals. Supported by international technical assistance, AR will continue to support Quality Improvement with a review of indicators, medical dossiers and viral load measurements to develop and strengthen clinical capacity for more efficient and quality-assured patient management. AR will ensure participation of health center and country program staff in District Health Team meetings for better collaboration. AR will work with the National Reference Laboratory to expand the diagnostic resources for HIV at the sites. Furthermore, it will endeavor to improve reporting linkages with CAMERWA, and it will continue mentoring health center staff to improve their ability to receive, manage, and forecast the needs for ARVs and drugs for OI and palliative care.

Performance-based financing (PBF) is a major component of the Rwanda PEPFAR strategy for ensuring long-term sustainability and for maximizing performance and quality of services. In coordination with the national HIV PBF project and according to the new support approach to improving key national HIV performance and quality indicators, Catholic Relief Services will shift its support for output financing based on sites performance to technical participation to health facility performance evaluations and extended PBF technical team meetings. Full or partially reduced payment of basic care and support as well as other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool. DHTs are now playing a critical role in the oversight and management of clinical and community service delivery. AR will strengthen the capacity of two DHTs to coordinate an effective network of basic care and support and other HIV/AIDS services. The basic package of financial and technical support includes staff for oversight and implementation, transportation, communication, training of providers, and other support to carry out key responsibilities.

This is a continuing activity from FY 2009.

In FY 2010 AIDSRelief (AR) will provide an expanded package of services for 18,047 pregnant women. In all, 413 of these HIV-positive women are expected to complete the course of ARV prophylaxis. AR will continue to provide support for the 6 transitioned sites to MOH for PMTCT quality services.

AR will offer a standard package of PMTCT services that includes CT with informed consent, male partner and family-centered testing, ARV prophylaxis using combination ARV regimens and HAART for eligible women, infant feeding counseling and support, referral for MCH services, and close follow-up of HIV-exposed infants for effective referral to appropriate services, and early infant diagnosis. In addition, AR will ensure access to a comprehensive network of services for PMTCT clients and their families, including linking PMTCT services with other HIV and MCH interventions, assuring an effective continuum of care by increasing patient involvement and community participation in PMTCT services and ensuring CD4 count for all HIV-positive pregnant women.

Linking with MCH services, AR will strengthen follow-up and tracking systems to ensure testing of family members, routine provision of CTX and HIV early infant diagnosis, ongoing infant feeding counseling using new nutritional assessment tools. AR supported sites will continue CD4 monitoring and clinical staging, management of OIs, including TB and other HIV-related illnesses, psychosocial support services at clinic and community levels, identify and refer women who may be victims of gender-based violence to appropriate care and access to clinical and community prevention, care, and treatment services for family members.

AR will ensure linkage to treatment for eligible women and infant follow-up by using peer support groups, community mobilization, community volunteers, home visits, referral slips, community-based registers, patient cards and other monitoring tools to facilitate transfer of information between facilities and communities. In collaboration with new USAID partner, AR 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. In addition AR will ensure referrals of pediatric patients from PMTCT sites and nutrition centers to ARV services.

In collaboration with TRAC Plus and Project San Francisco, AR, and all clinical partners, will support couples' counseling through training and on-site mentoring to improve pre- and post-test couple counseling quality, improve follow-up mechanisms for discordant couples and women testing negative in ANC to address seroconversion and pediatric infection during pregnancy and breastfeeding.

Health center staff will receive new and refresher on-the-job training on new national PMTCT protocol. In collaboration with DHTs, AR will conduct performance improvement and QA of PMTCT services through regular supervision of sites, coaching, and strengthening capacity of sites in M&E. DHTs will build their QA and M&E skills, including in data collection, data use, and reporting.

Through CAMERWA/SCMS, AR will ensure ARV drugs, CD4 tests, RPR test kits, PCR, rapid HIV test kits, and hemoglobin testing materials are available in all AR supported sites. AR will also collaborate with RPM+ to improve the capacity of providers in drug management, coordinated site-level storage, inventory, tracking and forecasting. In addition, AR will collaborate with new USAID partner, GFATM, and PMI to refer PLWHA and their families for malaria prevention services including bednet provision. In collaboration with CRS/Ibyiringiro, HIV-exposed infants - starting at six months, pregnant and lactating mothers in need of all PMTCT sites will receive respectively weaning food and supplemental food.

At PMTCT sites, enhanced follow-up of mothers and exposed infants will be promoted through support groups of HIV-positive women based on the mother-to-mother model. In this model, women who demonstrate steady consultation attendance and good baby care are identified and used to coach new HIV-positive mothers during pregnancy and after delivery to ensure that both women and their infants access needed services. During these groups sessions AR will provide nutrition counseling, enhancing family food support through training for improved home gardening and animal breading techniques. In addition, AR supported sites will provide health education on safe water and provision of water purification products. HIV-exposed infants identified at PMTCT sites will be followed in the context of existing MCH services offered at existing AR sites. Mother and infant information will be transferred from PMTCT to other MCH programs through the "carte de liaison" currently in use. Early infant diagnosis services, now available at 19 of AR supported sites, will be expanded to increase full coverage of sites by end of FY 2009. EID will be offered at six weeks of age and at later ages for symptomatic infants less than 18 months according to the national algorithm. AR will also work with the district health teams to ensure that samples collected at the sites are transferred efficiently to the National Reference Laboratory in Kigali and work with the MOH to increase reliability of result turn-around times.

DHTs play a critical role in the oversight and management of clinical and community service delivery. In line with the Partnership Framework sustainability and transition goals, AR will provide a package of support to two DHTs to strengthen their capacity to coordinate an effective network of PMTCT and other HIV/AIDS medical services. The basic package of financial and technical support includes staff for oversight and implementation, transportation, communication, training of providers, and other support to carry out key responsibilities. Support to DHTs will focus on strengthening the linkages, referral systems, transport, communications and financing systems.

PBF is a major component of the GOR's strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the national HIV PBF project, AR will shift its support from output financing based on sites performance to technical participation on health facility performance evaluations and on PBF technical extended team meetings.

Clinical Services: In FY07, AIDSRelief (AR) began to implement the national TB/HIV policy and guidelines at their 14 supported sites. The program's achievements include an improvement in the percentage of TB patients tested for HIV and improving the HIV-positive TB patient's access to HIV care and treatment (increased proportion of patients accessing Co-trimoxazoleand ART).

In FY 2010, the goal is to ensure at least 95% of all TB patients are HIV tested, 100% of co-infected patients receive Co-trimoxazoleand 100% of those eligible receive ART at 11 AR supported ART sites to achieve high HIV testing in TB patients. Additionally, AR will provide TA support to 5 transitioned Track 1.0 ART sites for them to achieve the same goal. Lower than expected numbers of PLHIV in care and treatment are diagnosed and treated for TB. The priority in FY 2010 will be to expand implementation of regular TB screening for all PLHIV, and for those with suspect TB, ensuring adequate diagnosis and complete treatment with DOTS.

In FY 2009 AR supported sites with staff materials and training routine recording and reporting for the national TB/HIV programmatic indicators. Initial uptake and quality of services has been variable at different sites. In FY 2010, AR will continue to support individual sites to collect quality data, and to report and review these data in order to understand and improve their program and support integration of TB and HIV services at the patient and facility level, per national guidelines.

In order to ensure effective integration of TB and HIV, AR is supporting integrated planning and TB/HIV training to both HIV service providers, TB service providers and at central level. AR also plans to increase support to integrate diagnostic services, including coordinating specimen transport for both programs, and patient transport for appropriate diagnostic services (such as chest radiography and diagnostics required for extrapulmonary TB) to referral centers and appropriate follow-up.

In FY 2010, AR will continue to support existing sites for the implementation of the TB/HIV component of the clinical package of HIV care such expansion of TB screening to PLHIV accessing other HIV services,

such as, VCT/PMTCT sites, as well as family members of HIV positive patients reached through home base care and community programs; timely and appropriate TB diagnosis and treatment via DOTS for all PLHIV that are TB suspects. Support sites to implement routine collection, recording, and reviewing of standard national TB/HIV program indicators at sites to inform and improve services at the patient and facility level. These data will also be routinely reported to the district and national levels through TRAC Plus and PNILT to inform the national program; support on-going trainings on TB screening and management and TB control at sites; support sites to develop community based cases finding of TB and HIV patients' case management and referrals between the HIV and TB services. In addition, all pediatric patients will be screened for TB at least once every six months. Children suspected of having TB will be further investigated and put on TB treatment or INH prophylaxis if infection or exposure is confirmed based on current national guidance.

Capacity Building: The objective of these activities is to increase the capacity of TRAC Plus (MOH), the Central University Hospitals in Kigali (CHUK) and Butare (CHUB), and the National Reference Laboratory (NRL) in the area of TB/HIV integration such that the GOR becomes capable of leading implementation and scale-up of these activities. Technical assistance (TA) currently includes updating and revision of national guidelines, development of training manuals for national trainers, support for conducting operational research activities, support to the clinical mentoring (training of trainers) program for District Hospital staff. In addition, TA is provided to CHUK/CHUB and NRL in support of improved diagnosis of extrapulmonary tuberculosis (EPTB) by use of fine needle aspiration (FNA) and histopathology services.

During FY 2009, AR is supporting the TRAC Plus HIV/AIDS/STI (HAS) Unit to conduct national level trainings of trainers (TOTs). These TOTs include didactic and practical material on TB for HIV-positive patients, as well as other aspects of clinical care included in the national HIV care and treatment clinical guidelines; to date, 6 TOTs have been conducted for doctors with 169 total participants (doctors) and (3 sessions + 3 refresher TOTs) for nurses with 168 total participants (nurses). Ongoing support is provided to TRAC Plus for 2-weeks long pediatric practical trainings organized in CHUK (9 participants per session). AR has been supporting TRAC Plus in development /revision and dissemination of national guidelines on TB/HIV (adult OIs, STI, adult and pediatric ART guidelines, discordant couples' tools). AR TA supports evidence-based decisions in several areas related to TB/HIV in adults and MCHC. AR is supporting MOH/TRAC Plus in documenting a model of adolescent services adapted to Rwanda context. Support is being provided to the TB/HIV focal person at TRAC Plus HAS unit for report preparation and revision, and AR participates in national technical working group (TWG) meetings.

In addition in FY 09, AR provided TA, training and materials to CHUB and CHUK national hospital pathology laboratories for the diagnosis of smear negative and EPTB. A total of 81 doctors were trained

in lymph node aspiration; additionally, 127 doctors were trained on TB/FNA techniques during national/district trainings on general adult and pediatric TB/HIV issues, while lab technicians were trained in specimens processing. AR initiated integration of TB/FNA by liaising with the TB Unit to ensure that this strategy is being taken in account in planning. In accordance with TRAC Plus, AR supports national capacity building by participating in pre-service training on TB/HIV for medical students (30 hours) and postgraduate students (CHUK).

For FY 2010, AR will continue to allocate two full-time TA staff for provision of technical assistance in TB/HIV and adult and pediatric HIV care and treatment programming, implementation, and monitoring in the HAS Unit/TRAC Plus, and will continue to work in collaboration with the TB Unit. Clinical mentoring on management of complex cases for TRAC Plus Clinic (doctors and nurses) and CHUK staff will continue. Clinical mentoring (TOT) to referral/district hospitals will continue. TA will continue to be provided to the TRAC Plus HAS unit TB/HIV focal person, and continued participation in the national TWG meetings will occur. Support of MOH for evidence based guidelines/tools development and operational research will continue.