TRAC Plus (Centre for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics) is an autonomous organization within the Ministry of Health, whose mission is "to provide evidence-based, technical leadership for the prevention and control of HIV & AIDS, tuberculosis, malaria and other epidemics, through independent applied research, multi-stakeholder participation, improved quality of services and strengthened health systems, thereby contributing to the improvement of the health status of the Rwanda population". TRAC Plus consists of 6 operational Units: • HIV/AIDS/STIs (HAS) - mandated to control HIV/AIDS and STIs in Rwanda through the development of guidelines and policies, implementation of programs and monitoring and evaluation • Malaria - mandated to run the malaria program in Rwanda • Tuberculosis - mandated to control TB infection in Rwanda • Surveillance, Bioinformatics & Information Technology (SBI) - providing cross-cutting support • Epidemic Infectious Diseases (EID) - provides insights for the prevention, control and response to other infectious diseases • Finance and Administration - providing cross-cutting support

In FY 2009 the Department of Epidemiology within the HAS Unit conducted multiple HIV surveillance activities aimed at better understanding the state of the HIV epidemic in Rwanda. These include HIV sentinel surveillance at antenatal care facilities, a behavioral surveillance survey (BSS+) among sex workers, youth and truck drivers, and standard WHO HIV drug resistance surveys. Additionally, TRAC Plus trained 210 data collectors or enumerators that constitute a pool of human resources availed for future surveys.

Quality of care for patients enrolled in HIV services was a high priority for TRAC Plus in FY 2009 resulting

in revised guidelines on HIV clinical prevention, care and treatment being disseminated. In addition TRAC Plus conducted training of trainers on the updated HIV guidelines for clinical providers at the district level. A total of 163 health workers, including nurses and medical doctors, have been trained in prevention, care, treatment and nutrition for HIV and TB patients. This contributed to improved quality of services provided to HIV patient across the country.

Another focus for TRAC Plus in FY 2009 was on data quality and use of information. Efforts have been made to develop data quality assessment tools. Central level, as well as district level, data audits have been conducted with feedback provided to the point of data collection. This process also includes capacity building at the district level to perform the similar data quality audit during their supervision activities. The data quality audit as a routine activity will contribute to improve the ownership and use of data by health centers and district hospitals authorities.

PMTCT, VCT, care and treatment program indicators have been revised and appropriate reference sheet has been developed to guide data collectors at health facility level. A module of these new indicators is currently being built onto the TRACnet system. During FY 2009 TRAC Plus managed the TRACnet system and provided training on the system to 194 health workers. These trainees are the end-users who report monthly program achievements via the TRACnet system. As of December 2009, 279 health facilities providing HIV AIDS services are reporting in TRACnet. In collaboration with Voxiva Inc, TRAC Plus printed and distributed information summarizing health facility achievements, something that was well received by the health care providers as the lack of feedback was a major criticisms.

In FY 2010 TRAC Plus will continue to build on experiences gained in previous years to strengthen its capacity. Activities identified for FY 2010 will cover prevention, care and treatment, strategic information.

In FY 2010, TRAC Plus will adjust PMTCT, care and treatment guidelines, revise tools and update training curricula as needed. The revised tools will be disseminated to all health facilities offering HIV services. At the district level, TRAC Plus will continue to support capacity building through the implementation of revised HIV guidelines, trainings and refresher training of trainers. In turn these trainers will train providers on HIV prevention, care and treatment services at the decentralized level. Emphasis will be put on the implementation of task shifting to facilitate scale-up of PMTCT and other HIV care and treatment services, including ART. Moreover, TRAC Plus in collaboration with USG implementing partners and the Global Fund, will continue to support the expansion of quality adult and pediatric HIV care and treatment services by providing continued clinical mentorship to clinical staff at the district level. District staff mentors will train hospital and health center service providers in adult HIV treatment, patient record-keeping, data recording and use, and quality performance measurement and improvement.

To ensure quality of pediatric training at decentralized level, TRAC Plus will supervise training on pediatric HIV care and treatment for facility-based and community-based providers at decentralized levels. In collaboration with the UPDC unit within the MOH, TRAC Plus will assist district health teams in mentoring child and adolescent support groups established at health facilities as a component of psychosocial support for HIV-positive children and adolescents. These clubs will be used to provide on-going support for children in care and on treatment or affected by HIV and assist with addressing issues around disclosure and adherence support. One child counselor per ART site will be trained to organize children support groups.

In FY 2010, TRAC Plus will emphasize quality improvement in pediatric care and treatment at ART sites and improving pediatric enrollment and retention into care. In collaboration with Columbia University and the Institute of Human Virology (IHV), TRAC Plus will implement a harmonized mentorship program to improve the quality of pediatric HIV care, treatment and support at district hospitals. PEPFAR will continue to support TRAC Plus in the sustainability of CHUK pediatric practical training and decentralization of this training at others sites. In order to reach the goal of universal access by treating all children in need of ART, TRAC Plus with PEPFAR support, will continue to upgrade HIV services in PEPFAR supported districts. In order to improve the enrollment of HIV-positive children into care and treatment, TRAC Plus, in collaboration with National Reference Laboratory, will assist district team to scale-up early infant HIV diagnosis.

TRAC Plus will also implement prevention with positive (PwP) activities and integrate them into care and treatment. The activities will reinforce and follow up programs started in FY 2009, by assuring training of physicians and community counselors who will be providing prevention counseling for HIV-positives. The activities will also reinforce the five prevention steps for HIV-positive individuals. In addition, they will assure training and incorporate PwP activities as a standard of care in ART sites. This will help ensure that people living with HIV/AIDS (PLWHA) will benefit from the tailored interventions to reduce transmission rates to HIV uninfected populations. Clinical and lay community counselors will promote couples counseling and testing and provide PwP messages to all their clients, but particularly PLWHA, to reduce their high risk behaviors through abstinence, being faithful to one partner or promoting secondary abstinence and counseling and discussing condom use for those discordant couples. Trained lay community counselors will benefit from training HIV positive individuals on aspects of health, including prevention interventions to all their HIV positive clients.

In FY 2010 TRAC Plus will strengthen the TB/HIV monitoring and evaluation system by revising M&E tools based on the WHO recommendation and by improving the data analysis and its utilization for decision making. The TB unit will continue scale-up the implementation of TB infection control policy in health facilities through development of infection control plans, their supervision, and monitoring &

evaluation. In addition TRAC Plus will continue to conduct an annual assessment of TB transmission risk among health care workers and, in collaboration with WHO, will conduct a national TB prevalence survey. FY 2010 funding will continue to support the MDR and X-DR TB surveillance and laboratory networking for sample transportation and ensure that MDR cases adhere to their treatment regimens.

USG PEPFAR has been supporting the Field Epidemiology and Laboratory Training Program (FELTP). In FY 2009 short courses were provided to 60 participants. In FY 2010 the two-year master's level course will be introduced. In FY 2010, TRAC Plus EID Unit will play a critical role in the implementation of the training during the practical, on-the-job training periods. This will complement the efforts of the USG team and the School of Public Health.

In FY 2010, the Department of Epidemiology in the HAS Unit of TRAC Plus will conduct multiple surveillance activities aimed at better understanding the state of the HIV epidemic in Rwanda. These include HIV sentinel surveillance at antenatal care facilities, syphilis and hepatitis B and C surveillance incorporated into HIV sentinel surveillance, and a behavioral surveillance survey (BSS+) among sex workers and street children. Standard HIV drug resistance surveys (early indicators, threshold and monitoring surveys) will be continued and scaled-up, in collaboration with USG, WHO, UNICEF, UNAIDS, UNFPA, GLIA and the National Reference Laboratory. Additionally, TRAC Plus will conduct a formative assessment of commercial sex workers' partner behaviors to inform the HIV/AIDS prevention program. A second data triangulation survey of HIV/AIDS program coverage was performed in December 2009 with technical assistance from the University of California San Francisco (UCSF) and CDC/Atlanta. A third data triangulation survey is planned in 2010, again utilizing technical support from UCSF and CDC/Atlanta. TRAC Plus will assume greater responsibility for this activity as the objective is to build local capacity for triangulation activities in Rwanda.

The focus of M&E activities in FY 2010 under the TRAC Plus cooperative agreement will be on the improvement of data quality, planning, reporting, and utilization of data for program management and service delivery. TRAC Plus will support data analysis and use as it relates to clinical prevention, care, treatment, to monitor the quality of services provided. As far as HMIS is concerned, TRAC Plus efforts will focus on maintenance, upgrading and implementation of the OpenMRS and the TRACnet system. TRAC Plus will conduct data quality assessment at central level and at health facilities level in order to improve the collection, use and dissemination of information. One of the keys to improve health data is to improve their source by putting in place mechanisms that help in the daily activity of health data management; it is in this regard that the MOH, through TRAC Plus, has opted to develop and implement an electronic medical record to improve data management.

The SBI Unit at TRAC Plus will continue the process of implementing and scaling up the national

electronic medical record (openMRS) and will help in various areas of data entry, management and reporting from individual data to their aggregation to be sent to the central level for decision making. The first implementation will cover HIV program (care and treatment, VCT and PMTCT) by developing electronic registers and automated aggregated reports from those electronic registers that are sent every month at TRAC Plus; later on a primary health care module will be developed.

In FY 2010, with the integration of new VCT and PMTCT indicators into TRACnet, the emphasis will continue to be put in data quality improvement reported into TRACnet System throughout decentralized trainings of districts supervisors, data managers and M&E officers. Feedback mechanisms will be enhanced, TRACnet data quality audit exercise and integrated supervisions will be continued and quarterly dissemination workshops will held on achievements in terms of TRACnet reporting completeness and timeliness. TRACnet end-users trainings and TRACnet TOTs will continue.

FY 2010 funding will also support the upgrade and maintenance of the electronic disease surveillance system set up in FY 2009 through collaborative efforts of the EID and SBI units within TRAC Plus, the National Reference Laboratory, MOH and USG. To maintain an operational and IT conducive working environment, funding of procurement of IT equipment will be supported as well as broadband internet connectivity and IT facilities hosting fees.

In order to accommodate the increase in activities and assure the successful implementation of programs, TRAC Plus is in need of cross-cutting support of functional units and activities. This support includes various facets, such as staff capacity building and training for the effective management of the funds and activities of this cooperative agreement's resources management in technical, administrative, financial and human resources elements. In addition, the cross-cutting support activities will co-ordinate and implement infrastructure improvement, personnel management, financial management as well as equipment and supplies procurement.

TRAC Plus will continue to provide support for the implementation of all project activities in the areas of planning, procurement, logistics, finance and personnel-related issues. Equipment and expendable supplies will be provide for all technical units and will continue as routine activities. TRAC Plus will continue to ensure financial management and reporting for the cooperative agreement, quarterly financial reports will continue to be submitted on a timely basis.

In FY 2009, TRAC Plus revised the national HIV care and treatment training curriculum and integrated modules on psychosocial support, nutritional assessment, counseling, management of malnutrition, and screening, diagnosis and management of STIs. TRAC Plus also coordinated the update of OI and STI guidelines and printed copies for national distribution. In additional TRAC Plus, with PEPFAR support, adapted the generic prevention with positives tools developed by CDC to reflect Rwanda's language, social norms and culture, and conducted a training of trainers with these revised tools.

In FY 2010 TRAC Plus will continue to implement prevention with positive activities and integrate them into care and treatment protocols. These activities will follow up programs started in FY 2009 and reinforce them through the training physicians and community counselors providing prevention counseling for HIV positive individuals. The activities will also reinforce the National Five Prevention Steps for HIV Infected Individuals and establish prevention with positives activities as a standard care at ART sites. These actions will ensure that PLWHA benefit from tailored interventions designed to reduce transmission rates to HIV negative populations. Clinical and lay community counselors will promote couples counseling and testing and provide prevention with positives messages to all their clients, but particularly PLWHA, to reduce their high risk behaviors through abstinence, being faithful to one partner, "secondary abstinence," and condom use for discordant couples. Lay community counselors will benefit from training on the unique health needs and challenges of HIV positive individuals.

The TRAC Plus specialist on STIs will work with CDC and clinical partners to coordinate trainings, data

analysis and data use. This collaboration will lead to a better understanding of the epidemiology of STIs in Rwanda and will inform implementing partners' work, particularly with high risk groups. The STI specialist will ensure that site staff are well trained and tools are available to screen, diagnose, and treat clients with STIs and their partners. The specialist will also make sure socio-demographic data on those clients is gathered, as that information may inform future prevention strategies.

TRAC Plus will supervise decentralized trainings on palliative care, both for facility-based providers and community-based providers. TRAC Plus will also design, in collaboration with the PBF and Community Health Units at MOH, HIV indicators to monitor PBF at community level. The nutrition advisor at TRAC Plus will provide oversight for all nutrition programming activities at the national level and provide supervision for nutrition training of health care providers, as well as the implementation of nutrition services at site and community levels. The TRAC Plus nutrition advisor will also work with the nutrition TWG and CRS to revise nutrition support tools related to food by prescription. Lastly, TRAC Plus in collaboration with SCMS, will provide timely and accurate data to CPDS on OI and STI drug and diagnostics supply consumption, as well as OI and STI-related morbidity and mortality. This information will facilitate the procurement and management of drugs and reagents. TRAC Plus will also supervise decentralized training on prevention with positives both for facility-based providers and community-based providers. TRAC Plus C will also design, in collaboration with Health QUAL and the MOH Community Health Unit, key HIV program-related indicators to monitor prevention with positives interventions at community level and facility levels.

These activities support the PEPFAR five-year strategic goals of promotion of a continuum of HIV care, as well as the Rwandan national plan for palliative care and integration prevention and HIV care interventions. This activity is also in line with the Partnership Framework objectives of empowering national institutions to assume greater oversight of HIV services and ensuring sustainability.

In FY 2009, with the PEPFAR support, TRAC Plus conducted training of trainer's sessions for care and treatment service provision for 550 individuals. In turn these trainers supported the training of HIV service providers at the decentralized level. Care and treatment guidelines have been revised based on WHO recommendations. Moreover, care and treatment tools such as adults medical file, appointment cards, pharmacy cards, and registers have been revised, printed and disseminated to all health facilities.

In order to improve the M&E system of HIV care and treatment program, indicators has been revised and

incorporated in to TRACnet system.

In FY 2009 TRAC Plus put emphasis on the quality of care for patients on ART, and in this framework conducted an assessment to track lost follow up patients at 364 sites. This exercise has allowed 11,913 patients who were previously lost to follow up to return to care. In FY 2010, TRAC Plus will revise care and treatment guidelines and tools as well as update training curricula as needed. Those revised tools will be disseminated to all health facilities offering and treatment. Furthermore, TRAC Plus will continue to support the district level capacity building in adult care and treatment. This assistance includes support for implementation of care and treatment guidelines, and training or refresh training of trainers. In FY 2010 the emphasis will on the implementation of task shifting to facilitate scale up of ART.

TRAC Plus, in collaboration with USG, implementing partners and the Global Fund, will continue to support the expansion of quality of adult care and treatment services by providing continued mentoring to clinical staff at district level. Mentor staff will train hospital and health center service providers in adult HIV treatment, patient record-keeping, data recording and use, and quality performance measurement and improvement. Two additional clinical mentors will be supported through COP10 to assist in quality improvement of HIV services at the 23 sites transitioned to the MoH. In addition, in partnership with MOH/UPDC, TRAC Plus will undertake formative supervision related to HIV care and treatment integration activities within each district at least twice per year. This supervision will be done with a standard checklist to assess the quality of care and treatment HIV services. The supervisory team will provide regular feedback to sites and share best practices in HIV care and treatment.

In FY 2009, TRAC Plus revised guidelines for prevention, the process of multiplication, translation and dissemination is on-going. PIT guidelines have been developed, and multiplication and dissemination is in process.

In FY 2010, TRAC Plus will continue to conduct TOT sessions on HCT and refresher training using the most recent norms and guidelines. TRAC Plus will also give supportive supervision to trainers who will conduct provider's trainings at district level. In collaboration with the Prevention TWG and other partners, TRAC Plus will continue to update national HCT norms and tools (e.g. client forms, reporting forms, registers, educational and supervision tools) and will disseminate them to all health facilities providing CT services. Ongoing revisions are necessary in order to address new approaches to HCT and PIT, couple

testing and discordant couple follow-up as new strategies of the national HCT program. The finger prick method of specimen collection will be incorporated in HCT activities; this will involve training of providers in FY 2010. As HCT in Rwanda has expanded to include mobile testing and PIT, in FY 2010, TRAC Plus will put more emphasis on counseling and testing of the high risk and vulnerable groups such as MSM, sex workers, military, truck drivers and people living with disability.

Another priority of FY 2010 in HCT is to put in place pre-ART services in HCT sites without ART services and ensure linkages of infected people to care and treatment. Trainings and tools for implementation of this system will be developed accordingly and disseminated to health facilities. Other activities which will continue in FY 2010 are the payment of 2 staffs and ensuring the capacity building of HCT staffs, salaries of HCT desk and office equipment.

In FY 2010 USG will support TRAC Plus to carry out a program evaluation to assess HIV acquisition rates in serodiscordant couples identified in PMTCT programs in Rwanda. Since 2007, TRAC Plus recommended that men should be encouraged to participate in antenatal activities with their female partners. Male participation in antenatal clinic (ANC) visits has been high: 78% of women who receive HIV testing in ANC/PMTCT sites throughout Rwanda also bring their male partners for testing. In 2008, approximately 187,000 couples were tested through partner HIV testing at >300 ANC/PMTCT sites in Rwanda. Of these, more than 5,800 were identified as discordant couples, meaning one partner's test results were HIV-positive, and the other partner's test results were HIV-negative. Of the 5,800 couples identified, more than 1000 were in Kigali. The evaluation will seek to identify clinical and social- behavioral factors associated with HIV acquisition in the negative partner. This evaluation will assist national planners in designing follow-up prevention interventions for discordant couples.

The USG works closely with relevant units of the MOH to develop and implement plans to extend HIV services for children in Rwanda. Since the initiation of PEPFAR, the USG has provided funding and TA support to the Treatment and AIDS Research Center (TRAC) of the MOH.

In FY 2009, the USG provided funding to the TRAC Plus unit of the MOH to strengthen central, district and site-level capacity to increase access and quality of pediatric HIV care and treatment services in Rwanda. TRAC Plus provides supervisory and technical support to districts and health facilities in the provision of services for HIV, malaria, TB and other infectious diseases following a network model. TRAC Plus also conducts training of trainers in pediatric HIV care and treatment and provides leadership in the

development of work plans and agendas, guidelines, training materials as well as general coordination to support scale-up of pediatric HIV care services in Rwanda.

In FY 2009, TRAC Plus initiated psychosocial care and support services for children and adolescents through formative supervision /mentorship in collaboration with implementing partners and districts hospitals. These services include HIV diagnosis disclosure support groups in more than 122 ART health facilities.

In FY 2010, TRAC Plus will develop and revise pediatric HIV care and treatment guidelines training materials, job aids and other tools as needed with TA from PEPFAR implementing partners. In addition, TRAC Plus will revise the pediatric HIV care and treatment training curriculum to include the management of opportunistic infections (OI), adolescent care and the new recommendations from WHO. Training of trainers will be conducted on the revised tools and guidelines.

To ensure quality of pediatric training at decentralized level, TRAC Plus will supervise training on pediatric HIV care and treatment for facility- and community-based providers at decentralized levels. In collaboration with the UPDC unit within the MOH, TRAC Plus will assist district health teams 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 or affected by HIV and assist with addressing issues around status disclosure and adherence support. One child counselor per ART site will be trained to organize children support groups.

In order to improve the enrollment of HIV-positive children on treatment, TRAC Plus in collaboration with the National Reference Laboratory will assist district teams to scale up early infant diagnosis (EID) and follow-up through training of PMTCT staff as well as lab technicians, and through developing efficient and reliable sample transportation systems.

In FY 2010, TRAC Plus will emphasize quality improvement in pediatric care and treatment at ART sites and improving pediatric enrollment and retention into care. In collaboration with Columbia University, TRAC Plus will continue a mentorship program to improve the quality of pediatric HIV care, treatment and support as well as to integrate mental health into pediatric HIV care. This budget will support salaries of two clinical psychologists to assist the mental health integration.

PEPFAR will continue to assist TRAC Plus to improve national M&E capacity for pediatric care and support and to link with the national system (HMIS). The revised pediatric HIV indicators and harmonized data collection tools developed in FY 2009 will be implemented nationally. In collaboration with SCMS,

TRAC Plus will provide timely data on OI diagnostics and drug consumption, as well as data on OI related morbidity and mortality for more accurate drug and reagent quantification and forecasting.

In FY 2009, PEPFAR funded TRAC Plus to ensure continuation and strengthening of different activities. With TA from PEPFAR implementing partners, TRAC Plus developed and revised pediatric HIV care and treatment guidelines according to new WHO recommendations. A manual on pediatric care and treatment in Rwanda has been developed in order to harmonize pediatric care and treatment in all sites. TRAC Plus revised pediatric indicators to be reported through the TRACnet system. A training of trainers was conducted on the revised guidelines. With TA from PEPFAR implementing partners, a center of pediatric practical training is functional at CHUK. In addition, pediatric mentorship was started in some sites.

In FY 2010, TRAC Plus will emphasize quality improvement in pediatric care and treatment at ART sites. It will also emphasize improving pediatric enrollment and retention into care. In collaboration with Columbia University and the Institute of Human Virology (IHV) of AIDS Relief, TRAC Plus will implement a harmonized mentorship program to improve the quality of pediatric HIV care, treatment and support at district hospitals. In collaboration with the UPDC unit within the MOH, TRAC Plus will continue the training of trainers and will supervise the training of facility- and community-based providers on pediatric HIV care and treatment. PEPFAR will continue to support TRAC Plus to ensure the sustainability of practical pediatric training at CHUK and the decentralization of this training to others sites.

With PEPFAR support, TRAC Plus will continue to upgrade HIV services in PEPFAR supported districts with the aim of achieving universal access of eligible children to ART.

In addition, TRAC Plus will develop an action plan for adolescent care and treatment programs and it will integrate adolescent health into the training curriculum for pediatric HIV care and treatment.

PEPFAR will continue to assist TRAC Plus to improve national M&E capacity for pediatric care and support and coordinate with the national HMIS (TRACnet) system. The revised pediatric HIV indicators and harmonized data collection tools developed in FY 2009 will be implemented nationally. Moreover, in collaboration with the Performance-Based Financing (PBF) working group and the Community Health Unit of the MOH, TRAC Plus will design pediatric HIV-related indicators to monitor PBF activities at the community level. It will also revise the set of pediatric HIV indicators for which data are collected at health

facilities. In collaboration with SCMS, TRAC Plus will provide timely data on ARV consumption including data on pediatric ARV for more accurate drug and reagent quantification and forecasting.

These activities support the PEPFAR five-year strategic goals to promote a continuum of HIV care as well as the Rwandan National Plan for integration of HIV prevention and care interventions at national, district and site-levels.

In FY 2010, TRAC Plus interventions within the Strategic Information domain will cover three major areas: surveys and surveillance; HMIS; and Monitoring and Evaluation. Over the years, the PEPFAR program has contributed to building local capacity within TRAC Plus to conduct national survey and surveillance activities such as the behavior surveillance surveys, KAP surveys, operational research and data triangulation. These efforts allow the gradual transition of the responsibility for these interventions to TRAC Plus.

In FY 2010, TRAC Plus will conduct multiple surveillance activities aimed at better understanding the state of the HIV epidemic in Rwanda. These include HIV, syphilis and hepatitis B and C sentinel surveillance at facilities providing antenatal care services and a behavioral surveillance survey (BSS+) among sex workers and street children. HIV drug resistance surveys (early warning indicators, threshold surveys, monitoring surveys) will be conducted in collaboration with CDC, WHO, UNICEF, UNAIDS, UNFPA, GLIA and the National Reference Laboratory. Moreover, TRAC Plus will conduct a formative assessment of clients of commercial sex workers to inform the HIV/AIDS prevention program. The surveillance team within the EID unit will be strengthened with additional staff. Surveillance tools will be developed for data collection, and health agents across the health system will be trained in their use.

TRAC Plus, with technical assistance from the University of California San Francisco (UCSF) and CDC/Atlanta, conducted the first HIV data triangulation exercise in 2008, and a third one is planned for 2010. The technical support provided so far has built capacity within TRAC Plus to undertake this activity. Various sources of data will be used including behavioral, environmental and health status data.

The focus of M&E activities in FY 2010 under the TRAC Plus cooperative agreement will be on the improvement of data quality, reporting, and utilization of data for program management and service delivery. TRAC Plus will support data analysis and use as it relates to clinical prevention, care, and treatment. The M&E unit of TRAC Plus will continue to train district level supervisors and data managers

from district hospitals in order to build their capacity to enhance data quality and the application of the generated information in the improvement of service provision. Those trained at district level will in turn have the responsibility to train health providers within their respective catchment areas. TRAC Plus will also continue to conduct integrated periodic supervision visits to health facilities in collaboration with the MOH to ensure quality of services. A data quality assessment at central and health facility levels will be carried out including capacity building at district level to support this initiative.

In the sphere of HMIS development, TRAC Plus efforts will focus on the maintenance, upgrade and implementation of the OpenMRS and the TRACnet system. The Ministry of Health has adopted OpenMRS as the national patient monitoring system to be implemented by TRAC Plus. Initial modules built on the system are HIV-related and allow the monitoring of HIV patients and drugs. Plans are underway to roll-out the system across the country. In FY 2010, PEPFAR will support the recruitment of program developers and the training of end-users of the system. OpenMRS is expected to make data management and reporting easier. The system will be connected to TRACnet, and a non-HIV primary health care package will be added to it.

Since the introduction of the TRACnet system three years ago, TRAC Plus has played an important role in its roll-out throughout the country. The training of end-users of the system relies heavily on TRAC Plus. With the addition of new modules onto TRACnet, TRAC Plus has set up a TRACnet technical support unit in collaboration with Voxiva, Inc., to provide technical assistance to district hospital and health center personnel who are using the system. TRAC Plus will recruit a TRACnet System Administrator that will back up the technical support unit and ensure more in-country management of the system as well as provide help to the end-users. The ART module is being updated to incorporate newly defined indicators, the PMTCT VCT module will be rolled out in COP09, while the Integrated Disease Surveillance and Response (IDSR) system is being built. TRAC Plus will train district hospital staff to act as trainers for the roll-out the TRACnet system. In FY 2010, TRAC Plus will endeavor to further improve the quality of data reported into TRACnet through training of health facility supervisors, data managers and M& E officers at sub-national levels. Feedback mechanisms will be strengthened, TRACnet data quality audits integrated in supervision visits will continue, and quarterly dissemination workshops will be held on the completeness and timeliness of reporting.

ICT equipment and statistical software packages will be acquired under this cooperative agreement to support activities of TRAC Plus. Internet connectivity of TRAC Plus will also be supported.

In FY 2009 USG supported the national planning process in the understanding that robust plans are the foundation on which to build capacity in the heath sector as a whole. TRAC Plus played a vital role in the development of the Health Sector Strategic Plan and the National Strategic Plans for HIV, Malaria and TB. The National Strategic Plans for HIV and TB were the basis on which the GFATM National Strategies Application was developed, in tandem with the PEPFAR Partnership Framework. In FY 2010, TRAC Plus will increase its role in supporting evidenced based planning at national level. This process will be strengthened through an enhanced ability to develop project proposal, research protocols and to analyze existing data. The budget for this activity includes payment of a senior project manager within the organization who will build capacity of junior staff at TRAC Plus

Rwanda is a landlocked country with porous borders. In the past few months the country experienced an outbreak of H1N1, and cholera outbreaks occur sporadically each year. The information necessary to monitor these outbreaks and the expertise needed to respond appropriately in a timely fashion do not yet meet international standards. To build the capacity of the country to respond effectively and efficiently to such outbreaks USG PEPFAR has been supporting the Field Epidemiology and Laboratory Training Program. In FY 2009 short courses were provided to 60 participants. In FY 2010 training at a masters level will be introduced. In FY 2010 TRAC Plus play will play a critical role in the implementation of the training during the practicum activities. This will compliment the efforts of the USG team and the School of Public Health. These funds will also support the tuition of 10 residents, as well as travel for international conference such as quarterly FELTP seminar and EIS conference.

As of December 2008, TRAC Plus created a desk for biomedical prevention within the prevention department. The purpose of this action was to assist in scaling-up activities related to male circumcision and prevention with positives. These activities were incorporated into a comprehensive prevention strategy focused on assisting people with HIV to take measures to avoid exposing other people to infection. TRAC Plus (biomedical prevention desk) has engaged in a variety of activities, including conducting a national health service assessment for male circumcision, the goal of which was to identify the capacity of health facilities, both public and private, to provide safe circumcision services. The data on health service assessment for MC are being analyzed and the results will be compiled into a report. In collaboration with the MC TWG and other partners, TRAC Plus has developed National Guidelines for Male Circumcision, a protocol which is awaiting approval from MOH.

In FY 2010 TRAC Plus will also conduct a national knowledge, attitudes and practices (KAP) study on

male circumcision. That study aims to provide baseline information on the KAP regarding MC in the Rwanda general population. The results of this survey will guide medium and long-term strategic program planning on MC. In accordance with WHO guidelines on MC, TRAC Plus is developing trainers' and providers' manuals on MC which will be distributed to health facilities which do not provide MC in their minimum package of services.

In FY 2010, TRAC Plus will continue trainings of trainers for all district hospitals, as well as training for all providers in military and police hospitals.

In FY 2010 TRAC Plus will conduct three training of trainer's sessions for PMTCT service provision and supervision for 120 district-level supervisors. In turn these trainers from all districts will support training of providers in HIV services at decentralized level. These training sessions cover all aspects of the expanded national PMTCT protocol, including ARV prophylaxis, PCR testing for HIV-exposed infants, CTX for all HIV-exposed infants, routine CD4 testing and clinical staging for all HIV-positive pregnant women, and counseling on infant feeding and nutrition for HIV-positive pregnant women and HIV exposed infants. In collaboration with Project San Francisco (PSF), TRAC Plus is developing M&E tools in order to reinforce follow-up of discordant couples.

In addition TRAC Plus is conducting the phase 1 implementation of the use of revised child health card which includes information on HIV exposure in three districts to determine whether an individual medical record in supporting longitudinal care of children contributes to better care. Upon completion of this phase, TRAC Plus will evaluate the experience to determine whether the revised child health card should be scaled up to national level. Moreover TRAC Plus is conducting a rapid assessment of HIV-exposed infant follow-up system in Rwanda, in order to guide the intervention towards the improvement of tracing of HIV-exposed infants and strengthening the HIV-exposed infant follow-up.

In FY 2010, in order to reduce the post-natal transmission of HIV, TRAC Plus in collaboration with the national PMTCT TWG will revise PMTCT norms and tools according to the new WHO recommendations and will disseminate them to all health facilities providing PMTCT services. To ensure quality of PMTCT services and consistent implementation of the new PMTCT guidelines, TRAC Plus will continue to conduct refresher training of trainers and supervisors (TOT and TOS) and supporting training of providers at decentralized level in the expanded PMTCT protocol. In addition it will conduct quarterly supervision of all districts. With TA from CDC and PSF, TRAC Plus will emphasize the quality of intervention

targeting couples testing and follow-up of discordant couples as well as the follow-up of HIV-exposed infant.

In FY 2010, TRAC Plus will also reinforce the M&E system for the PMTCT program, in particularly the M&E of the implementation of new PMTCT protocol, through the improvement of M&E tools, and documentation of best practices implemented by different partners. The budget for this activity includes payment of two PMTCT technical advisors within TRAC Plus/PMTCT desk and their capacity building.

The overall goal of this activity is to build capacity at central level for development of TB/HIV guidelines, tools, supervision, and monitoring and evaluation, as well as reinforcing the central and peripheral level health facilities capacity in the diagnosis of extrapulmonary tuberculosis (EPTB) through development of EPTB training guidelines, tools and training sessions.

In FY 2009, TRAC Plus has been supporting TB/HIV collaborative activities at the central level through continuation of existing TB/HIV advisors to oversee collaborative activities, which support guidelines, curricula, tool revision, networking with clinical partners, as well as supervision of all PEPFAR and non- PEPFAR sites for quality TB and HIV services to co-infected patients.

In FY 2010, PEPFAR will continue to support the positions of the national advisors at TRAC Plus, including both TB and HAS Units. The advisors will lead national activities on TB/HIV as related to guidelines, norms and tools review. They are part of the national team of TB/HIV supervisors in addition to those located at AIDS Relief, FHI, CDC, and WHO. They will plan and coordinate TB/HIV training at the central and peripheral level. In collaboration with PEPFAR clinical partners and Global Fund, TRAC Plus will implement one-stop TB/HIV service in 43 hospitals and all health centers providing ART. The team will participate in quarterly joint supervisions of TB/HIV activities conducted with other MOH desks at the district level, report issues, and gives feedback to the national technical working group.

In FY 2010 TRAC Plus will strengthen the TB/HIV monitoring and evaluation system by revising M&E tools based on the WHO recommendations and by improving the data analysis and its utilization for decision making. PEPFAR will continue supporting the TB unit within TRAC Plus in development of training guidelines and tools to increase the capacity in EPTB diagnosis.

The TB unit will scale up the implementation of TB infection control policy in health facilities through

development of infection control plans, their supervision, and monitoring & evaluation. In addition, TRAC Plus will conduct an annual assessment of TB transmission risk among health care workers. FY 2010 funding will continue to support the MDR and X-DR TB surveillance and laboratory networking for sample transportation and ensure that MDR cases adhere to their treatment regimens. TB unit at TRAC Plus will train 986 providers on TB infection control and support them implement the TB infection control activities based on available funds from PEPFAR implementing partners and global fund support at the site level. In order to improve the adherence of TB patients TB unit will supervise community DOTS approach by supervising the community health workers(CHW), developing tools related to community DOTS as well as by facilitating transportation of CHWs. PEPFAR will continue supporting the TB unit within TRAC Plus in development of training guidelines and tools to increase the capacity in EPTB diagnosis.

The TB unit will scale up the implementation of TB infection control policy in health facilities through development of infection control plans, their supervision, and monitoring & evaluation. In addition TRAC Plus will conduct an annual assessment of TB transmission risk among health care workers. FY 2010 funding will continue to support the MDR and X-DR TB surveillance and laboratory networking for sample transportation and ensure that MDR cases adhere to their treatment regimens. TB unit at TRAC Plus will train 986 providers on TB infection control and support them implement the TB infection control activities based on available funds from PEPFAR implementing partners and global fund support at the site level. In order to improve the adherence of TB patients TB unit will supervise community DOTS approach by supervising the community health workers(CHW), developing tools related to community DOTS as well as by facilitating transportation of CHWs. its utilization for decision making. PEPFAR will continue supporting the TB unit within TRAC Plus in development of training guidelines and tools to increase the capacity in EPTB diagnosis.

The TB unit will scale up the implementation of TB infection control policy in health facilities through development of infection control plans, routine supervision, and monitoring & evaluation. In addition TRAC Plus will conduct an annual assessment of TB transmission risk among health care workers. COP 2010 funding will continue to support the MDR and X-DR TB surveillance and laboratory networking for sample transportation and ensure that MDR cases adhere to their treatment regimens. TB unit at TRAC Plus will train 986 providers on TB infection control and support them implement the TB infection control activities based on available funds from PEPFAR implementing partners and global fund support at the site level. In order to improve the adherence of TB patients TB unit will supervise community DOTS approach by supervising the community health workers(CHW), developing tools related to community DOTS as well as by facilitating transportation of CHWs. In addition, PEPFAR will provide partial funding to support a national TB prevalence survey which is anticipated to provide a sound basis for strategic information and planning through 2015.