EGPAF has been receiving PEPFAR funds since 2007 to support the Government of Rwanda's (GOR) response to HIV under three goals: 1, strengthen five clinical district health networks to establish, maintain and supervise the key clinical services and systems necessary for quality HIV clinical services integrated into a strengthened primary healthcare system; 2, Support high quality, integrated HIV clinical services, including VCT, PMTCT, and Care and Treatment to contribute towards universal access to HIV clinical services and 3, Provide national TA in pediatric HIV/AIDS, Care and Treatment, PMTCT, and infant nutrition. EGPAF provides technical support to MOH, TRAC Plus, and PEPFAR partners to implement the HIV-exposed Infant and Young Child Feeding and Maternal Nutrition Program.

EGPAF is the lead PEPFAR partner in 5 districts in the East Province and supports 6 sites in Kigali. EGPAF provides financial assistance through 52 sub-grants to 5 administrative districts, 9 hospitals, 37 health centers and 1 prison. The target populations include women of reproductive age, pregnant and postpartum women, infants, PLHIV in care and treatment and their children, families, and communities. EGPAF supports the MOH in integrating HIV into strengthened primary health care services for pediatric and adult patients through TA; systems strengthening and institutional capacity building; financial and geographic accessibility; quantification of commodities; QI/QA initiatives; and strengthened specialized and integrated HIV and MCH services. The EGPAF program will therefore contribute to all the goals of the Partnership Framework: focusing on prevention efforts through VCT and PMTCT; reducing morbidity and mortality among PLHIV through access to care and treatment; contributing to equal opportunities for PLHIV including food and nutrition interventions and OVC; and supporting health system strengthening for sustainable public health systems.

Core actvities of the HIV program focus on improving access to VCT/PMTCT services, staging of HIV positive clients and providing OI treatment and ART where appropriate and referral for ART where necessary. EGPAF's main focus is minimizing loss to followup of pre-ART patients including pregnant women who receive HAART Prophylaxis but are not yet eligible for ART. The organization has historically been a champion of Pediatric HIV treatment and aims to provide Early Infant Diagnosis in 100% of supported sites. The partner also implements the national TB/HIV integration model, including intensified monitoring for Multi-Drug Resistant TB.. The partner also received funding for supportive supervision, quality improvement through use of an electronic database, referrals for care and support forvictims of SGBV , and for strategies to encourage male involvement in health care.

EGPAF has directly contributed to HSS through financial and technical support to 5 district health networks including renovations and electrification, joint supervision, performance-based financing evaluations, QI/QA initiatives, logistics and supply management, staffing support, medical waste management and transportation of lab samples. EGPAF builds governance and leadership, and technical, managerial and financial capacity within the networks to allow effective program management and reinforce the ability of networks to provide sustainable, quality HIV/AIDS services. The partner also supports Human Resources for Health in the supported districts through Implementation of task shifting; in-service training in quality HIV services and integration; salary support through sub- grants. Furthermore, EGPAF supports renovations that upgrade facilities to deliver ART and support family planning and MCH services integration. Furthermore, EGPAF implements Community and Clinic IMCI, improved growth and development monitoring of infants; and infant mortality audits.

Cost efficiency over time will be achieved as EGPAF builds District staff capacity to receive and manage funding, to assign the most efficient number of staff to sites and to implement task shifting and cross-train staff to share workloads. Case managers assure linkages across services, and strengthened CHW capacity supports clinical staff. Links with community services reduce duplication of efforts and support

sustainability. Service integration saves on costs for buildings, staff, and maintenance through co- location. Strengthened prevention services reduce PMTCT, and care and treatment costs. EGPAF will support sub grantees to operate in low resource environments, providing cost-accounting training for budget planning, cost driver reviews, efficiency and identification of new resources. Districts will increase responsibility in managing sub-grants, supervision, training, and QA with strong TA from EGPAF.

EGPAF's monitoring and evaluation is supported by a patient electronic database at all ARV sites, which facilitates reporting and patient retention. This facilitates data review and quality oversight and evidence- informed decision making. EGPAF will continue to provide regular clinical mentoring and reinforce district and site level data quality audits while building district and site capacity to use data for programming as part of transition. EGPAF will work with sites to improve PMTCT mother/infant tracking and medical record linkages. Improved monitoring and assessments of HIV integration into FP, MCH and TB is also a priority. EGPAF will support the MOH/TRAC Plus to develop and/or revise tools to monitor these activities.

This is a continuing activity

In FY 2009, EGPAF supported adult care and support activities at 40 sites, providing 20,727 PLWHA with care and support services. Services provided by EGPAF include: clinical staging and baseline CD4 for all patients; follow-up CD4 counts; STI/OI diagnosis and management of HIV and other HIV-related illnesses; and routine provision of CTX prophylaxis for eligible adults and children, based on national guidelines.

EGPAF implements a continuum of care (CoC) model at all supported sites, a model which includes two case managers: a community liaison agent (ALAC) and a focal point for service integration (POFIS). These two staff positions ensure that clients testing positive for HIV through any of the services at the facility are enrolled in care, family members are invited for testing, and referrals are provided to FP and HIV services. The POFIS helps to ensure early identification of infected individuals through the invitation of PLWHA family members and partners to HCT services and provides effective referrals of patients between services and sites. These referrals are tracked and in cases where family members do not present for testing, the POFIS provides additionally counseling and support to the PLWHA to bring the family in for testing. The ALAC ensures prompt enrollment in care services by liaising with all services at the facility providing testing, including PITC, and ensuring enrollment of those testing positive. Once a patient becomes eligible for ART, s/he is referred to ART services and the POFIS ensures enrollment and retention in ARV services. The CoC model also has a strong community-clinic linkages component, with defaulting patients or patients lost to follow up tracked through home visits by health providers and through the support of CHW and associations of PLWHA. By mentoring CHWs and liaising with community organizations and PLWHA associations, the ALAC, according to individual need, refers and connects patients to community-based care services such as adherence counseling, psychological and spiritual support, stigma reduction activities, OVC support, IGA and HBC activities. These networks and programs support retention in care and an improved quality of life for patients.

In FY 2010, EGPAF will continue to support the care of 20,727 existing patients, and an additional 2,771 new adult and pediatric patients. EGPAF will continue to support national level HIV care programming

and will advocate for, and participate in, the development of national program tools for the optimal provision of care for PLWHA. EGPAF will maintain its support of district health networks to coordinate the provision of HIV related care services for PLWHA. EGPAF's role will include but not be limited to the following: provision of technical support through supervision and on-the-job coaching to district level supervisors and case managers to improve implementation and to ensure optimal retention of all HIV positive patients; support for quality care and ensuring a continuum of care through operational partnerships and case managers (POFIS and ALAC); and assistance to improve the sustainability of services through PBF.

In FY 2010 EGPAF will continue to integrate family planning into care services at all facilities and provide same day counseling and contraceptive refills, a service crucial to the prevention of HIV transmission. Regular care and support service consultations and family planning consultations emphasize sexual prevention and ensure condoms are available to PLWHA patients. Additionally, EGPAF will work closely with Project San Francisco, which provides TA for discordant couple counseling and prevention with positives. EGPAF will also collaborate with the MOH to support scale up and quality improvement for couples' counseling, increase the quality of post test counseling through training and on-site mentoring, and reinforce mechanisms for follow-up of discordant couples and provision of HIV prevention and FP counseling to these couples. EGPAF will provide palliative care services, which include basic nutrition counseling and support, hygiene education, positive living and risk reduction counseling, pain and symptom management and end-of-life care. Case managers will provide referrals for all PLWHA and their families for malaria prevention services, including the provision of LLITNs in collaboration with GFTAM and PMI; and refer to CBO's and other community partners for distribution of water purification kits and hygiene education. Strengthened psychological support services for PLWHA will be made available through expanded TRAC Plus training in psychological support.

EGPAF-supported sites, in partnership with community partners and PLWHA associations, will continue to assess the individual needs of PLWHA enrolled in care and refer them to support services as necessary. These services may include adherence counseling, spiritual support, and activities addressing stigma, IGA, and HBC- services for palliative care, OVC, nutrition support, legal counseling, and end of life care, in line with national palliative care guidelines. In partnership with other food partners EGPAF will support the implementation of food by prescription for PLWHA who are malnourished and initiating ART, and will enhance linkages with other food program, such as Ibyiringiro. EGPAF will also work with districts, case managers, CHWs and community partners to develop a mapping of community services per sector and to improve referral systems. Case managers will have monthly clinic-wide case management meetings with CHWs to discuss issues pertaining to follow up of patients and referrals to services. These meetings will provide oversight of CHWs and opportunities to share key messages and health information for further sensitization in the community. EGPAF will partner with community partners

and the MOH to ensure CHWs in EGPAF supported districts receive training in HIV and MCH modules and the necessary follow up and support. EGPAF will use national screening tools and management guidelines to integrate mental health in HIV services during FY 2010.

In collaboration with the supply chain partner, EGPAF will provide diagnostic kits, CD4 tests, and other exams for clinical monitoring, and will work with SCMS for the appropriate management of all OI-related and other commodities. EGPAF will support patient tracking by the ALAC and POFIS and the use of the electronic patient data base, IQ Chart, pre-ART registers to ensure monitoring of all PLWHA in care services throughout all EGPAF sites.

EGPAF will support the national QI policy through: providing financial support to Mutuelles for indigent patients and district risk pooling; national PBF and QI initiatives such as strengthening health quality committees at health centers and PAQs; performing PDSA in each district; holding biannual district level meetings to discuss specific indicators (e.g. loss to follow up); ensuring transportation of lab samples and results; and providing supervision and mentoring. EGPAF will also work with districts and sites to strengthen data quality processes through regular data audits and data reviews in the joint supervision process to enable sites and district staff to use data appropriately and ensure quality. EGPAF will implement an assessment of the effectiveness of the continuum of care program including referrals to care and support from CT services.

In line with the Partnership Framework's sustainability and transition goals, EPGAF will work with sites to ensure that all patients receive a standard, comprehensive package of HIV services and that MCH and HIV services are co-located to the extent possible; continue to support a combination of funding through technical support, input based funding and output based financing through PBF; and ensure programmatic links to food programs and to community-based programs. In FY 2010, EGPAF will support one district hospital through training and mentoring to negotiate and manage the health facilities sub grants under its supervision through a system of payment on performance. EGPAF will support the administrative district to train and mentor the sector health units, and will assess and document implementation. EGPAF will work with the USG team and the GOR to establish benchmarks and strategies for transition. EGPAF will also learn from the Track 1.0 partners' experiences.

In FY 2009 EGPAF provide ART to 8,094 HIV positive individuals 27 supported ART sites, the later representing 64% of all EGPAF supported facilities, which together in FY 2009 served 1,811 new ART

patients, including children. EGPAF's support to ART services follows MOH guidelines and norms, and includes enrollment into care upon a positive HIV test, clinical and CD4 monitoring after initiation on treatment, CTX prophylaxis, OI/STI treatment, regular TB screening and adherence counseling. The model relies on task-shifting to allow facilities without trained doctors to dispense ARVs to stable patients under physician supervision. All patients on treatment receive the full package of HIV care and support services including positive prevention initiatives such as couples counseling, condom distribution, and family planning integration with same day counseling and contraceptive refills. EGPAF supports a continuum of care model to ensure retention of patients from HIV positive screening through ART services. This model includes clinic and community linkages for retracing of defaulting patients or patients lost to follow up and for referral to a variety of health, psychosocial and legal services. For pregnant women identified through PMTCT this model assures they are staged clinically and by CD4 and referred to ART services, EID via DBS/PCR, and that HIV positive infants receive ART according to national guidelines. All EGPAF-supported ART sites are implementing the WFP Food for ART program for malnourished patients initiating ART and are using IQ Chart to track and monitor pre ARV and ARV patients.

In FY 2010, EGPAF will continue the services and activities described above and will support the provision of ART services to 9,543 children at existing 27 ART sites.

EGPAF will continue its national involvement in TWGs to ensure accessible, high quality treatment services in Rwanda. EGPAF will provide support to the MOH and TRAC Plus for the revision of task- shifting guidelines, development of positive prevention guidelines and tools, and support the development of training curricula and job aids for the newest treatment guidelines.

EGPAF's strong commitment to the provision of quality treatment services to all Rwandans in need will continue in FY 2010 through a variety of site and district level activities. With regard to human resource development, EGPAF will provide continued support of in-service training and mentorship for the health care providers at EGPAF supported sites, as well as district health supervisors. Training will focus on: ART protocol for adults, adolescents and children; IQChart for data managers; the continuum of care model; nutrition for PLWHA; positive prevention; and QI initiatives. Joint on-site supervision by district and EGPAF teams will allow for the review and support of program, data, and QI activities, with districts taking increased responsibility as district and provider capacity is developed. Furthermore, EGPAF and district technical staff will continue to provide routine clinical mentoring to clinicians providing care and treatment for both adult and pediatric patients at EGPAF supported sites. This includes capacity building in treatment adherence, early detection of signs of treatment failure and adverse drug reactions, OI, STI and TB screening and treatment, and technical support for integrated clinical services. The mentoring will support appropriate and consistent use of job aids, algorithms, medical record flow charts and

supervision tools.

On a more clinical level, EGPAF will support the implementation of targeted viral load testing according to the national guidelines. EGPAF will continue its work with the MOH, districts and sites to ensure rapid turnaround of samples and laboratory results for rapid diagnosis and treatment/regimen change. In addition, EGPAF will promote a family-centered approach to care and treatment, and reinforcement same day service integration, including co-locating MCH and HIV health services, FP and HIV counseling, and TB and HIV treatment. EGPAF will also support the integration of mental health in HIV services according to national guidelines developed in FY 2009. Integrating services and using patient tracking through IQ charts, social workers and CHWs will greatly reduce loss to follow up of PLWHA, particularly pre-ART patients.

Positive prevention (PP) will be a key focus area in FY 2010. EGPAF will work with MOH, districts and sites to ensure that positive prevention is part of routine care for PLWHA, including those on ART. The positive prevention package for adults on treatment will include: prevention counseling at all visits for all patients; ARV adherence assessments at every visit; integrated STI management; integrated FP and MCH services; and condom distribution at every visit. Through partnership with Project San Francisco and the MOH, EGPAF supported districts and sites will be trained in couples counseling, including counseling for discordant couples. EGPAF will work with districts to strengthen mechanisms for the follow up of discordant couples and will support these couples through HIV prevention and FP counseling. EGPAF will ensure that sites have the necessary IEC materials for positive prevention, couples counseling, and discordant couples counseling.

In FY 2010 EGPAF will continue the implementation of the WFP Food for ART program and support exit strategies (e.g. demonstration and kitchen gardens) to decrease dependence on external food support and to support persons exiting EGPAF programs to maintain good nutritional status. As part of this intervention, EGPAF will continue to advocate for inclusion of nutrition services in prison ART services. In addition, EGPAF will continue to support palliative care services including basic nutrition counseling and support, hygiene education, positive living and risk reduction counseling, pain and symptom management and end-of-life care.

To strengthen the continuum of care, EGPAF sites, in partnership with community partners and PLWHA associations, will continue to refer PLWHA enrolled in care to community-based care services based on their needs such as adherence counseling, spiritual support, and activities addressing stigma, IGA, and HBC- services for palliative care, OVC, nutrition services, legal support services and end of life care in line with national palliative care guidelines. Furthermore, EGPAF will assist with staff training, strengthening of referral mechanisms and linkages between HIV prevention, care, treatment, TB/HIV,

FP/HIV and counseling services, improving program tools and reports, and conducting an assessment to identify gaps in the patient circuit to inform program improvement. EGPAF will work with community based partners and the MOH to ensure CHWs in EGPAF supported districts receive capacity building and training on the HIV module to better support HIV information sharing and referrals in the community.

EGPAF will support national QI policy through Mutuelles for indigent patients and district risk pooling; national PBF and QI initiatives such as strengthening health quality committees at health centers and PAQs; performing PDSA in each district; holding biannual district level meetings to discuss specific indicators (e.g. retention in care); ensuring transportation of lab samples and results; and providing supervision and mentoring. EGPAF will also work with districts and sites to strengthen data quality processes through regular data audits and data reviews in the joint supervision process to enable sites and district staff to appropriately use data and ensure quality. EGPAF will implement an assessment of the effectiveness of the continuum of care program including referrals to care and support from CT services. In addition, EGPAF will strengthen the use of IQ Chart software at all EGPAF supported ART sites thereby improving the monitoring of pre-ART and ART clients, including children. The software tracks key clinical and visit history information for individuals in care, improves medical record and quality and strengthens program monitoring by identifying defaulting patients to facilitate patient tracking. As part of treatment services support, EGPAF will continue to support districts and sites in commodity management, quantification and will collaborate with SCMS and CAMERWA in efforts to avoid stock outs and ensure proper stock management.

In line with the Partnership Framework sustainability and transition goals, EPGAF work with sites to ensure that all patients receive a standard, comprehensive package of HIV services and that MCH and HIV services are co-located to the extent possible; continue to support a combination of funding through technical support, input based funding and output based financing through PBF; ensure programmatic links to food programs and to community-based programs.

In FY 2010, EGPAF will support one district hospital through training and mentoring to negotiate and manage the health facilities sub grants under its supervision through a system of payment on performance. EGPAF will support the administrative district to train and mentor the sector health units. EGPAF will assess and document implementation.

Capacity building of health providers and district level health authorities are an important aspect in transferring responsibility. District appropriation of services, including training, supervision, evaluation, HR funding, quality of services and data use are benchmarks for evaluating sites and districts' readiness for transition. EGPAF will work with the USG team and the GOR to establish benchmarks and strategies for transition. EGPAF will also learn from the Track 1.0 care and treatment partners' experiences.

EGPAF supports a family approach to HIV services which includes HCT for families, particularly partners and children, in line with national guidelines. In FY 2009, EGPAF supported 33 HCT sites and provided testing to 114,753 persons in HCT services. EGPAF-supported sites also tested 31,082 women in PMTCT and 25,234 of their male partners. The introduction of DNA-PCR testing for infants at all EGPAF supported VCT/PMTCT sites has increased the number of HIV-positive infants identified. Additional efforts are necessary to identify a large number of the children who were infected perinatally over the last ten years and those who become infected through non-vertical transmission.

In FY 2010, EGPAF will continue to support the MOH for the following activities: implementation of the national HCT protocol, especially for children and adolescents; implementation of the PITC protocol at all entry points in the health facility; risk reduction counseling and tailored post-test counseling; positive prevention and scale up of couples CT and discordant couple follow-up; screening and treatment of STI/OI; and, linkages through the continuum of care including community-clinic linkages.

In FY 2010, EPGAF will support 38 HCT services, providing testing to 150,000 persons including 38,102 children under 18.

EGPAF's FY 2010 support at national level will include: strengthening HCT services including pediatric PITC and PITC M&E systems; implementation of innovative testing strategies including finger prick testing with same day results, couples counseling and testing and follow up of discordant couples though the continuum of care; development and implementation of national guidelines, tools, IEC materials and monitoring systems for a positive prevention program; and implementation of PEP as a prevention strategy for health facility staff, victims of SGBV and others in need of PEP treatment.

At decentralized level, EGPAF will continue to support district health networks to coordinate HIV services and to increase the percentage of adults and children that know their HIV status, by: • Working closely with Project San Francisco and the MOH to support scale-up of couples' counseling through training and on-site mentoring; work with districts and sites to improve post-test counseling quality and follow-up mechanisms for discordant couples; provide support to these couples including HIV prevention and FP counseling and referrals and immediate enrollment in the care program • Reinforcing prevention counseling for HIV-positive persons, providing condoms and FP services, and integrating HIV prevention education into general patient care; actively linking patients to community- based prevention and stigma reduction activities • Supporting the implementation of routine PITC in all points of care (TB, nutrition centers, vaccinations, OI, STI, HIV, hospitalization, consultations) to reach all target groups, especially children above the age of 12 months, men and couples • Continuing to ensure Early infant diagnosis (EID) and rapid turnaround time of infant DBS/PCR testing and results • Encouraging HCT of families, children and adolescents in the community through CHWs, awareness building campaigns, the national stratégie avancée (includes mobile HCT); supporting a pediatric week with testing of family, children and adolescents at sites 7 days a week; including special family/child testing days during vacations and exploring opportunities for home-based HIV-testing together with community partners • Strengthening referrals and linkages to care and treatment: EGPAF supports a continuum of care model which includes two staff positions (case managers): a community liaison agent (ALAC) and a focal point for service integration (POFIS). The program entails immediate enrollment by the ALAC of HIV-positive clients into care from all testing points at the health facilities, including transfers, or referrals from community programs. The ALAC ensures enrollment, and defaulter and lost to follow up tracing. The POFIS ensures that referral and counter referral between services within the site or between sites are effective and identifies defaulters. The ALAC will continue to encourage testing family members of patients in care and active post-test follow-up will be ensured by the POFIS. • Furthering support for service integration and family centered HIV prevention which will include: HIV testing of all TB clients; TB screening of HIV clients; HIV testing of FP patients and effective referrals including male circumcision (where available) and testing; and medical care and support for victims SGBV including referral to SGBV support groups in the community • Ensuring supply of post exposure prophylaxis and training for sites in its provision • Strengthening Quality Assurance by implementing national standard operating procedures to ensure biosafety in close collaboration with the NRL. CT funds will be used to leverage biomedical transmission/injection and blood safety through procurement of appropriate disposal of biowaste generated through the HIV program (such as incinerators and waste pits for sites).

EGPAF will support national QI policy through health insurance for indigent patients and district risk pooling; national PBF and QI initiatives such as strengthening health quality committees at health centers and PAQs; performing PDSA in each district; biannual district level meetings to discuss specific indicators (e.g. infant and adolescent testing); support HCT for all health service providers in EGPAF- supported sites and organize support group meetings to address health worker stigma reduction and burn-out. EGPAF will also work with districts and sites to strengthen data quality processes through regular data audits and data reviews in the joint supervision process to enable sites and district staff to appropriately use data and ensure quality. EGPAF will implement an assessment of the effectiveness of the continuum of care program including referrals to care and support from CT services.

EGPAF will work with community health workers, associations of PLWHA, community partners (such as CHF, CRS, World Vision) and other civil society members/organizations to support advocacy and community involvement, including local leaders and churches, to ensure mobilization of the population for CT services, support to safeguard seronegativity, and to support HCT efforts within communities such as community HTC days to reach families, children, men and non-pregnant women. ALAC and POFIS will support linkages with community services and ensure that HIV positive patients receive effective referrals to psychosocial support, patient education and positive-living counseling, and other community-based services, such as HBC, IGA through PLWHA associations, OVC, and malaria.

In line with the Partnership Framework sustainability and transition goals, EPGAF will: continue to support a combination of funding through technical support, input-based funding and output-based financing through PBF; ensure programmatic links to nutrition programs (WFP Food and the USAID/Ibyiringiro project) to avoid duplication, ensure implementation of exit strategies (e.g. kitchen gardens), and strengthen linkages to community-based programs. Currently EGPAF is preparing the District Hospital to support sub-grantees. In FY 2010, EGPAF will work with the districts to establish a unit to centralize district level funding. EGPAF will support one District Hospital through training and mentoring to negotiate and manage the health facilities sub-grants under its supervision through a system of payment on performance. EGPAF will support the administrative district to train and mentor the sector health units. EGPAF will assess and document implementation.

Capacity building of health providers and district level health authorities are an important aspect of the transition process and a key step in transferring responsibility. District appropriation of services, including training, supervision, evaluation, HR funding, quality of services and data use are benchmarks for evaluating sites and districts' readiness for transition. EGPAF will work with the USG team and the GOR to establish benchmarks and strategies for transition. EGPAF will also learn from the Track 1.0 care and treatment partners' experiences. These actors will jointly agree on a plan to document lessons learned and progress toward transition.

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has a well established program in Rwanda and is one of the principal implementing partners for PMTCT and HIV care and treatment. In FY 2009, EGPAF supported pediatric care activities at 37 sites, providing 3,762 HIV-positive children with care and support services.

EGPAF implements an HIV continuum of care (CoC) model (see HCBC section) at all EGPAF supported sites with two staff positions (case managers) supporting patients testing positive through the continuum of care from HIV testing through ART, supporting referrals and ensuring their effectiveness between services and sites. The case managers link clinical services to the community and vice versa to ensure effective tracing of defaulting patients or patients lost-to-follow-up. The model is described in the HCBC section and includes HIV care services at all sites including non ART sites. Once tested positive, the child is followed up in pre-ART services (with patient record number, patient files and registers) in all the sites including non ART sites. Pre-ART services include: clinical assessments (monthly for HIV-exposed infants and older HIV-positive children until 14 years, after which they are seen every 3 months); clinical staging and baseline CD4 for all patients; follow-up CD4 counts every six months, or more frequently if CD4 count is under 500; STI/OI diagnosis, treatment and management, as well as management of other HIV-related illnesses; and routine provision of Co-trimoxazole(CTX) prophylaxis for HIV-positive children and all HIV-exposed infants until they are determined HIV free. All pediatric patients are screened for TB at least once every six months. All children with suspected TB are examined and tested for TB, and those diagnosed with TB are treated according to national guidelines. HIV-positive children exposed to an active TB case but without TB themselves are provided with INH prophylaxis for six months.

In FY 2010, EGPAF support for pediatric care will continue the above mentioned activities and will prioritize early infant diagnosis (EID), early initiation of treatment, MCH/HIV service integration, retention in care, and infant feeding counseling and support. EGPAF will also continue to support the continuum of HIV related care for PLWHA at 43 sites and to provide HIV related care for 1,111 pediatric patients.

EGPAF's support for the MOH and TRAC Plus will include advocacy and implementation at select sites of a fully integrated model of MCH/HIV and other care; and providing same day, one stop service for both mothers and babies (see PMTCT narrative for details). Together with TRAC Plus, EGPAF will conduct a program assessment of the integration model to document best practices and inform policy and programming, revise and implement a national integrated child health card with HIV status, and update guidelines to reflect the upcoming revised WHO recommendations.

Implementation of the pediatric care approach will be strengthened at the district and site level, and activities will include: • Support to trainings and supervision of the implementation of the new pediatric care and treatment guidelines • Identification of HIV-positive children. Ensure that all sites implement DBS PCR testing with rapid turn- around of results; that HIV-exposed infants are retained in care and receive CTX prophylaxis until their HIV status is known. Provider-initiated HIV testing and counseling (PITC) services will be expanded to all

children with signs or symptoms of HIV from in- and outpatient wards, TB clinics, nutrition services, and vaccination clinics. Systematic testing of children of adults enrolled in care and treatment. • Strengthen referral of newly diagnosed children and their immediate enrollment into the care program. Case managers will reinforce links to PLWHA associations, community health workers (CHW) and other community-based organizations to support this referral system. Bridging PMTCT, PITC, VCT and ART services and ensuring retention into care is a key component of the continuum of care model. EGPAF and districts will ensure that mothers and infants lost-to-follow-up are tracked and retained through home visits and support from CHW and associations of PLWHA (see Adult Care and Support narrative). • Improve pediatric HIV care and treatment through a strengthened clinical mentorship program with the pediatric reference hospital established with MOH, TRAC Plus, UPDC and partners in FY 2009 in East Province (described in the pediatric Treatment section). • Exposed infants and young children will continue to receive food support through the weaning period. Strengthened nutritional services at EGPAF-supported sites will include staff training on infant and young child feeding practices (IYCF) and maternal nutrition; infant feeding and maternal nutrition counseling for HIV-positive mothers during pregnancy and after childbirth; nutritional assessments; food support for HIV-exposed infants and infected children; and management of malnutrition through provision of micronutrient and multivitamin supplements. EGPAF will continue to support exclusive breastfeeding campaigns and reinforce community sensitization on key IYCF and maternal nutrition messages. • Continue to support the MOH, districts and sites to scale-up IMCI services at MCH clinics; support improved growth monitoring and implement the integrated child health card. EGPAF offers comprehensive psychosocial services to children living with HIV at 24 ART sites, with sites providing group counseling sessions, assistance with status disclosure, recreational activities, and individual counseling. In FY 2009, EGPAF held the first Ariel Camp for children living with HIV, taking 28 participants with their counselors to a campsite for 3 days of activities and exchange. In FY 2010, EGPAF will support psychosocial care at all ART sites and Ariel Camp will continue twice per year over school holidays in close collaboration with CNLS, TRAC Plus and the Rwanda Pediatric Society. • Case managers will have monthly clinic-wide case management meetings with CHW and community partners to discuss issues pertaining to follow up of patients in the community, and referrals to service. These meetings will also provide oversight of CHW and opportunities to share key messages on pediatric HIV, care, IYCF, and health information for further sensitization in the community. By providing HIV messages on a regular basis, EGPAF sites will ensure a continuous flow of information to the community. • EGPAF will also support referrals for all HIV-positive children to malaria prevention services, including referral for provision of LLIN and integration of home-based management of malaria, in collaboration with GFATM and the PMI; referral to CBO's and other community partners for distribution of water purification kits and hygiene education; health education and legal support. • Through partnership with the districts, sites, Supply Chain Management System (SCMS) and in close collaboration with CAMERWA, EGPAF will provide diagnostic kits, CD4 reagents, and other laboratory

commodities for clinical monitoring of children in care and on treatment. In addition, EGPAF will work with SCMS and Pharmacy Task Force (PTF) to ensure appropriate storage, stock management, and reporting of all pediatric OI-related commodities.

EGPAF will support the national QI policy through Mutuelles for indigent patients and district risk pooling; national performance-based financing (PBF) and QI initiatives such as strengthening health quality committees at health centers and PAQs; performing Plan-Do-Study-Act (PDSA) in each district; holding biannual district level meetings to discuss specific indicators (e.g. loss to follow-up); ensuring transportation of lab samples and results; and providing supervision and mentoring. EGPAF supports IQ Chart at ART sites, and will also work with districts and sites to strengthen data quality processes through regular data audits and data reviews in the joint supervision process to enable sites and district staff to appropriately use data and ensure quality. EGPAF will implement program assessments on the integration model to document best practices and inform policy and programming.

In line with the Partnership Framework sustainability and transition goals, EPGAF works with sites to ensure that all patients receive a standard, comprehensive package of HIV services and that MCH and HIV services are co-located to the extent possible; continues to support a combination of funding through technical support, input based funding and output based financing through PBF; and ensures programmatic links to Food programs and to community-based programs.

In FY 2010, EGPAF will pilot part of their exit strategy by providing intensified technical assistance to one district hospital to manage sub grants for health centers in its catchment area; a task usually undertaken by EGPAF. This is in line with the Partnership Framework Implementation Plan. EGPAF will support the administrative district to train and mentor the sector health units. EGPAF will assess and document implementation experience to facilitate further transition of activities to host country institutions.

Capacity building of health providers and district level health authorities are an important aspect in transferring responsibility. District appropriation of services, including training, supervision, evaluation, HR funding, quality of services and data use are benchmarks for evaluating sites and districts for their readiness for transition. EGPAF will work with the USG team and the GOR to establish benchmarks and strategies for transition. EGPAF will also learn from the Track 1.0 care and treatment partners' experiences.

At the end of September 2009, EGPAF provided 6,242 patients with ART, including 515 pediatric patients. In FY 2009, EGPAF supported 27 ART sites with 1,811 new patients initiating treatment, including 126 children. As per the MOH guidelines, EGPAF's support to pediatric ART services includes immediate enrollment into care for HIV-positive children, clinical and CD4 staging, early initiation on treatment, Co-trimoxazole(CTX) prophylaxis, OI/STI treatment, and TB screening. The model utilizes task-shifting to allow facilities, which do not have trained doctors, to continue dispensing ARVs to stable patients under physician supervision and provide regular care to patients on treatment. In FY 2010, EGPAF will continue the range of services and activities described above and provide national, district and site level support. It will be supporting 728 pediatric patients in 27 sites.

EGPAF will continue to support the MOH and TRAC Plus via its participation in the TWG in the revision of adolescent and child treatment guidelines, and in the development of training curricula and job aids reflecting the latest national guidelines. EGPAF will also support TRAC Plus to define a pediatric mentorship program for HIV care and support, and it will work with UPDC to harmonize and implement the mentorship program in the East Province.

EGPAF's technical assistance to the provision of quality pediatric treatment services will continue through emphasis on site and district level support and programming. • EGPAF will support the establishment of a pediatric reference hospital in the East Province that will be linked to the neonatal service at Rwamagana District Hospital, the PIH pediatric center at Rwinkwavu and the pediatric center of excellence supported by ICAP at CHUK. • EGPAF will develop a focused pediatric mentoring program in the East Province in collaboration with the MOH, TRAC Plus, CHUK and NUR. Focus areas include management of patient flow, early infant diagnosis (EID), infant ART, post-care review, continuing quality improvement, appropriate infant feeding and benchmarks (e.g. CTX, dried blood spot (DBS), HIV testing, early initiation of ART, second-line ART). • Support task shifting and provide in-service training of health care workers in provision of pediatric HIV treatment services. • EGPAF will continue to support sites to ensure all HIV-positive infants less than 12 months are initiated on HAART, irrespective of their clinical or immunological staging, to decrease morbidity and mortality; work closely with the case managers to ensure that eligible infants and children are adequately prepared and initiated on HAART with minimal delay; through community-clinic linkages, defaulting patients or patients lost to follow-up will be tracked through home visits by health providers and through the support of CHW and associations of PLWHA. • EGPAF will ensure all children on HAART are also provided with other routine child services including immunizations and growth monitoring through emphasis on service integration and follow-up of pediatric patients in the continuum of care model.

• EGPAF will continue its work with the MOH, districts and sites to ensure rapid turn-around time of samples and laboratory results, in particular to facilitate EID and EIT with rapid DBS/PCR results. • Quality of care improvements will include improvements in patient flow to reduce missed school days and minimize loss to follow-up among children and adolescents; promotion of family-centered approaches to care and treatment; and reinforcement of service integration, such as maternal and child health services during HIV services. • Support advocacy efforts to mobilize national and local leaders for action on select issues including EID and EIT and male involvement in family health. • EGPAF will partner with community partners and the MOH to ensure CHWs in EGPAF-supported districts receive training in HIV and MCH modules and the necessary follow-up and support. Through strategic partnerships with community partners, civil society, private sector, FBO, CSO including PLWHA cooperatives, and CHW, districts will: disseminate key messages on treatment adherence, referral, and retention; and assist sites in systematic follow-up of infants and children in the community. Case managers will support linkages with community services and ensure that children receive effective referrals to psychosocial support and other maternal child health programs, including home-based care and support, malaria and OVC programs via CHF, CRS, and PMI.

EGPAF will also work with districts and sites to strengthen data quality processes through regular data audits and data reviews in the joint supervision process to enable sites and district staff to appropriately use data and ensure quality. EGPAF will implement an assessment of the effectiveness of the continuum of care program including referrals to care and support from counseling and testing services.

In line with the Partnership Framework sustainability and transition goals, EPGAF works with sites to ensure that all patients receive a standard, comprehensive package of HIV services and that MCH and HIV services are co-located to the extent possible. EGPAF continues to support a combination of funding through technical support, input based funding and output based financing through PBF. EGPAF also ensures programmatic links to Food programs and to community-based programs.

In FY 2010, EGPAF will pilot part of their exit strategy by providing intensified technical assistance to one district hospital to manage sub grants for health centers in its catchment area; a task usually undertaken by EGPAF. This is in line with the Partnership implementation plan. EGPAF will support the administrative district to train and mentor the sector health units. EGPAF will assess and document implementation experience to facilitate further transition of activities to host country institutions.

Capacity building of health providers and district level health authorities are an important aspect in transferring responsibility. District appropriation of services, including training, supervision, evaluation, HR funding, quality of services and data use are benchmarks for evaluating sites and districts for their

readiness for transition. EGPAF will work with the USG team and the GOR to establish benchmarks and strategies for transition. EGPAF will also learn from the Track 1.0 care and treatment partners' experiences.

EGPAF provides support to the Ministry of Health (MOH), district health networks and health facilities to optimize all four prongs of PMTCT and ensure comprehensive and integrated service provision. EGPAF's PMTCT activities support MOH guidelines and are in line with the Partnership Framework and include: quality opt-out counseling and testing including testing during labor and delivery, positive prevention including couples counseling and testing, PITC at all entry points within the health care system, clinical staging and CD4 count, ARV prophylaxis and treatment (combination regimens for non- eligible women and HAART for eligible women), STI, OI and TB screening and treatment, CTX prophylaxis for eligible women and exposed infants, counseling and support on infant feeding and safe weaning, nutrition assessment, and Early Infant Diagnosis (EID). In addition, EGPAF supports follow-up and referral of HIV-positive women and HIV-exposed infants and family members to care and treatment through a continuum of care model linking PMTCT with ART which includes: immediate enrollment in pre-ART (care) services even at sites without ART; referral to ART services when eligible; family testing via invitations and follow-up and community linkages. EGPAF supports HIV integration in MCH, including HIV screening at vaccinations, family planning counseling and refills at every facility visit, safer delivery practices through EMONC, and child survival through IMCI, malaria and referral to OVC services.

A core EGPAF competency, PMTCT will remain a priority in FY 2010. EGPAF will continue the above mentioned activities and prioritize efforts to scale up MCH integration and improve the PMTCT cascade; EID and early initiation on treatment (EIT); infant and young child feeding (IYCF) and maternal nutrition; task shifting; QI and M&E at all PMTCT supported services. In FY 2010, EGPAF will support 38 PMTCT sites; providing access to PMTCT to 35,319 women and reaching 2,475 women with prophylaxis.

EGPAF's FY 2010 national level support will include technical support to the MOH and TRAC Plus to revise the national guidelines and program tools on PMTCT and IYCF protocols to reflect the revised WHO recommendations; develop FP/HIV integration job aids and national tools; and revise nutritional care and support minimum standards for pregnant and lactating women.

In line with the MOH's service integration priorities and recommendation from the Fifth National Pediatric Conference, EGPAF will advocate for and implement a fully integrated model of care in select PMTCT

sites. The model will provide same day, one stop service by co-locating MCH, nutrition, HCT/PITC, CD4 testing, and ART services. This will entail renovations, revised patient flow, and monitoring tools. In this one stop service model, eligible HIV-positive pregnant women will be initiated on ART in the PMTCT program, those on HAART and attending ANC at these sites will be transferred out from the main ART sites until 18 months after delivery to allow for continuity of services for both mother and child in the MCH setting. EGPAF will assess and document this approach for possible scale up at national level.

EGPAF will support the MOH in the implementation of a national integrated child health card with interventions crucial to identifying at-risk children, including HIV status, and all existing aspects of the current child vaccination card.

EGPAF will continue to support district health networks to coordinate HIV services including: • Staff training; ongoing site supervision to support capacity building of district health networks and providers; joint supervisions with district teams to review programs, data and conduct QI activities will continue with districts taking on increased responsibility in the process of phased-out support. • Improve pediatric HIV care and treatment through a strengthened clinical mentorship program with the pediatric reference hospital established with the MOH, TRAC Plus and partners including ICAP, PIH, and Luxembourg Development, in FY 2009 in East Province. • Continue to support HCT in ANC, labor and delivery, postnatal and vaccination clinics; provide testing for siblings, family members and HIV-exposed infants through DBS/PCR at all EPGAF supported PMTCT sites and continue to ensure HIV exposed children are being identified at all entry points in the health facility including through PITC. • Along with all clinical partners, work closely with Project San Francisco and the MOH to support scale up of couples' counseling through training and on-site mentoring; work with districts and sites to improve pre- and post-test couple counseling quality and follow-up mechanisms for discordant couples and women testing negative in ANC to address seroconversion and pediatric infection during pregnancy and breastfeeding. • Continue support for EID, EIT for mother and baby through implementation of improved monitoring tools to track maternal CD4 and DBS/PCR result turnaround time. • Support task shifting policy, including provision of HAART at all EGPAF supported PMTCT sites. • MCH services through male champions and providing male friendly services. • Improve retention of mother-infant pairs by bridging PMTCT and ART services through case managers in the continuum of care model (see HBHC narrative). Follow-up of mother-infant pairs will include: unique patient identifiers for HIV-positive women that link their records to their infants'; sensitization and mentoring of health care workers on the importance of EID and EIT; inclusion of mother-infant pair follow- up in PBF; follow-up of mothers and infants by community health workers (CHW), peer mothers/expert clients (such as M2M/Imbuto) and PLWHA associations.

• Support male involvement in PMTCT. • Strengthen MCH services: dissemination of algorithms and job aids in focused antenatal care (FANC), EMONC, FP; support community and clinical IMCI, IYCF and maternal nutrition; implement the post- partum package including FP; malaria treatment and ITNs; support DH with kits for the Kangaroo technique and equipment for neonatal care; and continue support of the FP/HIV integration model within all EGPAF supported districts. • Work with CHWs to reinforce key SGBV messages in the community and support immediate referral to health facilities with trained staff for medical care and post exposure prophylaxis and referral to SGBV support groups. • Continue support for IYCF and maternal nutrition: integration of maternal and IYCF as part of FANC, post-partum care, vaccinations and regular infant follow-up; reinforce IYCF messages in the community; revision and/or development of IEC materials and program tools based on WHO maternal and IYCF nutrition recommendations; support for exclusive breastfeeding campaigns in the community. • Finalize data collection, analysis and report on the "Evaluation of the HIV exposed infant feeding program in Rwanda" PHE. • Work with MOH, SCMS, CAMERWA, the Pharmacy Task Force, districts and sites to ensure high quality commodity procurement, quantification and forecasting and to ensure no stock-outs occur and medicines are well managed and stocked. • Support advocacy efforts to mobilize national and local leaders for action on select issues including FP, IYCF, EBF, EID and male involvement in family health.

EGPAF will partner with community partners and the MOH to ensure CHWs in EGPAF-supported districts receive training in HIV and MCH modules and the necessary follow-up and support. Through strategic partnerships with community partners, civil society, private sector, FBO, CSO including cooperatives of PLWHA through RPP+, and CHW, districts will increase demand for PMTCT services, service utilization; disseminate key IYCF messages including safer breastfeeding practices; and assist sites in systematic follow-up of mothers and infants in the community. Case managers will support linkages with community services, and ensure that HIV-positive women and children receive effective referrals to psychosocial support and other maternal child health programs, including HBC care support, malaria and OVC programs via CHF, CRS, and PMI. EGPAF will involve community leaders and men's groups during special events such as umuganda.

EGPAF will support national QI policy through Mutuelles for indigent patients and district risk pooling; national PBF and QI initiatives such as strengthening health quality committees at health centers and PAQs; performing PDSA in each district; holding biannual district level meetings to discuss specific indicators (e.g. infant ARV prophylaxis); supporting the PMTCT IQ Chart and PMTCT modules in TRACnet; ensuring transportation of lab samples and results; and providing supervision and mentoring.

EGPAF will also work with districts and sites to strengthen data quality processes through regular data audits and data reviews in the joint supervision process to enable sites and district staff to appropriately use data and ensure quality. EGPAF will assess implementation of CD4 counts during pregnancy and the implementation of EID and EIT protocols at EGPAF-supported sites to evaluate whether these national policies are being correctly implemented, address weaknesses, and review their outcomes.

In line with the Partnership Framework sustainability and transition goals, EPGAF will ensure that all patients receive a standard, comprehensive package of PMTCT services and that MCH and HIV services are co-located to the extent possible; continue to support a combination of funding through technical support, input based funding and output based financing through PBF; ensure programmatic links to food programs (WFP Food and the USAID/Ibyiringiro project) to avoid duplication, ensure implementation of exit strategies (e.g., kitchen gardens) and strengthen linkages too community-based nutrition and IGA programs.

EGPAF will work with the districts to establish a unit to centralize district level funding. Currently EGPAF is preparing the District Hospital to support sub-grantees. In FY 2010, EGPAF will support one District Hospital through training and mentoring to negotiate and manage the health facilities sub grants under its supervision through a system of payment on performance. EGPAF will support the administrative district to train and mentor the sector health units. EGPAF will assess and document implementation.

Capacity building of health providers and district level health authorities are an important aspect of the transition process and a key step in transferring responsibility. District appropriation of services, including training, supervision, evaluation, HR funding, quality of services and data use are benchmarks for evaluating sites and districts' readiness for transition. EGPAF will work with the USG team and the GOR to establish benchmarks and strategies for transition. EGPAF will also learn from the Track 1.0 care and treatment partners' experiences. These actors will jointly agree on a plan to document lessons learned and progress toward transition.

To support the national and USG goals for reducing the number of deaths caused by TB through increased detection, successful treatment, focus on co-infection, and development of new tools for TB, EGPAF has advanced the TB/HIV one stop service model at all EPGAF supported District Hospitals and supports TB/HIV services at 40 sites. The one stop service model facilitates a comprehensive response to the needs of co-infected patients while reducing exposure of clients in regular HIV clinics to TB,

provides HIV testing for all TB patients, TB screening for all HIV-positive patients and treatment for TB- positive patients. In FY 2009, with EGPAF's support, 320 HIV patients were receiving TB treatment at EGPAF sites and 1,012 TB patients had been screened for TB.

In FY 2010, EGPAF will screen 18,937 HIV patients for TB and initiate TB treatment for 303 co-infected patients. EGPAF's TB-related activities for FY 2010 will continue to support the national, district/site, and community level implementation.

EGPAF's national level activities will include support to the MOH and TRAC Plus to roll-out one stop service and ensure infection control. EGPAF will continue to work collaboratively with clinical partners, TRAC-plus, and the UPDC unit of the MOH to support TB/HIV integration and improve the quality of services at all levels; participation in the TB/HIV TWG; .work closely with TRAC Plus supervisor to analyze quarterly reports and respond to identified weaknesses in TB services delivery and ensure the roll-out of infection control services within both out and in-patient settings for adults and children.

EGPAF's support of staff and systems at the district and sites builds human resource capacity and promotes sustainability. By working closely with staff and management at these levels EGPAF is working to ensure that there are sufficient trained personnel to carry out TB-HIV activities and sustain the program over time.

In FY 2010 EGPAF will:

• Continue to provide support to district health teams allowing them to roll-out supervision to non- PEPFAR funded sites within EGPAF supported districts, and to increase the diagnostic capacity of district hospitals and other TB treatment and diagnostic centers within EGPAF-supported districts. • Expand the one-stop model for TB/HIV treatment from the five District Hospitals where it is currently in place to all 27 health centers which offer ARVs. • Ensure that all of patients diagnosed with TB, or suspected to have TB, are offered an HIV test and that 100% of those testing HIV-positive are referred to, and arrive at, an ARV-treatment facility. • Screen at least 95% of HIV-positive clients for TB during their first consultation and subsequently every six months, and ensure that 100% of those patients diagnosed with TB receive treatment. • Work closely with sites to ensure they are better able to use the TB diagnostic algorithm, using simple criteria to diagnose TB-infected children to ensure that all exposed children receive Isoniazid prophylaxis after having excluded active TB. • Continue to support individual sites to improve data quality, not only for reporting, but also for analysis and use for site level program improvement and to support integration of TB and HIV services at the facility level per national guidelines. Additionally, EGPAF will collaborate with TRAC Plus to have two

staff persons from each district who are trained receive refresher training; they will become focal points for the TRAC-Plus coordinated mentoring activity so they can continue to provide supportive supervision to facilities in their districts. • Increase support to DHTs to provide supportive supervision to non PEPFAR funded sites within their supported districts; to increase diagnostic capacity of district hospitals and other CDTs for both pulmonary and extra pulmonary TB, to provide treatment under DOTS and to monitor treatment failure in order to facilitate early detection and management of MDR. • Continue to support existing sites and build capacity of DHTs to plan and implement a sustainable, integrated HIV/TB program within the existing health care delivery system. • Continue to support, in collaboration with TRAC Plus, integrated planning and TB/HIV training for both HIV and TB services providers. EGPAF will continue to improve diagnostic capacity for TB including coordinating specimen and patient transport for appropriate diagnostic services (such as chest radiography and FNA specimens) to referral centers and provide appropriate follow-up and prompt patient care. EGPAF sites will work with community health care workers to reinforce TB/HIV messages in the community. • Work with districts, sites, and community health workers to identify strategies and mechanisms to improve TB diagnosis among PLHA and screen HIV positive patients for TB. The goal is to have a one stop service centre where an HIV positive individual seeking any service is also screened for TB and is appropriately served or referred for family planning. • Ensure that health center staff is trained in infection control and implement an infection control plan consistent with national policy and guidelines.

Through its continuous technical assistance to sites via regular formative and evaluative supervision, along with improved data on TB/HIV EGPAF in collaboration with TRAC-plus, CNLS, PNILT and the national PBF program will support health facilities to maintain a system of quality improvement. By using TB/HIV data EGPAF's supported health facilities will regularly review program performance and implement recommendations.