Since 2007, FHI has received PEPFAR funds to support decentralized HIV/AIDS clinical services. The project aims to achieve sustainable, universal access to holistic HIV prevention, care and treatment services in the project's coverage zone by contributing to the PEPFAR goals and to the objectives of the Rwanda National Strategic Plan 2009-2012 for HIV. During COP10, FHI will continue to:

1. Provide "basic HIV care" services (VCT, PMTCT, opportunistic infection management, prevention with

PLHA, etc.) and maintain >80% PMTCT coverage in target districts; 2. Strengthen district care networks so that HIV/AIDS treatment is available to all clients in need within each district; 3. Strengthen district health systems in: infrastructure, comprehensiveness and quality of HIV services, continued integration of HIV care with TB, FP, MCH, and STI management, and expansion of integration activities to include management of childhood illnesses and other major services; patient management tools and systems,data collection and use, Quality Assurance/Quality Improvement initiatives; strengthening District Pharmacies in improved stock management, storage, procurement and regular supply to health facilities district-wide; monitoring and managing performance-based financing (PBF) grants, and District Health Unit planning, coordination, and supervision of health activities district-wide.

FHI will continue to support PBF grants to districts, district hospitals, primary health centers and other partners as needed with technical assistance (TA) and management support from FHI offices. FHI's field- based teams will fully participate in district-organized initiatives and remain responsive to articulated needs of district leadership. The partner will continue to work towards key milestones to mainstream HIV services into Rwanda's primary and secondary healthcare facilities and to transition out of direct TA to the facilities to a district-level focus. Complementing decentralized activities, the partner will continue to contribute to national-level health sector strategies, guidelines, action plans and tools through participation in Technical Working Groups, Task Forces, coordination meetings and conferences as well as through time-bound staff secondments.

FHI's TA and material support to national government, districts, and health facilities is in line with major indicators for prevention, care and treatment of HIV as well as indicators of health system strengthening, especially at the district level. Further, aligned with the transition milestones outlined in the Partner's 5- year Cooperative Agreement, a key approach promoted through this project has been district-led planning, management and coordination of activities. To further advance this shift, during FY 2010 FHI aims to introduce in one target district a new model to finance district-wide activities through one subgrant to a district hospital. To ensure no disruption of service delivery, "safety net" features will be build in these district grants. Experiences and lessons learned from this new financing model will be applied to the four other districts in the remaining year of the project.

FHI will continue to provide intensive support for comprehensive coverage in the five target districts (Muhanga, Kamonyi, Nyamagabe, Ruhango, and Nyaruguru) in Southern Province and to select health facilities in Kigali, Gakenke and Nyanza. The project targets clients and patients in need of integrated services in the project's intervention zones.

FHI will continue to strengthen health systems through rational use of human resources for health;

support for primary health insurance systems, PBF, improved infrastructure; mainstreaming and integrating AIDS care into primary and secondary level care; improved patient management and clinical skills; and district-level management and coordination of health activities.

FHI will maintain and improve cost efficiencies in FY 2010. With the introduction of district-level grants, FHI will begin to see better efficiencies in staff costs. Grants management - an important capacity building and accountability tool - comes with significant staffing demands on finance and internal audit teams, program management, and technical teams. As FHI transitions to a district focus, these demands should lessen over time and substantially improve FHI's cost effectiveness.

Additionally, FHI will continue to strongly advocate for and implement comprehensive, science-based prevention approaches spanning community and clinic-based initiatives. While difficult to measure, preventing new HIV infections is the single most important strategy for reducing program expenses and costs to the health system.

FHI will continue to monitor progress in clinical services using strategic information and data management systems and tools; to conduct routine data verification with TRAC Plus of site-level data; to collect and use data on special projects and initiatives as indicated and in collaboration with the health facilities and health authorities; to support site-level Data Managers and data management teams to collect, interpret, and use health facility data; to conduct routine data quality audits associated with data management capacity building at the site and district levels; and to provide quarterly and annual reports to the districts, the province, and the MOH.

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.

In FY 2009, FHI supported 40 health facilities (34 health centers, five district hospitals and one prison) to provide ARV services. In FY 2010 FHI will support 14,132 adults and children already on ART and an additional 2,537 initiating ART, bringing the total number of patients on ART to 16,670.

One of the ART services supported by FHI is the provision of periodic CD4 counts in non-ART patients, which allows providers to determine ART eligibility and to refer eligible patients to the closest health facility providing treatment. In September 2009 ART sites began implementing a new first line ART regimen (which includes Tenofovir), in accordance with the revised national guidelines for treatment and follow-up of people living with HIV/AIDS (PLWHA). In FY 2010 FHI will continue to support sites to implement the revised national protocol.

In the context of scaling-up of ART services and improving access to CD4 counts, the MOH, in collaboration with its partners, plans to place a Faxcount machine for counting CD4 in two district hospitals (Gitwe and Remera Rukoma), both of which are supported by FHI for HIV services. This activity is expected to improve HIV care services in catchment area of these districts hospital through better monitoring and availability of CD4 counts. In FY 2009 the majority of patients had been on ART for three or more years, yet almost all of them remained on a first-line regimen. Early detection of treatment

failure would indicate more patients in need of second line regimen and FHI will focus on targeted viral load testing as an essential part of ensuring quality of care.

The shortage of human resources for health, and physicians in particular, has been a major barrier to achieving universal access to HIV care and treatment. In September 2005, FHI launched a pilot intervention to shift ART-related tasks from physicians to nurses. Through this task-shifting initiative, nurses were trained at three primary health centers to initiate ART through prescription of ARVs to non- complex adult patients and provide follow-up care. Following the 2009 publication of the results of the evaluation showing the positive impact of the task-shifting, the Rwandan MOH fully endorsed prescription of ARVs by trained nurses and FHI began rolling out and institutionalizing task-shifting in FY 2009. In FY 2010 FHI will support MOH/TRAC Plus to develop a training module for task-shifting to facilitate rollout. District hospitals will start training nurses from health centers which fulfill certain eligibility criteria, such as: comprehensive services for HIV care in place (counseling and testing, prevention of mother-to-child transmission, and AIDS patient care and treatment); supervision and support from a district hospital already providing ART to patients; and a nurse on staff with at least two years experience providing clinical care for non-HIV pathologies. In FY 2010, at least two health centers per district will provide ART through task-shifting.

Post-exposure prophylaxis (PEP) has been and will continue to be an integral part of FHI's HIV prevention policy. For health care workers and patients exposed to HIV in health-facility settings, a comprehensive package of PEP drugs and services will be provided in accordance with existing protocols. PEP services for sexual violence or other non-occupational exposure will continue to include: first AID, counseling, HIV/STI testing, provision of ARVs, medical care, trauma counseling, linkages with police, referrals for legal assistance, and other follow-up and support services. In FY 2010, FHI will continue to support the integration of MCH and Family Planning in HIV services and initiate integration of mental health services according to existing guidelines developed in FY 2009. Diagnosis of OIs and loss to follow-up especially among Pre-ART patients will remain a priority in FY 2010.

In line with the Partnership Framework sustainability and transition goals, FHI 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. FHI will also continue to support a combination of funding through technical support, input based funding and output based financing through PBF, as well as ensure programmatic links to food programs and to community-based services.

In FY 2010 FHI will support one district hospital through training and mentoring to manage the health facilities under its supervision through a system of payment on performance. FHI will support the

administrative district to train and mentor the sector health units, and assess and document implementation. Capacity building of health providers and district level health authorities is an important element for the transfer of 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. FHI will work with the USG team and the GOR to establish benchmarks and strategies for transition. FHI will also learn from the Track 1.0 care and treatment partners' experiences.

Uptake of voluntary HIV testing in Rwanda continues to be phenomenally high. Since the beginning of this project, more than 200,000 clients have been tested for HIV at FHI-supported sites alone. During FY 2010, FHI will work with districts to introduce HCT to new health facility partners.

Other FHI priorities in FY 2010 include:

1. COUPLES VOLUNTARY COUNSELING AND TESTING (CHCT): As a form facilitated disclosure and a critical opportunity for prevention, a major priority in FY 2010 will be to scale-up to all health facilities supported by FHI couples HCT based on Project San Francisco's experience of delivering test results to the couple rather than to the partners separately.

2. SYSTEMATIC AND WELL DOCUMENTED PROVIDER-INITIATED HIV TESTING (PIT): Specifically, FHI will focus on strengthening and further improving TB/HIV service integration and in particular ensuring systematic TB screening in HIV patients, not only at the initial clinical assessment but at regular intervals in the follow-up visits. Also, FHI will focus on ensuring systematic and documented PIT in malnourished children, patients with STI, and patients with other signs and symptoms of HIV disease. Finally, FHI will improve PIT through family-based testing for HIV-affected households. Because PIT data have to date not been routinely collected and reported, FHI will devise ways to document PIT that do not add more burden on health facilities.

3. DIAGNOSIS ANNOUNCEMENT TO CHILDREN AND ADOLESCENTS: Continuing FHI's collaboration with TRAC Plus to deliver HIV diagnosis to infected children and adolescents to provide them with needed psychosocial care and support, FHI will extend this process to all VCT sites it supports. As of the beginning of FY 2009, the HIV-positive diagnosis and psychosocial care program for children and adolescents was active in 28 sites.

4. IMPROVING PRIMARY PREVENTION WITHIN VCT: With a separate funding source, FHI will work with TRAC Plus to establish an effective approach for identifying most-at risk HIV-negative clients within VCT and providing with intensified and personalized risk reduction counseling. As guidelines and tools from this initiative become available, FHI will work with the districts and individual health facilities to introduce it as part of routine, clinic-based primary prevention activities. The "prevention with PLHA" interventions mentioned in the HVOP narrative will also play an important role in such primary prevention efforts linked to Testing and Counseling services.

Family Health International (FHI) is one of the USG partners providing HIV care and treatment services for HIV-positive adults and children in Rwanda. In collaboration with local service providers, FHI is currently providing a comprehensive package of services for pediatric care and support which includes: testing of infants born to HIV-positive mothers early infant diagnosis EID), provision of co-trimoxazole prophylaxis (CTX) to HIV-exposed infants, follow-up services for HIV-exposed infants and HIV-positive mothers, nutrition counseling and food support for parents, safe water interventions, and other services for children under 5 years (ex. immunization, growth monitoring, IMCI services, etc.).

In FY2010, FHI will support 56 sites to continue delivering basic care and support to HIV-positive or exposed children, reaching a total of 2103 of children with pediatric care and support by the end of the year. Details on planned/ongoing interventions are described hereafter:

Increasing pediatric patient enrollment is a major priority for all PEPFAR clinical partners in FY2010 as in previous years. As such, the basic package of HIV pediatric care and support will include the promotion of EID (i.e., the extent to which infants born to HIV-positive women are tested to determine their HIV status within the first 12 months of life) which is now available at 56 of FHI-supported sites. Early virological testing for HIV will be offered at 6 weeks and at older ages according to the national algorithm. At FHI-supported sites HIV-positive children will be staged clinically and using CD4 (counts or percentages as these become available), and eligible infants and children will be enrolled in ART. Systematic chart reviews to identify children eligible for treatment based on new CD4 cut-offs will be done. FHI will continue working with the district health teams to ensure that samples collected at the sites are transferred efficiently to the processing lab at the National Reference Laboratory in Kigali, and with the MOH in order to improve reliability of result turn-around times.

CTX is a simple and cost-effective intervention to prevent Pneumocystis jiroveci pneumonia (PCP) among HIV-exposed and infected infants. PCP is the leading cause of serious respiratory disease among young HIV-positive infants in resource-limited countries and often occurs before HIV infection can be diagnosed. All infants born to women living with HIV will systematically start CTX prophylaxis at 6 weeks after birth. CTX will be continued until HIV infection has been excluded and the infant is no longer at risk of acquiring HIV through breastfeeding. It is estimated that 1107 infants born to HIV-positive women will be started on CTX within 2 months of birth; and 1223 infants born to HIV-positive mothers will receive an HIV test within 12 months of birth in FY2010.

Follow-up of HIV-exposed infants will be promoted through support groups of HIV-positive women based on the mother-to-mother model. In this model, women who demonstrate steady consultation attendance and good baby care are identified and used to coach new HIV-positive mothers during pregnancy and after delivery to ensure that both women and their infants access needed services. Moreover, FHI will support the implementation of the revised child health card which includes information about maternal HIV status as well as ARV prophylaxis.

Newly identified patients will be screened at enrollment and at regular intervals for signs and symptoms of common opportunistic infections or other infectious complications of HIV in children, including: candidiasis, pneumonia, malaria, meningitis, and PCP. In addition, all pediatric patients will be screened for TB at least once every six months. Children suspected of having TB will be further investigated and put on TB treatment if infection is confirmed based on current national guidance. Additionally, infants and children on ART will also be assessed at each visit for issues related to adverse events, toxicity and adherence to ART.

All pediatric patients will have regular anthropometric evaluations to identify early signs of malnutrition and to ensure prompt initiation of nutrition rehabilitation interventions. Through the mother-to-mother group sessions supported by FHI, health workers will provide nutrition counseling, enhancing family food support through training for improved home gardening and animal breading techniques. FHI will provide food supplementation to mother-infant pairs. This latter activity will be conducted in collaboration with a Prime PEPFAR funded Community Partner, the World Food Program and Catholic Relief Services.

Using complementary USG funding, FHI-supported sites will provide health education on safe water and water purification products such as Sûr'Eau. HIV-exposed infants identified at PMTCT sites will be followed in the context of MCH services offered at existing FHI sites.

Pediatric HIV care and treatment programs in Rwanda still face many challenges, including the need for increased numbers of qualified pediatric health care providers. FHI will ensure that site-level providers

are trained and/or receive refresher training session in pediatric HIV patient management, in conformity with the national guidelines. Providers will receive regularly planned in-service trainings and mentoring in pediatric HIV care and treatment.

FHI will continue working with other clinical implementing partners and the MOH to train health care providers on newly updated pediatric HIV treatment guidelines. Staff will be trained to ensure, as much as possible, the early detection of signs of immunologic and clinical failure and the initiation of second- line treatment regimens based on national protocols.

FHI will assist heath facilities in mentoring children and adolescent support groups that have been established at the sites as a component of psychosocial support for HIV-positive children and adolescents. These clubs will be used to provide ongoing support for children in care and on treatment or affected by HIV and assist with addressing issues around status disclosure and adherence support.

In Rwanda, efforts are increasing to provide HIV/AIDS care and treatment to infants and children who are still underserved by antiretroviral treatment compared with adults. Family Health International (FHI) is committed to increasing access to HIV care and treatment for HIV-positive or HIV-exposed children. By the end of FY2009, FHI will be supporting at least 56 health centers to provide PMTCT services and to perform HIV early infant diagnosis. This activity contributes to the identification of HIV-positive infants/children and to providing them with ART or linking them to ARV services. The number of sites providing ART services will be at least 36 by the end of FY2010; it may be more given the recent MOH instructions on task-shifting for prescription of ART by nurses. FHI/HCSP targets the following number of ART children in FY2010: 267new cases; 1666 current cases; and 1933 cumulative cases.

FHI will continue to provide technical and financial assistance for the following activities that benefit pediatric HIV patients: administer co-trimoxazole prophylaxis to HIV-positive infants at the age of 6 weeks; initiate ARV treatment to HIV-positive infants less than 12 months old and to young children according national guidelines; provide other HIV-related treatment to all eligible infants/children through the District Care Networks; and ensure that HIV test results are announced to children/adolescents and their parents/guardians with counseling and organized support groups. FHI will assist heath care providers in mentoring children and adolescent support groups that are established at the sites as a component of psychosocial support for HIV-positive children and adolescents. These clubs will be used to provide ongoing support for children in care and on treatment and to assist with addressing issues

around treatment adherence.

Conduct routine clinical monitoring with intensification based on health status using the Acuity Case Management (ACM) approach. Few staff are trained in pediatric HIV, and most health care workers lack confidence in HIV pediatric care and treatment in general. FHI, in collaboration with the Center of Excellence at CHUK, will provide financial support to Pediatric Practical Staff Training in 5 district hospitals. Health providers' skills will also be reinforced in screening, diagnosis and treatment of TB in infants and children by organizing training and by providing tools.

FHI will work with other partners to provide two new FACSCount machines for CD4 testing to Remera- Rukoma and Gitwe District Hospitals, and to make these machines operational. FHI will continue to support all facilities in transportation of blood samples to NRL for DBS-PCR and facilitate the procurement of pediatric drugs and lab commodities through the district pharmacies.

The establishment of District Networks of HIV Care will further strengthen the connection between ART and PMTCT programs and facilitate scaling-up of the national ARV regimen for children.

In FY2010, FHI will be enhancing HIV early infant diagnosis to be offered in 100% of health centers in targeted districts as part of standard HIV care. As such, co-trimoxazole prophylaxis will be provided at 6 weeks of age to all HIV exposed infants. In addition, FHI/HCSP will support the following: early HIV testing using PCR/DBS at 6 weeks of age and in all infants with signs suggesting HIV infection (e.g. low weight, repetitive infections, and slow growth); care and treatment services for infants diagnosed as HIV- positive; active family-based testing of children, including home-visits as indicated; intensified and expanded counseling; education and support for post-weaning child nutrition (the latter through PHC- based initiatives with locally produced foods); and implementation of breastfeeding recommendations to mothers of these infants according to HIV-status.

FHI will continue to work closely with WFP through Food for ART Program to provide nutritional support to children affected and infected with HIV. FHI will also work with all health facilities to ensure good nutritional counseling of clients, and it will provide Job Aids patient educational materials on nutrition to the facilities.

FHI/HCSP will promote and implement interventions targeting the general public and most-at-risk individuals as part of a comprehensive, science-based approach to primary, secondary, and tertiary prevention of HIV. In FY 2010, FHI/HCSP will prioritize cross-referrals spanning community and clinical contexts to provide individuals with multiple behavioral and biomedical prevention services and, where indicated and feasible, these will include reducing socio-economic vulnerabilities that lead to high-risk situations.

In the clinic setting, in FY 2010 primary prevention activities will entail behavior change education to reduce sexual risk, including delayed sexual onset for youth, consistent and correct condom use for youth and adults, partner testing and couples VCT, and improved STI diagnosis and management. With a separate funding source, FHI/HCSP will work with TRAC Plus to establish an effective approach for identifying most-at-risk HIV-negative clients within VCT services, and providing them with intensified and personalized risk reduction counseling. As guidelines and tools from this initiative become available, FHI/HCSP will work with the districts and individual health facilities to introduce it as part of routine, clinic- based primary prevention activities.

Comprehensive "positive prevention" programs targeting HIV-positive persons and HIV-affected couples will comprise a core set of activities for secondary and tertiary prevention health facilities in FY 2010. Systematic and expanded positive prevention programs will include: 1. Behavior change education and support to HIV-positive persons to reduce risk of transmission to HIV- negative partners. 2. Condom promotion and delivery to HIV-positive individuals and -affected couples. 3. PMTCT, dual method promotion and family planning delivery for HIV-positive women and -affected couples. 4. HIV testing for partners of HIV-positive persons and couples VCT. 5. Counseling and support for adherence to treatment. 6. Counseling and support for HIV sero-discordant couples. 7. Routine STI screening and treatment for HIV-positive patients. 8. Referral to care, treatment and support services for HIV-positive persons including to community- based program.

In two primary health centers in Kigali, FHI/HCSP will also continue to support HIV prevention and enhanced syndromic management of STIs among female sex workers. In addition to diagnosing and treating STIs in this at-risk population, this initiative also includes HIV counseling and testing, family planning services, sexual risk reduction education, provision and promotion of condoms, social support and income generation. To improve support to the women for alternative economic options, FHI/HCSP will apply successful strategies and approaches used in the separately funded ROADS II project

(LifeWorks program) that focuses prevention and impact mitigation in high-risk communities located along the transport corridor.

FHI/HCSP will continue to engage in program level data analysis to better understand the needs of the community served but also to generate evidence for program improvement and planning. FHI/HCSP will continue to participate in SI activities that support better prevention programming and outcome assessment, like behavioral surveys. In FY 2010, FHI/HCSP will conduct an evaluation of their activities with MARPs in the sites they support. FHI/HCSP will also continue to support national efforts and use national tools aimed at improving M&E capacity and quality assurance.

This is continuing activity from FY 2009.

In FY 2010, FHI will continue to support Rwanda's national program to offer PMTCT as a routine part of antenatal care (ANC). As of the beginning of FY 2009, 56 FHI/HCSP-supported sites (both health centers and district hospitals) were providing PMTCT. MOH's 2009 instructions on task shifting for prescription of ARV treatment by the nurses could significantly improve access to ART by pregnant women and their family members in need of treatment.

Family Health International (FHI) will provide an expanded package of services for 42,493 pregnant women at 56 existing FHI supported CT/PMTCT sites. FHI will offer a standard package of PMTCT services that includes CT with informed consent, male partner and family-centered testing, intermittent preventive treatment of malaria in pregnant women (IPTp) in collaboration with PMI, ARV prophylaxis using combination ARV regimens and HAART for eligible women, infant feeding counseling and support, referral for MCH services, and close follow-up of HIV-exposed infants for effective referral to appropriate services, and early infant diagnosis. In addition, FHI will ensure access to a comprehensive network of services for PMTCT clients and their families, link PMTCT services with other HIV and MCH interventions, and assure an effective continuum of care by increasing patient involvement and community participation in PMTCT services and ensuring prompt CD4 count and clinical staging for HIV- positive pregnant women.

This also will include screening and treating STIs, including systematic syphilis testing for all pregnant women coming to ANC services, and HIV counseling and testing services for pregnant women and their sexual partners. In collaboration with TRAC Plus and Project San Francisco, FHI, and all clinical

partners, will support couples' counseling through training and on-site mentoring 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. FHI will also support HIV testing in labor and delivery wards for women of unknown status.

Pregnant women will also be offered iron and folic acid supplements in line with MCH guidelines, and they will be provided with educational materials on post-partum care, infant consultations, family planning, and other RH/MCH-related topics. In addition, systematic referral/counseling will continue for regular ANC visits, growth monitoring, vaccination services and family planning. Finally, MCH services will be enhanced through other USG funding sources, to complement the PEPFAR-funded activities.

Women meeting poverty criteria by the PHC committee will be enrolled, with their families, in the PHC's health insurance system (Mutuelles); and provided with nutritional supplements prior to birth and after birth.

FHI will strengthen follow-up and tracking systems to ensure testing of family members, routine provision of CTX PT and infant diagnosis, ongoing infant feeding counseling, CD4 monitoring and clinical staging, management of OIs, including TB and other HIV-related illnesses, psychosocial support services at clinic and community levels, identification and referral for victims of gender-based violence to appropriate care in collaboration with community care workers, peer educators and other HIV clinical partners, and access to clinical and community prevention, care, and treatment services for family members. FHI will assure linkage to treatment for eligible women and infant follow-up by using peer support groups, community mobilization, community volunteers, home visits done by health workers to encourage them to continue in the program and to provide continuing counseling and advice. In addition, all HIV-positive women are included in child weaning courses (which include education on nutrition and food preparation). At PHCs, family planning is also encouraged and either provided directly by the health facility or the woman is referred for services.

Infants born to HIV-positive mothers will continue to receive ARV prophylaxis and IMCI services and immunization services with support from FHI under HCSP. Prophylactic treatment with Co-trimoxazoleis provided to infants at 6 weeks of age; early infant diagnosis services, now available at 43 of FHI supported sites, will be expanded to increase full coverage of sites. EID will be offered at six weeks of age and at later ages for symptomatic infants less than 18 months of age according to the national algorithm. HIV positive infants will continue to receive preventive therapy (PT) with co-trimoxazole, and HAART according to the national guidelines. In FY 2010 FHI will collaborate with Catholic Relief Service (CRS) which is the principle PEPFAR sub -awardee for the purchase and distribution of nutritional supplements to people infected and affected by HIV and AIDS including weaning food supplements in

PMTCT. Under this collaboration, CRS bears the responsibly of purchase and distribution food supplements in the form of fortified weaning food to the mothers of HIV-exposed infants from age of 6 months to 18 months as well as nutritional supplements to include pregnant and lactating mothers.

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. FHI will work with the USG team and the GOR to establish benchmarks and strategies for transition. FHI 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.

Sustainability of services and improvements in program outcomes will be promoted through a combination of input technical assistance and output performance-based financing (PBF). Procurement, forecasting and distribution of ART, CTX and other PMTCT commodities will be further strengthened through SCMS, the MOH and CAMERWA.

District Health Teams and site level teams will be supported through training, formative supervision to better coordinate PMTCT and other HIV and health clinical and preventive services. This will maximize effective referrals between HIV/AIDS services, improve integration with other MCH services (e.g., distribution bed nets to prevent malaria, family planning counseling and referral, syphilis screening, nutrition counseling and support) and improve the quality of care at the most decentralized level.

In FY 2007, FHI began implementing the national TB/HIV policy using national guidelines at 59 FHI- supported health facilities. The program's achievements include an improvement in the percentage of TB patients tested for HIV from less than 70% to 95% and improving HIV-positive TB patients' access to HIV care and treatment (increased proportion of patients accessing Co-trimoxazoleand ART). In FY 2008, with the MOH, districts and individual health facilities, FHI focused on ensuring that PLHA receiving basic care services were diagnosed and treated for TB and to ensure systematic audits of the availability and use of national TB tools at FHI-supported health facilities. Additionally, in FY 2009, FYI disseminated the new MOH guidelines to help in TB diagnosis among children and this activity will continue to be reinforced in FY 2010.

Under the lead of TRAC Plus, for the FY 2010 period FHI will continue to improve services for TB/HIV management, including a strong focus on infection control standards and increased diagnostic capacity for both pulmonary and extra pulmonary TB as well as fully expanded implementation of regular TB screening for all PLHA (adults and children). For those HIV-positive clients suspected to have TB infection, the project will ensure complete treatment with DOTS, monitor for treatment failure in order to facilitate early detection of MDR TB, and track exposed family members for appropriate HIV and TB screening and or initiation of Isoniazid prophylactic therapy for children under 5 years old, as indicated in the national guidelines.

FHI recently seconded staff to the TRAC Plus TB unit within the MOH to strengthen coordinated planning and improved integrated service delivery on a national scale. These positions will continued to be supported in the FY 2010 funding period. Also under FY 2010, FHI will conduct an audit of TB infection control needs at health facilities supported by FHI, in coordination with the TB Unit at MOH. As needed and possible, infrastructural improvements will be made for better infection control. At all health facilities, education aimed both at providers and patients for TB infection control will be supported.