IntraHealth HIV Clinical Services Project (HCSP) serves nearly 1.5 million people living in Gasabo, Gicumbi, Nyagatare, and Rulindo districts. HCSP aims to build national and district capacity to support, manage and expand HIV/AIDS clinical activities and services in select District Health networks (DHNs). HCSP supports CT, PMTCT, ART, FP/MCH/HIV/AIDS integration, GBV, ABC prevention, prevention of medical transmission, BCS, TB/HIV integration, and nutrition.

HCSP's work is in line with the PFIP to empower districts to assume leadership and technical/financial responsibilities by 2012. In COP10, HCSP will continue to strengthen DHNs skills in financial management, budgeting, reporting, accounting, sub grant management, HR and program management, planning, and M&E. HCSP will support quarterly meetings with DHNs to monitor performance.

To build on previous cost-efficiency practices such as On the Job Training (OJT), HCSP will adopt the following approaches: develop a procurement plan for all sub-partners to procure supplies, equipment and commodities; integrate training sessions to reduce costs; expand coverage of sites with low marginal costs; and gradually reduce salary support and input financing where possible.

HCSP's M&E program complies with Rwanda's Three Ones policy, the OGAC SI strategy, and the Rwandan M&E Plan. HCSP has improved data quality and will continue to work in close collaboration with districts and sites to strengthen M&E capacity. Two major goals for COP10 will be to support sites in collecting and analyzing their own service data for informed decision-making, and achieve 100% site-level data computerization.

Cross-cutting programs To ensure quality service delivery and increase ART coverage/treatment compliance, HCSP will implement task shifting and the Mobile District Physician scheme. Health facility staff salaries will also be supported, although in COP10 HCSP will further negotiations with the MOH to transfer some salary support to the government. Staff retention will be promoted through work space improvement and

continuous technical support for high performance-based financing scores.

HCSP will renovate 3 new sites, and will continue to conduct small renovations/maintenance for existing sites. All HCSP-supported sites currently have some energy source. But, HCSP will ensure the electrification of all sites by the end of 2012.

HCSP aims to have 95% of beneficiaries with normal anthropometric indicators after 6 months of nutrition support, and at least 95% of ART patients comply with treatment. HCSP will provide nutritional support to HIV-exposed infants between the ages of 6 and 8 months; malnourished women in the final trimester of pregnancy; and malnourished breast-feeding mothers with children up to 6 months. HCSP will also train providers in care and treatment. In collaboration with CRS and WFP, the nutrition and well-being of ART and HIV+ patients, especially mothers and infants, will be improved.

Given increased vulnerability to poverty among PLWHA, HCSP will support projects to increase household income. Approximately 350 families will receive support in nutrition-sustaining activities. PLWHA cooperatives will be engaged in these activities as well to motivate and support HIV-affected individuals and households.

HCSP will continue to build capacity of districts, health facilities and community GBV committees to prevent and mitigate GBV. Activities will include assessing GBV-related knowledge, attitudes and practices among providers; assessing HIV/AIDS service readiness to provide GBV services; increase linkages with police, communities and districts in the management of GBV survivors; and support community sensitization and mobilization. Other key issues related to gender will be advanced, including CVCT, prenuptial CT, scaling up and involving male involvement in CVCT and PMTCT, and engaging both male and female partners. Health providers will train Community partners for Quality assurance (PAQ) teams to disseminate messages and mobilize community members.

Key Issues HCSP will address a number of key issues including conducting a full program evaluation, continuing workplace programs by providing technical and financial assistance to PLWHA support groups and advancing gender and related cross cutting issues as discussed above.

The HCSP will also implement health-related wraparounds in child survival and safe motherhood, FP and TB.

HCSP will continue to support IMNCI training and activities; routine vaccination and follow-up of HIV- exposed children; DBS-PCR and serology testing of infants and subsequent ART and OI treatment;

appropriate HIV status disclosure to children and children's support groups; and education and support for parents of HIV-infected children. Other strategic interventions will focus on mother and child health including but not limited to the promotion of 4 ANC visits per pregnancy and facility-based deliveries; quality provision of emergency obstetric and neonatal services.

With USAID FP funding, HCSP will build on its significant FP/HIV integration advances: integrated planning; reorganization of internal services, roles and responsibilities; training; MIS and monitoring; and supervision. HCSP will ensure that FP counseling and methods are available and systematically offered in all HIV/AIDS service points, with a vision of a one-stop shop model.

HCSP will continue systematic TB/HIV screening and treat all co-infected patients, while ensuring sufficient trained staff to carry out this double screening.

This is a continuing activity.

In FY 2009 IntraHealth International HIV Clinical Services Project provided basic HIV care and support services to 11,500 adult HIV clients at 41 clinical sites. Services provided 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.

In FY 2010, HCSP will continue to support 41 sites including 29 ART sites. HCSP is expected to reach 15,518 individuals with these services. HCSP will support health facilities to link VCT centers, TB services, and PMTCT services to care and treatment services, as well as to routine pediatric care, nutrition services and maternal health services. Additionally, clinical services will be linked to community services to facilitate a continuum of care. All confirmed HIV patients will be staged for level of care required, potentially receiving WHO clinical staging, a CD4 count, and/or screening and treatment of any HIV-related opportunistic infections. Retention in care of adult patients not yet eligible for ARVs is a challenge in Rwanda where patients are diagnosed early in the course of HIV infection but have few opportunistic infections which require them to come visit health facilities. In FY 2010 HCSP will reinforce patient retention strategies such as intensified psychosocial counseling at diagnosis, immediate clinical staging, CD4 cell count and home visits. In addition, engagement in prevention with positives activities and the new strategy of providing Co-trimoxazole to all HIV positive individuals will facilitate retention in care and adherence support as clients come for their Co-trimoxazole refills. Once a patient becomes eligible for ART, s/he is referred to ART services, a process facilitated by a social worker and CHW to ensure enrollment and retention in ARV services.

An electronic data base, the IQ Chart, has been installed in all ART sites, and is being expanded to include VCT and PMTCT along with ART, creating a synergy which will improve data recording, patient follow-up at, and patient tracking and will reduce loss to follow-up. HCSP will continue to train data managers and health service providers on data use for program improvement. With improved data on adult basic care and support, HCSP, in collaboration with TRAC Plus and other national quality

assurance initiatives, will support health facilities to build and sustain a system of quality performance measurement and quality improvement using data to regularly review program performance and design/implement an improvement plan. As part of supportive supervision and quality assurance, HCSP will ensure that site- and district-level review meetings take place and that respective improvement plans are implemented. Selected indicators such as CD4 count, Co-trimoxazole prophylaxis, condom use, STI screening and treatment, loss to follow-up and mortality rates, and TB screening, will be used to monitor program quality. This activity supports PEPFAR goals in Rwanda and is in line with the national HIV program guidelines.

In collaboration with Community Services Providers (CSP), GFTAM and PMI, HCSP will provide LLITNs, nutrition counseling, food support through IGAs, home gardening and animal breeding training, and point of use water purification kits. In addition, IntraHealth supported sites will provide health education on safe water and use MCH funds to ensure safe water supply and storage at the supported sites. IntraHealth will also continue to integrate family planning and IMCI into the program. Using screening and management guidelines developed by TRACPlus, IntraHealth will introduce the integration of mental health services in supported sites.

In line with the Partnership Framework goals, in FY 2010 and in collaboration with District Health Networks (DHN), IntraHealth will evaluate the extent to which site graduation criteria have been achieved. Based on the results of this evaluation, and with guidance from the USG, IntraHealth will begin its exit process while reinforcing capacity of district teams to manage HIV services delivery and maintaining service quality. IntraHealth will continue to support performance-based financing and negotiate with district authorities to gradually assume responsibility for staff salaries currently supported by the HIV Clinical Services Project (HCSP). IntraHealth will work with the USG team and the GOR to establish benchmarks and strategies for transition. IntraHealth will also learn from the Track 1.0 care and treatment partners' experiences.

The IntraHealth HIV Clinical Services Project (HCSP) supports health facilities in the provision of an integrated package of ARV services, including clinical evaluations, CD4 monitoring and ARV prescription services; side effects monitoring, adherence support, viral load, early treatment failure detection and switching to alternative regimens or second line regimens. In FY 2010 HCSP will continue to provide the same package of services to 6,347 existing ART patients and add 2,023 new patients at 29 ART sites, with the goal providing Art to 8,370 HIV-positive individuals. HCSP will support health facilities to perform

regular clinical evaluations and monitor their CD4 count according to the national treatment protocol. Patients will be regularly screened for OIs, receive adherence counseling, nutritional evaluation and counseling. Targeted viral load testing will be provided to facilitate early detection of treatment failure.

In line with the recent MOH instruction on task shifting, which authorizes qualified nurses to prescribe ARVs, HCSP will collaborate with TRAC Plus to provide clinical mentoring to all HCSP providers, who will subsequently be supported by district hospital doctors who tour the health facilities and coach nurses on their new role.

Through a partnership with Supply Chain Management Systems, CAMERWA(the national pharmaceutical warehouse), and district pharmacies, HCSP will provide health facilities with appropriate ARV drugs and train health care providers on stock management, dosage, and administration.

In collaboration with the National Reference Laboratory and regional laboratory network, HCSP will support sites to access CD4 counts and viral load test. Health facilities will be equipped with hematology and biochemistry materials and equipment, and will be provided with reagents for improved patient immunological and biological monitoring. Basic materials and equipment for clinical care, such as weight scales, height measures and otoscopes, will be provided. In collaboration with Mildmay International, HCSP will develop a program for HIV pediatric patient counseling and treatment adherence support, which will include treatment preparation sessions with child patient groups, distribution of flyers, and visual materials. In addition at selected sites HCSP will provide ARV treatment support to at-risk children identified through home-based care or routine consultation. Parents of children on ARV will be coached and supported during routine consultations to improve their ability to respect ARV dosage, frequency of administration and precautions in particular circumstances including school, sleepovers, and vacations without parents or guardians present.

IQ Chart has been installed in all supported ART sites, and in FY 2009 the program was expanded to include VCT and PMTCT, along with ART, in order to improve data recording, analysis and use at supported clinical sites. HCSP will continue to train data managers and health service providers on the use of the software and data. With improved data on adult basic care and support, HCSP, in collaboration with TRAC Plus and the HIVQUAL project, will support health facilities to build and sustain a system of quality performance measurement and quality improvement using data to regularly review program performance and design/implement an improvement plan. As part of supportive supervision and quality assurance, HCSP staff will ensure that site- and district-level review meetings take place and that respective improvement plans are implemented. Selected indicators such as CD4 count, Co-trimoxazole prophylaxis, condom use, STI screening and treatment, lost to follow-up and mortality rates, and TB screening will be used to monitor program quality in providing basic care and support to

adult HIV patients. IntraHealth with also support the integration of mental health services according to national guidelines under development. This activity supports PEPFAR goals in Rwanda and is in line with the national HIV program guidelines.

FY 2010 target estimation was set with consideration of four elements: supported sites' current populations and growth rates; national HIV prevalence; projected family planning user rates; and the opening of new sites. An effective and rigorous M&E system will be maintained to evaluate program results. HCSP will also collaborate with health center data managers, TRAC Plus and other partners to ensure quality data collection, evaluation and reporting using national the TB/HIV M&E Framework and tools.

Throughout FY 2010 and in collaboration with DHNs, HCSP will conduct an evaluation to measure the extent to which site graduation criteria have been achieved. Based on the results of this evaluation, and with guidance from USG, HCSP will begin its exit process while reinforcing capacity of district supervisors in the domains of supportive supervision, task shifting, and site support, while ensuring service data quality. HCSP will continue to support performance-based financing and negotiate with district authorities to assume responsibility for staff salaries currently supported by HCSP. This will be a gradual process aiming for complete transition of responsibility to the government by program close in 2012.

In the IntraHealth HCSP's first three years, access to VCT significantly expanded in the four target districts. In FY 2008, 170,068 individuals were tested through HCT services at 34 HCSP-supported HCT service outlets. Partnering with community health worker teams and other district stakeholders, HCSP supported HIV/AIDS community prevention services to 594,511 individuals. In FY 2009, HCSP will provide VCT to 114,000 at 35 HCT sites in its four districts. HCSP conducts HCT with respect to national protocols and algorithms.

In FY 2010, in line with the Partnership Framework Implementation Plan, HCSP will continue to support and mentor its 35 HCT sites. HCSP will also continue to conduct supportive supervision and quality assurance in collaboration with District Health Networks (DHNs), while expanding HCT via several approaches. HCT services will be extended into communities through community mobilization in collaboration with local leaders, with focus on family-based testing and couples-based prenuptial counseling. HCSP will also encourage provider-initiated testing at all supported sites. Meanwhile HCSP will continue to integrate reproductive health services in all HCT points, including in prenuptial

counseling. All clients who are tested and receive a positive status will be referred for ART. In FY 2010, HCSP aims to test at least 128,850 individuals and have them receive their test results. HCSP is confident to achieve this target given its successful performance thus far in ensuring effective referrals between HCT services and other HIV/AIDS clinical service points, as well as its achievements in mobilizing communities and families to be tested owing to strong community linkages, family-oriented weekend HCT sessions and participation in national HIV-testing campaigns, among other strategies.

FY 2010 target estimation was set with consideration of four elements: supported sites' current populations and growth rates; national HIV prevalence; projected family planning user rates; and the opening of new sites. An effective and rigorous M&E system will be maintained to evaluate program results.

Throughout FY 2010 and in collaboration with DHNs, HCSP will conduct an evaluation to measure the extent to which site graduation criteria have been achieved. Based on the results of this evaluation, and with guidance from USAID, HCSP will begin its exit process while reinforcing capacity of district supervisors in the domains of supportive supervision and task shifting site support, while ensuring service data quality. HCSP will continue to support performance-based financing and negotiate with district authorities to assume responsibility for staff salaries currently supported by HCSP. This will be a gradual process aiming for complete transition of responsibility to the government by program close in 2012.

In FY 2009, IntraHealth HCSP collaborated with community service providers to offer a comprehensive package of basic care and support services to 1,633 HIV-positive children at 41 sites including Co- trimoxazoleprophylaxis, nutrition counseling and food support, insecticide-treated bed nets (ITN), and safe water. In FY 2010, HCSP will continue to provide the same package to 1,633 HIV-positive children at 41 existing sites, and expand services to 401 new children from four new sites. HCSP will ensure that HIV-exposed children are followed and adhere to Co-trimoxazoleprophylaxis, in part by promoting integration with routine pediatric care, nutrition and maternal health services.

During FY 2010 at least 829 infants born to HIV-positive women will be started on Co- trimoxazoleprophylaxis within two months of birth, and they will receive their HIV status within 12 months through the early infant diagnosis (EID) program. HCSP-supported sites will link with OVC service providers operating in the Northern Zone to screen children for HIV according to national guidelines, and enroll exposed and infected children into care. In addition, HCSP-supported sites will link with all

malnutrition centers within their facility or at specialized sites and provide HIV testing to all in- and outpatients. HCSP-supported sites will enroll infected children into care and treatment services.

Using a family-centered approach, HCSP will offer HIV testing to all partners and children within families of HIV-positive adults and will enroll infected family members into care and treatment services. HCSP will also help link with PLWHA cooperatives, local PLWHA networks, and administrative district authorities to support the sensitization of adult patients and the guardians of children orphaned by AIDS for the testing of children and their enrollment into care. In FY 2010, HCSP will aim for 10,567 PLWHA to receive a minimum prevention with positives package. At PMTCT sites, mothers and exposed children will be followed up through maternal HIV care and mother counseling groups using the mother-to-mother model where HIV-positive mothers who demonstrate steady consultation attendance and good baby care will coach new HIV-positive mothers to do the same. During these counseling sessions HCSP will provide ITN, nutrition counseling, and nutrition support through IGA, home gardening, animal breeding, and food support in collaboration with CHF, WFP, as well as the consortium CRS/ACDI/VOCA/World Vision.

In addition, HCSP-supported sites will provide health education on safe water and distribute water purification products. At HCSP-supported sites HIV-positive children will be staged and those eligible for ARV will be enrolled in ART. All pediatric patients will have anthropometric evaluation, and those who are found malnourished will be rehabilitated. They will be screened at enrollment and at regular intervals later on for opportunistic infections, particularly candidiasis, meningitis, and PCP. In addition, all pediatric patients will be screened for TB at least once every six months, and those suspected of having TB will be further investigated and put on TB treatment if confirmed or strongly suspected.

HIV-exposed, infected and affected children do not have the same level of vulnerability and risk of death as non-infected or affected populations. For this reason IntraHealth will work to implement a system to assess vulnerability based on a model implemented at the Mildmay pediatric HIV clinic in Uganda, and it will provide daycare services at supported sites for children at risk of dying due to extreme poverty, parental illness or other factors. The package of daycare services will include home visits for families with HIV-positive children, nursing, and medication adherence in a child-friendly environment.

HCSP will ensure that health service providers are trained or retrained in pediatric HIV care according to national guidelines, and that they receive on-the-job coaching regularly. The trainings will particularly be related to new pediatric guidelines including topics for clinical staff as well as lab technicians. To provide early initiation of ART for all HIV-positive infants, HCSP will assist in the implementation of early infant diagnosis and follow-up through training for PMTCT staff and lab technicians, and through developing efficient and reliable sample transportation systems. HCSP staff will also train service providers at health centers in clinical HIV care, basic care and support, data recording and use, and quality performance

measurement and improvement.

Through a partnership with Supply Chain Management System, CAMERWA, the national pharmaceutical warehouse, and district pharmacies, HCSP will provide health facilities with appropriate ARV drugs and train health care providers on opportunistic infection drugs and reagents, stock management and distribution, patient counseling and pharmacy record keeping/data use. HCSP will collaborate with health facilities to survey energy needs for proper laboratory operation, IT equipment and drugs conservation.

IQChart, an electronic patient management system, has been installed in all supported ART sites, and in FY 2009 it was expanded to include VCT and PMTCT along with ART. HCSP will continue to train data managers and health service providers on the use of the software and data. With a link between pediatric HIV care indicators and PMTCT indicators in this database, follow-up of children exposed to HIV will be improved. With improved data on pediatric HIV care, HCSP in collaboration with TRAC Plus, the national performance-based financing program and the HealthQual project, will support health facilities to build and sustain a system of quality performance measurement and quality improvement using data to regularly review program performance and design/implement an improvement plan. As part of supportive supervision and quality assurance, HCSP staff will ensure that site- and district-level review meetings take place and that respective improvement plans are implemented. HCSP will ensure that pediatric HIV care is integrated with adult HIV care and that the family approach is reinforced. This activity supports PEPFAR goals in Rwanda and is in line with the national HIV program guidelines.

FY 2010 target estimation was set with consideration of four elements: supported sites' current populations and growth rates; national HIV prevalence; projected family planning user rates; and the opening of new sites. An effective and rigorous M&E system will be maintained to evaluate program results. HCSP will also collaborate with health center data managers, TRAC Plus and other partners to ensure quality data collection, evaluation and reporting using national the TB/HIV M&E Framework and tools.

Throughout FY 2010 and in collaboration with district health networks, HCSP will conduct an evaluation to measure the extent to which site graduation criteria have been achieved. Based on the results of this evaluation, and with guidance from USAID, HCSP will begin its exit process while reinforcing capacity of district supervisors in the domains of formative supervision, task shifting site support, and data quality assurance. HCSP will continue to support performance-based financing and negotiate with district authorities to progressively assume responsibility for staff salaries currently supported by HCSP. This will be a gradual process aiming for complete transition of responsibility to the government by program close in 2012.

As of the end of FY 2009, IntraHealth HCSP has 41 sites in four districts. Of these facilities, 35 provide PMTCT, and 25 provide ART for adults and for children (along with the comprehensive package of VCT, PMTCT and OI). In FY 2009, IntraHealth HCSP collaborated with community service providers to offer a comprehensive package of basic care and support services to 1,633 HIV-positive children at 41 sites including Co-trimoxazoleprophylaxis, nutrition counseling and food support, insecticide-treated bed nets (ITN), and safe water interventions. In FY 2010, HCSP will continue to provide the same package to 1,633 HIV-positive children at 41 existing sites. HCSP will ensure that HIV-exposed children are followed and adhere to Co-trimoxazoleprophylaxis, in part by promoting integration with routine pediatric care, nutrition services and maternal health services.

Throughout FY 2010, IntraHealth HCSP will continue to provide the same service package to 3,170 HIV- positive and HIV-exposed infants and children. IntraHealth will also scale up pediatric participation in treatment programs to 2,273 children at a total of 29 ART sites.

To improve pediatric HIV diagnosis, HCSP will increase testing for targeted pediatric populations within the catchment area of its sites. Using each HIV adult patient enrolled in care and treatment at HCSP- supported sites as an index case, IntraHealth HCSP will offer HIV-testing for their partners and children and enroll any infected family members into care and treatment services. HCSP-supported sites will link with OVC service providers operating in northern Rwanda to offer HIV testing services for children according to national guidelines, and ensure enrollment of HIV-positive children into care and treatment services. In addition, HCSP-supported sites will link with malnutrition and TB centers within their facilities or at specialized sites located in the vicinity to provide HIV testing to all pediatric in- and outpatients and enroll the infected children into care and treatment services. HCSP will also work to establish and strengthen linkages with PLWHA cooperatives in the local network, and the administrative district authorities and health teams to support activities aiming at raising awareness in communities on issues related to pediatric HIV, at to increase pediatric HIV testing and enrollment into care. IntraHealth will assist heath 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.

Early infant diagnosis (EID) services, now available at 33 of IntraHealth supported sites, will be expanded to achieve full coverage of sites by the end of FY 2010. EID will be offered at six weeks of age. HCSP will also work with the district health teams to ensure that samples collected at the sites are transferred

efficiently to the processing lab in Kigali, and it will collaborate with the MOH to increase reliability of result turn-around times.

At HCSP-supported sites, HIV-positive children will be staged clinically as well as using CD4 (counts and percentages as these are available). Eligible infants and children will be enrolled in ART. IntraHealth will work with other clinical implementing partners and the MOH to train health care providers on newly updated pediatric HIV treatment guidelines which include changes for early treatment of HIV-positive infants and in CD4 thresholds for treatment initiation of children between 36 and 59 months of age.

All pediatric patients will have regular anthropometric evaluations to identify early signs of malnutrition and to ensure prompt initiation of nutrition rehabilitation interventions. Newly identified patients will be screened at enrollment and at regular intervals for signs and symptoms of common opportunistic infections or other infectious complications of HIV in children, including: candidiasis, pneumonia, malaria, meningitis, and Pneumocystis jiroveci pneumonia (PCP). In addition, all pediatric patients will be screened for TB at least once every six months. Children suspected of having TB will be further investigated and put on TB treatment or INH prophylaxis if infection or exposure is confirmed based on current national guidance. Additionally, infants and children on ART will also be assessed at each visit for issues related to adverse events, toxicity and adherence to ART. 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 guidance.

Pediatric HIV care and treatment programs in Rwanda face many challenges, including the need for increased numbers of qualified trained pediatric health care providers. The HCSP will ensure that site- level providers are trained or receive refresher training session in pediatric HIV patient management according to national guidelines. Providers will receive regularly planned in-service trainings and coaching sessions. In collaboration with TRAC Plus, HCSP clinical staff will be trained to become clinical mentors who will train hospital and health center service providers in pediatric clinical HIV care, palliative care, patient record-keeping, data recording and use, and in quality performance measurement and improvement.

Through work with the Supply Chain Management System (SCMS) and CAMERWA, the national pharmaceutical warehouse, the district-level pharmacy, the National Reference Laboratory (NRL) and the regional laboratory network, the HCSP will ensure training of health service providers on HIV-related opportunistic infections, ARV drug and reagent stock management and distribution, adherence counseling, and on good pharmacy record-keeping and data use.

IQChart has been installed in all supported ART sites, and in FY 2009 the system was expanded to

include VCT and PMTCT along with ART. HCSP will continue to train data managers and health service providers on the use of the software and data. With a link between pediatric HIV care and PMTCT indicators in this database, follow-up of children exposed to HIV will be improved. Basic pediatric HIV care and support and treatment data will be used to regularly review program performance and design/implement appropriate interventions to improve the quality of services provided to children and their families. HCSP staff in charge of each district will ensure that meetings to review internal data take place on a regular basis and that the improvement plan is implemented at individual sites. Yearly district- level meetings are planned where each facility will share their performance data and improvement strategies. HCSP will ensure that pediatric HIV care is integrated with adult HIV care and that the family approach is reinforced.

An effective and rigorous M&E system will be maintained to evaluate program results. HCSP will collaborate with health center data managers, TRAC Plus and other partners to ensure quality data collection, evaluation and reporting using the national TB/HIV M&E Framework and tools.

Throughout FY 2010 and in collaboration with DHNs, HCSP will conduct an evaluation to measure the extent to which site graduation criteria have been achieved. Based on the results of this evaluation, and with guidance from USAID, HCSP will begin its exit process while reinforcing the capacity of district supervisors in the domains of supportive supervision, task shifting site support, and data quality assurance. HCSP will continue to support performance-based financing and negotiate with district authorities to progressively assume responsibility for staff salaries currently supported by HCSP. This will be a gradual process aiming for complete transition of responsibility to the government by program close in 2012.

IntraHealth HCSP has expanded and advanced PMTCT services in Rwanda. During HCSP's second year, pregnant women received comprehensive PMTCT services at 35 PMTCT sites. Male involvement rates were also high at PMTCT sites with 17,336 male partners tested (80%). Male participation rates at Nyagatare Health Center and Kibagabaga Hospital reached 100% in certain months. A total of 2,364 couples received pre-nuptial counseling and testing service at HCSP-supported PMTCT sites; among these couples, 17 were sero-discordant.

During FY 2009 HCSP effectively integrated family planning and safe motherhood counseling within the PMTCT service package to address primary prevention of HIV infection; prevent unintended pregnancies

among women infected with HIV; and prevent mother-to-child transmission of HIV. As of September 2009, 557 HIV-positive couples receiving services at HCSP-supported sites were using a FP method. In collaboration with the World Food Program (WFP), 33 PMTCT/CT HCSP service sites were provided with weaning food and nutritional support for 1,500 families. Throughout FY 2010, in collaboration with DHNs, HCSP will continue to facilitate supportive supervision of these same services at 35 PMTCT sites. To promote integration with routine FP/MCH/RH services, HCSP will support provider training and IEC material dissemination, as well as ensure that FP methods are available and offered in all HIV/AIDS clinical service points.

In FY 2010, HCSP will provide an expanded PMTCT package of services to 24,037 pregnant women at 33 existing CT/PMTCT sites. Target estimation was set with consideration of four elements: supported sites' current populations and growth rates; national HIV prevalence; projected family planning user rates; and the opening of new sites. The PMTCT package includes training master trainers to ensure on-the- job training and ensuring linkages between PMTCT and HIV care and treatment, MCH, and nutrition in HCSP-supported sites. Linkages with the surrounding community via PAQ teams and PLWHA cooperatives will also be reinforced. An emphasis will be placed on following-up HIV-exposed infants as well as conducting CD4 counts for all HIV-positive pregnant women and providing treatment for all those found eligible. HCSP will also provide supplemental food for HIV-positive infants, and pregnant or lactating women. All health providers will be trained on couples counseling therefore implement interventions for discordant couples and reinforce repeat testing for HIV-negative partners. Services will be provided to keep discordant couples in care, ensure that positive partners of negative women receive ART and the negative partners remain negative.

In line with the Partnership Framework Implementation Plan, HCSP will gradually transfer supervision and management of PMTCT sites to DHNs and, graduating sites as outlined in the original program proposal document and with guidance from USG. Expanding PMTCT services also involves cross- cutting issues such as strengthening Human Resources for Health, food and nutrition, and preventing and reducing gender-based violence.

HCSP will provide support to District health networks and health facilities to optimize all four prongs of PMTCT and ensure comprehensive and integrated service provision. HCSP'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, HCSP will 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. HCPS 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. An effective and rigorous M&E system will be maintained to evaluate program results.

Throughout FY 2010 and in collaboration with DHNs, HCSP will conduct an evaluation to measure the extent to which site graduation criteria have been achieved. Based on the results of this evaluation, and with guidance from USG, HCSP will begin its exit process while reinforcing capacity of district supervisors in the domains of supportive supervision and task shifting site support, while ensuring service data quality. HCSP will continue to support performance-based financing and negotiate with district authorities to assume responsibility for staff salaries currently supported by HCSP. This will be a gradual process aiming for complete transition of responsibility to the government by program close in 2012.

As of FY 2009 IntraHealth HCSP supports TB HIV services at 40 health facilities. TB-HIV collaborative activities have the following components: HIV testing for all TB patients; Co-trimoxazole preventive therapy for co-infected patients; TB testing for HIV-positive clients and TB treatment; Co-trimoxazole preventive therapy for those diagnosed with TB; and TB infection control measures at the four district hospitals at which staff were trained on infection control.

In FY 2010, IntraHealth HCSP will continue the same package of services at 40 existing sites to screen 21,134 HIV-positive clients for TB and provide TB treatment for 226 HIV-positive clients. HCSP will collaborate with TRAC Plus, the district support department at the MOH, and the local district team to ensure that new HIV services are put primarily in facilities that already have TB services in order to facilitate integration efforts. In addition to the core activities of TB-HIV integration, HCSP will improve finding active TB cases among PLWHA enrolled in care by training motivated community volunteers, traditional healers, drug dispensers and lab technicians in the use of a five-question questionnaire so that laboratory tests, drug refills, traditional healers, and home visits are also opportunities to screen PLWHA for TB. In addition, HCSP will ensure with in-service training that there are sufficient numbers of trained personnel to support VCT services to also screen HIV-negative people for TB using the same

questionnaire, given that symptoms that motivate HIV testing are similar to TB symptoms even in HIV- negative patients. HCSP will ensure that TB service providers are trained in HIV service provision and that Co-trimoxazoleand ARVs are available to them in order to provide HIV services to TB patients during TB care before they are transferred to the ART ward at the end of their treatment. In line with MOH policies and strategic plans, HCSP will ensure that laboratory staff is trained in the newly-adopted TB diagnosis and that HIV and particularly pediatric patients are supported with transport and exam costs during investigation for smear-negative and extra pulmonary TB diagnoses. HCSP will ensure good compliance to ionized preventive therapy for all children under five who are living with smear-positive diagnosed adult TB patients according to national guidelines. In addition, HCSP will ensure that health center staff is trained in infection control and in implementing their infection control plan. In collaboration with DHNs, HCSP will conduct supportive supervision and coordinate with civil society partners to mobilize the community.

FY 2010 target estimation were based on four elements: supported sites' current populations and growth rates; national HIV prevalence; projected family planning user rates; and the opening of new sites. An effective and rigorous M&E system will be maintained to evaluate program results. HCSP will also collaborate with health center data managers, TRAC Plus and other partners to ensure quality data collection, evaluation and reporting using national the TB/HIV M&E Framework and tools. HCSP continuously reviews data collection tools to make sure collected TB/HIV data are accurate.

Throughout FY 2010 and in collaboration with DHNs, HCSP will conduct an evaluation to measure the extent to which site graduation criteria have been achieved. Based on the results of this evaluation, and with guidance from USAID, HCSP will begin its exit process while reinforcing capacity of district supervisors in the domains of supportive supervision and task shifting site support, while ensuring service data quality. HCSP will continue to support performance-based financing and negotiate with district authorities to assume responsibility for staff salaries currently supported by HCSP. This will be a gradual process aiming for complete transition of responsibility to the government by program close in 2012.