ICAP is one of the USG partners providing HIV care and treatment services for HIV-positive adults and children in Rwanda. By the end of FY 2009, Columbia was supporting 56 sites in 9 districts to offer high quality HIV care and treatment services. In addition, Columbia supported the Government of Rwanda's effort to integrate services with the aim of maximizing efficiency and effectiveness of HIV services. In this respect, Columbia supported TRAC Plus to introduce the integration of mental health and HIV at Ndera Pneuropsychiatric hospital, and the Maternal and child health unit and TRAC Plus to pilot a tool for the screening of family planning needs. In addition, using its multidisciplinary, quality and family centred approach to the provision of HIV care local while targeting capacitation and sustainability, Columbia supported district teams to own, oversee, supervise and mentor health centers under their jurisdiction. In FY 2010, Columbia will enhance this transfer of skills to UPDC and the district teams, starting with the progressive transfer of responsibility for subagreement management and then program management, monitoring and evaluation and reporting.

Columbia will support 9 DHTs to strengthen their capacity to coordinate an effective network of PMTCT and other HIV/AIDS medical services. Support to DHTs will focus on strengthening the linkages, referral, transport, communications and financing systems necessary to support an effective PMTCT and other HIV/AIDS care network. Columbia will provide financial and technical support to DHTs, including staff positions, transportation, communication, training of providers using the trainers trained by TRAC+, and other support to carry out their key responsibilities. PBF is a major component of the Rwanda exit strategy for ensuring long-term sustainability and maximizing performance and quality of services. In coordination with the HIV PBF project, Columbia has shifted some of its support from input to output financing based on sites' performance in improving key national HIV performance and quality indicators. Full or partially reduced payment of PMTCT and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national quality supervision tool. In FY 2010 ICAP will continue to assist DHTs to strengthen the M&E system through training service providers and managers in appropriate use of M&E tools as well as use of data for planning and activity monitoring. ICAP will assist the national and district program to improve data collection and reporting on key indicators. In FY 2010, ICAP will transition the management of some of the subagreements as well as the M&E and reporting functions of TRAC clinic to the MOH depatrment UPDC. During this transition, ICAP will provide support to UPDC on financial and project management as well as reporting to UPDC. ICAP will train and mentor relevant UPDC staff on aspects of project management and reporting and gradually withdraw its support as the capacity of UPDC develops. With the support of the 3 technical advisers seconded to UPDC, ICAP will intensify the training and mentorship of UPDC on the measurement and assessment of the quality of care; gradually leaving this exercise to them.

In FY 2009, Columbia provided basic care services (BCS) to 38,302 and ART to 19,170 PLWHA at 46 sites; which included 4,646 and 4,777 new patients enrolled into care and ART respectively. In FY 2010, ICAP will continue to provide high quality BCS at the 46 existing sites to 38,302 existing patients and an additional 6,070 new patients; and continue to provide high quality ART to the existing 19,170 patients and initiate 3,591 new patients on ART (in accordance with the new generation indicators bringing the cumulative total in care to 44,372 and on ART to 22,761. To ensure comprehensive services across a continuum, ICAP will continue to support the referral of patients enrolled in care to community-based BCS services based on their individual needs.

In FY 2009, Columbia supported TRAC Plus and Ndera Neuropsychiatric Hospital to integrate HIV and mental health services. Under this approach, mental health patients are evaluated for their mental illness as well as HIV/AIDS. Depending on the mental and medical status, an HIV test is proposed and performed either immediately (if the patient is very ill with signs of AIDS) or later (after stabilization) if the medical situation is not worrisome or suggestive of advanced AIDS disease. In FY 2010, ICAP will work with Ndera Neuropsychiatric Hospital, TRAC Plus and the Mental Health unit to scale up mental health and HIV integration services to the other 9 ICAP-supported district hospitals.

In FY 2009, ICAP continued to support high quality pediatric HIV care and treatment services at the two model centers and 44 other sites. A comprehensive package of basic care and support services was provided to 4,688 HIV-positive children and treatment to 2,570. ICAP has been instrumental in initiating family testing as a means to identify HIV-positive children and other adults in the household who would benefit of early care interventions. In FY 2010, ICAP will continue to provide a comprehensive package of care to 4,688 old HIV-positive children and 400 new ones. And provide treatment services for 242 new children to reach a cumulative total of 5,088 of children in care and 2,812 of children on ART by end of FY 2010. To address the need to expand diagnosis of HIV in the pediatric population ICAP will continue to strengthen testing for targeted pediatric populations within the catchment area of its existing sites. Using each HIV adult patient enrolled in care and treatment at ICAP-supported sites, as an index case, ICAP will offer HIV-testing for their partners and children and enrolls the infected family members into care and treatment services.

At PMTCT sites, support groups of HIV-positive women will be strengthened based on the mother-to- mother model and PEARL program approach. Early infant diagnosis services, now available at all ICAP PMTCT supported sites, will be strengthened. EID will continue to be offered at six weeks of age and at any other ages for symptomatic infants less than 18 months post natal according to the national algorithm. ICAP will continue support to 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 work with the MOH to increase reliability of result turn-around times.

The prevention of unintended pregnancy amongst HIV-positive women is one of the most cost-effective means of preventing mother to child transmission. In FY 2009, Columbia supported the Maternal and child health unit of the Ministry of Health and TRAC Plus to pilot, at 3 sites in Kigali, a tool for the screening of family planning desires amongst HIV patients. In FY 2010, Columbia will support the MOH institutions in finalizing the review of the tool and scaling up its utilization at national level.

In FY 2009, ICAP supported MOH to develop SGBV guidelines and piloted the initiative at Muhima and Gisenyi District Hospitals. In FY 2010, ICAP will continue to support the Ministry of Health during the national training of trainers on SGBV and roll-out SGBV in HIV programs considering the lessons learned from one year implementation program of the SGBV pilot phase. ICAP will scale-up the initiative at 5 district hospitals and 10 health centers. ICAP will train Peer Educators on SGBV to enable them to sensitize community on prevention of SGBV. In collaboration with the Rwanda National Police, ICAP will support the health facilities to assure that the SGBV victims receive the services on time as recommended in national guidelines.

In the context of the transition plan, ICAP-CU will transition its sub-Agreement with CAAC to MOH. During COP 10, ICAP-CU will continue to actively participate in the PBF extended technical working group, and provide support DHTs and site staff for capacity building through training in use of PBF tools, improvement of site documentation, sites performance evaluation, site data quality assurance to improve key national HIV performance and quality indicators. Full or partially reduced payment of BCS and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool. In collaboration with MOH Community Desk and RRP+ ICAP-Cu will continue to support the two local NGOs for capacity building in implanting community PBF through its Peer Education Program (PEARL) to improve key community health indicators.

Under the transition arrangements/planning, CDC will channel funding for some of the ICAP-supported sites to UPDC or another entity to be identified jointly by CDC and GOR, and the PBF funds directly to CAAC. In FY 2010, ICAP will support UPDC to provide technical support and mentorship to the transitioned sites and support develop the capacities of UPDC in financial and programmatic

management and reporting. ICAP will continue its support to CAAC in financial management, training of districts staff on PBF as well as the evaluation and verification of bills.

In FY 2009 Columbia provided a comprehensive package of ART services to 23,309 patients at 46, including 2,330 children. In FY 2010 Columbia will completely transition the provision of ART services at TRAC Plus clinic to the MOH. Columbia will support the provision of ART at the remaining 45 sites, providing ART to 22,888 existing patients and initiating ART with 3,325 new patients, including 333 pediatric patients. The package of services provided in FY 2010 will include treatment with ARV drugs, routine CD4 follow up, CD4 tests for all HIV-positive people tested at non-ART sites and Bactrim provision before they become eligible to ART and then transferred to ART sites, viral load testing screening, management of ARV drug side effects, and patient referrals to community-based care. In FY 2010 Columbia will expand quality clinical services, continue support to DHTs, increase sustainability through quality assurance and capacity building, delegate greater responsibility to district teams, and strengthen SI at all levels. To ensure a continuum of care, Columbia will support the training and supervision of community volunteers including CHWs, PLWHA association members, and other caretakers.

In FY2010 ICAP will provide support to the MOH and TRAC Plus for the revision of task-shifting guidelines,and will provide continued support of in-service training and mentorship for the health care providers at ICAP supported sites,

In FY 2010 Columbia will support TRAC Plus and Ndera Neuropsychiatric Hospital to scale up the integration of mental health and HIV treatment at the nine Columbia-supported district hospitals. Columbia will support the training of two doctors and four nurses from each district hospital in mental health and HIV service integration, in addition to providing support for the finalization and roll out of mental health screening tools to the nine hospitals. Columbia will also promote the development of a referral and counter-referral system between Ndera Hospital and Columbia-supported facilities. Finally, Columbia will support mentorship and supervision visit by the neuropsychiatric hospital's staff to the nine district hospitals.