In 2008, ICAP was awarded a cooperative agreement, Strengthening the Capacity of the Rwandan Ministry of Health (SCMOH), to strengthen the capacity of the Rwandan Ministry of Health (MOH) and district health teams to integrate TB/HIV, provide quality pediatric HIV care, and laboratory support to HIV and TB programs, building on the successes of the UTAP Program. The program emphasizes knowledge and skills transfer to GOR partners to ensure long term impact and builds on earlier successes through the UTAP program. UTAP began in 2003, and included a range of technical assistance to the MOH, including TB/HIV program integration, HIV-related laboratory services strengthening, expanding pediatric HIV care and treatment services, strengthening the capacity of Rwandan nurses to treat PLWHA, and public health evaluations.

In the first year of the SCMOH project, ICAP made significant progress in implementing planned activities. As a new program, the first few months focused on program start up activities, and most importantly, collaborating with key MOH partners on work plans to secure full buy-in to the project and to assure that the activities meet the capacity building and technical assistance needs of the government. ICAP also began recruiting new staff and negotiated subcontracts with key partners. Major achievements thus far include: 1. Supported the national TB/HIV integration Technical Working Group (TWG), including development of a plan of action for 2009 2. Assisted UPDC and TRAC Plus with on-site training in TB screening at 71 non-USG supported care and treatment sites, follow-up supervision, evaluation of TB/HIV standards of care and strengthening of the TB/HIV M&E capacity of the sites teams and district health teams 4. Supported the National Reference Laboratory (NRL) and the two university teaching hospitals (CHUK, CHUB) to improve the lab infrastructure by renovating and equipping the TB labs and defining the minimum package of activities for each level of the lab network 5. Supported NRL with the development of a QA/QC program within the TB lab network by implementing integrated supervision tools and strengthening and expanding existing QC programs 6. Supported CHUK with the development of the concept and work plan for the practical training program in pediatric HIV at the pediatric model center and conducted a first training session in October, 2009 for 9 participants from health facilities in Kigali

This program emphasizes systems strengthening and the transfer of skills and competencies as central components of ICAP's activities. A variety of approaches ensure capacity-building at all levels: • ICAP staff transfer capacity to the staff and institutions of TRAC Plus, MOH, and partners via technical working groups, meetings, trainings and institutional support. • Tools and best practices are shared with MOH and other partners including USG and non-USG funded institutions • The capacity of district health team (DHT) and health facility staff is strengthened via educational and training activities including on-site implementation workshops, supervision and mentoring, and support for evidence-based program and performance management, as well as off-site training to enhance knowledge and skills.

In the second year of the SCMOH program, ICAP continues to strengthen the capacity of TRAC Plus, UPDC and District Health Teams (DHTs) by supporting implementation of a quality assurance approach for TB/HIV and pediatric HIV through decentralized training, supervision and mentoring. Support continues to TRAC Plus to scale up the full package of TB/HIV collaborative activities at sites nationwide. ICAP is providing support to CHUK for expansion of the pediatric HIV practical trainings. In addition, ICAP

is currently supporting the laboratory network for improvement of quality control and implementation of new diagnostic techniques for TB diagnosis.

In FY 2010 ICAP will continue to strengthen the capacity of TRAC Plus, UPDC, partner institutions and DHT by supporting decentralized training, supervision and mentoring of TB/HIV integration activities. ICAP will provide continuous support to TRAC Plus and its partners to scale-up the "one-stop" TB service model and routine screening of PLWHA to all TB and HIV service sites nationwide with additional focus on TB infection control. The ICAP TB/HIV and M&E teams will also provide technical support enabling TRAC Plus to fully integrate M&E of TB/HIV services within the national system. In collaboration with TRAC-plus and UPDC, ICAP will continue to organize decentralized evaluation meetings each semester in order to permit the analysis of TB and HIV data and to inform the program at district and national level. In addition, ICAP will continue to collaborate with TRAC Plus and UPDC to scale up implementation of the quality improvement program based on Standards of Care (SOC) evaluation for TB/HIV which will be utilized by DHTs in collaboration with on-site providers.

ICAP will continue to strengthen HIV-related laboratory services by supporting central level labs (NRL, CHUs) and the national laboratory network. This will include support to the TB and HIV lab technical working group to plan, implement and coordinate the national TB and HIV lab activities. Key activities in FY 2010 will be to train TB and HIV lab specialists at the central and peripheral level, and to strengthen implementation of new TB lab techniques introduced in the first and second year of the program to improve the quality of diagnosis. Quality improvement within the lab network will be addressed by supporting supervision, QA/QC program implementation by lab level and specific diagnosis areas. To reinforce the management of the laboratory network, specific support will be provided to NRL to secure the national supply of lab reagents, equipment and consumables, and to improve lab data management and analysis in order to generate accurate lab indicators to monitor the lab program. In FY 2010, ICAP will continue support to NRL for the WHO-AFRO accreditation process for the HIV and TB central level labs.

In addition, in FY 2010, ICAP will continue providing technical assistance to key MOH partners to increase national capacity to provide quality HIV care and treatment services for children. With TRAC Plus and UPDC, ICAP will continue its support of the national pediatric TWG, which includes participation from all implementing partners. ICAP will continue support for the revision of necessary national program tools and job aids and will provide financial support and technical guidance to CHUK on implementation of the practical training program. In addition to support to the TWG, ICAP will provide technical support to UPDC to implement a standardized approach to pediatric HIV care and treatment quality improvement at the district level and to evaluate the system.

None

ICAP is committed to strengthening national capacity to deliver high quality pediatric HIV services through intensive support to TRAC Plus, UPDC and the University Teaching Hospital of Kigali (CHUK), with a focus on training and quality improvement. ICAP gives technical assistance to TRAC Plus through the pediatric technical working group. Another major accomplishment has been the development of an approach for the CHUK national pediatric training center. The first training was organized in October 2009 for 9 participants from different health facilities in Kigali.

In FY 2010, ICAP will continue to support TRAC Plus through a high level Senior Pediatric HIV Advisor to supervise the implementation of the new pediatric care and treatment guidelines, to develop or update related job aids as required, and to plan for the evaluation of its implementation. In addition, support will be provided to TRAC Plus to organize quarterly meetings of the pediatric HIV technical working group to share lessons learnt by different partner institutions in pediatric program implementation; to promote

harmonization, standardization and quality improvement of pediatric care; and to jointly seek solutions for identified challenges.

ICAP will continue to support 2 additional staff at CHUK (Pediatric HIV Training Officer and Pediatric HIV Nursing Officer). In addition, ICAP has a direct sub-agreement with CHUK for organization of practical training sessions on pediatric HIV care and treatment for multidisciplinary teams from district hospitals and health centers. 9 practical training sessions will be organized during FY 2010. Each session will accommodate 9 members of 3 different multidisciplinary teams from district hospitals and health centers nationwide. The cadre of pediatric nurses at CHUK will train staff from clinical sites on issues related to testing children in various clinical settings, on counseling children's parents as well as on HIV diagnosis disclosure for older children. In addition, Columbia University will support CHUK in establishing a library and in gaining access to scientific journals on pediatric HIV care and treatment. A group of physicians from the CHUK pediatric HIV model center will provide long-distance mentoring, discuss the management of difficult cases with district hospital staff, and serve as an on-site training resource for health care providers from the various districts hospitals and health centers. This assistance is expected to improve the clinical skills of health professionals managing pediatric HIV cases at the peripheral level. ICAP will also support a stakeholders gathering to develop and implement a CHUK training evaluation plan so as to assess progress made, identify challenges and ways for improvement.

ICAP will also continue to provide support to UPDC through the District Support Specialist and the Pediatric HIV District Support Nursing Officer to strengthen implementation at district and site level of a quality approach using pediatric HIV standards of care evaluation. Training in the quality assurance approach will be carried out for 10 DHT, followed by intensive supervision and site support by the UPDC teams in collaboration with ICAP.

ICAP will also work with TRAC Plus, UPDC and CHUK to train and supervise a cadre of TRAC Plus and UPDC mentors who will be critical in harmonizing the approach of pediatric HIV care best practices for all the sites, and continuously improve overall pediatric care quality throughout the country.

ICAP is committed to strengthening national capacity to deliver high quality pediatric HIV services through intensive support to TRAC Plus, UPDC and the University Teaching Hospital of Kigali (CHUK), with a focus on training and quality improvement. ICAP supported the drafting of terms of reference for the national pediatric HIV working group. Another major accomplishment has been the development of

the approach for the CHUK national pediatric training center, and the first training was organized in October 2009 for 9 participants from different health facilities in Kigali.

In FY 2010, ICAP will continue to support TRAC Plus through a high level Senior Pediatric HIV Advisor to supervise the implementation of the pediatric care and treatment guidelines, to develop or update related job aids as required, and to plan for the evaluation of its implementation. In addition, support will be provided to TRAC Plus to organize quarterly meetings of the pediatric HIV technical working group to share lessons learnt by different partner institutions in pediatric ART program implementation; to promote harmonization, standardization and quality improvement of pediatric treatment; and to jointly seek solutions for identified challenges.

ICAP will continue to support 2 additional staff at CHUK (Pediatric HIV Training Officer and Pediatric HIV Nursing Officer) in addition to a direct sub-agreement with CHUK for organization of practical training sessions on pediatric ART for multidisciplinary teams from district hospitals and health centers. 9 practical training sessions will be organized during FY 2010. Each session will accommodate 9 members of 3 different multidisciplinary teams from district hospitals and health centers nationwide. The cadre of pediatric nurses at CHUK will be used to train staff from clinical sites on issues related to testing children in various clinical settings, on counseling children's parents', and on HIV diagnosis disclosure for older children. A group of physicians from the CHUK pediatric HIV model center will provide long-distance mentoring support, discuss management of difficult cases with district hospitals staff, and serve as on- site training resource for ART providers from the various districts hospitals and health centers. This assistance is expected to improve the clinical skills of health professionals managing pediatric HIV cases at the peripheral level. ICAP will also support a stakeholders gathering to develop and implement a CHUK training evaluation plan so as to assess progress made, identify challenges and ways for improvement.

ICAP will also continue to provide support to UPDC through the District Support Specialist and the Pediatric HIV District Support Nursing Officer to strengthen implementation at district and site level of a quality approach using pediatric HIV standards of care evaluation. Training in the quality assurance approach will be carried out for 10 DHT, followed by intensive supervision and site support by the UPDC teams in collaboration with ICAP.

ICAP will also work with TRAC Plus, UPDC and CHUK to train and supervise a cadre of TRAC Plus and UPDC mentors who will be critical in harmonizing the approach of pediatric ART best practices for all the sites, and continuously improve overall quality of pediatric treatment throughout the country.

ICAP will continue to support Quality Improvement with a review of indicators, medical dossiers and viral

load measurements to develop and strengthen clinical capacity for more efficient and quality-assured patient management. ICAP will ensure participation of health center and country program staff in District Health Team meetings for better collaboration. ICAP will work with the National Reference Laboratory to expand the diagnostic resources for HIV at the sites. ICAP will also work to improve reporting linkages with CAMERWA and continue mentoring health center staff to strengthen their ability to receive, manage, and forecast the needs for ARVs.

5. Columbia University Mailman School of Public Health/MCAP

In FY 2009, ICAP has been supporting pediatric HIV care at 46 sites in the western province, in Kigali region and in Huye district in Rwanda. Site support included staff training and mentoring on identification HIV-positive children at various entry points of care, their enrolment in care and treatment program, and long term follow-up. In addition, ICAP site-support teams have been providing guidance to sites for the strengthening of their care system: patient flow, delivery of a standardized package of care at follow-up visits, regular multidisciplinary team meetings, appropriate documentation of pediatric care practices, and regular use of a standards of care (SOCs) tool to monitor progress in delivering quality care for children. By September 2009, 4,027 children were enrolled in care, including 2,172 children on ART.

In FY 2010, ICAP will continue to collaborate with the district to ensure refresher training of health care providers on pediatric HIV treatment at the 46 supported sites. This will include, among other topics related to pediatric HIV treatment, the new national pediatric ARV treatment guidelines, identification and management of ART failure cases, and psychosocial support to children, adolescents and their families for ART adherence.

ICAP pediatric and clinical advisors will be carrying out monthly site visits for staff mentoring during which support will continue to be provided for the strengthening of the care system and of children support groups activities, and for the active tracking of follow-up defaulters. ICAP will also be providing support to sites for the appropriate documentation of pediatric HIV treatment practices, for the use standards of care tools to monitor progress in delivering quality care to children, as well as for regular multidisciplinary meetings to discuss SOCs findings and to address identified challenges.

All these activities will be contributing to the site maturation process that will be monitored through global SOCs scores and an assessment of the capacity of health care providers to design interventions to address identified challenges. FY 2010 starts the first year of transition of TRAC 1.0 partners' activities. ICAP-CU AIDS will transition to the Ministry of Health (MOH) XXXX HIV care and treatment sites which will be selected based on their demonstrated capacity to continue implementing high quality care for children with minimum support.

Since 2004, ICAP has provided financial and technical support to the National Reference Laboratory (NRL) and to the entire national laboratory network to improve laboratory infrastructure and capacity for TB and HIV/AIDS testing, care and treatment.

In FY 2009, through ICAP's long-term Lab advisors placed at NRL, comprehensive technical assistance and implementation support has strengthened essential elements of the laboratory system and improved the quality and consistency of services. ICAP has conducted assessments of laboratory services and together with district health teams (DHTs) and NRL supervisors have conducted training of laboratory staff both offsite and onsite trainings that included ART laboratory monitoring, equipment operation and preventive maintenance, comprehensive laboratory tests including TB microscopy and early infant diagnosis (EID) using dried blood spot (DBS) samples for DNA PCR.

The National Reference Laboratory and two referral laboratories located in Rwanda (Kigali University Teaching Hospital (CHUK), and Butare University Teaching Hospital (CHUB)) are being equipped to perform more complex testing such as TB culture, TB molecular diagnostics (PCR), TB drug susceptibility testing and identification of Mycobacterium Avium Complex (MAC) and other atypical mycobacteria. In FY 2010, ICAP will continue to provide technical assistance to the 3 labs in ensuring the development of the required capacities for using these new technologies. In addition, the NRL and the two referral laboratories will oversee the training and supervision of TB-related activities in the lower tier labs to improve the quality of microscopy-based diagnostic tests. A joint approach has been developed for specimen transportation from the lower tier labs to the reference laboratories for TB culture and other specialized tests.

In FY 2010, ICAP will continue to provide technical assistance in conducting training at NRL, CHUK and CHUB for TB solid and liquid culture, molecular diagnostic (PCR) detection of MDR-TB and the identification of MAC and other atypical mycobacterium as the demand is expected to grow in FY 2010 with scale-up of active TB case findings among PLWHA and their families. ICAP will provide technical assistance to conduct 2 refresher courses planned for staff of NRL, CHUK and CHUB in the new TB diagnostic techniques.

ICAP will provide technical assistance to strengthen and expand quality assurance (QA) programs within the laboratory network in both international and national EQA programs, to support continuous improvement via on-site supervision, coaching and mentorship and by revising and implementing SOPs, log books and documentation and records. ICAP will continue to provide technical and logistic support to implement and expand systems for specimen transportation among testing health centers, district hospitals and referral hospitals.

ICAP will continue to provide technical support to strengthen laboratory management towards accreditation of the higher tier of laboratories: NRL, CHUK, CHUB, King Faysal Hospital and Kanombe Military Hospital. To assist in having a relevant data management system at the central level of the lab network, ICAP will provide assistance to the NRL and APHL to support the implementation and decentralization of the LIS.

In FY 2009, Columbia continued to implement the national TB/HIV policy and guidelines at 44 ICAP supported sites including 2 state prisons. The program's achievements in 2008, 98% of all patients with TB were tested for HIV, 91% of all infected patients received Co-trimoxazolepreventive therapy and 46% received ART. At 44 MCAP-supported HIV care and treatment sites, 93% of patients newly enrolled in HIV care in 2008 were screened for TB.

In FY 2010, Columbia will continue to support 46 existing sites and add 10 new sites for the implementation of the TB/HIV component of the clinical package of HIV care. The priority in FY 2010 will be to expand HIV testing to all TB suspects and enroll those positive in HIV care and treatment, expand implementation of regular TB screening for all PLHIV, and for those suspected to have active TB, ensuring adequate quality diagnosis and complete treatment with DOTS.. In FY 2010, Columbia will continue to support individual sites to continue early case detection, quality case management and follow-up. In addition, in FY 2010, ICAP will support scale up of the implementation of the TB infection control policy as well as the national PIT policy at ICAP supported ART sites. ICAP will ensure high quality recording of individual patient information, collect quality data, and to report and review these data. ICAP will then use program data to understand and improve their program and to support integration of TB and HIV services at the patient and facility level based on national guidelines. Efforts will be made to progressively transition the supervision and mentoring of the TB/HIV activities at site level to the district teams. This will be done through a collaborative approach based on evaluation of TB/HIV standards of care, district evaluation meetings and supportive supervision and mentorship of the district team.