FHP is follow-on to USAIDs HCSPs, which ends in COP11. FHP will continue to build service delivery capacity preparing for the eventual transition of HIV/AIDS clinical services to the GOR.

Under FHP, USG will support 120 health centers and 10 district hospitals in 12 administrative districts to implement HIV/AIDS programs as part of the Partnership Framework Strategy. Services include: VCT; staging patients in pre-ART services; ART for children and adults; PMTCT; OI diagnosis and treatment with TB screening among PLHIVs and HIV screening among TB patients; psychosocial support; nutrition screening and food supplementation for eligible clients; support for community health insurance schemes for PLHIV identified as indigents; support for income generating activities for PLHIV and OVC; and strengthened linkages to community care services.

FHP will support district health teams and local government with health decentralization. In COP12, FHP will support quality improvement initiatives, improved M&E, planning, program implementation, and capacity building in all supported health facilities to manage quality HIV/AIDS programs. Monitoring and quality services to prepare transition of clinical sites to GOR will be prioritized.

In COP11, the USG, through HIV/AIDS Clinical Service Project (HCSP), provides basic HIV care and support to the targeted 46,824 adult HIV clients at 158 clinical sites in 15 admin districts. The package of services includes: WHO clinical staging; baseline and regular CD4 counts; prevention education; screening, diagnosis and treatment of OIs including TB and STIs; adherence support; condom provision; food and nutrition support; and provision of clean water. Under HCSP, the first National Palliative Care (PC) Policy is being rolled out. The package includes pain management, psychosocial and spiritual support in both clinical and community locations, including home-based care. Additionally, HCSP is supporting the national roll out of PC in holistic approach, including support to MOH for national program coordination, development of a palliative care implementation plan, training materials, and curriculum development as well as procurement of related supplies and commodities.

In COP12, FHP in collaboration with other entities such as the National Police, legal and civil society institutions will continue to support SGBV services, including community sensitization, TA (training of site staff to handle SGBV cases at clinical levels) and linkages to community. Through FHP, USG will continue to support HIV care services in existing sites, including provision of Co-trimoxazole and other OI drugs, STIs and TB screening, and wrap around activates that facilitate a one-stop services center for PLHIV. IHSP will continue to emphasize retention of patients in pre-ART services and strong linkages to community services for economic strengthening and/or psycho-social support.

FHP will work closely with the Rwanda Biomedical Center (RBC), in providing required TA for the implementation of evidence-based care and support interventions. FHP will also support community health workers (CHWs) implementing the new palliative care policy, and monitor the quality of services provided

In COP10, HCSP supported TB/HIV integration for adults and children across ART sites in 15 districts. Services included TB screening, diagnosis and treatment among HIV positive persons. HCSP supported TB/HIV national guideline revision and its implementation at decentralized levels. In Cop 11, HCSP supported the TB/HIV training curriculum revision, theory and practical trainings as well as TA for supervision at TB diagnostic and treatment centers in the 158 sites across 15 districts.In COP12, FHP, in collaboration with other stakeholders including MOH institutions, and other implementing partners, will continue to support TB/HIV integration and collaborative activities at the health facility level. Activities will include participating in the national TB/HIV working group for revising and updating guidelines, curriculums, and tools. Supportive supervision for quality TB and HIV service delivery to co-infected patients - particularly to strengthen the implementation of routine HIV counseling and testing, especially in TB suspected cases will also be carried out. Prevention education and referral for HIV care, if indicated, for all patients with TB at the TB/DOT clinics will also be supported. In addition, FHP will support the implementation of standardized symptom-based TB screening and intensified TB case-finding for patients living with HIV. TB/HIV integrated service provision will be improved and the one stop service TB care will continue to be supported in order to avoid new co-infections.

Through collaboration with RBC, MOH, and other implementing partners, FHP will strengthen mentorship and supervision capacity at central and district level to improve quality of TB diagnosis in TB suspected cases. TB/HIV integration mentoring, including TA and supportive supervision will also be supported.

GOR estimates that there are 22,240 HIV-positive children less than 15 years of age currently in Rwanda (Epi Update, April 2010). Most of them acquired HIV through vertical transmission. In COP11 HCSP supported the scale up of Early Infant Diagnosis (EID) in all PMTCT sites. In COP12, FHP will continue to support integrated training in PMTCT, EID and nutrition to improve the capacity of health care workers on cascade testing, nutrition assessment and support, psychosocial support, and linkage to ART units for those who test positive.

Additionally, all HIV positive children will be provided with OI prevention and treatment services as recommended by the national guidelines. FHP will also continue to support EID implementation at the facility level.

FHP will continue to support and consolidate HCSP efforts to enhance adequate pediatric care within national and international recommended guidelines. In COP12 FHP will support efforts to improve and maintain quality through periodic program data reviews, feedback to the facilities and mentorship.FHP will support PICT at all entry points to ensure testing of more children and strengthen referral of newly diagnosed to ART services. FHP will also support nutrition counseling and supplementation, referrals for all HIV-positive children to malaria prevention services for provision of LLITN, as well enhancement of water purification kits and hygiene education.

USG has been supporting health systems strengthening through different mechanisms, some of which are typically clinical services projects, drawing money from non-health systems strengthening budgets. Strengthening district pharmacies, training of providers to build skill for quality health services, supporting performance-based financing and community health insurance, putting in place generators or solar panels for energy provision at health facilities and infrastructure renovations have been supported. In COP12, FHP will continue to provide targeted support to the national and district systems strengthening in support of the eventual transition clinical services to the GOR.

In COP11 HCSP supports 158 sites in 15 districts to provide CT services to a targeted 466,053 clients from the general population and provides a package of services that include: voluntary counseling and testing (VCT); couples counseling and testing (CVCT); prevention messages including BCC at health facility and community levels (including sensitization and community service outlets for VCT); as well, as referral of HIV positive cases to care and treatment programs. Provider-initiated testing and counseling (PICT), involving clients from outpatient departments, ANC, TB clinics, immunization services, hospital admissions, nutritional services, etc., are also supported. HCSP also supports GOR with decentralized trainings including on-the job-training and supportive supervision to improve the quality of services offered to clients and to implement national protocols.

In COP12, FHP will continue to support and consolidate effort made by HCSP in CT services including family-centered approaches and streamlining PICT in all facilities to maximize testing opportunities. FHP will continue to support CT activities including rapid finger prick testing in all 130 supported sites in the 12 districts. FHP will support linkages to other HIV services mainly between PMTCT and ART services and enforce a continuum of care framework to improve enrollments and support adherence to treatment. During COP12 FHP will continue to support improved pre-test and post-test counseling approaches especially for children and adolescents in order to facilitate the disclosure process and prevention (including prevention with PHIV). Human resource capacity will continue to be strengthened, including TA, targeted new and refresher trainings, as well as supportive supervision. FHP will support regular data collection, management, and reporting in order to improve the informed decision making.

In COP12 FHP will promote and implement interventions targeting the general public and most-at-risk individuals as part of a broad, science-based approach to primary, secondary, and tertiary prevention of HIV. In COP 11, HCSP prioritized cross-referrals spanning community and clinical contexts to provide individuals with multiple behavioral and biomedical prevention services and, where indicated and feasible, reducing socio-economic vulnerabilities that lead to high-risk situations.

In COP12, primary prevention activities will entail correct condom use for youth and adults, partner testing, couples VCT, and improved STI diagnosis and management. FHP will continue to identify most-at-risk HIV-negative clients within VCT services, and provide them with intensified and personalized risk reduction counseling.

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 COP12. 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, and 8) Referral to care, treatment and support services for HIV-positive persons, including high risk groups to community-based programs.

GOR has developed a five-year National Strategic Plan on HIV and AIDS 2009 -2012 (NSP) with a goal to halve HIV incidence in the general population by 2012. USG, has supported the scaling up of PMTCT services to improve geographic accessibility, and by COP11, through USAID, 158 health facilities in 15 districts were providing PMTCT services. From October 2010 to September2011, the number of pregnant women counseled, tested and given their results (including maternity) were 101,233 (99% of those attending ANC). A total of 1,673 (1.65%) pregnant women tested HIV positive. Of the women who accepted the test, 83% were tested with their partners. HCSP provided technical support to the central and decentralized levels through trainings, mentorship and technical supervision and facilitated joint site level monitoring with district health teams as a way of building national capacity. HCSP supported GOR to implement the new WHO PMTCT option B protocol of using more efficacious regimen as well as the current elimination of MTCT strategy of reducing HIV mother-to-child transmission rate below 2% by 2015.

For COP12, FHP targeting considered national goals to target 90,883 pregnant women with known HIV status for PMTCT services for COP12. In COP12 strategies to improve testing in PMTCT including finger prick and provider-initiated counseling and testing (PICT) testing models will be used. FHPs support to GOR will emphasize monitoring implementation and progress of these activities including the establishment of five new PMTCT sites whose support is planned with Partnership Framework money.

FHP will consolidate and reinforce previous efforts to integrate PMTCT into existing maternal and child health interventions, integrated management of childhood illnesses, expanded program of immunization as well as sexual and reproductive health. FHP will continue to support nutrition in PMTCT services and ensure effective use of the infant and young children counseling and training package within a harmonized framework to enhance adherence and mother/infant pair follow-up

In COP11 HCSP supports 27,210 adults currently on ART in 13 district hospitals and 145 health centers in 15 districts. The treatment program includes: clinical staging and baseline CD4 count for all PLHA; timely initiation for those eligible for ART according to CD4 cell counts of 350 cells/ µl or WHO clinical staging according to national guidelines; follow-up of patients CD4 counts every six months; management of opportunistic infections (OIs) and other HIV-related illnesses - including OI diagnosis, preventive therapy with Co-trimoxazole (CTX) prophylaxis regardless of CD4 counts; nutritional counseling and food support; psychosocial counseling and support; positive living and risk reduction counseling; and palliative care for pain and symptom management and end-of-life care.

Currently the majority of patients on ART are on first line drugs, an indication that early diagnosis of treatment failure may still be weak. In COP12 FHP will support capacity building for early diagnosis and management of treatment failure through mentoring and targeted viral load testing according to clinical indications. FHP will support targeted refresher trainings, participate in national TWGs, provide mentorship and supportive supervision to the national treatment program, support program data analysis to inform planning, and link with other stakeholders at the national and decentralized levels to support a sustainable HIV program. In COP12 FHP will continue to use electronic databases that facilitate patient follow-up and support to district health networks and districts administrations to improve planning for health and provide better coordination.

Under FHP, USG will continue to support capacity building for providers, district pharmacies, as well as technical assistance for clinical treatment to enable the eventual transition of services to GOR institutions without any lost in the quality of services provided.

During COP11, HCSP implementers continue to support the national HIV pediatric program at central and decentralized levels. HCSP supports dissemination of guidelines, tools, & training materials used in HIV pediatric care & treatment programs. HCSP supports GOR to conduct refresher training for trainers and training of providers on task shifting. HCSP also supports provider-initiated testing at all pediatric in- and outpatient settings at PEPFAR supported sites, laboratory trainings & mentorship to improve diagnostic capacity of facility staff, reinforced psychosocial support for HIV-positive children and adolescents through support groups to address issues around status disclosure and adherence support.

HCSP supports pediatric HIV integration with other services including TB screening, assessment, and provision of nutrition services as well as integrated management of childhood illness. During COP 11, HCSP targeted 400 children under 15 years that were enrolled in care and treatment programs. In COP11 4,663 targeted children are provided with at least a minimum package of care.

In COP12, FHP will continue to support pediatric treatment integration within the national healthcare system. Efforts will be made to reinforce PICT at all entry points to enroll more children, support capacity building strategies through training, joint supportive supervision, and effective strategies to maintain quality care provision. FHP will support: 1) National roll out of the Mother/Infant/Young Children Nutrition package to all sites and community level that were initiated in COP10; 2) Improved nutritional services at all PMTCT & ART sites, including staff training on infant and young child feeding and maternal nutrition; 3) Improved 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; 4) Pediatric treatment adherence through support groups, and 5) Neonatal, infant and child death audits within an integrated model.