Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 4729
Country/Region: Rwanda
Year: 2007
Main Partner: FHI 360
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $0

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $0

[CONTINUING ACTIVITY FROM FY2006 -- NO NEW FUNDING IN FY2007] This activity relates to FHI-BHC ( 4767), FHI CT(4769), CHAMP-OVC (2810), CHAMP PMTCT (2805), PBF PMTCT (2814), and FHI ART(4770).

In partnership with the GOR and other donors, Rwanda EP will improve the quality and efficiency of PMTCT service delivery and will prioritize sustainability of PMTCT services through innovative approaches for quality assurance, performance improvement, and health financing. In line with the Rwanda EP five-year strategy and GOR priorities, FHI will ensure access to a comprehensive network of services for PMTCT clients and their families, link PMTCT services with other HIV and MCH interventions, and engage communities to seek and promote PMTCT interventions.

In line with GOR national guidelines and protocols, FHI will ensure the provision of the full package of PMTCT services, including revised CT strategy to include opt-out CT with informed consent; ARV prophylaxis using an expanded bi-therapy regimen; IF counseling and support; and provision or referral for FP and MCH services at 21 existing and 10 new sites. To support the EP goal for sustainability, FHI will prepare 14 sites for graduation to the PBF to ensure quality of services meet PBF technical critera. PBF and FHI will each be responsible for 6 months worth of targets for the 14 graduated sites. HIV rapid test kits will be procured through RPM+, and ARVs, hemoglobin testing materials for the new regimen will be procured through Columbia MCAP.

Providers will receive training in the expanded national PMTCT protocol. FHI will build capacity of sites to provide the new PMTCT regimen through the use of existing national checklists and algorithms, M&E, supervision of providers, and appropriate documentation of implementation of the new regimen. FHI will incorporate additional safe motherhood, FP and GBV counseling into PMTCT activities in collaboration with IntraHealth. Sites will increase testing of male partners, particularly partners of HIV-positive PMTCT clients, and will work to facilitate disclosure and mitigate the impact of GBV. FHI will support HCs to use national infant feeding counseling tools and guidelines developed by UNICEF and TRAC, monitor infant feeding practices among HIV-positive women, and leverage food support for pregnant and lactating mothers and weaned or non-breastfeeding infants.

FHI will support the network model through the provision of, or formal referral for, a comprehensive package of prevention, care, and treatment services. This package includes systematic provision of CTX PT for and PCR testing of HIV-exposed infants; routine CD4 testing and/or clinical staging of all HIV-positive pregnant and postpartum mothers and infants; clinical monitoring, referral for ART and treatment adherence support; TB screening, diagnosis, and treatment; management of other OIs and HIV-related illnesses; psychosocial services; and access to prevention, care and treatment services for family members. In collaboration with the CHAMP and CS Coordinators, FHI will ensure referral of PMTCT clients and their families to HBC services, OVC support programs, PLWHA Associations, IGA, and facility- and community-based MCH services promoting key preventive interventions. These community-based services will assist HCs to monitor and track pregnant and postpartum HIV-positive women and their infants, as well as promote MCH and PMTCT health seeking behaviors.

To ensure the success of the network system, FHI will fund a CS Coordinator at their sites when applicable, and will work with CHAMP partners, the CS Coordinators, DHTs and referral facilities to develop monitoring and tracking mechanisms between facility and community-based services. This could include use of referral slips, community-based registers, patient cards and other monitoring tools to facilitate transfer of information between facilities and communities. Through targeted program support for DHTs, FHI will also build the supervisory and monitoring and evaluation skills of 8 DHTs, including routine data collection, data use and reporting for PMTCT services at facility and community levels. See FHI-ARV (4770).

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $0

[CONTINUING ACTIVITY FROM FY 2006 -- NO NEW FUNDING IN FY 2007] This activity is linked to FHI's CT activity (4769) and PSI's condom distribution activity (4877).

This project will focus on HIV prevention, CT, and STI screening and syndromic management for CSW in Kigali. FHI will continue this successful intervention which began under COP05 at the Biryogo HC. The project aims to improve CSWs' knowledge of how to prevent STIs and HIV/AIDS. FHI will expand outreach efforts, CT, clinical care, STI screening and treatment services to CSWs in Kigali. An FBO formed by current and former CSWs will continue outreach efforts to refer CSWs and their clients to the clinic for these services. CSWs and their clients receive both pre- and post-test counseling which includes ABC prevention information. For individuals testing HIV positive, Biryogo HC offers CD4 and ART services and referrals to community HIV care programs.

A new element to the program will involve connecting CSWs to local microfinance activities (both USG-funded and non-USG funded), in order to offer CSWs alternative means of income. This program will work with PSI to ensure condom availability at the Biryogo clinic as well as information for CSWs on other points-of-sale for condoms in the area. The information gathered from this project will contribute to the development of national guidelines on HIV prevention and STI screening and treatment. FHI will follow the National STI Protocol developed in 2002. This activity anticipates reaching at least 100 known CSWs and many more women who will not identify themselves as CSWs, although they engage in transactional sex. This project did not set a target for the number of men reached, acknowledging that men will not identify themselves as clients of CSWs. FHI will combine ABC prevention education, quality CT ensuring confidentiality and informed consent and STI services to reduce risky behaviors among CSW and their clients. This activity supports the Rwanda EP five-year strategy and the National Prevention Plan by targeting high-risk populations.

***PLUS-UP ADDITION: Under this activity, FHI will provide technical assistance to TRAC for the design, execution and analysis of a survey on sexual and risk behaviors among PLWHA in Rwanda (see description in TRAC activity). Once the survey results have been analyzed, FHI will collaborate with TRAC and national network of PLWHA (RRP+) to 1) conduct an inventory of "prevention for positives" IEC materials currently available in the country; 2) identify critical gaps in the content of these IEC materials; 3) design clinical and community IEC materials to fill these gaps; 4) develop a training module on prevention for positives for clinical settings (to be integrated with the national care and treatment training curriculum); and 5) incorporate the findings of the behavioral survey into the national care and treatment norms and guidelines. Clinical IEC materials will be printed, reproduced and distributed by TRAC, while community IEC materials will be produced and distributed by CHAMP in cooperation with RRP+.***

Funding for Care: Adult Care and Support (HBHC): $0

[CONTINUING ACTIVITY FROM FY2006 -- NO NEW FUNDING IN FY2007] This activity relates to activities under PBF in BHC (#2815) and under FHI under ARV Services (#4770).

FHI will expand palliative and basic health care in eight districts to reach 10,400 HIV-positive, including 6,431 ART patients at 10 new, 26 continuing and 14 graduating health facilities (See BHC-PBF #2815). In 2005, FHI is piloting expanding the role of nurses at HCs to include limited ARV support. This will enable ARV patients to receive basic and palliative care and ART at their local HC. In COP05, FHI supported CTX prophylaxis for eligible PLWHAs. In COP06, basic and palliative care support will provide for all PLWHAs: initiation of an individual patient medical record, clinical staging and semi-annual CD4 counts, CTX prophylaxis, OI care, palliative care, "prevention for positives" counseling, ARV treatment for eligible patients, and referral to community support services. FHI will support training and monitor the quality of practice of providers in basic and palliative care. The USG will procure OI and palliative care drugs for all USG supported health facilities. (See Activity #5116.)

FHI and PBF will develop a joint transition plan to graduate 14 HCs to performance-based contracting. BHC targets and COP06 financing for these 14 sites will be divided between the PBF and FHI for the transitional year. Sites will need to demonstrate sufficient technical and institutional capacity before transfer to PBF. FHI will also support eight health districts to strengthen their network of care.

FHI will treat 985 children with CTX prophylaxis. HCs will identify these children through follow-up of PMTCT mothers, identification of exposed infants at immunization, early infant diagnosis through PCR dry-blood spot technology and improved identification of older infected children. FHI will support HC nurses to monitor HIV-infected infants and to stage them for ART. FHI will support eight DHTs and district physicians to supervise HCs providing ARV and basic services to infants and children.

FHI will support HCs to coordinate their basic services with community basic and palliative services through a Clinical Care Coordinator at each health center. FHI will work with CHAMP (Activity #2811) to develop effective referral systems between clinical care providers and psycho-social and medical support services in non-clinical settings. Community services will support HBC services, adherence counseling, spiritual support, stigma reducing activities, OVC support, IGA activities, and legal support services. FHI will support HCs to refer children to OVC programming for access to education, medical, social and legal services. FHI will support HCs to identify and support women who may be vulnerable when disclosing their status to their partner. HC counseling will include the role of alcohol in contributing to high-risk behaviors. EP partners will leverage food aid, including therapeutic feeding, for PLWHA and for food insecure households (particularly for pregnant and lactating women and their infants). Strengthening basic and palliative health care nationally will help to achieve the goal of sustainability as outlined in the Rwanda EP five-year strategy.

Funding for Care: TB/HIV (HVTB): $0

[CONTINUING ACTIVITY FROM FY2006 -- NO NEW FUNDING IN FY2007] This activity is also related to ARV services (#4770 ), CT (#4769), and HIV/TB (#5129). Integration of TB and HIV services is a fundamental component of the Rwanda EP five-year strategy, which describes training and supervision activities, HIV/TB surveillance, and the development of model centers for TB/HIV testing and treatment. This activity will support the strengthening of TB/HIV services at 38 health centers, including 28 existing and 10 new sites. FHI will also prepare 14 sites offering TB/HIV services for graduation to PBF through limited technical support provided to the MSH/PBF for the graduating sites to ensure TB/HIV service delivery in line with PBF graduation criteria. Targets for these graduating sites are divided evenly between FHI and MSH/PBF.

FHI will reach 163 TB/HIV co-infected patients through routine testing of all TB clients for HIV, systematic screening of HIV-positive clients for TB, and provision or referral for TB treatment. FHI will provide TA to the health centers, hospitals and DHTs in eight districts in the development of referral systems for TB/HIV services. This will include the collection and transport of sputum samples for testing at TB referral sites, and when necessary, the referral of clients for chest x-rays or other TB services not available on site. Health providers will refer family members of HIV-positive co-infected patients for TB screening and treatment. In collaboration with PNILT, DHTs, and other partners, FHI will enhance provider capacity in management of TB/HIV through ongoing supervision and QA of TB/HIV activities, and use of job aids and site-level algorithms in line with PNILT guidelines. FHI will also integrate messages on the importance of TB/HIV co-infection into health center education activities.

To strengthen follow-up and monitoring of TB/HIV patients, FHI will develop monitoring and tracking mechanisms within and across facilities to assure that patients access and complete treatment. This will include working with districts, sites and PNILT to strengthen routine data collection and reporting of TB/HIV co-infection. FHI will also coordinate with CHAMP to ensure community-based follow-up of HIV/TB co-infected patients through the pilot Community-Based DOTS activity. In collaboration with CHAMP, the facility-based CS Coordinator and facility staff will support and supervise community TB DOTS volunteers on TB/HIV follow-up and referrals. ****PLUS-UP**** $260,000 - This activity supports the establishment of x-ray capacity at four district hospitals to increase timely, quality TB diagnosis and active TB disease case detection among PLWHA. This support will include procurement of x-ray machines and supplies, all necessary renovations, and technician and health care personnel training to interpret chest radiographs for radiological findings (often atypical) consistent with pulmonary TB disease among PLWHA, as an important diagnostic tool. The HIV epidemic has been associated with a significant increase in the reported incidence of smear negative pulmonary TB in PLWHA when compared to those without HIV infection. PLWHA with smear-negative pulmonary TB have poorer treatment outcomes and higher mortality in resource-limited settings. Therefore, timely, quality diagnosis is imperative. Both international guidelines and Rwanda National TB program guidelines include chest radiography as an important component of the diagnostic algorithm of smear-negative pulmonary TB. There is international consensus to strongly encourage the use of chest radiography early in the diagnosis of smear negative pulmonary TB among PLWHA wherever possible, and to improve chest x-ray interpretation and reading capacity by clinical practitioners, including nurses, through specialized trainings and by encouraging peer review. Increased chest radiography capacity at these sites is also expected to improve smear negative TB case detection among patients presenting with TB symptoms and provide additional numbers of patients to be tested for HIV and referred for HIV care and treatment services.

An additional 400 HIV-infected clients attending HIV care/treatment services will be appropriately screened for TB using x-ray. 36 HIV infected clients attending HIV care and treatment services will receive treatment for TB disease. An additional 20 personnel will be trained in a key elements of diagnosing TB among PLWHA and will provide timely treatment.

Funding for Testing: HIV Testing and Counseling (HVCT): $0


This activity also relates to activities in FHI- HBHC (#4767) and FHI-Other Prev (#4765). In line with the EP goals, FHI will reach 94,746 individuals including 9022, through a strategic mix of high-quality PIT and client-initiated CT services that ensure confidentiality, combat stigma and discrimination, and reach those individuals most likely to need treatment. This activity will strengthen CT services at 22 existing and 10 new health facilities, and will prepare 14 sites for graduation to the PBF through limited technical support to the PBF contractor for the graduating sites. All 14 sites will be allocated to the PBF contractor and CT targets will be divided evenly between FHI and the PBF.

At all FHI-supported health facilites, including eight DHs reaching 9022 patients (50% of expected in-patients), PIT CT services will target adult and pediatric inpatients, patients presenting with TB and other HIV-related OIs and symptoms, malnourished adults and children, HIV-exposed infants, and STI patients, with the goal of achieving 25% through PIT of all those counseled and tested. Providers will routinely encourage testing of family members, particularly children, of ART and PMTCT patients. In collaboration with CHAMP and the CS coordinator, health providers will work with PLWHA associations, churches, community DOTS programs, and OVC and HBC programs to identify infected patients, in particular HIV-exposed infants, family members of PLWHA, and OVC. Health facilities will continue to provide traditional VCT (client-initiated) services for pre- and post-nuptial couples, ANC male partners, and youth. Counseling messages will emphasize prevention, including abstinence and fidelity, alcohol reduction, GBV sensitization, and disclosure of test results. FHI will support training or refresher training of new and existing staff in confidential PIT that includes modified counseling messages, and enhanced prevention to promote abstinence and fidelity, alcohol reduction, GBV, and disclosure. In line with the revised GOR CT protocol, health facilities will modify testing procedures from venous blood draw to whole blood/finger prick to maximize efficiency of rapid tests. To enhance efficiency of client-initiated testing at sites, nurse counselors will also be trained to perform rapid tests under the supervision of a laboratory technician. Lay counselors, PLWHA association members, and other non-health professionals will be utilized to support counseling and testing activities at the health facility level under supervision of nurses or other health center staff. To strengthen the network model for PLWHA and their families, FHI will establish a formalized referral system to link community care and clinical services. PLWHA will be offered or referred for CTX PT, TB screening, CD4 and clinical staging, and other prevention, care and treatment services. The CHAMP clinical-community coordinator will ensure HIV-positive patients are referred for community-based services, such as IGA, PLWHA associations, OVC, and HBC programs

At the health facility level, FHI will ensure a system for supportive supervision of nursing and counseling staff, including training of select staff in supervision for CT, use of quality control checklists, and data quality control. Through FHI and PBF-funded district support, DHTs will gain skills in planning, monitoring, and evaluating CT services, through support for QA and supervision, data analysis and use, reporting, and financial management.

Funding for Treatment: Adult Treatment (HTXS): $0

[CONTINUING ACTIVITY FROM FY 2006 -- NO NEW FUNDING IN FY 2007] This activity relates to activities CHAMP-ARV (2809) and PBF-ARV (4003). This financing covers costs of sub-agreements with 25 health facilities for ARV service delivery and the cost of supporting eight DHTs to strengthen the ARV network of care.

ARV Service Delivery: In collaboration with other ARV implementing partners and consistent with MOH vision, FHI will provide a standardized package of ARV services to 3960 patients (including 200 pediatric patients) at 18 sites and expand ARV services to 2575 new patients (including 636 new pediatric patients) at approximately 7 new sites through support and development of a coordinated network of HIV/AIDS services in eight districts. FHI will provide full ARV services at larger health centers and a limited package of ART services at satellite health centers using nurses as the primary ARV provider with physician back-up. FHI will ensure that eligible women in PMTCT and eligible PLWHA are enrolled for ART at the health-center level or according to DHT plans.

In COP05, FHI is piloting expanded role of nurses in the provision of ARV care. This model of care will be implemented more broadly by all implementing partners in 2006. District hospital physicians will support nurses through regular visits, on-going phone access for urgent questions and use of clinical protocols to guide nurses' ARV practice. Patients needing urgent medical care beyond nurses' scope of expertise will be referred to the appropriate level of care. The long term goal is to maximize the capacity of the most decentralized level of service, thus increasing patient access to ARV care in rural communities. CHAMP will similarly decentralize and provide ARV patients with community support services for adherence and retention.

Additionally, FHI will continue to expand pediatric ART outpatient services, as part of a coordinated pediatric project including early infant diagnosis through PCR, CTX prophylaxis, and ARV treatment of eligible infants and children. FHI will pilot the graduation of two ARV sites to performance-based contracting -- one full ARV site and one ARV satellite -- by the end of 2006. FHI will assure a service environment sensitive to issues that may limit women's access to HIV/AIDS care.

Strengthen the ARV Network Model: Rwanda is actively decentralizing local government and has recently aligned administrative districts with health districts. Health districts now have budgetary and administrative authority over health service delivery. The USS has been charged with integrating all HIV/AIDS services into the minimum package of care to be provided in all health facilities and managed at the district level. Through PBF Pol System Strengthening (2813) USG will also support the USS and DHTs to coordinate performance-based contracting and quality assurance. FHI will provide a package of support to eight DHTs in Byumba, Gitwe, Kabgayi, Remera-Rukoma, Kigeme, Kibugo, Bugasera and Ruli districts to strengthen their capacity to coordinate an effective network of ARV and other HIV/AIDS medical services. Support to DHTs will focus on strengthening the linkages, referral systems, transport, communications and financing systems necessary to support an effective ART and other HIV/AIDS care network. This network focuses on maximizing access to ARVs and other HIV/AIDS services and improving quality of care at the most decentralized level. CHAMP will link community services to clinical care at decentralized health centers, reflecting a dual bottom-up/top-down approach to expansion of service outlets and entry points for care.

FHI will provide a basic package of financial and technical support to DHTs, including staff positions, transportation, communication, training, and other support. Key responsibilities of DHTs include assuring access of patients to quality HIV/AIDS care, organization of specific care components (full and limited ARV services, ARV and OI medications, commodities, lab tests, community services) and good management of resources.

Strengthening the capacity of the USS and DHTs supports the sustainability and national scale-up goals outlined in the Rwanda EP five year strategy. The ARV network model fully supports the Rwanda EP five year strategy by pursuing ARV treatment targets through cost-effective utilization of Rwanda's limited human and financial resources. In addition, this FY2006 assistance will build district and site capacity for future transfer of USG partner- supported sites to local entities through the PBF project.

****PLUS-UP**** $815,000 - Under the base COP06 budget, a limited amount of funding was allocated for a basic package of district support. With supplemental funding, FHI will provide additional personnel and TA support to nine DHTs to further enhance transport and communications activities between health centers, district hospitals, district pharmacies and community based services. DHTs will have increased capacity to conduct supervision, quality assurance, and M&E of the network model.

Rwanda is facing a long-term energy crisis due to the country's small capacity for energy production and distribution. Supply of electricity to rural areas is poor, and many health facilities rely on one or more high-capacity generators just to support their most basic functions. Generators are extremely expensive to procure and maintain and are not a sustainable solution in the long term. Some USG partners have already begun investing in solar energy as a more cost-effective means of supplying power to lab machines, refrigerators and other essential equipment at ARV sites. With the funding allotted for this activity, USG will support an assessment of electrical infrastructure and supply at Rwanda's district hospitals and procure solar equipment (panels, circuitry and batteries) for the hospitals in most dire need. It is anticipated that USG will be able to provide a solar energy package for ARV services at approximately 7-9 district hospitals with the funds indicated.

Subpartners Total: $0
Muyanza Health Center: NA
Byumba Hospital: NA
Nyabikenke Health Center: NA
Health Centrer, Mukungu: NA
Kigeme Hospital: NA
Kirambi Health Center: NA
Ruramba Health Center: NA
Kivumu Health Center: NA
Mugina Health Center: NA
Nyarusange Health Center: NA
Ruhango Health Center: NA
Centre de Santé Kabgayi: NA
Gitwe Hospital, Rwanda: NA
Remera Rukoma Hospita: NA
Masaka Health Center: NA
Nyamata Hospital: NA
Ruli Hospital: NA
Biryogo Health Center: NA
Bungwe Health Center: NA
Rugege Health Center: NA
Health Center, Kayove: NA
Kigufi Health Center: NA
Health Centre, Murara: NA
Gitarama Health Cente: NA