PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Subdivisions of Program Areas, these track general higher level sub-classifications of expenditure.
Subdivisions of Major categories, these are the most detailed expenditure data.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008
This is a continuing activity from FY 2007. No narrative required.
This is a continuing activity from FY 2007.
Columbia began providing basic palliative care to 28,000 PLHIV at 46 sites. Palliative care services in FY
2008 will continue including clinical staging and baseline CD4 count for all patients, follow-up CD4 every six
months, management of OIs and other HIV-related illnesses, including OI diagnosis and treatment, and
routine provision of CTX prophylaxis for eligible adults, children and exposed infants based on national
guidelines, basic nutritional counseling and support, positive living and risk reduction counseling, pain and
symptom management, and end-of-life care. In addition, Columbia will continue to provide psychosocial
counseling including counseling and referrals for HIV-infected female victims of domestic violence. To
ensure comprehensive services across a continuum, Columbia, through the partnership with CHAMP and
other community services providers, refers patients enrolled in care to community-based palliative care
services based on their individual need, including adherence counseling, spiritual support, stigma reducing
activities, OVC support, IGA activities, and HBC services for end-of-life care. Through SCMS, Columbia will
provide diagnostic kits, CD4 tests, and other exams for clinical monitoring, and will work with SCMS for the
appropriate storage, stock management, and reporting of all OI-related commodities.
In FY 2008, Columbia will expand its services to provide palliative care for 28,000 existing patients and add
an additional 4,646 new patients at 46 existing sites and 10 new sites, including 46 ART sites and 10
TC/PMTCT sites. Expanded services will emphasize on quality of care, continuum of care through
operational partnerships, and sustainability of services through PBF. Strengthened nutritional services
through training and provision of nutritional care will include counseling, nutritional assessments using
anthropometric indicators, and management of malnutrition through provision of micronutrient and
multivitamin supplements, and links to Title II food support for clinically eligible PLHIV and children in line
national nutrition guidelines. Columbia will also support referrals for all PLHIV and their families for malaria
prevention services, including for the provision of LLITNs, in collaboration with CHAMP, GFATM and PMI;
and referral of PLHIV and their families to CHAMP CBOs and other community-service providers for
distribution of water purification kits and health education on hygiene. In addition family planning education,
counseling and methods will be provided to PLHIV and their spouses. This service will be located within the
counseling unit of the site to reduce need for referrals.
Strengthened psychological and spiritual support services for PLHIV at clinic and community levels will be
done through expanded TRAC training in psychological support for all Columbia-supported health facilities
and community-based providers, including GBV counseling, positive living, and counseling on Prevention
In addition the Ministry of Health will implement a new community health policy in FY 2008. The policy calls
for the election of male and female leaders for every 100 households to lead community health activities,
organize other community volunteers into associations and supervise their activities. Columbia will support
56 facilities to train, equip, and supervise 20 community health leads per health facility, in addition to other
health care workers, reaching a total of 1,254 health workers trained. These community health workers will
organize periodic meetings to ensure quality and coverage of community-based HIV services and linkages
between community and facilities. The facility-based case managers, community health leads and
community based services providers constitute an effective system that ensures continuum, coverage and
quality of palliative care.
In order to ensure continuum of HIV care, Columbia in collaboration with CHAMP, will recruit case
managers at each of the supported sites. These case managers, with training in HIV patient follow-up, will
ensure referrals to care services for pediatric patients identified through PMTCT programs, PLHIV
associations, malnutrition centers, and OVC programs. To do this, the case managers will have planning
sessions with facilities and community-based service providers and OVC services providers for more
efficient use of patient referrals slips to ensure timely enrollment in care and treatment for children
diagnosed with HIV/AIDS. Columbia -supported sites will assess individual PLHIV needs, organize monthly
clinic-wide case management meetings to minimize follow-up losses of patients, and provide direct
oversight of community volunteers. The community volunteers will be organized in associations motivated
through community PBF based on the number of patients they assist and quality of services provided.
Columbia will work with CHAMP to develop effective referral systems between clinical care providers and
psycho-social and livelihood support services, through the use of patient routing slips for referrals and
counter referrals from community to facilities and vice versa. Depending on the needs of individuals and
families, health facilities will refer PLHIV to community-based HBC services, adherence counseling, spiritual
support through church-based programs, stigma reducing activities, CHAMP-funded OVC support, IGA
activities (particularly for PLHIV female and child-headed households), legal support services, and
community-based pain management and end-of-life care in line with national palliative care guidelines.
Increasing pediatric patient enrollment is a major priority for all EP clinical partners in FY 2008. To expand
quality pediatric care, Rwanda's few available pediatricians will train other clinical providers, using the
innovative model developed in FY 2006 and continuing in FY 2007 and FY 2008. Columbia will support
health facilities to refer HIV-infected children to OVC programming for access to education, medical, social
and legal services. Columbia will also support sites to identify and support women who may be vulnerable
when disclosing their status to their partner, and include in counseling the role of alcohol in contributing to
high-risk behaviors. Case managers will conduct regular case reviews with other partners included in the
referral system to review the effectiveness of the system, identify challenges and design common strategies
to overcome any barrier to pediatric patients routing between services. In addition, adult patients enrolled in
care will be encouraged to have their children tested and infected ones taken to HIV care and treatment
PBF is a major component of the Rwanda EP strategy for ensuring long-term sustainability and maximizing
performance and quality of services. In coordination with the HIV PBF project, Columbia will shift some of
their 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 palliative care 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 the context of decentralization, DHTs now play a critical role in the oversight and management of clinical
and community service delivery. Columbia will strengthen the capacity of four DHTs to coordinate an
effective network of palliative care and other HIV/AIDS services. The basic package of financial and
Activity Narrative: technical support includes staff for oversight and implementation, transportation, communication, training of
providers, and other support to carry out key responsibilities.
This activity addresses the key legislative areas of gender, wrap around for food, microfinance and other
activities, and stigma and discrimination through increased community participation in care and support of
In FY 2007, Columbia began implementing the national TB/HIV policy and guidelines at their 46 supported
sites including two state prisons. The program's achievements include an improvement in the percentage of
TB patients tested for HIV from less than 70% to 90% and improving HIV-infected TB patient's access to
HIV care and treatment (increased proportion of patients accessing cotrimoxazole and ART).
In FY 2008, the goal is to ensure at least 95% of all TB patients are HIV tested, and 100% of co-infected
patients receive cotrimoxazole, and 100% of those eligible will receive ART. At 10 MCAP-supported PMTCT
and HIV care and treatment sites, 95% of 40,800 patients enrolled in HIV care will be routinely screened for
TB. However, lower than expected numbers of PLHIV in care and treatment are diagnosed and treated for
TB. The priority in FY 2008 will be to expand implementation of regular TB screening and for all PLHIV, and
for those with suspect TB, ensuring adequate diagnosis and complete treatment with DOTS.
In FY 2007 Columbia supported training in routine recording and reporting for the national TB/HIV
programmatic indicators. Initial uptake and quality of services has been variable at different sites. In FY
2008, Columbia will support individual sites to both collect quality data, and to report and review these data
in order to understand and improve their program and support integration of TB and HIV services at the
patient and facility level, per national guidelines. Additionally, in FY 2007 two staff from each of the seven
supported district underwent initial respiratory infection control training and have begun drafting infection
control plans and one is being implemented at a district hospital.
HIV services are not yet available at all facilities in Rwanda. In order to ensure effective integration of TB
and HIV, Columbia is supporting integrated planning and TB/HIV training to both HIV services providers and
TB services providers. It also plans to increase support to integrate diagnostic services, including
coordinating specimen transport for both programs and patient transport for appropriate diagnostic services
(such as chest radiography and diagnostics required for extra pulmonary TB) to referral centers and
In FY 2008, 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. This activity reflects the ideas presented in the
EP five-year strategy and the Rwandan National Prevention Plan by advancing the integration of TB/HIV
services through the operationalization of policies and increased coordination of prevention, counseling and
testing and care and treatment services. Lessons learned from integrating TB and HIV will serve in
integrating HIV into the primary healthcare.
This activity is continuning from FY 2007. No new narrative is required.
Noted April 24, 2008: This activity has been abandonned.
With these funds Columbia MCAP in collaboration with CDC, TRAC and clinical partners will conduct a
targeted evaluation of the causes of deaths of a representative sample of patients enrolled in HIV care at
selected health facilities in Rwanda.
Title of study: A descriptive analysis of the causes of death in patients enrolled in HIV care in Rwanda
Time and money summary: $200,000 for a total duration of 12 months
Local Co-investigator: The study will be conducted by Columbia University and TRAC in collaboration with
CDC, and clinical partners providing HIV services in Rwanda.
Project description: In both resource rich and poor settings, access to ART significantly increases the
survival of HIV-infected patients, prevents OIs, and delays the onset of AIDS stages 1-6. However, high risk
of mortality has been observed among ART patients in resource-poor settings, especially during the first few
months after ART initiation, compared to those in resource-rich settings. The risk of death increases during
the first 6 months after starting ART, then it decreases continuously thereafter. About two-third of the early
deaths are observed during the first three months after starting ART. In a study among ART-naïve patients
enrolled in a community-based ART program in South Africa, the mortality rate (deaths per 100 person-
years) was 35.6 at 1 month before starting ART, and access to ART resulted in a significant decrease in the
mortality, to 17.5 at 4 weeks, 6.2 at 6 months, and 2.7 at 9 months, after ART initiation. Advanced HIV
disease at enrollment and the occurrence of OIs (e.g. mycobacterial infection/tuberculosis) were identified
as the causes for the increased risk of mortality during the first months after starting ART. The risk of death
was significantly associated with WHO clinical stage of disease and blood CD4 cell count at baseline.
While CD4 count, clinical stage and OIs like tuberculosis are predictive of increased risk of mortality among
patients on ART, routine data collection has found deaths both in patients on ART and pre ART. This raises
issues of medical follow-up, lack of adherence to treatment and family and community support and delay in
enrollment on ART.
The number of patients on ART in Rwanda has increased from 17,000 in December 2005 and reached
40,768 by the end of July 2007. It is expected that 64,226 patients will be on ART by December 2007.
National data shows a cumulative death rate of around 7% among patients on ART. But an analysis of the
ART outcomes, particularly in terms of survival and circumstances of death among HIV-infected patients on
ART (which is currently being conducted) would be substantially enhanced by inclusion of controls (ART
patients who do not die) as a comparison group.
Hypothesis: When compared with PLHIV in care and ART who are alive (controls), PLHIV in care and on
antiretroviral therapy (ART patients) who died within the 12 months of enrollment (cases) are less likely to:
1. Live closer to ART site
2. Have CD4 count testing at regular intervals
3. Have antiretroviral drug (ARV) regimen changes
4. Have home visits and adhere to treatment
5. Receive social support services in family and through PLHIV associations
6. Receive care from a health facility that offers a comprehensive package of care
7. Have diagnosed and timely treated concurrent TB respiratory infections
1. When does death occur in pre-ART and ART patients?
2. What factors are associated with mortality among ART patients?
3. What factors are associated with mortality among pre-ART patients enrolled into care?
4. Is there a significant difference in mortality and the causes thereof between pre-ART and ART patients?
5. What is the association between CD4 cell count testing at regular intervals, ARV regimen changes,
distance from clinic, support from family, communities and PLHIV support group, home visits, and mortality
among ART patients?
Programmatic importance/anticipated outcomes:
This evaluation will utilize routinely collected data from Rwandan HIV care and treatment sites on patients
who are enrolled into care and treatment. The result of the data analysis will be used by HIV program
implementers and the Ministry of Health's Treatment and Research AIDS Center (MOH/TRAC) for program
evaluation and improvement. It will provide expedient and essential data to the MOH/TRAC and other
partners regarding the performance of the national HIV care and treatment program and facilitate
prioritization of limited resources for program improvement. Knowing mortality predictors will guide the
design of interventions that decrease mortality rates among PLWA receiving care and treatment.
A retrospective chart abstraction will be used. Additional information will be collected at home to understand
the circumstances of death, adherence issues, etc. A case-control methodology will be utilized for analysis
of the data. One case will be selected for three controls in ART patients and six controls in the pre-ART
patients respectively. A statistically representative sample of ART-naive PLHIV who initiated ART between
October 1, 2004 and at least one month prior to the date of data abstraction, and who are known to have
died within the first 12 months of enrollment will be considered cases. A statistically representative sample
of ART naive PLHIV who initiated ART in the same month as cases and who have similar baseline WHO
clinical stage as cases and were not known by the health care facility to have died, and who initiated ART
between October 1, 2004 and at least one month prior to the date of data abstraction will be included as
A statistically representative sample of pre-ART PLHIV who enrolled into care between October 1, 2004 and
at least three months prior to the date of data abstraction, and who are known to have died will be
considered cases. A statistically representative sample of pre-ART PLHIV who have similar baseline WHO
clinical stage as cases, were enrolled in the same month and were not known to have died by the health
care facility, and who enrolled into care between October 1, 2004 and at least three months prior to the date
Activity Narrative: of data abstraction will be included as controls.
For any single case, the controls will be selected from patients with similar WHO clinical stage who initiated
ART (in the case of ART controls), or enrolled into care (in case of the pre-ART patients) two months before
or after the corresponding date for the case.
Study Population: HIV patients enrolled into care or on ART who die and their controls who did not die.
Sample size calculation:
A representative sample will be calculated considering a power of 80%, 95% confidence interval, and
considering a relative risk of death at 2 and alpha value at .05.
For the ART patients:
1) Cases: ART naive PLHIV who initiated ART between October 1, 2004 and at least one month prior to the
date of data abstraction, and who are known to have died by the health care facility or after home visits
during the first 12 months after ART initiation.
2) Controls: ART naive PLHIV who have similar baseline WHO clinical stage of disease as cases, were not
known to have died by the health care facility, and who initiated ART between October 1, 2004 and at least
one month prior to the date of data abstraction.
3) Matching criteria: There will be three controls per case. Cases and controls will be matched by 60 days
before or after date of ART initiation and on WHO clinical stage of disease.
For the pre-ART patients
4) Cases: Pre-ART PLHIV who enrolled into care between October 1, 2004 and at least three months prior
to the date of data abstraction, and who are known to have died by the health care facility or after home
visits during the first 12 months after enrollment into HIV care.
5) Controls: Pre-ART PLHIV who have similar baseline WHO clinical stage of disease as cases, were
enrolled the same month, were not known to have died by the health care facility, and who were enrolled
between October 1, 2004 and at least one month prior to the date of data abstraction.
6) Matching criteria: There will be six controls per case. Cases and controls will be matched by 60 days
before or after date of enrollment and on WHO clinical stage of disease.
Exclusion criteria: the exclusion criteria include one or more of the following conditions:
1) Non-enrollment into the care and treatment program.
2) Starting ART before October 1, 2004 or less than one month before the date of data abstraction in case
of the ART cases and controls; or enrollment into care before October 1, 2004 or less than three months
before the date of data abstraction in the case of pre-ART patients.
Sites selected will have been offering HIV care and treatment services by July 1, 2008. Also sites with a
large number of patients enrolled into care and in ART by the July 1, 2008. Sites will be stratified to account
for rural-urban distribution.
Information Dissemination Plan:
The results from this study will be disseminated to Ministry TRAC, TB program and reference laboratory, the
clinical partners and districts health teams. The results will inform planning and quality improvement
interventions for HIV care.
This will be finalized.
In FY 2008, Columbia will continue its TA and capacity building activities at NRL by supporting technical
activities as well as strengthening the institutional infrastructure and management capacity critical to sustain
the national network of laboratories for the Rwandan HIV care and treatment program. Direct TA will
continue to be provided through long-term advisors and periodic short-term consultants as needed. Two
long-term technical advisors positions will be continued in FY 2008. The first provides support for HIV-
related quality laboratory services, including evaluations of new technologies, technician trainings, and
guidance on technical and policy issues. The second advisor, a local-hire senior lab technician, will remain
responsible for development and implementation of national standards, QA systems, and training. These
two technical advisors will continue to transfer skills, knowledge and capacity, ensuring a sustained impact.
In FY 2008, Columbia will continue to improve NRL's laboratory management through support of an
international-hire management advisor. The laboratory management advisor will help develop management
systems for finances, logistics, program data, transport and commodities and will mentor the new NRL
Director and Finance position funded under the CDC cooperative agreement. The management advisor
position continues to be critical in strengthening NRL's capacity to effectively manage multiple projects and
multiple streams of funding, including substantial EP resources. Columbia will continue through these
technical and financial positions to support the decentralization of NRL supervision and QA within the
national laboratory network. This decentralization will include continued strengthening of the five regional
district laboratories. PCR for Early Infant Diagnosis and viral load determination will continue to be
supported at NRL and CHUB via equipment maintenance and staff training.
TB services at NRL continue to require strengthening to meet the EP priority of providing reliable AFB
microscopy at the health facility level. Columbia will continue to support laboratory TA to the NRL and
CHUB TB laboratories to ensure high quality smear microscopy, liquid culture and drug sensitivity testing
capability. These TB diagnostic and treatment capabilities are essential in order to provide PLHIV adequate
access to comprehensive quality TB-related services. These capabilities are also essential for the support
of patients with MDR TB. Extrapulmonary TB diagnostics will be available through continued support to
CHUB and CHUK anatomopathology laboratories.
ACM (Atelier central de maintenance) and NRL maintenance units for laboratory equipment will continue to
be strengthened with training and staffing to guarantee the quality of results within the national laboratory
network. Also, small laboratory renovation/rehabilitation will be performed to assure building sustainability
inside the national laboratory network.
Columbia will also continue to strengthen and integrate QA/QC/QI into all HIV-related laboratory areas:
serology, chemistry, hematology, CD4, TB, and malaria. New QA/QC approaches will continue to be
explored in those HIV specific areas. National specimen transportation systems will continue to be
strengthened. Specific laboratory target evaluations on new technical alternatives and new technologies will
be supported to improve the accessibility and reliability of care and treatment programs. For example, new
alternatives technologies will focus on specific HIV areas like, CD4 (dipsticks, micro-chips etc) or TB infants
diagnostics. Protocols and/or indicators should be designed to evaluate laboratory performance impacts on
care and treatment programs.
Columbia will continue to support laboratory staff skills development through local (KHI), regional and
international training programs, with an emphasis on integration of all HIV-related laboratory activities and
total quality management as part of the laboratory accreditation process. In collaboration with CDC,
Columbia will continue to maintain and improve the laboratory information system for NRL and will continue
to support the LIS extension at district hospitals. The laboratory information system will manage financial
record keeping, as well as specimen tracking, inventory control, and programmatic indicators.
All of these activities are consistent with Rwanda's EP five-year strategic goals of strengthening NRL's
capacity to manage a national network of laboratories, standardize technical approaches, and support QA
of HIV-related services throughout the national laboratory network.