Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 132
Country/Region: Rwanda
Year: 2009
Main Partner: Population Services International
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USDOD
Total Funding: $939,000

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $150,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The overall goal of this activity is to decrease new HIV infections through behavior change communication.

The focus is on abstinence and fidelity targeting military personnel.

PSI/Rwanda and the Directorate of Military Services (DMS) work together to promote HIV prevention

among members of the Rwanda Defense Forces (RDF). While some soldiers practice sexual abstinence

and fidelity, living away from their families, mobility and age make them vulnerable to HIV.

PSI/Rwanda is implementing community-based activities among soldiers, their sexual partners, and

surrounding communities to increase safer sexual behaviors. Key prevention strategies are 1) capacity

building of AIDS support clubs 2) peer education and IPC sessions (including cine-mobiles), and 3)

promotion of counseling and testing services

Using the results of a behavioral survey conducted in late 2007, the DMS and PSI will update

communication materials to reflect best practices in the following areas; AB; couples counseling and

testing; integration of FP into HIV/AIDS prevention (including PMTCT); men as partners; GBV and

prevention of alcohol abuse.

In FY 2009, these activities will continue with the program reaching at least 20,000 members of RDF with

prevention messages. The military AIDS support clubs will work to sensitize surrounding communities about

risky sexual behavior. The DMS will strongly encourage soldiers to get tested with their partners. MC

activities (described in CIRC narratives) will be closely integrated into this activity.

This activity is related to HVOP and CIRC activities.

New/Continuing Activity: Continuing Activity

Continuing Activity: 12873

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

12873 4004.08 Department of Population 6322 132.08 PSI-DOD $80,000

Defense Services

International

7230 4004.07 Department of Population 4344 132.07 PSI-DOD $60,000

Defense Services

International

4004 4004.06 Department of Population 2574 132.06 PSI-DOD $35,000

Defense Services

International

Emphasis Areas

Gender

* Addressing male norms and behaviors

Military Populations

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Estimated amount of funding that is planned for Education $150,000

Water

Table 3.3.02:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $144,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The overall goal of this activity is to decrease new HIV infections in the military through BCC with a focus on

correct andconsistent use of condoms.

PSI and the Directorate of Military Services (DMS) work together to promote HIV prevention among

members of the Rwanda Defense Forces (RDF). While some soldiers practice sexual abstinence and

fidelity, living away from their families, mobility and age increase their HIV risk.

PSI is implementing community-based activities among soldiers, their sexual partners, and surrounding

communities to increase safer sexual behaviors. Key prevention strategies are 1) capacity building of AIDS

support clubs 2) peer education and IPC sessions (including cine-mobiles), and 3) promotion of counseling

and testing services

Using the results of a behavioral survey conducted in late 2007, the DMS and PSI will update

communication materials to reflect best practices in the following areas: AB, couples counseling and

testing, integration of FP into HIV/AIDS prevention (including PMTCT), condoms for dual protection, men as

partners, Gender Based Violence and prevention of alcohol abuse.

In FY 2009, PSI will continue these activities, emphasizing correct and consistent condom use; ensuring

condom access and availability including minimizing the stigma surrounding condoms; promoting condom

negotiation skills with partners, and further emphasis on the role alcohol plays in risky behavior. Additional

IEC materials promoting condom use will be developed. PSI will train 200 volunteers to reach 30,000

individuals with prevention messages. The military AIDS support clubs will work to sensitize surrounding

communities about risky sexual behavior.

The DMS will strongly encourage soldiers to have HIV tests together with their partners. Male Circumcison

activities (described in CIRC narratives) will be closely integrated into this activity. The DMS will also

distribute approximately 2,000,000 condoms in FY 2009.

This activity is related to HVAB and CIRC activities.

New/Continuing Activity: Continuing Activity

Continuing Activity: 12874

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

12874 2803.08 Department of Population 6322 132.08 PSI-DOD $144,000

Defense Services

International

7229 2803.07 Department of Population 4344 132.07 PSI-DOD $60,000

Defense Services

International

2803 2803.06 Department of Population 2574 132.06 PSI-DOD $35,000

Defense Services

International

Emphasis Areas

Military Populations

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $144,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.03:

Funding for Biomedical Prevention: Voluntary Medical Male Circumcision (CIRC): $150,000

ACTIVITY IS NEW IN FY 2009.

The overall goal of this activity is to decrease new HIV infections in the Rwanda Defense Forces (RDF)

through male circumcision (MC) with emphasis that MC be offered as a part of an expanded approach to

reduce HIV infections in conjunction with other prevention programs, including HIV testing and counseling

(TC), treatment for other sexually transmitted infections, promotion of safer-sex practices and condom

distribution. Male circumcision will not replace other known methods of HIV prevention and will be

considered as part of a comprehensive HIV prevention package.

In FY 2009, Population Services International (PSI) will conduct MC communication and messaging

activities targeting the general population. The activities will utilize interpersonal communication strategies

as well as local- and national-level media campaigns that encourage safe MC as part of a complete

approach to prevention, that the benefits accrue over time, and that MC does not provide complete

protection.

Additionally, PSI will conduct a study tour to the Society for Family Health Zambia (a PSI Affiliate that began

piloting MC services in September 2007, and launched mobile MC in March 2008) to assess their fixed and

mobile MC/TC programs for piloting in Rwanda. This partner will also develop and integrate MC counseling

messaging into all military BCC and VCT activities. These messages will focus on: MC myths and

misconceptions; emphasizing that MC will not fully prevent HIV transmission; reinforcing condom and

partner reduction messaging; the need to know HIV status before receiving MC; and the need to abstain

from sexual activity to allow for complete wound healing.

In FY 2008, PEPFAR worked closely with the Rwanda Ministry of Health (MOH) and other donors in a

national task force to develop policy that recognizes the MC as an effective HIV prevention method

alongside the ABC strategy. The MOH has also requested donor support for the expansion of MC services

beginning with the Rwanda military (one of Rwanda's most at-risk populations). Conducting MC in the

Rwanda military is considered vital since the military is predominately male, typically young, highly mobile

and is considered a high risk group.

These activities address the key legislative issues on gender, particularly with respect to male norms and

stigma reduction. The activity supports the Rwanda PEPFAR five-year strategy by collaborating with the

GOR to implement prevention activities for the military. Focusing prevention efforts on the military is a key

strategy of both PEPFAR and Government of Rwanda.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Military Populations

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $10,823,667

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The Government of Rwanda (GOR), in collaboration with international donors, implementing partners, and local organizations,

continues the rapid scale up of HIV prevention, care, and treatment services. According to EPP/Spectrum data from 2008, the

median estimate of the number of HIV-infected individuals in Rwanda is 149,000. Of these, 71,799 are estimated to be in need of

ART. (Source: 2008 Epidemic Update; MOH and CNLS).

Statistics:

Cumulative national cohort through March 2008:

•As of September 2008, 63,878 patients had initiated ART, of which 6,095 (9.5%) were children (Sources: TRACnet; CIDC/MOH)

oOf these, 58,082 (91%) patients were currently on ART (Note: likely overestimation).

oApproximately 1% of adult patients were on second line regimens (Source: CIDC, HIV/AIDS/STI (HAS) Unit)

•As of March 2008, 51,387 patients were currently on ARV treatment, including 5,058 children, at 176 health facilities across

Rwanda (Sources: TRACnet; CIDC/MOH)

oOf these, 30,370 (59%) were on ART at sites supported by PEPFAR partners.

oOf health facilities, 114 (65%) were directly supported by PEPFAR.

•National ART coverage: in 2007 was estimated at 70%; will likely reach or exceed the national target of 80% by the end of 2008.

•ART Outcomes - of adult patients who initiated ART during 2004 and 2005, roughly 86% and 92% were alive on ART after 6 and

12 months, respectively. By 6 months, 3.6% were dead, 3.1% were LTFU, 0.2% had stopped treatment, and 1.3% had

transferred out; by 12 months, 4.6% were dead, 4.9% were LTFU, 0.27% had stopped treatment, and 4.3% (were transferred out.

(Source: TRACPlus Report on the Evaluation of Clinical and Immunologic Outcomes from the National Antiretroviral Treatment

Program in Rwanda, 2004 - 2005; MOH) - More recent data are not currently available.

•The National Treatment Plan aims to extend ART treatment services to >67,000 patients, including >6,400 pediatric patients by

December of 2008 - surpassing the PEPFAR target of 50,000 on ART by the end of FY 2009.

•CTX prophylaxis - there are no reliable data regarding the coverage of cotrimoxazole prophylaxis among eligible HIV-infected

patients, either nationally or within PEPFAR-supported clinical settings.

Key Policy Changes during FY2007-2008:

In FY 2007, TRACPlus - Center for Infectious Disease Control/MOH (CIDC) disseminated new clinical guidelines for HIV care and

treatment. Significant changes include a recommendation for routine viral load testing at 12 months however this

recommendation has not been fully implemented by clinical partners for a variety of reasons, including lack of training, inadequate

laboratory capacity, and cost. In addition, in FY 2008, the CIDC HAS Unit intends to change from preferred zidovudine- and

stavudine-containing first-line ART regimens to preferred tenofivir (TDF)-containing first-line ART regimens. PEPFAR partners

expect that this change will begin implementation in late FY 2008, and that it will have implications for FY 2009, particularly given

the immediate cost increases associated with transition to TDF.

In FY 2007, the GoR made significant strides towards establishing an effective policy basis for HIV pre-ART care in Rwanda,

including revised cotrimoxazole prophylaxis (CTX) guidelines, new opportunistic diagnostic and treatment guidelines, and new

guidelines for diagnosis and treatment of sexually transmitted infections. These guidelines have been elaborated in draft form and

will be finalized in FY 2008. In addition, Mildmay International and the African Palliative Care Association have provided support

to the MOH for development of a national policy on opioid drugs, which will lay the foundation for implementation and scale-up of

effective pain management strategies. A new national policy on task shifting to support nurse ART prescription is also expected in

FY 2008. In FY 2008, performance based financing, a key aspect of the PEPFAR Rwanda strategy for ensuring program

sustainability and quality which has been rolled out to all health centers, will be scaled up to include all District and referral

hospitals, as well as community-based services.

Treatment:

In FY 2008, PEPFAR will continue supporting all levels of the decentralized ART network, starting from central level institutions

and extending to the community as the most peripheral point of service. PEPFAR will scale-up ART support by putting 11,922

newly eligible patients including 1,106 children on ART at 157 PEPFAR-supported sites. As the number of patients rapidly grows,

PEPFAR will continue to work with GOR and other donors to evaluate and ensure the quality of HIV-related services. This

includes programs designed to provide site and program-level feedback regarding quality of clinical services and support at

central levels to update guidelines, training materials, and job aids. PEPFAR will also provide training to assist clinicians to identify

patients in need of 2nd-line regimens by evaluating clinical, adherence-related and immunological criteria, as well as the use of

targeted viral load testing (until laboratory capacity has been expanded to enable compliance with the current guidelines).

At the central level, PEPFAR will continue working with CIDC, the National Reference Laboratory (NRL), and other key Units in

MOH through direct cooperative agreements and a number of its partners. PEPFAR will continue to support MOH to revise

national guidelines, tools, curricula, and conduct training of trainers. In FY 2009, with PEPFAR funding, MOH will coordinate joint

supervisory visits to clinical sites in coordination with the district health teams (DHTs) to provide promote data quality and use.

At the district level, PEPFAR partners will continue providing financial and technical support to their respective DHTs to strengthen

linkages, referrals, transportation of patients and specimens, communications, forecasting, drugs and commodities distribution,

and financial systems. In addition, PEPFAR partners will strengthen district level supervisory, management, mentoring and

reporting capabilities. Each USG partner has been assigned districts where they are charged with providing support to all of their

health care facilities and personnel. In districts where other donors are supporting some HIV-related clinical services (e.g. VCT by

GFATM), PEPFAR partners are still responsible to work with donors to establish functional linkages that support continuity of care

across sites and services. Each partner also is charged with providing direct mentoring and capacity building support to their

district health team, thus building capacity to decentralize supervisory and quality assurance activities.

At site level, PEPFAR partners will provide a standardized package of ARV services through support and development of a

coordinated network of HIV/AIDS services linking ART with PMTCT, TB, FP, MCH and other services. Following a tiered

approach to service delivery, USG partners will provide comprehensive ART services at larger facilities and a basic ART services

at satellite health centers. Nurses will serve as the primary HIV service provider at these more distal sites of the health care

system and have physician back-up at district level facilities. PEPFAR will continue supporting task shifting by strengthening

nurse training through pre-service and in-service training, use of simplified protocols, and assigning district hospital physicians to

support nurses in managing ART cases through regular mentoring visits and remote support via telephone for urgent questions.

At the community level, PEPFAR partners will ensure continuity of care and adherence support through case managers,

community health workers (CHWs), and peer support groups. Through community mobilization activities, home visits, and

monitoring and evaluation tools, community health workers will facilitate communication and linkage between facilities and

communities in order to improve patient retention. CHWs will provide adherence counseling, patient education, and referrals for

drug side effect management. In FY 2009, PEPFAR will continue to expand efforts to provide nutritional support to qualifying

adults and pregnant and lactating women. In FY 2009, PEPFAR will support basic program evaluation activities, such as an

evaluation of patient outcomes in the national HIV care and treatment program.

Basic Care and Support:

Consistent with the guidance from the PEPFAR Basic Care and Support TWG, the Rwanda country team defines Basic Care and

Support as the delivery of at least 1 clinical and 1 non-clinical intervention to an HIV-infected individual. PEPFAR and its

implementing partners have supported and will continue to support access to a comprehensive range of basic care and support

(BCS; formerly "palliative care"; also referred to as "care") services, including clinical and non-clinical (prevention, psychological,

spiritual, and social care services) interventions at both the facility and community level. To date, the majority of prevention, care,

and treatment services for PLHIV have been provided in the health facility setting, with implicit linkages to community care.

Clinical services include the provision of CTX for eligible adults

(revised national guidelines now call for universal prophylaxis for all HIV-infected individuals, regardless of clinical and

immunologic status), CD4 testing and clinical staging, diagnosis and treatment of common opportunistic infections (OIs),

adherence counseling, clinical monitoring, nutritional assessment and support, prevention counseling, including "prevention for

positives", and referrals to community-based care and support services. While social care services have been primarily provided

through community-based activities, some clinical partners also provide patients with health "mutuelles" (a basic type of health

insurance), transportation support, income generation through PLHIV associations, and linkages to food support. Coordination of

community-based BCS activities continues to be a challenge. PEPFAR Rwanda and partners are working with the national

Palliative Care TWG, and relevant GOR entities, such as the Community Health Task Force in MOH, to ensure that HIV/AIDS

community services are integrated into overall community health planning.

Prevention, psychological, social, and spiritual services in the community are provided through 12 Rwandan faith- and community-

based organizations, and hundreds of PLHIV associations in 20 districts (out of 30). All care providers (facility- and community-

based) have incorporated prevention messages and appropriate prevention counseling into their care activities, especially for HIV-

positive individuals and their families. In FY 2007, PEPFAR supported an assessment of facility-community linkage models

developed by clinical partners (report currently pending). In addition, the "Rwanda Community Health Needs Assessment" was

completed in September 2008. Findings from these assessments will inform BCS programming in FY 2008 and 2009.

Specifically, PEPFAR will continue to promote a linkages model, which utilizes facility-based staff, and community- and home-

based volunteers. The model aims to improve the communication and coordination between clinical and community levels to

ensure a continuum of care for HIV-positive individuals and their families. Robust supervision, monitoring and evaluation of these

linkages will be essential.

To date, PEPFAR-Rwanda has counted persons as receiving care through the reporting of clinical partners only, not community-

based partners. Each clinical partner is responsible for a unique set of districts and, overall, PEPFAR supports clinical services in

23 of 30 districts in Rwanda. In addition to of service provision, PEPFAR is augmenting the capacity of Rwandan community-

based organizations to ensure the sustainability of care services, including technical and organizational capacity for the 12

Rwandan partner organizations currently under CHAMP. This community services project will be ending with FY 2008 funding,

and PEPFAR is planning to design and award a new community services activity for FY 2009.

PEPFAR procures all BCS-related commodities through the Supply Chain Management System (SCMS), including drugs for the

prevention and treatment of OIs, and laboratory and diagnostic kits for improved and expanded OI diagnosis, and in coordination

with the GOR's central procurement agency, CAMERWA. The exceptions are: the provision of bed-nets for PLHIV, which is being

done through JSI/DELIVER; and the provision of Sur Eau, which is being procured and distributed by PSI through the POUZN

project.

For a variety of reasons, a standard "package" of BCS services has not been identified, either by GOR stakeholders or

implementing partners. Nonetheless, PEPFAR Rwanda will continue to promote coverage of key clinical interventions (CTX, bed-

nets, safe water products, etc.) that have been demonstrated to reduce morbidity and mortality of PLHIVs. In FY 2009, PEPFAR

will also continue to emphasize the use of a family-centered approach for care; improvement of pain management; improved

prevention counseling for HIV-positives through the provision of targeted risk reduction and behavior change messages (in both

clinical and community settings); support for caregivers; and, improved linkages (community to clinic, within clinical services and

wrap-arounds). On-going wrap-around activities in FY 2009 include: the provision of bed-nets (through PMI), provision of safe

water product and hygiene education (through POUZN); a new award to leverage food aid for PLHIV (Title II and WFP); support

for economic growth and livelihoods (IGA assessment with EGAT; Land O'Lakes dairy IGA project); and links to services for

gender based violence. Improvement of psychosocial support, including mental health screening and treatment within HIV

services, is an increasing priority for the GOR, and one that PEPFAR plans to support in FY 2009. Finally, PEPFAR Rwanda will

support basic program evaluation activities, including assessment of patient outcomes in pre-ART settings and the impact of

community-based clinical services.

Table 3.3.08:

Funding for Testing: HIV Testing and Counseling (HVCT): $495,000

This is a continuing activity from FY 2008. No narrative required.

New/Continuing Activity: Continuing Activity

Continuing Activity: 12875

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

12875 4006.08 Department of Population 6322 132.08 PSI-DOD $495,000

Defense Services

International

7231 4006.07 Department of Population 4344 132.07 PSI-DOD $450,000

Defense Services

International

4006 4006.06 Department of Population 2574 132.06 PSI-DOD $255,000

Defense Services

International

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Military Populations

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Cross Cutting Budget Categories and Known Amounts Total: $294,000
Education $150,000
Human Resources for Health $144,000