Rwanda FY 2007 Country Operational Plan (COP)


Project Title: Rwanda Fiscal Year 2007 Country Operational Plan (COP)

Budget Summary:

  Field Programs Funding by Account  Central Programs Funding by Account  
   Notified as of March 2007 Notified as of June 2007 Notified as of November 2006   
Implementing Agency GAP GHAI Subtotal: Field Programs Funding GAP GHAI New Subtotal: Field Programs Funding GHAI Central Programs Total Dollars Allocated: Field & Central Funding
DOD 0 1,924,858 1,924,858 0 2,249,858 2,249,858 0 2,249,858
DOL 0 0 0 0 0 0 0 0
HHS 1,135,000 13,979,240 15,114,240 1,135,000 16,629,240 17,764,240 8,321,139 26,085,379
Peace Corps 0 200,000 200,000 0 200,000 200,000 0 200,000
State 0 337,420 337,420 0 357,420 357,420 0 357,420
USAID 0 53,586,729 53,586,729 0 72,424,482 72,424,482 1,724,731 74,149,213
TOTAL Approved 1,135,000 70,028,247 71,163,247 1,135,000 91,861,000 92,996,000 10,045,870 103,041,870

* At the request of the Government of Rwanda, the Peace Corps will conduct a country assessment in Rwanda in July 2007. Pending the assessment and available funding, the Peace Corps will determine if re-entry is feasible

HIV/AIDS Epidemic in Rwanda
Estimated Population: 9,038,000*
HIV Prevalence rate: 3.1%*�
# of HIV infected: 190,000*
Estimated # of OVCs: 210,000*�
*Figures are from the 2006 Report on the Global AIDS Epidemic, UNAIDS
Prevalence is in adults only (15-49 years)
Orphans aged 0-17 due to AIDS

Country Results and Projections to Achieve 2-7-10 Goals:


Total # Individuals Receiving Care and Support

Total # Individuals Receiving ART

End of Fiscal Year 2004*



End of Fiscal Year 2005**



End of Fiscal Year 2006***



End of Fiscal Year 2007****



End of Fiscal Year 2008****



* Results. �Engendering Bold Leadership: The President�s Emergency Plan for AIDS Relief.� First Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, March 2005
** Results. �Action Today, a Foundation for Tomorrow: The President�s Emergency Plan for AIDS Relief.� Second Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February, 2006
*** Results. �Power of Partnerships: The President�s Emergency Plan for AIDS Relief.� Third Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February, 2007
**** FY 2007 Country Operational Plan targets

Program Description

Rwanda is one of the most densely populated countries in sub-Saharan Africa. Twelve years after the genocide, which killed almost one million people, Rwanda faces multiple health and development challenges. An estimated 3.1% of the adult population is infected with HIV (3.6% of adult women and 2.3% of adult males); 160,000 Rwandan adults and 27,000 children are living with HIV in a total population of nine million people (UNAIDS). The repercussions of the HIV epidemic, combined with the ongoing effects of the genocide, have resulted in more than 210,000 orphans and a continuing loss of approximately 21,000 persons to HIV-related illness each year.

Rwanda�s HIV/AIDS epidemic is primarily driven by heterosexual contact and mother-to-child transmission. Populations most at risk for HIV in Rwanda include people in prostitution and their clients and partners; uniformed personnel, including military and police forces; long distance truck-drivers, refugees, genocide widows, prisoners, and HIV-discordant couples, who are estimated to make up 2.2% of all married couples. There are currently a large number of prisoners accused of genocide crimes who are in prison now or are being released into the community. Although the HIV prevalence rate among this population is unknown, there is cause for concern, for the prisoners as well as their spouses and partners, as they reintegrate into the community. Although historically the median age of sexual debut for Rwandan males (20.8 years) and females (20.3 years) is relatively late, youth are another high-risk group. Rwanda�s estimated 210,000 orphans face unique risks of sexual exploitation, violence, abuse, food insecurity, and poverty. Tuberculosis (TB) remains a significant problem in Rwanda; WHO estimates that 26% of adults with TB are also infected with HIV.

Additional Funding: In June 2007, an additional $10,600,000 was allocated to further strengthen activities in HIV/TB, PMTCT, Treatment, OVC, SI and Care. The additional funds will also support innovative wrap-around programs targeting PLWHA in the areas of food, micro-economic activities and safe water, as well as new medical male circumcision activities.

Emergency plan funding will be focused on the following programmatic areas to achieve the 2-7-10 targets:

Prevention: $17,776,444 ($14,070,444 Field and $3,706,000 Central) (20.2% of prevention, care and treatment budget)

Prevention activities include prevention of mother-to-child transmission (PMTCT), abstinence and faithfulness programs, condom and other prevention strategies, blood and injection safety, and other behavioral initiatives, including those that focus on most-at-risk populations. In fiscal year 2007, the USG will partner with the Government of Rwanda (GOR), the Global Fund to Prevent HIV/AIDS, Tuberculosis and Malaria (Global Fund), and individual health districts to strengthen the scope, quality and sustainability of PMTCT services in a decentralized health delivery system. The program will emphasize tracing women and their babies to ensure adequate testing and follow-up of HIV-exposed infants and treatment of HIV-positive mothers. The PMTCT program will expand to new sites and will work to ensure that 60% of HIV-positive pregnant women who are eligible for ART have access to the service. Performance-based financing approaches will be integrated in all PMTCT sites, to improve the quality of services and promote sustainability. Finally, the USG program will support linkages between the health facility and community mobilization and care programs, to ensure follow-up support of families at the community level.

The Emergency Plan emphasizes abstinence and faithfulness programs in order to prevent the spread of HIV, and supports Rwanda�s National Prevention Plan 2005-2009. AB messaging programs target both the most-at-risk groups and the general population. The Emergency Plan supports high quality behavior change programs, including mass media and community-based behavior change programs, peer education, projects in collaboration with religious organizations, and initiatives involving associations of PLWHA and health care providers. In fiscal year 2007, the Emergency Plan will continue to program the majority of AB prevention assistance through local Rwandan faith-based organizations (FBOs) and community-based organizations (CBOs).

The Emergency Plan will work to ensure that training curricula, mass media spots, and other materials address the links among alcohol abuse, gender-based violence and HIV. Other topics which will continue to be addressed include transactional sex, coercive and cross-generational sex, and HIV-discordant couples, in order to change not only behavior but also the underlying societal norms and community standards of behavior.

The USG will expand efforts to reduce new infections among most-at-risk and high transmitter groups (such as people in prostitution, members of the military and police, and HIV-discordant couples) through mobile CT, condom social marketing, peer education, and mass media.

In order to strengthen systems for blood collection, testing, storage, and handling, the Emergency Plan will provide direct funding and technical assistance to Rwanda�s National Program for Blood Transfusion, for the purpose of building infrastructure and capacity. Activities will focus on institutionalizing the high quality provision of transfusion services.

Principal Partners: National Blood Transfusion Program (CNTS), American Association of Blood Banks (AABB), John Snow, Inc.-MMIS, Columbia University, Catholic Relief Services, Drew University, Bureau of Population Refugees and Migration (DOS), Community Habitat Finance, World Relief, Family Health International, Population Services International, Basics, IntraHealth, and TRAC.

Care: $27,709,596 ($26,590,865 Field and $1,118,731 Central) (31.5% of prevention, care and treatment budget)

Care activities include counseling and testing (CT), basic palliative care, support for TB/HIV integration, and support for orphans and vulnerable children (OVC). The USG program will work to integrate activities of the President�s Malaria Initiative (PMI) and other streams of funding, in order to provide the most comprehensive set of services possible. The Emergency Plan will expand the CT program to support medical facilities in the increased use of provider-initiated HIV testing (PIT), and will increase pediatric case identification through routine HIV testing in all malnutrition centers in USG-supported districts. The Emergency Plan program will continue to pursue a family-centered approach to CT, which encourages all members of an HIV-positive person�s family to be tested. In accordance with new GOR policies, all CT activities will be linked directly to nutritional counseling and appropriate referral. This will include implementing policies and protocols for PIT and family CT and adapting training tools for health workers in nutritional counseling. As pre-marital HIV testing is emphasized by religious leaders in Rwanda, Emergency Plan partners will work with FBOs to make pre-marital testing more widely available; post-test counseling will emphasize the importance of marital fidelity. Most-at-risk-populations (MARPs) � including members of the military, prisoners, refugees, and people in prostitution � will be reached through expanded mobile and outreach testing activities.

The Emergency Plan will work to ensure that all people living with HIV/AIDS (PLWHA), at every stage of their illness, receive services through a comprehensive network of district hospitals, health centers, and communities. Clinical activities will include prevention and treatment of opportunistic infections, pain management, positive living and prevention counseling for positives, nutritional counseling and assistance, support for treatment adherence, CD4 testing, general clinical staging and monitoring, wraparound family planning support, and linkages to community services. Community and home-based palliative care interventions will continue to focus on spiritual and emotional support, home-based care kits, anti-malarial bed nets, treatment of opportunistic infections, cotrimoxazole prophylaxis, counseling on hygiene and nutrition, and care for OVC. In addition, Food for Peace Title II resources will be leveraged to provide nutritional support for OVC and PLWHA.

In fiscal year 2007, the Emergency Plan will support implementation of the national policy to strengthen and integrate TB/HIV services, in close coordination with the Global Fund. The program will develop TB/HIV integration activities in all Emergency Plan health districts and will improve systems to track co-infected patients. All TB patients routinely will be offered HIV testing, and PLWHA will be screened routinely for TB, in order to ensure that those who are co-infected receive treatment.

Due to the combined impact of the genocide and HIV/AIDS, Rwanda has one of the highest proportions of orphans in the world. Emergency Plan partners will work closely with the GOR to increase national capacity to respond to top OVC priorities in the areas of policy and legal reform, government and civil society coordination, and monitoring of OVC services. The Emergency Plan will support national efforts to identify and register OVC and will support individual assessments to tailor the package of services that each child receives. The Emergency Plan will offer a menu of OVC services, including education, health, psychosocial support, nutrition, and economic interventions in a gender-sensitive manner to beneficiaries in Emergency Plan-supported districts. HIV prevention messages will continue to be integrated into OVC programs.

Principal Partners: CHF International, Population Services International, American Refugee Committee, World Relief, Management Sciences for Health, IntraHealth, Elizabeth Glaser Pediatric AIDS Foundation, Family Health International, Drew University, Columbia University, and TRAC.

Treatment: $42,490,150 ($37,269,011 Field and $5,221,139 Central) (48.3% of prevention, care and treatment budget)

Treatment activities include the provision of ARV drug and service programs as well as laboratory support. In fiscal year 2007, the Emergency Plan will assist the Ministry of Health (MOH) to increase program quality and sustainability through district-level support for implementing the HIV treatment program. Working with international partners, the Emergency Plan will strengthen district-level capacity to plan, implement, and monitor HIV treatment programs through technical and financial assistance, including the integration of performance-based financing mechanisms into all facilities. The Emergency Plan will continue to provide technical and financial assistance for the MOH-led national ARV procurement and supply chain management, in order to ensure an adequate drug supply in the country.

Emergency Plan technical support for laboratory infrastructure in fiscal year 2007 will focus on key reference laboratory functions, including training, quality assurance, and the development of in-country expertise for HIV-related care and treatment. Emergency Plan resources will strengthen the national laboratory network through direct support to individual facilities and district level capacity building for HIV-related laboratory testing. Enhanced support for pre-service training at the Kigali Health Institute and the National Reference Laboratory will assure sustained laboratory capacity for the future.

Principal partners: American Society of Clinical Pathologists, Catholic Relief Services, CDC, Columbia University, Elizabeth Glaser Pediatric AIDS Foundation, Family Health International, IntraHealth, Management Sciences for Health, Ministry of Health, and National Reference Laboratory.

Other Costs: $15,065,680

The Ministry of Health, the National AIDS Control Commission, and its district structures will receive technical and financial assistance through the Emergency Plan to strengthen capacity to plan, coordinate, monitor, and report on the progress of the national response. Support will include improving decentralized reporting systems for HIV-related activities, including electronic networking. The Emergency Plan will support HIV surveillance, facilities surveys, public health evaluations, and policy-related analysis in fiscal year 2007.

The Emergency Plan supports interventions to improve human capacity and strengthen systems. Human capacity interventions include an HIV/AIDS public sector program management fellowship, a Masters of Public Health program, support to the National School of Medicine, and in-service and pre-service nursing training programs at all five national nursing schools. These human capacity interventions are designed to train the Rwandan workforce to sustain the expanded HIV/AIDS program. The USG will provide a package of support to the MOH at central and district levels for strengthening supervision and quality of clinical services. The Emergency Plan also will help strengthen HIV/AIDS policies and systems through the National AIDS Control Program (CNLS) across health and non-health sectors. Performance-based financing is a major sustainability strategy for the Emergency Plan in Rwanda. This innovative funding approach will be integrated across clinical and community services, in order to enhance performance and strengthen decentralized management and service delivery capacity.

Principal partners: CDC, Columbia University, Drew University, Family Health International, IntraHealth, Management Sciences for Health, Ministry of Health, Tulane University, and University of North Carolina.

Management and staffing funds will support in-country personnel needed for USAID, HHS, State Department, Peace Corps, and the Department of Defense. Funds will ensure program monitoring and accountability, including active Emergency Plan co-management with the GOR. Management and staffing costs will cover compensation, logistics, and office and administrative costs.

Other Donors, Global Fund Activities, Coordination Mechanisms:

The USG is the largest HIV/AIDS bilateral donor in Rwanda. Other major HIV/AIDS and health donors include the Global Fund, Belgium, Luxembourg, and the Clinton Foundation. The Global Fund has awarded five grants to Rwanda, totaling $159 million over five years for AIDS, TB, and malaria programs. CNLS is the primary HIV/AIDS coordinating body. The Executive Secretary of CNLS chairs the Emergency Plan Steering Committee, the GOR-USG co-management mechanism to ensure that USG program support complements the Rwandan national HIV/AIDS plan.

Program Contact: Deputy Chief of Mission, Michael Thurston

Time Frame: Fiscal year 2007 � fiscal year 2008

Approved Funding by Program Area: Rwanda

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