Rwanda Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

RWANDA

Project Title: Rwanda Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

Budget Summary:

	Field Programs Funding by Account						Central Programs
	Notified November 2007			Notified February 2008			Notified as of February 2008	Allocations to Date
Implementing Agency	GAP	GHCS - State	Subtotal: Field Programs Funding	GAP	GHCS - State	Subtotal: Field Programs Funding	Subtotal: GHCS Central Programs	Grand Total:  Field & Central Funding
DOD	-	359,756	359,756	-	2,833,101	2,833,101	-	3,192,857
DOL	-	-	-	-	-	-	-	-
HHS	-	5,357,940	5,357,940	1,135,000	19,945,563	21,080,563	10,506,947	36,945,450
Peace Corps	-	-	-	-	2,500,000	2,500,000	-	2,500,000
State	-	-	-	-	413,344	413,344	-	413,344
USAID	-	1,500,000	1,500,000	-	76,690,296	76,690,296	1,826,893	80,017,189
TOTAL	-	7,217,696	7,217,696	1,135,000	102,382,304	103,517,304	12,333,840	123,068,840

HIV/AIDS Epidemic in Rwanda
Adults (aged 15-49) HIV Prevalence Rate: 3.1% (UNAIDS, 2006)
Estimated number of People Living with HIV: 190,000 (UNAIDS, 2006)
Estimated number of Orphans due to AIDS: 210,000 (UNAIDS, 2006)

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

Rwanda	Total # Individuals Receiving Care and Support	Total # Individuals Receiving ART
End of FY 2004*	17,860	4,300
End of FY 2005**	89,700	15,900
End of FY 2006***	100,800	30,000
End of FY 2007****	102,700	44,400
End of FY 2008*****	156,095	51,760
End of FY 2009*****	198,085	63,750

^* "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.
^** “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.
^*** "The 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.
^**** "The Power of Partnerships: The President's Emergency Plan for AIDS Relief." 2008 Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, January 2008.
^***** Projections from FY 2008 Country Operational Plan

Program Description/Country Context:

Rwanda is one of the most densely populated countries in sub-Saharan Africa. Thirteen years after genocide, Rwanda still 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). Out of a total population of nine million, 160,000 Rwandan adults and 27,000 children are living with HIV (UNAIDS). The repercussions of genocide, combined with HIV, 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 epidemic is primarily driven by heterosexual contact and mother-to-child transmission. Populations most at risk for HIV in Rwanda include people in prostitution, their clients and partners; military and police personnel; long distance truck-drivers, refugees, genocide widows, prisoners, and discordant couples. Discordant couples are estimated to make up 2.2% of all married couples. There are a high number of Rwandans incarcerated for various crimes, including genocide. Current data from prison testing show that the prevalence among incarcerated populations is approximately 7.5%. Although the median age of sexual debut for Rwandan males (20.8 years) and females (20.3 years) is relatively late, youth remain a high-risk group. The estimated 210,000 Rwandan orphans face unique challenges of sexual exploitation, violence, abuse, food insecurity and poverty. Furthermore, as in many African societies, cross-generational sex poses significant risk for young girls. WHO estimates that 26% of adult TB cases are also co-infected, indicating that TB remains a significant problem in Rwanda.

In FY 2008, PEPFAR funding will be focused on the following programmatic areas to achieve the 2-7-10 targets:

Prevention: $23,569,699 ($17,582,191 Field; $5,987,508 Central) (22.8% of prevention, care and treatment budget)

Prevention activities include prevention of mother-to-child transmission (PMTCT), abstinence and faithfulness (AB) programs, condom and other prevention strategies, blood and injection safety, and other behavioral initiatives including those that focus on most at risk populations. In FY 2008, the USG will partner with the Government of Rwanda (GOR), the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (Global Fund), and health districts to strengthen the scope, quality and sustainability of PMTCT services in a decentralized health system. The program will continue to emphasize the tracing of women and their children after birth to follow-up HIV-exposed infants and mothers. The program will also increase the proportion of HIV infected pregnant women eligible for antiretroviral treatment (ART), and will support the opening of new PMTCT sites. The PMTCT program will integrate performance-based financing approaches to improve the quality of services and promote sustainability. Substantial resources will be devoted to providing nutrition support to infants during the weaning period and to pregnant and lactating women at risk of malnutrition. Finally, the program will strengthen its linkages with MCH and IMCI programs to ensure the continuum of care and reduce morbidity and mortality among HIV-exposed infants.

PEPFAR emphasizes abstinence and faithfulness programs to stem the spread of HIV and supports the Rwanda 2005-2009 National Prevention Plan. AB programming targets persons engaged in high risk behaviors and the general population with AB messages. In FY 2008, the USG will continue to program significant AB resources through local Rwandan faith-based organizations (FBOs) and community-based organizations (CBOs) and will ensure that training curricula, mass media spots, and other materials address the links between alcohol abuse, gender-based violence and HIV. The USG will also reinforce the capacity of the Rwanda National Police to address gender based violence, and will address transactional sex, coercive and cross-generational sex and discordant couples in order to positively influence societal norms and community standards of behavior. In FY 2008, there will be an increasing focus on high risk youth, people in prostitution, and other persons engaged in high risk behaviors.

The USG will expand efforts to reduce new infections among persons engaged in high risk behaviors (such as people in prostitution, military, police, and, importantly, discordant couples) through counseling and testing (CT), condom social marketing and distribution, peer education and mass media prevention messaging.

Significant new prevention initiatives are being refined or proposed in FY 2008. First, the USG will engage with the Rwanda Defense Force (RDF) and Ministry of Health (MOH) to launch a voluntary male circumcision program for members of the Rwandan military. Contingent upon the commitment of the MOH and the RDF, PEPFAR will provide technical assistance to train health care providers in safe circumcision and infection control. Second, PEPFAR will scale up prevention for people in prostitution through services for sexually transmitted infections (STIs), evaluations, and development of model best practices for Rwanda and other focus countries. Through an innovative public-private partnership, the USG will work with a local brewery to promote prevention among farm workers. Finally, several activities with the coffee, dairy, food distribution and ecotourism sectors will be implemented to incorporate HIV prevention activities and reach diverse populations.

In order to strengthen blood collection, testing, storage and handling systems, the USG will support Rwanda’s National Program for Blood Transfusion for infrastructure and capacity building. In FY 2008, the USG will maintain blood transfusion service outlets at district hospitals and will increase the number of blood units collected safely. USG support will help the National Blood Transfusion Program to increase the production of plasma, platelets, and red cells. USG safe injection activities will reduce the burden of HIV transmission due to unsafe and unnecessary medical injections, and contact with infectious medical waste. The USG will support procurement of safe injection equipment, and biosafety equipment and a comprehensive training component for all levels of medical providers.

Principal Partners: National Blood Transfusion Program (CNTS), American Association of Blood Banks (AABB), John Snow, Inc.-MMIS, Columbia University, Partnership for Supply Chain Management (SCMS), Catholic Relief Services, Drew University, Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Family Health International (FHI), IntraHealth International, Community Habitat Finance, World Relief, Population Services International (PSI) , Basics, TRAC.

Care: $34,541,750 ($33,416,557 Field; $1,125,193 Central) (33.4% of prevention, care and treatment budget)

Care activities include HIV counseling and testing (CT), basic palliative care, support for TB/HIV integration, and support to orphans and vulnerable children (OVC). The USG will integrate the President’s Malaria Initiative (PMI) activities and other funding streams to provide a comprehensive set of services, including insecticide-treated bednets for people living with HIV/AIDS (PLWHA) The USG will expand the CT program to increase levels of provider-initiated HIV testing and counseling (PITC) and through routine testing of all maternity clients. In addition, the USG will pursue a family-centered approach to CT, explicitly supporting policies and protocols for CT of youth and discordant couples. As pre-marital testing is scaled up in Rwanda, USG partners will work with FBOs to make this service more widely available. Persons engaged in high risk behaviors, including the military, prisoners, refugees, and people in prostitutions, will be reached through mobile and outreach testing activities. To reach the highest at-risk youth, the USG will support comprehensive CT services at urban youth centers.

The USG will work to ensure that all PLWHA receive support through a comprehensive network of district hospitals, health centers and community services. Clinical activities will include prevention and treatment of opportunistic infections and STIs, positive living and prevention counseling for PLWHA, nutritional counseling and assistance, support for treatment adherence, CD4 testing, general clinical staging and monitoring, family planning support and linkages to community services. The USG will work with the GOR to assure that a policy on pain management is developed and implemented. Community and home-based palliative care interventions will focus on spiritual and emotional support, home-based care kits, bed nets, cotrimoxazole prophylaxis and treatment of opportunistic infections, counseling on hygiene and nutrition, and care for vulnerable children. Linking community service partners with clinical partners will be emphasized. The USG will leverage Food for Peace/Title II resources to provide nutritional support for OVC and PLWHA.

In FY 2008, the USG will continue to support integration of TB/HIV services in collaboration with the Global Fund. The program will also improve systems to track co-infected patients. All TB patients will be routinely offered HIV testing and PLWHAs will be routinely screened for TB to treat co-infected individuals. TB infection control systems will be improved in USG supported district hospitals.

Rwanda has one of the highest proportions of orphans in the world. The USG will target support towards child-headed households and the most vulnerable orphans, investing significant new resources for OVC in FY 2008. Critical to these efforts will be leveraging other partners’ investments. USG implementing partners will increase national capacity to respond to OVC priorities such as policy and legal reform, government and civil society coordination, and monitoring of services. The USG will support national efforts to identify and register OVC. The USG will assess OVC needs to provide a menu of services including education, health, psychosocial support, nutrition, and economic interventions to beneficiaries in USG-supported districts. HIV prevention messages will continue to be integrated into OVC programs.

Principal Partners: CHF International, PSI, UNHCR, World Relief, Management Sciences for Health, IntraHealth, EGPAF, FHI, Drew University, Africare, SCMS, Columbia University, TRAC, Catholic Relief Service, Advocat Sans Frontier.

Treatment: $45,325,268 ($40,104,129 Field; $5,221,139 Central) (43.8% of prevention, care and treatment budget)

Treatment activities include the provision of antiretroviral treatment (ART) programs as well as laboratory support. In FY 2008, the USG will assist the MOH to increase program quality and sustainability through national and district-level support. The USG will strengthen district-level capacity to plan, implement and monitor HIV treatment programs through technical and financial assistance including integration of performance-based financing approaches. Pediatric HIV technical expertise will be strengthened. The USG will continue to provide technical and financial assistance to ensure an adequate drug supply. Quality of services will be strengthened through clinical mentoring and capacity building for in-service and pre-service care. Pediatric HIV treatment will also be supported through centers of excellence and integration with PMTCT, integrated management of child illness programs, and family planning. Finally, a more strategic approach to ART will be supported including, task shifting, decentralization of services, and targeted use of viral load testing.

USG technical support for laboratory infrastructure in FY 2008 will focus on key reference laboratory functions, including training, quality assurance, and developing in-country expertise for HIV-related care and treatment. Bio-safety in the USG supported sites will be strengthened. USG resources will strengthen the national laboratory network through district level capacity building for HIV-related laboratory testing. Enhanced support for pre-service training at the Kigali Health Institute and at the National Reference Laboratory will assure sustained laboratory capacity for the future. The USG will support the National Reference Laboratory to obtain WHO accreditation.

Principal partners: CRS, ICAP, Drew University. EGPAF, FHI, IntraHealth, Laboratory Coalition Partners, MSH, MOH, NRL, SCMS.

Other Costs: $19,632,123

The MOH, CNLS and its district structures will receive USG assistance to strengthen capacity to plan, coordinate, monitor and report on the progress of the national response. This will cover the improvement of decentralized reporting and feedback systems for HIV-related activities. The USG will support HIV surveillance, facilities surveys, and policy-related analysis in FY 2008.

The USG supports interventions to improve human capacity and strengthen systems required to achieve 2-7-10 goals. Human capacity interventions include an HIV/AIDS fellowship program, an MPH and PhD program, support to the Butare University Medical School, the Field Epidemiology and Laboratory Training Program (FELTP), the Sustainable Management Development Program (SMDP), and in-service and pre-service nurse training programs at the five national nursing schools. The USG will provide a package of support to the MOH at central and district levels for strengthening supervision and quality of clinical services. 23 of 30 health districts will receive a uniform comprehensive support package. Performance based financing is a critical systems strengthening strategy supported by the USG, and is integrated across clinical and community services to enhance performance and strengthen decentralized management capacity. Moreover, the USG will place a strong emphasis on reduction of gender-based violence by working with the Rwandan national police and the larger health system to ensure appropriate responses to gender-based violence and sexual assault.

Principal partners: MOH, CHF, IntraHealth, Avocats Sans Frontier, Voxiva, Constella, TRAC, MSH

Management and staffing funds will support in-country personnel for USAID, HHS/CDC, Department of State, Peace Corps and Department of Defense. Funds will ensure program monitoring and accountability, including active USG 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 United States is the largest HIV/AIDS bilateral donor in Rwanda, having provided over $100 million in 2007. Other major donors include the Global Fund, the Clinton Foundation, and governments of Belgium, Germany, Luxembourg. The Global Fund has awarded eight grants to Rwanda totaling $239 million for AIDS, TB, and malaria programs. The CNLS is the primary HIV/AIDS coordinating body. The Executive Secretary of CNLS chairs the PEPFAR 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, Cheryl Sim

Time Frame: FY 2008 – FY 2009

Approved Funding by Program Area: Rwanda