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Rwanda FY 2006 Country Operational Plan (COP)RWANDA Project Title: Rwanda FY 2006 Country Operational Plan (COP) Budget Summary:
HIV/AIDS Epidemic in Rwanda: Adult HIV Prevalence Rate: 3.1% [2.9-3.2] (UNAIDS 2006) Country Results and Projections to Achieve 2-7-10 Goals:
*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 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% [2.9-3.2] of the adult population is infected with HIV, thus 230,000 Rwandan adults and 22,000 children are living with HIV/AIDS in a total population of 8.4 million people (Rwanda 2005 EST.). The repercussions of the HIV epidemic combined with the ongoing effects of the genocide have resulted in more than 810,000 total orphans and a continuing loss of approximately 22,000 persons from AIDS each year. Rwanda’s HIV/AIDS epidemic is primarily transmitted through heterosexual contact and from mother to child. High risk groups for HIV in Rwanda include commercial sex workers and their clients and partners; uniformed personnel including military and police forces; long distance truck-drivers, refugees, genocide widows, prisoners, and discordant couples. There are currently a large number of prisoners who are accused of genocide crimes that are now being released into the community. Although the 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 age of sexual debut in Rwanda is relatively late (approx 21 years DHS 2000), homeless children and orphans are at high risk for exposure. Resulting from both HIV and the genocide, orphans face unique challenges of sexual exploitation, violence, abuse, food insecurity and poverty. Tuberculosis (TB) remains a significant problem in Rwanda; the World Health Organization (WHO) estimates that 28% of adults infected with TB cases are co-infected with HIV. Emergency plan funding will be focused on the following programmatic areas to achieve the 2-7-10 targets: Prevention: $12,540,794 as of August 2006 ($7,889,390 Field and $4,651,404 Central) (20.8% of prevention, care, and treatment budget) Prevention activities include prevention of mother-to-child transmission (PMTCT), abstinence and be faithful (AB) programs, blood and injection safety, and other behavioral prevention initiatives including those that focus on high-risk populations. With FY 2006 funds, the President’s Emergency Plan for HIV/AIDS (EP) will partner with the Government of Rwanda, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the World Bank, and individual health districts to strengthen the scope, quality and sustainability of PMTCT services in a decentralized health delivery system. The PMTCT program will work to ensure that 50% of HIV positive pregnant women who are eligible for antiretroviral therapy (ART) have access to the service. The program will expand to 22 new PMTCT sites for a total of 117 sites serving 121,095 women and children. In order to achieve sustainability, 44 sites will “graduate” from direct EP support through clinical partners to the performance-based financing mechanism. The EP in Rwanda emphasizes AB programs in order to prevent the spread of HIV and supports the National Prevention Plan 2005-2009. Programs target both high-risk groups as well as the general population with AB messages. The EP supports quality behavior change programs including mass media and community-based behavior change programs, peer education, and work with religious organizations, associations of people living with HIV/AIDS and health care providers. With FY 2006 funds, the EP will program the majority of AB prevention assistance through local Rwandan faith and community based organizations (FBO/CBO). The EP will work to ensure that training curricula, mass media spots, and other information, education and information (IEC) materials address the links between alcohol abuse, gender-based violence and HIV. Other topics addressed will include transactional sex, coercive and cross-generational sex and discordant couples in order to change not only behavior but also harmful societal norms. Over 463,000 individuals will be reached with face-to-face messages and 8,200 individuals will be trained to promote abstinence and fidelity with the support of FY 2006 funds. With FY 2006 funding, the EP will expand efforts to reduce new infections among high risk and high transmitter groups (such as commercial sex workers, military, police, and discordant couples) through mobile counseling and testing (CT), condom social marketing, peer education and mass media. The USG will target 75,600 individuals through these ABC programs. In order to strengthen systems for blood collection, testing, storage and handling, the EP will provide direct funding and technical assistance to Rwanda’s National Program for Blood Transfusion for infrastructure and capacity building. Activities will focus on institutionalizing quality provision of transfusion services. Beginning in FY 2006 with the associated funding, the EP will increase to 40 the number of blood safety service outlets and will add 15 new collection sites. The EP’s safe injection activities in Rwanda will reduce the burden of HIV transmission due to unsafe and unnecessary medical injections, and contact with infectious medical waste. The package of interventions includes procurement of safe injection equipment and a comprehensive training component for all levels of medical providers. FY 2006 funded activities will include the expansion of provider training and procurement of injection safety supplies to a total of 23 health districts, in order to continue working toward full national coverage of injection safety activities. In the May 2006 notification, an additional $475,000 was allocated for prevention activities. The additional funds will support expanded prevention of mother-to-child transmission, provide technical assistance to assess risk behaviors among people living with HIV/AIDS (PLWHA), and improve prevention-for-positives programming. There is no change in the amount of funding allocated for prevention as of this operational plan. Principal Partners: American Refugee Committee, African Humanitarian Action, Centers for Disease Control (CDC), Community Habitat Finance International, Elizabeth Glaser Pediatric AIDS Foundation, Family Health International, Management Sciences for Health, Ministry of Health, IntraHealth, Population Service International, Sanquin Diagnostic Services, and World Relief. Care: $21,456,820 as of August 2006 ($20,361,929 Field and $1,094,891 Central) (35.6% of prevention, care, and treatment budget) Care activities include CT, basic palliative care, support for TB/HIV integration, and support to orphans and vulnerable children (OVC). With FY 2006 funds, the EP will expand the CT program to support medical facilities to increase levels of informed consent provider-initiated testing (PIT). This will include working with the Government of Rwanda (GOR) to establish policies and protocols for PIT and developing training tools for health workers. As pre-marital testing is emphasized by religious leaders in Rwanda, EP partners will work with faith-based organizations to make pre-marital testing more widely available, and post-test counseling sessions will emphasize the importance of marital fidelity. The EP will build on new testing approaches to expand family-based and home-based testing. High risk populations including the military, prisoners, refugees, and sex workers, will be reached through expanded mobile and outreach testing activities. The EP will work to ensure that all PLWHA at every stage of their illness receive services through a comprehensive network of district hospitals, health centers and communities. Clinical setting activities will include prevention and treatment of opportunistic infections, pain management, positive living and prevention counseling for positives, nutrition counseling and support, support for treatment adherence, CD4 testing, general clinical staging and monitoring, and wraparound family planning support. Community and home-based palliative care interventions will continue to focus on spiritual and emotional support, home-based care kits, counseling on hygiene and nutrition, and care for vulnerable children in the family. Food for Peace Title II resources will be leveraged to provide nutritional support for OVC and PLWHA. The EP will reach over 87,000 HIV positive patients with basic palliative care by September 2007. With FY 2006 funding, the EP will support implementation of the national policy to strengthen and integrate TB/HIV services in close coordination with GFATM. The program will expand TB/HIV integration activities in all EP health districts and will improve systems to track co-infected patients. All TB patients will be routinely offered HIV testing and PLWHA will be routinely screened for TB 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. The EP’s partners will work closely with the GOR to increase national capacity to respond to OVC priorities of policy and legal reform, government and civil society coordination, and monitoring services to OVC. Funding from FY 2006 will support a package of comprehensive OVC services including education, health, psychosocial support, nutrition, and economic interventions in a gender-sensitive manner to beneficiaries of EP-assisted facilities. HIV prevention messages will continue to be integrated into OVC programs; an estimated total of 52,000 will be reached with all programs. In the May 2006 notification, an additional $2,616,000 was allocated for care activities. The additional funds will support expanded testing (including the purchase of 380,000 HIV test kits), coordination with WFP and Title II resources to leverage food supplements, purchase of infant formula for 1,000 infants born to HIV-positive mothers, therapeutic feeding for 750 malnourished PLWHA, improved access to safe water, and improved capacity to diagnose TB among PLWHA (including children). In August 2006, an additional $82,913 was allocated for care activities. The $82,913 will be used to strengthen VCT services through the AIHA twinning mechanism. 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 the Treatment and Research AIDS Center (TRAC). Treatment: $26,312,752 as of August 2006 ($21,091,613 Field and $5,221,139 Central) (43.6% of prevention, care, and treatment budget) Treatment activities include the provision of antiretroviral (ARV) drug and service programs as well as laboratory support. At present, there are 15,975 individuals on ART at 71 sites1, and by September 2007, this number is expected to increase to 33,000 individuals on treatment at approximately 120 sites. With FY 2006 funds, the EP will assist the Ministry of Health (MOH) to increase program quality and sustainability through integration and decentralization of the HIV treatment program. Working with international partners, the EP will strengthen district-level capacity to plan, implement and monitor HIV treatment programs through technical and financial assistance including a performance-based financing mechanism. Utilizing FY 2006 funds, pediatric HIV technical expertise will be strengthened to care for more than 4,000 children by September 2007. The EP will provide technical and financial assistance for the MOH-led national ARV procurement and supply chain management to ensure an adequate drug supply in the country. The Plan’s FY 2006 funded technical support for laboratory infrastructure will focus on key reference laboratory functions, including training, quality assurance, and developing in-country expertise for HIV-related care and treatment. 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. In the May 2006 notification, an additional $2,692,000 was allocated for treatment activities. The additional funds will support completion of a pediatric AIDS module of Integrated Management of Childhood Illness (IMCI) as national protocol, development of training materials for community-based pediatric AIDS risk-sign identification, testing and referral, increased availability of clinical materials for PMTCT, VCT, and ART, additional technical assistance for district health teams to enhance supervision, quality assurance and communications between health facilities, assessment of electrical infrastructure and supply at district hospitals, provision of solar energy packages for seven to nine district hospitals, allowance for an additional 40,000 CD4 tests, and provision of ARVs for an additional 500 patients. There is no change in the amount of funding allocated for treatment as of this operational plan. Please note that pediatric AIDS funding that is attributed to OVC programs is included in the care program area total and is deducted from the treatment program area total. Principal Partners: American Society of Clinical Pathologists, Association of Public Health Laboratories, Catholic Relief Services, CDC, Columbia University, Elizabeth Glazer Pediatric AIDS Foundation, Family Health International, IntraHealth, Management Sciences for Health, Ministry of Health, and the National Reference Laboratory. 1 Treatment and Research AIDS Center (TRAC) net Report, September 30, 2005, Rwanda. Other Costs: $11,792,068 as of August 2006 The MOH, the National AIDS Control Commission and its district structures will receive technical and financial assistance through the Emergency Plan to strengthen the capacity to plan, coordinate, monitor and report on the progress of the national response. Support will include the improvement of a decentralized reporting system for HIV-related activities including electronic networking. The EP will also support HIV surveillance and targeted evaluations. The EP supports interventions to improve human capacity and strengthen systems required to achieve 2-7-10 goals. Human capacity interventions include an HIV/AIDS public sector program management fellowship, a Masters in Public Health program, and in-service and pre-service nursing training support. 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 MOH’s Health Care Unit will receive FY 2006 financial and technical assistance through a sub-contract with an EP partner; 20 of the 30 health districts will receive a uniform support package consisting of infrastructure, equipment, support for communication, supervision, management, transportation and human resources. The EP will also help strengthen HIV/AIDS policies and systems through the Commission Nationale de Lutte contre le SIDA (CNLS) across health and non-health sectors. Management and staffing funds will support in-country personnel needed for U.S. Agency for International Development (USAID), the Department of Health and Human Services (HHS), the Department of State and the Department of Defense. Funds will ensure program monitoring and accountability, including active EP co-management with the GOR. Management and staffing costs will cover compensation, logistics, and office and administrative costs. In the May 2006 notification, an additional $1,180,000 was allocated for other activities. The additional funds will support policy and system strengthening in Human Resources management in the MOH through technical assistance to develop incentive systems to maintain health care workers in rural areas, improved management in newly decentralized health districts, a human resources database and tracking system, and facility renovation to improve the quality of HIV services, including renovation of two isolation wards for HIV patients with multi-drug-resistant TB. In August 2006, an additional $100,000 was allocated for other costs. The funding will be used to strengthen existing HHS/CDC strategic information activities as a new procurement through the CDC GAP 6 task order mechanism. Principal Partners: Columbia University, Drew University, Family Health International, IntraHealth, Management Sciences for Health, Ministry of Health, Tulane University, and University of North Carolina. Other Donors, Global Fund Activities, Coordination Mechanisms: The United States is the largest HIV/AIDS bilateral donor, having provided $56.9 million in support in 2005. Other major HIV/AIDS and health donors include the World Bank, GFATM, Belgium, Luxembourg, and Clinton Foundation. The GFATM has awarded four grants to Rwanda, totaling $100 million over five years for AIDS, TB and malaria programs. The CNLS is the primary HIV/AIDS coordinating body. The Executive Secretary of CNLS chairs the President’s Emergency Plan for AIDS Relief (PEPFAR) Steering Committee, the GOR-USG co-management mechanism, to ensure that USG program support and complements the Rwandan national HIV/AIDS plan. Program Contact: Ambassador Michael Arietti and USAID Director, Kevin Mullally Time Frame: FY 2006 – FY 2007 | | | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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